Beneficial cardiovascular effects of bariatric surgical and dietary weight loss in obesity

Effects of bariatric surgery on muscle strength and quality: A systematic review and meta-analysis

Obesity is a major health burden worldwide. Although bariatric surgery (BS) is recognized as an effective strategy for weight loss and comorbidities improvement, its impact on muscle strength and quality is still unclear. We aimed to examine postoperative changes in muscle strength and quality and their relationship with body mass index (BMI) changes among adults undergoing BS. To this end, we systematically searched the WoS, PubMed, EBSCO, and Scopus databases. The meta-analyses, which included 24 articles (666 participants), showed that BS reduces absolute lower-limb isometric strength (ES = -0.599; 95% CI = -0.972, -0.226; p = 0.002). Subjects who experienced a more significant reduction in BMI after BS also suffered a higher loss of absolute muscle strength. Similarly, absolute handgrip strength showed a significant decrease (ES = -0.376; 95% CI = -0.630, -0.121; p = 0.004). We found insufficient studies investigating medium- and long-term changes in muscle strength and/or quality after BS. This study provides moderate-quality evidence that BS-induced weight loss can reduce the strength of appendicular muscles in the short term, which should be addressed in management these subjects. More high-quality studies are needed to evaluate the impact of BS on muscle strength and the different domains of muscle quality in the medium and long term (registered on PROSPERO CRD42022332581).

Ninerafaxstat in the Treatment of Diabetic Cardiomyopathy and Nonobstructive Hypertrophic Cardiomyopathy

Ninerafaxstat is a novel mitotrope under investigation in 2 large clinical trials: IMPROVE-DiCE (a phase IIa trial investigating ninerafaxstat) and IMPROVE-hypertrophic cardiomyopathy (HCM). IMPROVE-DiCE is a single-center, open-label, phase 2a trial investigating the effectiveness of ninerafaxstat in diabetic cardiomyopathy. Ninerafaxstat significantly improved phosphocreatine/adenosine triphosphate median by 32% (P < 0.01) and reduced myocardial triglyceride content by 34% (P = 0.026). Magnetic resonance imaging (MRI) analysis showed improved left ventricular peak circumferential diastolic strain rate by 15% (P < 0.047) and peak left ventricular filling rate by 11% (P < 0.05). Pyruvate dehydrogenase flux was increased in 7 of 9 patients (P = 0.08), consistent with improved glucose utilization. IMPROVE-HCM (ninerafaxstat safe, effective for nonobstructive hypertrophic cardiomyopathy patients) is a phase 2, multicenter, randomized controlled and double-blinded study. From baseline to 12 weeks, ninerafaxstat was associated with a significantly improved ventilatory efficiency slope compared with placebo (P = 0.006). In a post hoc analysis with 35 patients with baseline Kansas City Cardiomyopathy Questionnaire score ≤80, changes in ventilatory efficiency slope favored ninerafaxstat versus placebo (P = 0.02). Left atrial size, a surrogate marker of diastolic dysfunction, was significantly decreased in patients on ninerafaxstat versus placebo (P = 0.01). These findings support a larger phase 3 study in symptomatic nonobstructive HCM patients to further investigate ninerafaxstat. Several drugs that also improve glucose utilization including fatty acid oxidation inhibitors, carnitine palmitoyltransferase I inhibitors, and glucagon-like peptide-1 receptor agonists are presently under investigation in clinical trials.

Hyperpolarized 13C and 31P MRS detects differences in cardiac energetics, metabolism, and function in obesity, and responses following treatment

Obesity is associated with important changes in cardiac energetics and function, and an increased risk of adverse cardiovascular outcomes. Multi-nuclear MRS and MRI techniques have the potential to provide a comprehensive non-invasive assessment of cardiac metabolic perturbation in obesity. A rat model of obesity was created by high-fat diet feeding. This model was characterized using in vivo hyperpolarized [1-13C]pyruvate and [2-13C]pyruvate MRS, echocardiography and perfused heart 31P MRS. Two groups of obese rats were subsequently treated with either caloric restriction or the glucagon-like peptide-1 analogue/agonist liraglutide, prior to reassessment. The model recapitulated cardiovascular consequences of human obesity, including mild left ventricular hypertrophy, and diastolic, but not systolic, dysfunction. Hyperpolarized 13C and 31P MRS demonstrated that obesity was associated with reduced myocardial pyruvate dehydrogenase flux, altered cardiac tricarboxylic acid (TCA) cycle metabolism, and impaired myocardial energetic status (lower phosphocreatine to adenosine triphosphate ratio and impaired cardiac ΔG~ATP). Both caloric restriction and liraglutide treatment were associated with normalization of metabolic changes, alongside improvement in cardiac diastolic function. In this model of obesity, hyperpolarized 13C and 31P MRS demonstrated abnormalities in cardiac metabolism at multiple levels, including myocardial substrate selection, TCA cycle, and high-energy phosphorus metabolism. Metabolic changes were linked with impairment of diastolic function and were reversed in concert following either caloric restriction or liraglutide treatment. With hyperpolarized 13C and 31P techniques now available for human use, the findings support a role for multi-nuclear MRS in the development of new therapies for obesity.

The effect of bariatric surgery type on cardiac reverse remodelling

INTRODUCTION

Bariatric surgery is effective in reversing adverse cardiac remodelling in obesity. However, it is unclear whether the three commonly performed operations; Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Adjustable Gastric Band (LAGB) are equal in their ability to reverse remodelling.

METHODS

Fifty-eight patients underwent CMR to assess left ventricular mass (LVM), LV mass:volume ratio (LVMVR) and LV eccentricity index (LVei) before and after bariatric surgery (26 RYGB, 22 LSG and 10 LAGB), including 46 with short-term (median 251-273 days) and 43 with longer-term (median 983-1027 days) follow-up. Abdominal visceral adipose tissue (VAT) and epicardial adipose tissue (EAT) were also assessed.

