AF and VTE: Global Considerations in the Evolving Space of Real-World Data

Patient Case Study: Obesity

Transcript

Announcer:
Welcome to CME on ReachMD. This episode is part of our MinuteCE curriculum. Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements as well as the learning objectives.

Dr. Lopes:
Hello. This is CME on ReachMD, and I am Dr. Renato Lopes. And I'm here today with Dr. Valeria Caso. Welcome, Valeria.

Dr. Caso:
Hello.

Dr. Lopes:
So, Valeria, do you have a patient case which you would like to present to us?

Dr. Caso:
Yes. Thank you, Renato. And I have a young patient, relatively young patient, a 64-year-old lady. And she has a long history of AF diagnosed for 2 years, but she always refused to be treated. She had a of problems with compliance and she never was really adherent to her treatment. Her BMI is 41. She weighs more than 100 kg. And her medical history, you can imagine, also, to the obesity is hypertension, obstructive sleep apnea. She's treated with CPAP, but again, her compliance is not the best one.

And she has a history of diabetes mellitus, and you know diabetes mellitus always changes the risk profile of a patient because it’s not only doubling but increased the risk of having a stroke in an important way.

And another two points, she had already a minor stroke without neurological sequelae, but there is a lesion. So we have a patient who is really, despite her age, in a very strong condition for having stroke recurrence.

She is on metoprolol, losartan, semaglutide. However, we know that when there's obesity, we have alternate drug observation. We have the different distribution of the drug. We know that there’s a reduced plasma concentration patient who have BMI over 40 or weigh more than 120.

So in these cases, how can we, again, use the best drug for lady, Renato? Because we really want her to be protected from stroke recurrence.

Dr. Lopes:
Yeah, Valeria. I think you brought up a challenging case. And of course, we don't have tremendous amount of data on obese patients, although we have some data. A subgroup analysis from the major trials and also some other studies on obese patients. But as we start going up in the BMI, then we start having less and less data.

I think that when we look at the weight per se, when we have reasonable amount of data up to 140 kg in terms of DOACs, in terms of the efficacy and safety of DOACs compared to warfarin. The reason ACC/AHA/ACCP/HRS guidelines also recommend as reasonable to use DOACs over warfarin with a 2A recommendation for patients with obesity Level 3. So, again, when we have this patient population greater than 40 of BMI, it seems reasonable to use NOACs compare to warfarin. Of course, we might have more data with similar NOAC versus the other, but I think we have enough to reasonably chose NOACs over warfarin. The problem is when you start getting in the stage 4 or level 5, above 50 or 60 of BMI, then I think we have very minimal data. But we also don't have a lot of data with warfarin. The only thing is that, with warfarin, we have a way to monitor the level of drug that we need to give. But that’s a zone that we’re going to have to really customize, individualize, and look at overall patient profile to be able to choose the right agent, the right dose for this very challenging group of patients.

Would you agree?

Dr. Caso:
Absolutely. No, I think it's a very important message. Again, we have some data on DOAC, and as you said, I think the point that you made about buffering because we don’t have so many data. Okay, we have the possibility to monitor, but how close can we monitor? And we know there’s often more buffering resistance, so we want patient to continue the drug without knowing this is a fixed dose which makes life much more easy. So I think this is a very good message to say. We have space in these patients for being treated with NOAC.

Dr. Lopes:
Well, this has been a great discussion, Valeria. I think we continue to try to do new trials and try to close the gaps on those challenging group of patients, and hopefully continue to advance the field of stroke prevention in atrial fibrillation.

Thank you very much for listening.

