Αππτθμίερ & παφτςαπκία

Αππτθμίερ & παφτςαπκία Εμμ. Μ. Κανοτπάκηρ Επιμελησήρ Α Καπδιολογική Κλινική Πανεπιςσημίοτ Κπήσηρ

Obesity & cardiovascular disease

Παφτςαπκία & κολπική μαπμαπτγή

Παφτςαπκία & κολπική μαπμαπτγή Τι μάθαμε από μεγάλερ επιδημιολογικέρ μελέσερ; Πωρ ςτνδέεσαι η παφτςαπκία με σην κολπική μαπμαπτγή; Επηπεάζει η παφτςαπκία σην θεπαπεία και έκβαςη σων αςθενών με κολπική μαπμαπτγή;

The Framingham Heart Study 5282 participants, mean follow-up of 13.7 yrs a 4% increase in AF risk per 1 unit increase in BMI Wang et al, JAMA 2004;292:2471-2477

A Danish study 47589 participants, mean follow-up 5.7 yrs Overweight and obesity are associated with an increased risk of a diagnosis of AF Frost et al, American J Medicine 2005; 118: 489 495

Results of a meta-analysis In 123.249 subjects, overweight and obese patients have an associated 49% increased risk of developing AF Wanahita et al, Am Heart J 2008;155:310-5

The Swedish Primary Prevention Study 6903 men, max follow-up 34.3 yrs Large body size in youth Weight gain from age 20 to midlife independently related to the development of AF Rosengren et al, Europ Heart J 2009;30: 1113 1120

Weight gain & AF risk In 34.309 participants in the WHS during 13 yrs of follow-up BMI is linearly associated with risk of incident AF. The risk for incident AF is especially high in subjects who gained weight rapidly. This risk decreases after normalization of BMI. Obesity appears to be a reversible risk factor for AF Tedrow et al, J Am Coll Cardiol 2010;55:2319 27

A longitudinal study over 21 years Α graded risk relationship between BMI and progression from paroxysmal to permanent AF Larger LA size augmented the risk of such progression BMI and LA volume were independent predictors of progression to permanent AF Tsang et al, Europ Heart J 2008;29:2227 2233

Sleep apnea & AF Significant OSA is present in 40% of obese individuals Wolk et al, Curr Probl Cardiol 2005;30:625-662

28 449 participants without baseline AF Physicians should be aware that subjects with the metabolic syndrome are at increased risk for the development of AF, even in the absence of diabetes or hypertension. Circulation 2008;117:1255-1260

Is there obesity cardiomyopathy? Lavie et al, J Am Coll Cardiol 2009; 53:1925 32

Obesity & LA enlargement Strong associations of obesity, arterial hypertension and age with LA size The effect of obesity was almost twice the effect of hypertension Obesity is identified as the most important determinant of LA enlargement Stritzke et al, J Am Coll Cardiol 2009;54:1982 9

Mechano-electric feedback & AF Atrial stretch induces both early and delay afterdepolarizations Genesis and persistence of reentrant arrhythmias: inhomogeneity in electrophysiological properties length of the excitation wave (CV x RP) tissue mass

CRP in obesity Higher BMI is associated with higher CRP concentrations, even among young adults aged 17 to 39 years. These findings suggest a state of low-grade systemic inflammation in overweight and obese persons Visser et al, JAMA 1999;282:2131-2135

Adipose tissue produces adipokines Fernández-Sánchez et al, Int. J Mol Sci 2011;12:3117-3132

Circulation 2001;104:2886-2891

Inflammation & AF Korantzopoulos et al, Med Sci Monit, 2003; 9: 225-229

Epicardial adipose tissue Batal et al, Circ Arrhythm Electrophysiol. 2010;3:230-236

Epicardial fat & AF burden Patients with persistent AF have a significantly thicker mean LA-ESO fat pad than patients with no AF or with paroxysmal AF Batal et al, Circ Arrhythm Electrophysiol. 2010;3:230-236

Potential association between epicardial fat & AF Compression of the heart decrease LV diastolic filling, leading to atrial dilation. Local inflammation and resultant fibrosis. An important local source of TNF-α and IL-6, with direct arrhythmogenic effects Modulate the activity of the intrinsic ANS. In animals parasympathetic nerve activity within fat pads promotes inducibility for AF, by shortening the ARP Thanassoulis et al, Circ Arrhythm Electrophysiol. 2010;3:345-350