RESULTS

All three procedures resulted in significant decreases in excess body weight (48-70%). Percentage change in VAT and EAT was significantly greater following RYGB and LSG compared to LAGB at both timepoints (VAT:RYGB -47% and -57%, LSG -47% and -54%, LAGB -31% and -25%; EAT:RYGB -13% and -14%, LSG -16% and -19%, LAGB -5% and -5%). Patients undergoing LAGB, whilst having reduced LVM (-1% and -4%), had a smaller decrease at both short (RYGB: -8%, p < 0.005; LSG: -11%, p < 0.0001) and long (RYGB: -12%, p = 0.009; LSG: -13%, p < 0.0001) term timepoints. There was a significant decrease in LVMVR at the long-term timepoint following both RYGB (-7%, p = 0.006) and LSG (-7%, p = 0.021), but not LAGB (-2%, p = 0.912). LVei appeared to decrease at the long-term timepoint in those undergoing RYGB (-3%, p = 0.063) and LSG (-4%, p = 0.015), but not in those undergoing LAGB (1%, p = 0.857). In all patients, the change in LVM correlated with change in VAT (r = 0.338, p = 0.0134), while the change in LVei correlated with change in EAT (r = 0.437, p = 0.001).

CONCLUSIONS

RYGB and LSG appear to result in greater decreases in visceral adiposity, and greater reverse LV remodelling with larger reductions in LVM, concentric remodelling and pericardial restraint than LAGB.

Adiposity influences on myocardial deformation: a cardiovascular magnetic resonance feature tracking study in people with overweight to obesity without established cardiovascular disease

The objective of this study was to assess whether dietary-induced weight loss improves myocardial deformation in people with overweight to obesity without established cardiovascular disease applying cardiovascular magnetic resonance (CMR) with feature tracking (FT) based strain analysis. Ninety people with overweight to obesity without established cardiovascular disease (age 44.6 ± 9.3 years, body mass index (BMI) 32.6 ± 4 kg/m2) underwent CMR. We retrospectively quantified FT based strain and LA size and function at baseline and after a 6-month hypocaloric diet, with either low-carbohydrate or low-fat intake. The study cohort was compared to thirty-four healthy normal-weight controls (age 40.8 ± 16.0 years, BMI 22.5 ± 1.4 kg/m2). At baseline, the study cohort with overweight to obesity without established cardiovascular disease displayed significantly increased global circumferential strain (GCS), global radial strain (GRS) and LA size (all p < 0.0001 versus controls) but normal global longitudinal strain (GLS) and normal LA ejection fraction (all p > 0.05 versus controls). Dietary-induced weight loss led to a significant reduction in GCS, GRS and LA size irrespective of macronutrient composition (all p < 0.01). In a population with overweight to obesity without established cardiovascular disease subclinical myocardial changes can be detected applying CMR. After dietary-induced weight loss improvement of myocardial deformation could be shown. A potential clinical impact needs further studies.

The Effect of Weight Loss Through Lifestyle Interventions in Patients With Heart Failure With Preserved Ejection Fraction-A Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) accounts for >50% of heart failure cases and is associated with significant morbidity and health system burden. To date, there have been limited treatment options proven to improve outcomes in these patients, with sodium glucose co-transporter 2 (SGLT2) inhibitors the first class of drug to demonstrate significant clinical benefits, including reductions in heart failure hospitalisation. Obesity is associated with all forms of heart failure and has been linked with worse clinical outcomes. Numerous reviews support the benefits of weight loss in heart failure, more specifically in patients with heart failure with reduced ejection fraction. However, the evidence in HFpEF patients is less clear. With limited pharmacotherapy options and growing support for weight loss in patients with HFpEF, this systematic review and meta-analysis aims to examine the effects of lifestyle interventions on weight loss and other health outcomes in patients with HFpEF.

METHODS

Web of Science, Embase, Scopus, and PubMed databases were searched to identify relevant studies up to February 2023. Included studies were randomised controlled trials (with a duration of four weeks or more) of lifestyle interventions conducted in adults with HFpEF that reported weight loss. Outcomes of interest were body weight, body mass index (BMI), blood pressure (systolic and diastolic), aerobic capacity (6-minute walk distance), New York Heart Association (NYHA) Functional Classification, self-reported health quality of life (Minnesota Living with Heart Failure Questionnaire; MLHFQ), and N-terminal pro B-Type Natriuretic Peptide (NT-proBNP) levels. Review Manager software was used to conduct random effect meta-analyses, forest plots were generated for each outcome, and between-study heterogeneity was estimated using the I2 test statistic. Risk-of-bias assessment used the Cochrane risk-of-bias tool, and the certainty of the evidence was assessed using GRADE.

RESULTS

From 2,282 records identified, six studies with a total of 375 participants, between three to six months in duration, were included in this systematic review and meta-analysis. Lifestyle interventions consisted of diet only, exercise only, combination of diet and exercise, and education and exercise. Over a mean follow-up of 4.5 months, pooled effects of the interventions were associated with a reduction in body weight of >5kg (weight mean difference (WMD): -5.30 kg; 95% CI: -8.72 to -1.87; p=0.002), and a reduction in resting systolic (WMD: -2.98 mmHg; 95% CI: -4.20 to -1.76; p<0.001) and diastolic blood pressure (WMD: -4.51 mmHg; 95% CI: -8.39 to -0.64; p=0.02) compared with those who received usual care. Interventions also improved 6-minute walk distance (WMD: 43.63 m; 95% CI: 22.28 to 64.97; p<0.001), NYHA class (WMD: -0.54; 95% CI: -0.75 to -0.33; p<0.001), and MLHFQ score (WMD: -17.77; 95% CL: -19.00 to -16.53; p<0.001).