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Overview
The effective management of atrial fibrillation (AF) remains a high priority for many clinicians worldwide because a significant number of people globally who are living with AF are at risk of developing venous thromboembolism (VTE). This makes our understanding and implementation of new findings and clinical trial outcomes that much more important as we develop effective, personalized treatment plans for our patients. Tune in to our micro learning course to make sure you’re up to date and providing the care your patients deserve.
Disclosure of Relevant Financial Relationships
In accordance with the ACCME Standards for Integrity and Independence, Global Learning Collaborative (GLC) requires that individuals in a position to control the content of an educational activity disclose all relevant financial relationships with any ineligible company. GLC mitigates all conflicts of interest to ensure independence, objectivity, balance, and scientific rigor in all its educational programs.
Chair:
Renato D. Lopes, MD, MHS, PhD
Professor of Medicine, Division of Cardiology
Duke University Medical Center
Duke Clinical Research Institute
Durham, NC
Dr. Lopes has reported the following relevant financial relationships or relationships with ineligible companies of any amount during the past 24 months:
Consulting Fees: AstraZeneca, Bayer, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Novo Nordisk, Pfizer
Contracted Research: Amgen, Bristol-Myers Squibb, Glaxo Smith Kline, Medtronic, Pfizer, Sanofi
Faculty:
Valeria Caso, MD, PhD
Stroke Unit
Santa Maria della Misericordia Hospital
Perugia, Italy
Dr. Caso has reported the following relevant financial relationships or relationships with ineligible companies of any amount during the past 24 months:
Consulting Fees: Bayer, BMS, Daiichi Sankyo, Ever Pharma, Pfizer
Alexander T. Cohen, MD, MBBS
Consultant Vascular Physician
Guy’s and St Thomas' NHS Foundation Trust
King's College London
London, UK
Dr. Cohen has reported the following relevant financial relationships or relationships with ineligible companies of any amount during the past 24 months:
Consulting Fees: AstraZeneca, Bayer, BMS, Pfizer
Contracted Research: AstraZeneca, Medtronics
Reviewers/Content Planners/Authors:
- Cindy Davidson has no relevant relationships to disclose.
- Anita Galdieri, PharmD, has no relevant relationships to disclose.
- Brian P. McDonough, MD, FAAFP, has no relevant relationships to disclose.
- Katie Sheridan, PhD, has no relevant relationships to disclose.
Learning Objectives
After participating in this educational activity, participants should be better able to:
- Identify the challenges in using real-world evidence when making clinical decisions in everyday practice for the management of atrial fibrillation (AF) or venous thromboembolism (VTE)
- Optimize the selection process for oral anticoagulation in patients with AF or VTE, balancing bleeding risk with thrombotic risk reduction
Target Audience
This activity has been designed to meet the educational needs of cardiologists and generalists as well as all other physicians, nurses, physician assistants, nurse practitioners, pharmacists, and all other healthcare providers involved in managing patients with AF and VTE. 
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In support of improving patient care, Global Learning Collaborative (GLC) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.

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Global Learning Collaborative (GLC) designates this enduring activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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Global Learning Collaborative (GLC) designates this activity for 1.0 contact hour(s)/0.1 CEUs of pharmacy contact hour(s).
The Universal Activity Number for this program is JA0006235-0000-25-016-H01-P. This learning activity is knowledge-based. Your CE credits will be electronically submitted to the NABP upon successful completion of the activity. Pharmacists with questions can contact NABP customer service (custserv@nabp.net). 
Global Learning Collaborative (GLC) has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit(s) for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.0 AAPA Category 1 CME credit(s). Approval is valid until February 14, 2026. PAs should claim only the credit commensurate with the extent of their participation in the activity.

This enduring activity is accredited by the European Board for Accreditation of Continuing Education for Health Professional (EBAC) for 60 minutes of effective education time.
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Commercial Support
This activity is supported by an independent educational grant from Pfizer Inc.
Disclaimer
The views and opinions expressed in this educational activity are those of the faculty and do not necessarily represent the views of GLC and Total CME. This presentation is not intended to define an exclusive course of patient management; the participant should use his/her clinical judgment, knowledge, experience, and diagnostic skills in applying or adopting for professional use any of the information provided herein. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients’ conditions and contraindications or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities. Links to other sites may be provided as additional sources of information. Once you elect to access a site outside of Total CME you are subject to the terms and conditions of use, including copyright and licensing restriction, of that site.
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Publication Dates
Release Date: 02/14/2025
Expiration Date: 02/14/2026