{"id":796,"date":"2015-08-06T17:19:52","date_gmt":"2015-08-06T17:19:52","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=796"},"modified":"2017-08-21T11:42:06","modified_gmt":"2017-08-21T11:42:06","slug":"primary-care-corner-with-geoffrey-modest-md-atrial-fibrillation-and-weight-loss-2","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/08\/06\/primary-care-corner-with-geoffrey-modest-md-atrial-fibrillation-and-weight-loss-2\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Atrial Fibrillation and Weight Loss"},"content":{"rendered":"<p><strong>By: Dr. Geoffrey Modest<\/strong><\/p>\n<p><span style=\"font-family: 'Calibri',sans-serif;color: black\">A 5-year study from Australia (the LEGACY study, Long-term Effect of Goal directed weight management on Atrial fibrillation Cohort) looked at a cohort of people with atrial fibrillation (paroxysmal or persistent) to assess the relationship between weight loss, weight fluctuations and atrial fibrillation (see <a href=\"http:\/\/dx.doi.org\/10.1016\/j.jacc.2015.03.002\">doi.org<\/a>\/10.1016\/j.jacc.2015.03.002). Details:<\/p>\n<ul>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">355 patients with atrial fibrillation (AF)\u00a0and BMI<a href=\"http:\/\/dx.doi.org\/10.1016\/j.jacc.2015.03.002\"><span style=\"background: white\">\u2265<\/span><\/a> 27 kg\/m2 (mean age 65, 64%\u00a0male,<span style=\"background: white\">\u00a0weight\u00a0100 kg<\/span>,\u00a0BMI 33,\u00a053% with paroxysmal AF, 80% hypertensive, 30% diabetic, 30% drinking &gt;30g alcohol\/week) were offered weight management\n<ul>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">Face-to-face counseling, with 3-monthly evaluation. Meals were high protein\/low glycemic index and calorie-controlled. \u00a0If patient lost &lt;3% of weight after 3 months,\u00a0<\/span><span style=\"font-family: 'Calibri',sans-serif;color: black\">they received very-low-calorie meal replacement sachets for 1-2 meals\/day. Also, there was an\u00a0exercise component, increasing to 300 min of moderate-intensity\u00a0<\/span><span style=\"font-family: 'Calibri',sans-serif;color: black\">activity\/week.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">AF management was independent of this\u00a0weight loss study, with rate and rhythm control strategies per the physicians there (rhythm control mostly by flecainide or sotolol). Ablation was used if patients remained symptomatic.<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">AF was determined at least annually by clinical review, 12-lead EKG, and 7-day Holter monitoring.<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">AFSS (AF Severity Scale) was used to monitor the clinical burden of AF (this scale assesses the frequency, duration, and clinical\u00a0severity of AF). And the 7-day Holter assessed the freedom from AF.<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">Weight loss was categorized as\u00a0<a href=\"http:\/\/dx.doi.org\/10.1016\/j.jacc.2015.03.002\"><span style=\"background: white\">\u2265<\/span><\/a> 10% (group 1, with 135 patients and mean wt loss of 16 kg), 3-9% (group 2, with 103 patients and mean wt loss of 6 kg), and &lt;3% (group 3, with 117 patients, and mean wt gain of 2 kg). No difference in baseline characteristics or follow-up among these groups.<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">Of note, for those with \u2265\u200b 10 kg wt loss, the loss was pretty durable: 66% who lost his amount in the first year maintained it at 34.5 months. This was likely because 85% of them continued attending the weight management clinics.<\/li>\n<\/ul>\n<p><span style=\"font-family: 'Calibri',sans-serif;color: black\">Results:<\/p>\n<ul>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">Weight loss was associated with changes in cardiac\u00a0risk factors (all findings were significant, and almost all at p&lt;0.001 level):\n<ul>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">Systolic blood pressure, from baseline of around 145,\u00a0decreased 18 mmHg in group 1, 10\u00a0mmHg in group 2 and 7<span style=\"background: white\">\u00a0<\/span>mmHg in group 3 (p&lt;0.001) &#8212; despite decreasing blood pressure meds in group 1 and increasing them in group 3.<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">Lipids: for groups 1,\u00a02, and 3 &#8212; from baseline of around 110,\u00a0decreased 37, 23 and increased 4 mg\/dL; HDL increased 8, 4, and 4 mg\/dL<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">hsCRP: for groups 1,\u00a02, and 3 &#8212;\u00a0from baseline of around 5,\u00a0decreased 3.9, 1.7, and increased 0.8 mg\/dL<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">Echo findings: for groups 1,\u00a02, and 3 &#8212; LA volume from baseline of around 38,\u00a0<span style=\"background: white\">decreased\u00a0<\/span> 6.7, 4.8, and and increased 1.4 ml\/m<sup>2<\/sup>;\u00a0IV septum\u00a0from baseline of around 11.5, decreased \u00a01.6, 0.6, and 0.1 mm; E\/E&#8217; ratio from baseline of around 13 decreased 4.3, 2.8 and increased 2.1.