CONCLUSION

In patients with HFpEF, lifestyle intervention was associated with a significant reduction in body weight and had favourable effects on blood pressure, aerobic capacity, NYHA class, and health-related quality of life. Further research is needed in this population to examine the feasibility and durability of weight loss interventions and to examine the potential impact on hard clinical endpoints.

Chapter 2: Clinical and Mechanistic Potential of Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors in Heart Failure with Preserved Ejection Fraction

Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have emerged as an important approach for the treatment of heart failure in patients with or without diabetes. Although the precise mechanisms underpinning their clinical impact remain incompletely resolved, mechanistic studies and insights from major clinical trials have demonstrated the impact of SGLT2 inhibitors on numerous cardio-renal-metabolic pathways of relevance to heart failure with preserved ejection fraction (HFpEF), which, in the contemporary era, constitutes approximately half of all patients with heart failure. Despite rates of morbidity and mortality that are commensurate with those of heart failure with reduced ejection fraction, disease-modifying therapies have comparatively been severely lacking. As such, HFpEF remains among the greatest unmet needs in cardiovascular medicine. Within the past decade, HFpEF has been established as a highly integrated disorder, involving not only the cardiovascular system, but also the lungs, kidneys, skeletal muscle, and adipose tissue. Given their multisystem impact, SGLT2i offer unique promise in addressing the complex pathophysiology of HFpEF, and in recent randomized controlled trials, were shown to significantly reduce heart failure events and cardiovascular death in patients with HFpEF. Herein, we discuss several proposed mechanisms of clinical benefit of SGLT2i in HFpEF.

The weight of obesity in hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is one of the most frequently diagnosed primary conditions of the heart muscle. It is considered to be inherited, caused by genetic mutations encoding for sarcomere proteins. The marked heterogeneity in clinical manifestations and natural course of the disease, even among family members sharing the same genetic mutation, has raised the question of non-genetic environmental factors contributing to the phenotype. Obesity has been associated with worse cardiovascular outcomes in the general population. Its prevalence is increased in hypertrophic cardiomyopathy, and the two conditions share some similar pathophysiological and clinical characteristics. In this review, we aim to summarise the effects of obesity in the cardiac phenotype, the symptoms and management in patients with hypertrophic cardiomyopathy.

Weight cycling and risk of clinical adverse events in patients with heart failure with preserved ejection fraction: a post-hoc analysis of TOPCAT

Background

Previous studies hardly evaluated the association of variability of body mass index (BMI) or waist circumference with clinical adverse events and investigated whether weight cycling had an effect on the prognosis of patients with heart failure with preserved ejection fraction (HFpEF).

Methods

This study was a post-hoc analysis of TOPCAT. Three outcomes were evaluated: the primary endpoint, cardiovascular disease (CVD) death, and heart failure hospitalization. Among them, CVD death and hospitalization were outcomes of heart failure. Kaplan-Meier curves were used to describe the cumulative risk of outcome and were tested using the log-rank test. Cox proportional hazards regression models were used to calculate hazard ratios (HRs) and 95%CIs for outcomes. We also performed a subgroup analysis, and several subgroups were compared.

Results

A total of 3,146 patients were included. In the Kaplan-Meier curves, the coefficients of variation of both BMI and waist circumference were grouped according to quartiles, with the Q4 group having the highest cumulative risk (log-rank P < 0.001). In the coefficient of BMI variation and the outcomes, the HRs for group Q4 of coefficient of variation of BMI were 2.35 (95%CI: 1.82, 3.03) for the primary endpoint, 2.40 (95%CI: 1.69, 3.40) for death, and 2.33 (95%CI: 1.68, 3.22) for HF hospitalization in model 3 (fully adjusted model) compared with group Q1. In the coefficient of waist circumference variation and the outcomes, group Q4 had increased hazard of the primary endpoint [HR: 2.39 (95%CI: 1.84, 3.12)], CVD death [HR: 3.29 (95%CI: 2.28, 4.77)], and HF hospitalization [HR: 1.98 (95%CI 1.43, 2.75)] in model 3 (fully adjusted model) compared with group Q1. In the subgroup analysis, there was a significant interaction in the diabetes mellitus subgroup (P for interaction = 0.0234).

Conclusion

Weight cycling had a negative effect on the prognosis of patients with HFpEF. The presence of comorbid diabetes weakened the relationship between waist circumference variability and clinical adverse events.

Obesity, Preserved Ejection Fraction Heart Failure, and Left Ventricular Remodeling

Owing to the overwhelming obesity epidemic, preserved ejection fraction heart failure commonly ensues in patients with severe obesity and the obese phenotype of preserved ejection fraction heart failure is now commonplace in clinical practice. Severe obesity and preserved ejection fraction heart failure share congruent cardiovascular, immune, and renal derangements that make it difficult to ascertain whether the obese phenotype of preserved ejection fraction heart failure is the convergence of two highly prevalent conditions or severe obesity enables the development and progression of the syndrome of preserved ejection fraction heart failure. Nevertheless, the obese phenotype of preserved ejection fraction heart failure provides a unique opportunity to assess whether sustained and sizeable loss of excess body weight via metabolic bariatric surgery reverses the concentric left ventricular remodeling that patients with preserved ejection fraction heart failure commonly display.

