Integrating Pharmacologic Weight Management Into the Electrophysiology Practice for Better Atrial Fibrillation Outcomes

Interview With Olivia Gilbert, MD, MSc, FACC

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EP LAB DIGEST. 2025;25(9):ONLINE ONLY.

Interview by Jodie Elrod

In this episode of The EP Edit podcast, we speak with Olivia Gilbert, MD, MSc, FACC, about the new ACC Concise Clinical Guidance report on medical weight management for optimizing cardiovascular health,¹ including practical applications of the study's findings and offering insights for electrophysiology (EP) professionals seeking to enhance atrial fibrillation (AF) management through pharmacologic weight strategies.

Can you start by introducing yourself? 

My name is Olivia Gilbert. I am an advanced heart failure and transplant cardiologist at Atrium Health, Wake Forest Baptist in Winston-Salem, North Carolina, and I am involved with the American College of Cardiology (ACC) Science and Quality Committee. I had become engaged in efforts and high-priority topics within the college, specifically with the topic of weight management, and had come to support and chair a roundtable discussion on weight management in cardiovascular medicine, wanting to acknowledge all the increasing evidence surrounding improved cardiovascular outcomes for those receiving anti-obesity weight management medications in the nutrient-stimulated hormone (NuSH) categories, which is a broad spectrum term that we use to include medications that, by different mechanisms, inhibit the appetite and result in weight loss. So, that is how I became involved in weight management and in this effort, and from the roundtable that we hosted on this through the ACC, there was this Concise Clinical Guidance that included the takeaway points from the multidisciplinary conversation that took place during the roundtable a year ago.  

Can you share why the ACC issued a Concise Clinical Guidance focused on obesity management? Why is addressing obesity increasingly recognized as a critical part of optimizing care?

There is increasing acknowledgement of the improvement in cardiovascular outcomes with weight management across the spectrum of heart failure outcomes, preventing clinical outcomes like cardiovascular death, and even as we know with recent literature, things like atrial arrhythmias that can be mitigated and reduced with these medications. So, we wanted to call attention to or call to action the fact that there are such strong cardiovascular improvements with these medications and that it is probably time for cardiologists to take a more active role in prescribing them. 

The article emphasizes a multidisciplinary approach to pharmacologic weight management. From your perspective, what roles should EP clinicians, primary care, cardiologists, and obesity specialists play in coordinating care for patients with AF and obesity? How does integrating various specialties enhance patient outcomes?

This can be intimidating in some ways for cardiologists to take on in the sense that these originated as diabetes medications. So, similar to what we faced and explored with SGLT2 inhibitors a couple of years ago in the cardiovascular space, we have had to learn to embrace and garner the benefits of what originally had been deemed diabetic medications and adopt them as cardiovascular medications with diabetic benefits, essentially rebranding and relabeling these medications. I think that is sort of the first barrier—to acknowledge in the multidisciplinary space that these medications can be used for other purposes. When other issues are present, such as uncontrolled diabetes and people who are on 3 or 4 or 5 different diabetes agents, I think that interdisciplinary approach is that much more important, and perhaps we should pause and engage endocrinologists and primary care physicians when prescribing them. 

But beyond that scenario, with more straightforward weight loss indications looking for those benefits in the cardiovascular space, I think that this is a very complex issue that leads to obesity in the sense of societal repercussions, all that people are brainwashed with in terms of advertisements and fast food and processed foods, and all the addictions as a result. So, there are a lot of personal beliefs, perceptions, and mentalities that play into this. I think it is more complex than just straightforward medicine, and we must rely on interdisciplinary partners like behavioral therapists, exercise physiologists, pharmacists, and nurses, to be able to overcome this multidisciplinary problem, and that it is not just an isolated medical issue. The other part of that is we can certainly help promote weight loss or inhibit a patient’s weight for whatever period that they are going to be on these medications, but if we want to promote long-term success and the ability to eventually wean from these medications, all those interdisciplinary behavioral interventions become that much more necessary for long-term success. 

What are the key pharmacological agents highlighted in your study, and how do they compare in terms of efficacy and safety?