<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">All clinical\u00a0scores measured (AF frequency, duration, episode severity, symptom subscale and global well-being) were dramatically better in groups 1 vs 2 vs 3<\/li>\n<\/ul>\n<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">At final followup: for groups 1, 2, and 3 &#8212;\u00a045.5%, 22.2% and 13.4% remained free from arrhythmia without antiarrhythmic drugs or ablation (p&lt;0.001), with group 1 having a 6-fold greater probability of arrhythmia-free survival than the other 2 groups.<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">On multivariate analysis: predictors of AF recurrence were group 2 vs group 1 [HR:3.0 (1.4-2.9)] and group 3 vs group 1 [HR 3.0 (2.0-4.3)], both p&lt;0.001. also, echo IV septum thickness and E\/E&#8217; ratio were independent predictors, as well as a history of diabetes.<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">Arrhythmia-free survival with and without rhythm control strategies was greatest in group 1 (p&lt;0.001, comparing to group 2 or 3): 86.2% in group 1, 65.5% in group 2, and 39.6% in group 3<\/li>\n<li><span style=\"font-family: 'Calibri',sans-serif;color: black\">Weight fluctuation of &gt;5% partially offset this benefit (2-fold increased risk of arrhythmia recurrence)<\/li>\n<\/ul>\n<p style=\"background: white\"><span style=\"font-family: 'Calibri',sans-serif;color: black\">So, what does this mean??\u00a0<\/span><\/p>\n<p style=\"background: white\"><span style=\"font-family: 'Calibri',sans-serif;color: black\">This is the best study I&#8217;ve seen showing that weight loss is helpful in the treatment of AF. I did send out a blog 2 years ago of a short-term trial\u00a0from Australia by this same group\u00a0which showed efficacy of weight loss, including echocardiographic\u00a0changes (see\u00a0<a href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2013\/12\/03\/primary-care-corner-with-dr-geoffrey-modest-atrial-fibrillation-and-weight-reduction\/\">https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2013\/12\/03\/primary-care-corner-with-dr-geoffrey-modest-atrial-fibrillation-and-weight-reduction\/<\/a>\u00a0). But the current\u00a0study is long-term and found really profound differences in cardiac risk factors, structural changes in the heart and both AF\u00a0control and recurrences, and AF symptoms and general well-being. \u00a0These changes raise the untested possibility of stopping anticoagulation in those no longer with AF, with the associated personal benefits to patients (anticoagulation management, adverse effects of drugs, medicalization) and costs to the system.<\/span><\/p>\n<p style=\"background: white\"><span style=\"font-family: 'Calibri',sans-serif;color: black\">This study also reinforces how hard it is to achieve the weight loss. They had a long-term study (with up to 5 years of followup), finding that the group that\u00a0consistently lost weight and maintained\u00a0the weight loss had regular prolonged involvement in weight management clinics. In this group, there were sustained changes in many cardiac risk factors as well as AF, and\u00a0it certainly seems to me that instituting and supporting long-term weight management clinics is not only potentially beneficial to the individuals i<span style=\"background: white\">nvolved and\u00a0<\/span>in many ways (medical, psychological, general functioning)\u00a0but also very cost-effective.<\/span><\/p>\n<p style=\"background: white\"><span style=\"font-family: 'Calibri',sans-serif;color: black\">Of interest, NPR just had a segment on exercise in Finland (see\u00a0<a href=\"http:\/\/www.npr.org\/sections\/health-shots\/2015\/07\/28\/426748088\/how-finns-make-sports-part-of-everyday-life\">http:\/\/www.npr.org\/sections\/health-shots\/2015\/07\/28\/426748088\/how-finns-make-sports-part-of-everyday-life<\/a>\u200b ), finding that exercise there is treated as a right (government subsidies, integration into workday including paid time to workout during the week, extensive bike and walking trail systems), is associated with better work performance (more workforce cohesion\/loyalty) and decreasing health care costs in a more physically active workforce (the Finnish minister of health estimates a $5.5 billion cost savings by people riding their bike to work, which now happens with 1\/2 of the male and 1\/3 of female employees).\u200b<\/span><\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Primary Care Corner with Geoffrey Modest MD: Atrial Fibrillation and Weight Loss [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/08\/06\/primary-care-corner-with-geoffrey-modest-md-atrial-fibrillation-and-weight-loss-2\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-796","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/796","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=796"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/796\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=796"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=796"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=796"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}