Reducing Cardiac Steatosis: Interventions to Improve Diastolic Function - A Narrative Review

Heart failure is one of the main causes of morbidity and mortality around the globe. Heart failure with preserved ejection fraction is primarily caused by diastolic dysfunction. Adipose tissue deposition in the heart has been previously explained in the pathogenesis of diastolic dysfunction. In this article, we aim to discuss the potential interventions that can reduce the risk of diastolic dysfunction by reducing cardiac adipose tissue. A healthy diet with reduced dietary fat content can reduce visceral adiposity and improve diastolic function. Aerobic and resistance exercises also reduce visceral and epicardial fat and ameliorate diastolic dysfunction. Some medications, include metformin, glucagon-like peptide-1 analogues, dipeptidyl peptidase-4 inhibitors, thiazolidinediones, sodium-glucose co-transporter-2, inhibitors, statins, ACE-Is, and ARBs, have shown different degrees of effectiveness in improving cardiac steatosis and diastolic function. Bariatric surgery has also shown promising results in this field.

Changes in epicardial and visceral adipose tissue depots following bariatric surgery and their effect on cardiac geometry

Introduction

Obesity affects cardiac geometry, causing both eccentric (due to increased cardiac output) and concentric (due to insulin resistance) remodelling. Following bariatric surgery, reversal of both processes should occur. Furthermore, epicardial adipose tissue loss following bariatric surgery may reduce pericardial restraint, allowing further chamber expansion. We investigated these changes in a serial imaging study of adipose depots and cardiac geometry following bariatric surgery.

Methods

62 patients underwent cardiac magnetic resonance (CMR) before and after bariatric surgery, including 36 with short-term (median 212 days), 37 medium-term (median 428 days) and 32 long-term (median 1030 days) follow-up. CMR was used to assess cardiac geometry (left atrial volume (LAV) and left ventricular end-diastolic volume (LVEDV)), LV mass (LVM) and LV eccentricity index (LVei - a marker of pericardial restraint). Abdominal visceral (VAT) and epicardial (EAT) adipose tissue were also measured.

Results

Patients on average had lost 21kg (38.9% excess weight loss, EWL) at 212 days and 36kg (64.7% EWL) at 1030 days following bariatric surgery. Most VAT and EAT loss (43% and 14%, p<0.0001) occurred within the first 212 days, with non-significant reductions thereafter. In the short-term LVM (7.4%), LVEDV (8.6%) and LAV (13%) all decreased (all p<0.0001), with change in cardiac output correlated with LVEDV (r=0.35,p=0.03) and LAV change (r=0.37,p=0.03). Whereas LVM continued to decrease with time (12% decrease relative to baseline at 1030 days, p<0.0001), both LAV and LVEDV had returned to baseline by 1030 days. LV mass:volume ratio (a marker of concentric hypertrophy) reached its nadir at the longest timepoint (p<0.001). At baseline, LVei correlated with baseline EAT (r=0.37,p=0.0040), and decreased significantly from 1.09 at baseline to a low of 1.04 at 428 days (p<0.0001). Furthermore, change in EAT following bariatric surgery correlated with change in LVei (r=0.43,p=0.0007).

Conclusions

Cardiac volumes show a biphasic response to weight loss, initially becoming smaller and then returning to pre-operative sizes by 1030 days. We propose this is due to an initial reversal of eccentric remodelling followed by reversal of concentric remodelling. Furthermore, we provide evidence for a role of EAT contributing to pericardial restraint, with EAT loss improving markers of pericardial restraint.

Effect of Weight Loss on Early Left Atrial Myopathy in People With Obesity But No Established Cardiovascular Disease

Background Obesity is associated with left atrial (LA) remodeling (ie, dilatation and dysfunction) which is an independent determinant of future cardiovascular events. We aimed to assess whether LA remodeling is present in obesity even in individuals without established cardiovascular disease and whether it can be improved by intentional weight loss. Methods and Results Forty-five individuals with severe obesity without established cardiovascular disease (age, 45±11 years; body mass index; 39.1±6.7 kg/m²; excess body weight, 51±18 kg) underwent cardiac magnetic resonance for quantification of LA and left ventricular size and function before and at a median of 373 days following either a low glycemic index diet (n=28) or bariatric surgery (n=17). Results were compared with those obtained in 27 normal-weight controls with similar age and sex. At baseline, individuals with obesity displayed reduced LA reservoir function (a marker of atrial distensibility), and a higher mass and LA maximum volume (all P<0.05 controls) but normal LA emptying fraction. On average, weight loss led to a significant reduction of LA maximum volume and left ventricular mass (both P<0.01); however, significant improvement of the LA reservoir function was only observed in those at the upper tertile of weight loss (≥47% excess body weight loss). Following weight loss, we found an average residual increase in left ventricular mass compared with controls but no residual significant differences in LA maximum volume and strain function (all P>0.05). Conclusions Obesity is linked to subtle LA myopathy in the absence of overt cardiovascular disease. Only larger volumes of weight loss can completely reverse the LA myopathic phenotype.

Long-Term Changes in Cardiac Structure and Function Following Bariatric Surgery

BACKGROUND

Studies with short-term follow-up have demonstrated favorable effects of weight loss (WL) on the heart, but little information is available regarding long-term effects or effects of visceral fat reduction.

OBJECTIVES

The purpose of this study was to evaluate the effects of long-term WL following bariatric surgery on cardiac structure, function, ventricular interaction, and body composition, including epicardial adipose thickness and abdominal visceral adipose tissue (VAT).

METHODS

A total of 213 obese patients underwent echocardiography before and >180 days following bariatric surgery. Abdominal VAT area was measured by computed tomography in 52 of these patients.

RESULTS

After 5.3 years (IQR: 2.9-7.9 years), body mass index (BMI) decreased by 22%, with favorable reductions in blood pressure, fasting glucose, and left ventricular (LV) remodeling in the full sample. In the subgroup of patients with abdominal computed tomography, VAT area decreased by 30%. In all subjects, epicardial adipose thickness was reduced by 14% (both P < 0.0001) in tandem with reductions in ventricular interdependence. LV and right ventricular longitudinal strain improved following WL, but left atrial (LA) strain deteriorated, while LA volume and estimated LA pressures increased. In subgroup analysis, LV wall thickness and strain correlated more strongly with VAT than BMI at baseline, and reductions in LV mass following surgery were correlated with decreases in VAT, but not BMI.