We use the group term “NuSH” therapies. I think most people are familiar with the GLP-1 agonists, which include liraglutide and semaglutide, which are single receptor agents that ultimately act to inhibit the appetite. However, we now have multi-receptor agonists like tirzepatide, which are GLP-1 and GIP agonists, and multi-receptor agonists are that much more potent in their efficacy for inhibiting the appetite. So, with more action at multiple sites, there is greater weight loss demonstrated and appreciated. There are more medications on the horizon as far as that goes. A patient might expect a 5% to 10% weight loss with liraglutide, a 15% weight loss with semaglutide, and up to a 20% weight loss with tirzepatide, so we can get a sense for the varying degrees of effectiveness with more receptors being affected. 

Access to pharmacologic weight management therapies can vary widely across regions and patient populations. What strategies are recommended to ensure equitable access for patients across different health care settings? What practical advice do you have for EP professionals facing barriers to prescribing or coordinating these therapies?

In my practice, I really have not seen challenges with equitable access in the traditional sense that you might be referring to with sociodemographics and those who might be challenged in those regards, having more difficulty. Ironically, I have seen a couple of patients about these medications through our free hospital-supported medication program and other people who are fully insured and not able to get them. So, I would say they are more strict in the indications that they are approving it for at this point in time, and that varies by insurance provider. This includes obstructive sleep apnea being increasingly acknowledged and covered, diabetes widely accepted as coverage, high-risk cardiovascular prevention indications for secondary prevention, and those kinds of things. The things that do not have strong indications yet are heart failure and AF, which we know there is evidence to support prescribing them and that there would be benefit, but they just have not made it to the level of guidelines or the level of ubiquitous insurance coverage. So, it has been very hit or miss for what I have seen in terms of who has it and who does not. 

The other part to acknowledge there was just the vast national shortages of these medications with everybody wanting them—even if you could get approved, maybe there had been access issues with receiving them. So, it has been interesting to watch the prescription patterns there and the success in acquisition. 

For EP programs looking to incorporate pharmacologic weight management into their practice, what are the initial steps and considerations to ensure a seamless integration? Are there specific models or touchpoints—such as preablation consultations or follow-up visits—where this discussion fits best?

Certainly. I think there are not strong insurance indications for coverage for this yet, specifically for EP indications. So, understanding that it can improve the success of ablations and can help with rhythm management at that point, my advice is to always think outside the box in terms of what can be approved. For example, For many of my heart failure patients, when coverage is not approved based on heart failure indications alone, I often rely on diagnoses that I know are more acceptably covered, such as sleep apnea or diabetes. So, I am on the lookout for leveraging concomitant diagnoses that can qualify these patients for those medications. 

Beyond that, as far as having a structured approach to diagnoses, I think a lot of health systems, including my own, are exploring this right now in terms of having consolidated pathways to get patients on these medications in the most efficient way possible. There are multiple players who are interested, including the pulmonologists wanting to treat their sleep apnea patients, preventative cardiologists, and weight management specialists. We are working on a consolidated pathway that is not siloed and where we can connect to that pathway with pharmacy support for expedited initiation and maintenance of these medications. So, that is something we are working on in my health system right now. 

Looking ahead, what future research directions or clinical trials do you foresee as being pivotal in further understanding the role of pharmacologic weight management in cardiovascular care?

Specifically, for heart failure, I think that there is absolutely the opportunity to explore larger clinical trials demonstrating the effectiveness. We have had certainly smaller studies demonstrating encouragement, impact, and direction, but I think integration into the guidelines will be important for these sorts of insurance coverage that we are looking for. So, I think as we are all learning and exploring the beautiful impact that these medications have on our different cardiovascular disease states, we can hope to graduate to guideline acceptance, and hopefully, better coverage for our patients. Part of the intent of this document is that while we may not be able to change insurance policies and insurance coverage with this document, we can at least raise the awareness of the potential benefit and garner the clinical evidence to move us in the direction for better coverage. 

 The transcripts were edited for clarity and length.

Reference

1.     Gilbert O, Gulati M, Gluckman TJ, et al. 2025 Concise Clinical Guidance: An ACC Expert Consensus Statement on medical weight management for optimization of cardiovascular health: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2025:S0735-1097(25)06504-0. doi:10.1016/j.jacc.2025.05.024