Epicardial fat & atrial arrhythmogenicity Lin et al, Medical Hypotheses 2010; 74:1026 1029

Θεπαπετσικέρ επιλογέρ

Θεπαπετσικέρ επιλογέρ The likelihood of obtaining adequate heart rate control was substantially lower in obese patients. Similar outcomes for rate- and rhythm-control strategies in each BMI category. The decision to pursue a rate or rhythm-control strategy in an individual patient should be based on factors other than BMI. Ardestani et al, Am J Cardiol 2010;106:369 373

The obesity paradox in AF Overweight and obese patients had lower cardiovascular mortality as compared with the normal weight patients Badheka et al, American Journal of Medicine 2010;123: 646-651

The obesity paradox speculative mechanisms TNF-α has been associated with increased atrial arrhythmogenesis. Adipose tissue produces soluble TNF-α receptors, which may play an anti-inflammatory, cardioprotective role. Atrial natriuretic peptide levels are significantly increased in AF Obesity is associated with lower atrial natriuretic peptide levels The higher BP levels seen in obese patients may allow for greater uptitration of beneficial therapies such as ACE inhibitors and β-blockers.

Catheter Ablation & obesity In 523 consecutive pts 44% were overweight and 38% were obese Catheter ablation restored SR and improved QoL for all BMI groups. Obese patients with AF had the same degree of improvement as nonobese patients. Yong-Mei Cha et al, Circulation 2008;117:2583-2590

Conflicting results Obesity, is an independent predictor of procedural failure

Pericardial fat & ablation outcome Pericardial fat is associated with the presence of AF, the severity of AF, left atrial volumes, and poorer outcomes after AF ablation. Wong et al, J Am Coll Cardiol 2011;57:1745 51

Obesity: a modifiable risk factor for AF

Παφτςαπκία & κοιλιακέρ αππτθμίερ

Sudden death is more common in those who are naturally fat than in the lean Hippocrates The annual SCD rate was nearly 40 times higher than in a matched non-obese population The Framingham Heart Study

Prevalence of PVCs in lean and obese pts without or with eccentric LVH Messerli et al, Arch Intern Med 1987;147:1725-1728

SCD in obese patients speculative mechanisms Histopathological changes Ventricular repolarization abnormalities Increased sympathetic activity leptin Higher incidence of ACS diabetes dyslipidemia hypertension

Sudden death in morbid obesity No increase in the amount of epicardial fat No increase in the distribution or amount of myocardial fibrous tissue No significant focal coronary atherosclerosis Microscopic features typical of hypertrophy Duflou et al, Am Heart J 1995;130:306-13

Obesity & QT prolongation A positive association between QTc interval and BMI El-Gamal et al, Am J Cardiol 1995;75:956-9 Papaioannou A, Kanoupakis E et al, Obesity Surgery 2003

Obesity as a Risk Factor for SVT in MADIT II pts In post-infarction nondiabetic patients with LV dysfunction, individuals with BMI 30 had significantly higher risk of receiving ICD therapy for ventricular tachyarrhythmia One possible explanation could be increased sympathetic activity caused by leptin. Pietrasik et al, J Cardiovasc Electrophysiol 2007;18:181-184

The obesity paradox The presence of additional body mass, is truly protective once cardiovascular disease has become established. Consistently in patients with established chronic CHD, acute MI, acute and chronic HF, and PAD.

Obesity paradox and risk of SCD in HF 1. The obesity paradox in HF affects all-cause mortality and pump failure death but not sudden death. 2. The risk of dying suddenly was similar across BMI categories Gastelurrutia et al, Am Heart J 2011;161:158-64

Take home messages Παπά σα κενά ποτ τπάπφοτν ςσην παθουτςιολογική επμηνεία σων αππτθμιών ςσην παφτςαπκία τπάπφοτν ςαυείρ ενδείξειρ για σην αισιολογική σοτρ ςτςφέσιςη. Η επίπσωςη, οι τποσποπέρ και σο ςτνολικό υοπσίο σων αππτθμιών ςε παφύςαπκοτρ αςθενείρ αποσελεί ππόκπιμα για αναζήσηςη ενόρ πιο αδύνασοτ μονσέλοτ ζωήρ ποτ θα μειώςει σον κίνδτνο και σιρ επιπλοκέρ από σην εμυάνιςηρ σοτρ.