CONCLUSIONS

In this observational study, weight loss following bariatric surgery was associated with epicardial fat reduction, reduced ventricular interaction, LV reverse remodeling, and improved longitudinal biventricular mechanics, but LA myopathy and hemodynamic congestion still progressed. Reduction in visceral fat was associated with favorable cardiac effects, suggesting this might be a key target of WL interventions.

Incidence of Preclinical Heart Failure in a Community Population

Background

A high prevalence of preclinical heart failure (HF) (Stages A and B) has previously been shown. The aim of this study was to explore factors associated with the incidence of preclinical HF in a community population.

Methods and Results

Retrospective review of 393 healthy community individuals aged ≥45 years from the Olmsted County Heart Function Study that returned for 2 visits, 4 years apart. At visit 2, individuals that remained normal were compared with those that developed preclinical HF. By the second visit, 191 (49%) developed preclinical HF (12.1 cases per 100 person‐years of follow‐up); 65 (34%) Stage A and 126 (66%) Stage B. Those that developed preclinical HF (n=191) were older (P=0.004), had a higher body mass index (P<0.001), and increased left ventricular mass index (P=0.006). When evaluated separately, increased body mass index was seen with development of Stage A (P<0.001) or Stage B (P=0.009). Echocardiographic markers of diastolic function were statistically different in those that developed Stage A [higher E/e’ (P<0.001), lower e’ (P<0.001)] and Stage B [higher left atrial volume index (P<0.001), higher E/e’ (P<0.001), lower e’ (P<0.001)]. NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) was higher at visit 2 in those that developed Stage A or B (P<0.001 for both). Hypertension (57%), obesity (34%), and hyperlipidemia (25%) were common in the development of Stage A. Of patients who developed Stage B, 71% (n=84) had moderate or severe diastolic dysfunction.

Conclusions

There is a high incidence of preclinical HF in a community population. Development of Stage A was driven by hypertension and obesity, while preclinical diastolic dysfunction was seen commonly in those that developed Stage B.

Longitudinal Effect of Bariatric Surgery on Retinal Microcirculation and Target Organ Damage: the BASTOD Study

PURPOSE

Obesity is associated with increased cardiovascular risk. Bariatric surgery (BS) improves the clinical and metabolic profile. Retinal caliber changes could precede cardiovascular events. Different studies have shown an improvement in retinal caliber after BS. The aim of this study was to examine retinal caliber and other cardiovascular target organ damage before and after BS.

MATERIALS AND METHODS

Monocentric, prospective cohort study at the Montpellier University Hospital. Biologic features, vessel stiffness, echocardiograph variables, and retinal caliber at baseline and 6 and 12 months were assessed in consecutive patients with class 2 or 3 obesity undergoing BS. A mixed linear model adjusted for age and sex was used.

RESULTS

We included 88 patients (75 women). The mean (SD) age was 43 years (11) and mean (SD) baseline weight 117 (21) Kg. Mean changes in the first year after BS were - 5.1 µm in central retinal vein equivalent (CRVE) (p < 0.0001), + 0.02 in arteriole-to-venule ratio (AVR) (p < 0.0001), - 1.4 mmol/L in glycemia (p < 0.0001), - 1.0 mg/L in natural logarithm of C-reactive protein (p < 0.0001), and - 54.0 g in left ventricular mass (p = 0.0005). We observed no significant improvement in arterial stiffness markers. Predictors of improvement in CRVE were high baseline weight (p = 0.030), male sex (p = 0.025), and no diabetes history (p Dynamic links between variations = 0.047).

CONCLUSION

The retinal microvascular phenotype improved during the first year after bariatric surgery, with decreased CRVE and increased AVR. Factors associated with retinal microvascular plasticity were male sex, high baseline weight, and absence of diabetes. Longitudinal assessment of retinal vascular calibers may offer new insights into the pathophysiology of subclinical vascular processes.

Diabetes Mellitus and Heart Failure With Preserved Ejection Fraction: Role of Obesity

Heart failure with preserved ejection fraction is a growing epidemic and accounts for half of all patients with heart failure. Increasing prevalence, morbidity, and clinical inertia have spurred a rethinking of the pathophysiology of heart failure with preserved ejection fraction. Unlike heart failure with reduced ejection fraction, heart failure with preserved ejection fraction has distinct clinical phenotypes. The obese-diabetic phenotype is the most often encountered phenotype in clinical practice and shares the greatest burden of morbidity and mortality. Left ventricular remodeling plays a major role in its pathophysiology. Understanding the interplay of obesity, diabetes mellitus, and inflammation in the pathophysiology of left ventricular remodeling may help in the discovery of new therapeutic targets to improve clinical outcomes in heart failure with preserved ejection fraction. Anti-diabetic agents like glucagon-like-peptide 1 analogs and sodium-glucose co-transporter 2 are promising therapeutic modalities for the obese-diabetic phenotype of heart failure with preserved ejection fraction and aggressive weight loss via lifestyle or bariatric surgery is still key to reverse adverse left ventricular remodeling. This review focuses on the obese-diabetic phenotype of heart failure with preserved ejection fraction highlighting the interaction between obesity, diabetes, and coronary microvascular dysfunction in the development and progression of left ventricular remodeling. Recent therapeutic advances are reviewed.

Lifetime obesity trends are associated with subclinical myocardial injury: The Trøndelag health study

BACKGROUND

Obesity is associated with subclinical myocardial injury as quantified by concentrations of cardiac troponin T, but whether lifetime excess weight history is associated with increased concentrations of cardiac troponin I (cTnI) and how indices of abdominal adiposity and glycemic dysregulation affect these associations remain unclear.

METHODS

We analyzed cTnI with a high-sensitivity assay in 9739 participants in the Trøndelag Health (HUNT) Study at study visit 4 (2017-2019). BMI was assessed at study Visit 1 (1984-1986), 2 (1995-1997), 3 (2006-2008), and 4.

RESULTS

Median age at visit 4 was 68.7 years and 59% were women. Concentrations of cTnI were detectable in 84.1% of study participants, with a median of 2.5 (1.5-4.5 ng/L). We identified three clusters of BMI trajectories from visit 1 to 4, (1) stable normal weight, (2) stable overweight, and (3) stable obesity. Participants in clusters 2 and 3 were at increased risk of elevated concentrations of cTnI at visit 4 (odds ratio 1.27, 95% CI 1.09-1.47, and odds ratio 1.70, 95% CI 1.33-2.17, p for trend <0.001). Participants in cluster 3 had 22.0 (95% CI 14.1-29.9) higher concentrations of cTnI compared to participants in cluster 1 (p for trend <0.001). Dysregulated glucose metabolism and abdominal obesity did not influence our results.

CONCLUSIONS

Individuals with stable overweight or obesity are at increased risk of subclinical myocardial injury, independently of glycemic dysregulation and abdominal adiposity. Our data support a direct detrimental effect of long-standing obesity on cardiovascular health.

Development of a Nomogram for Estimating the Risk of Left Ventricular Diastolic Dysfunction in Patients with Non-Alcoholic Fatty Liver Disease

BACKGROUND

Patients with non-alcoholic fatty liver disease (NAFLD) are more likely to develop left ventricular diastolic dysfunction (LVDD). Although lifestyle adjustments contribute to the improvement of NAFLD, thereby delaying or even preventing LVDD progression, it is difficult to maintain a healthy lifestyle, resulting in a higher incidence of LVDD in NAFLD patients.

OBJECTIVE

This study aims to develop a nomogram for assessing the risk of LVDD progression in NAFLD patients to increase their adherence to therapeutic interventions and adjust their treatment regimens timely.

METHODS

A total of 148 medical records of NAFLD patients were retrospectively analyzed. Sixty-three were assigned to the LVDD+ group and 85 were assigned to the LVDD- group. The independent correlates of LVDD, which were screened via least absolute shrinkage and selection operator logistic regression model first, followed by multivariate Logistic regression model, constituted the nomogram to determine the likelihood of LVDD in NAFLD patients.

RESULTS

Number of comorbidities, glycosylated hemoglobin, and epicardial adipose tissue (EAT) volume index were independent correlates of LVDD (all P < 0.05). They served as components in the newly developed nomogram. It obtained significant clinical benefit in detecting NAFLD patients at the risk of LVDD progression, with satisfied discrimination and calibration.

CONCLUSION

We developed a nomogram for identifying NAFLD patients with a normal diastolic function who are at risk of LVDD progression, thus contributing to effective prevention of LVDD progression.

A Stepwise Guide to the Diagnosis and Treatment of Heart Failure with Preserved Ejection Fraction

Heart failure with a preserved ejection fraction (HFpEF) is a growing epidemic owing to an increasingly obese and aging patient population. Making the diagnosis of HFpEF is often challenging as patients frequently have multiple co-morbidities and alternative reasons for exercise intolerance that is hallmark to the disease. Additionally, a universal diagnostic algorithm and definition of HFpEF is lacking. The treatment of HFpEF is equally challenging as there has been significant difficulty in identifying therapies to improve survival in HFpEF, and management to date requires intensive optimization of HFpEF risk factors. In this review, we highlight a stepwise approach to the diagnosis and management of HFpEF inclusive of 1) how to establish a clinical diagnosis of HFpEF, 2) when to refer for invasive testing, 3) treatment of HFpEF including pharmacologic, non-pharmacologic, and risk factor modification interventions, and 4) when to refer to a dedicated HFpEF center or advanced heart failure specialist. With this systematic stepwise approach to HFpEF management, we aim to improve accurate diagnosis of the disease as well as raise awareness of all available therapeutic options for this challenging patient population. Heart failure with preserved ejection fraction (HFpEF) is becoming increasingly common due to our aging patient population with a higher prevalence of hypertension, diabetes, and obesity. Accurate diagnosis is important, particularly to ensure that an alternative heart failure diagnosis is not missed. We highlight a stepwise approach to the diagnosis of HFpEF, including when to pursue exercise or invasive hemodynamic testing. We also discuss pertinent treatment options by both medication class and co-morbidity status.

The Influence of Surgical Weight Reduction on Left Atrial Strain

BACKGROUND

Obesity increases and surgical weight reduction decreases the risk of atrial fibrillation (AF) and heart failure (HF). We hypothesized that surgically induced weight loss may favorably affect left atrial (LA) mechanical function measured by longitudinal strain, which has recently emerged as an independent imaging biomarker of increased AF and HF risk.

METHODS

We retrospectively evaluated echocardiograms performed before and 12.2 ± 2.2 months after bariatric surgery in 65 patients with severe obesity (mean age 39 [36; 47] years, 72% of females) with no known cardiac disease or arrhythmia. The LA mechanical function was measured by the longitudinal strain using the semi-automatic speckle tracking method.

RESULTS

After surgery, body mass index decreased from 43.72 ± 4.34 to 30.04 ± 4.33 kg/m2. We observed a significant improvement in all components of the LA strain. LA reservoir strain (LASR) and LA conduit strain (LASCD) significantly increased (35.7% vs 38.95%, p = 0.0005 and - 19.6% vs - 24.4%, p < 0.0001) and LA contraction strain (LASCT) significantly decreased (- 16% vs - 14%, p = 0.0075). There was a significant correlation between an increase in LASR and LASCD and the improvement in parameters of left ventricular diastolic and longitudinal systolic function (increase in E' and MAPSE). Another significant correlation was identified between the decrease in LASCT and an improvement in LA function (decrease in A').

CONCLUSIONS

The left atrial mechanical function improves after bariatric surgery. It is partially explained by the beneficial effect of weight reduction on the left ventricular diastolic and longitudinal systolic function. This effect may contribute to decreased risk of AF and HF after bariatric surgery.

Obesity modifies the energetic phenotype of dilated cardiomyopathy

AIMS

We sought to determine if myocardial energetics could distinguish obesity cardiomyopathy as a distinct entity from dilated cardiomyopathy.

METHODS AND RESULTS

Sixteen normal weight participants with dilated cardiomyopathy (DCMNW), and 27 with DCM and obesity (DCMOB), were compared to 26 normal weight controls (CTLNW). All underwent cardiac magnetic resonance imaging and 31P spectroscopy to assess function and energetics. Nineteen DCMOB underwent repeat assessment after a dietary weight loss intervention. Adenosine triphosphate (ATP) delivery through creatine kinase (CK flux) was 55% lower in DCMNW than in CTLNW (P = 0.004), correlating with left ventricular ejection fraction (LVEF, r = 0.4, P = 0.015). In contrast, despite similar LVEF (DCMOB 41 ± 7%, DCMNW 38 ± 6%, P = 0.14), CK flux was two-fold higher in DCMOB (P < 0.001), due to higher rate through CK [median kf 0.21 (0.14) vs. 0.11 (0.12) s-1, P = 0.002]. During increased workload, the CTLNW heart increased CK flux by 97% (P < 0.001). In contrast, CK flux was unchanged in DCMNW and fell in DCMOB (by >50%, P < 0.001). Intentional weight loss was associated with positive left ventricular remodelling, with reduced left ventricular end-diastolic volume (by 8%, P < 0.001) and a change in LVEF (40 ± 9% vs. 45 ± 10%, P = 0.002). This occurred alongside a fall in ATP delivery rate with weight loss (by 7%, P = 0.049).

CONCLUSIONS

In normal weight, DCM is associated with reduced resting ATP delivery. In obese DCM, ATP demand through CK is greater, suggesting reduced efficiency of energy utilization. Dietary weight loss is associated with significant improvement in myocardial contractility, and a fall in ATP delivery, suggesting improved metabolic efficiency. This highlights distinct energetic pathways in obesity cardiomyopathy, which are both different from dilated cardiomyopathy, and may be reversible with weight loss.

Effects of Exercise and Weight Loss on Proximal Aortic Stiffness in Older Adults With Obesity

BACKGROUND

Obesity may accelerate age-related increases in aortic stiffness. Although aerobic exercise training generally has favorable effects on aortic structure and function, exercise alone may not be sufficient to improve aortic stiffness in older adults with obesity. We determined the effects of aerobic exercise training with and without moderate- to high-caloric restriction (CR) on the structure and function of the proximal aorta in 160 older (65-79 years) men and women with obesity (body mass index=30-45 kg/m²).

METHODS

Participants were randomly assigned to 1 of 3 groups: aerobic exercise training only (treadmill 4 days/week for 30 minutes at 65% to 70% of heart rate reserve; n=56), aerobic exercise training plus moderate CR (n=55), or aerobic exercise training plus more intensive CR (n=49) for 20 weeks. Aortic pulse wave velocity, aortic distensibility, and other measures of aortic structure and function were assessed by cardiovascular magnetic resonance imaging. Pearson correlation coefficients were examined to assess associations between changes in proximal aortic stiffness and changes in fitness, fatness, and other potential confounders.

RESULTS

Weight loss in the aerobic exercise training plus moderate CR (-8.0 kg [95% CI, -9.17 to -6.87]) and aerobic exercise training plus more intensive CR (-8.98 kg [95% CI, -10.23 to -7.73) groups was significantly greater compared with the aerobic exercise training-only group (-1.66 kg [95% CI, -2.94 to -0.38]; P<0.017 for both). There were significant treatment effects for descending aorta distensibility (P=0.008) and strain (P=0.004) and aortic arch pulse wave velocity (P=0.01) with the aerobic exercise training plus moderate CR group having a 21% increase in distensibility (P=0.016) and an 8% decrease in pulse wave velocity (P=0.058). None of the aortic stiffness measures changed significantly in the aerobic exercise training-only or aerobic exercise training plus more intensive CR groups, and there were no significant changes in any other measure of aortic structure or function in these groups. Overall, increases in aortic distensibility were correlated with improvements in body weight and body fat distribution, but these associations were not statistically significant after adjustment for multiple comparisons.

CONCLUSIONS

In older adults with obesity, combining aerobic exercise with moderate CR leads to greater improvements in proximal aortic stiffness than exercise alone. Registration: URL: https://clinicaltrials.gov; Unique identifier: NCT01048736.

Obesity in the absence of comorbidities is not related to clinically meaningful left ventricular hypertrophy

Obesity is associated with the development of left ventricular (LV) hypertrophy. Whether obesity in in the absence of comorbidities can cause LV hypertrophy to an extent which could create diagnostic uncertainty with pathological states (such as hypertrophic cardiomyopathy) is unknown. We used cine cardiovascular magnetic resonance imaging to precisely measure LV wall thickness in the septum and lateral wall in 764 people with body mass indices ranging from 18.5 kg/m2 to 59.2 kg/m2 in the absence of major comorbidities. Obesity was related to LV wall thickness across the cohort (basal septum r 0.30, P < 0.001 and basal lateral wall r 0.18, P < 0.001). Although no participant had hypertension, these associations remained highly significant after controlling for systolic blood pressure (all P < 0.01). Each 10 kg/m2 increase in BMI was associated with an increase in basal septal wall thickness of 1.0 mm males and 0.8 mm in females, with no statistically significant difference between genders (P = 0.1). Even in class 3 obesity (BMI > 40 kg/m2), no LV wall thickness > 13.4 mm in males or > 12.7 mm in females was observed in this cohort. We confirm that obesity in the absence of comorbidities is associated with LV hypertrophy, and establish that the magnitude of this change is modest even in severe obesity. LV hypertrophy > 14 mm cannot safely be attributed to obesity alone and alternative diagnoses should be considered.

Obesity cardiomyopathy: evidence, mechanisms, and therapeutic implications

The prevalence of heart failure is on the rise and imposes a major health threat, in part, due to the rapidly increased prevalence of overweight and obesity. To this point, epidemiological, clinical, and experimental evidence supports the existence of a unique disease entity termed “obesity cardiomyopathy,” which develops independent of hypertension, coronary heart disease, and other heart diseases. Our contemporary review evaluates the evidence for this pathological condition, examines putative responsible mechanisms, and discusses therapeutic options for this disorder. Clinical findings have consolidated the presence of left ventricular dysfunction in obesity. Experimental investigations have uncovered pathophysiological changes in myocardial structure and function in genetically predisposed and diet-induced obesity. Indeed, contemporary evidence consolidates a wide array of cellular and molecular mechanisms underlying the etiology of obesity cardiomyopathy including adipose tissue dysfunction, systemic inflammation, metabolic disturbances (insulin resistance, abnormal glucose transport, spillover of free fatty acids, lipotoxicity, and amino acid derangement), altered intracellular especially mitochondrial Ca²⁺ homeostasis, oxidative stress, autophagy/mitophagy defect, myocardial fibrosis, dampened coronary flow reserve, coronary microvascular disease (microangiopathy), and endothelial impairment. Given the important role of obesity in the increased risk of heart failure, especially that with preserved systolic function and the recent rises in COVID-19-associated cardiovascular mortality, this review should provide compelling evidence for the presence of obesity cardiomyopathy, independent of various comorbid conditions, underlying mechanisms, and offer new insights into potential therapeutic approaches (pharmacological and lifestyle modification) for the clinical management of obesity cardiomyopathy.

Dynamic changes in aortic stiffness after substantial weight loss by laparoscopic sleeve gastrectomy in patients with obesity: a 1-year follow-up study

Arterial stiffness has been identified as a powerful and independent risk factor for cardiovascular disease. Obesity is associated with an increased risk of aortic stiffness (AS) and adverse cardiovascular events. Herein, we aimed to evaluate the effects of weight loss after laparoscopic sleeve gastrectomy (LSG) on AS in individuals with morbid obesity by using the transthoracic echocardiography (TTE).A total of 53 patients with obesity (17 males, 36 females) who underwent LSG and did not have any known heart disease were included in the study. The AS parameters were measured with TTE. The demographic and echocardiographic data of the patients were studied before, at 1 month and 12 months after surgery.The mean age of the study group was 34.41±11.62, 68% of whom were female. There were no significant differences in terms of the standard echocardiography and Doppler measurements as compared with preoperative values (all p>0.05). When the elastic parameters of the aorta were compared, no significant differences were detected regarding aortic strain (%) ((16.28±4.11) vs (16.68±4.56), p=(0.998)), distensibility (cm²/dyn) ((6.74±1.78) vs (7.03±2.31), p=(0.997)) and Aortic Stiffness Index values ((10.73±3.84) vs (10.63±3.34), p=0.998) between baseline and first month after surgery. In the 12-month follow-up, it was determined that the aortic strain ((16.28±4.11) vs (22.74±5.79), p≤0.001) and distensibility ((6.74±1.78) vs (10.34±3.059), p<0.001)) values increased at significant levels.Weight loss by LSG improves arterial stiffness parameters in patients with obesity over a 1-year follow-up.

Improvement of left ventricular systolic function in morbidly obese patients after bariatric surgery: Case report

INTRODUCTION

Morbid obesity (body mass index > 40 kg/m2) is a risk factor for the development of left ventricular systolic dysfunction (LVSD) and can complicate the management of LVSD. Bariatric surgery is increasingly recognized as a safe and effective way to achieve marked weight loss, but studies on improving LVSD populations are limited. We retrospectively analyzed the first case of the Asia-Pacific region with morbid obesity and left ventricular ejection fraction (LVEF) < 50% who underwent bariatric surgery at our medical center.

PATIENT CONCERNS

The patient was admitted to the hospital due to progressive weight gain for more than 10 years. The patient used to be in good health. One year before admission, the patient was hospitalized in another hospital due to shortness of breath. After the relevant examination, the patient was diagnosed with dilated cardiomyopathy.

DIAGNOSIS

The body mass index of the patient was 45.9 kg/m2, and the patient was diagnosed with morbid obesity. He was diagnosed with dilated cardiomyopathy and cardiac function class IV in another hospital. After completing a preoperative examination, the patient was diagnosed with hyperuricemia, hyperlipidemia, fatty liver disease and severe sleep apnea.

INTERVENTIONS

The patient successfully underwent laparoscopic sleeve gastrectomy plus jejunal bypass.

OUTCOMES

Six months after the surgery, patient weight lost was 33.6 kg, and the LVEF increased from 31% to 55%. The cardiac function of the patient recovered from class IV to class I, and the patient's hyperuricemia, hyperlipidemia and sleep apnea were significantly improved.

CONCLUSION

Bariatric surgery may be a safe and effective intervention for morbidly obese patients with LVSD. Bariatric surgery was associated with an improvement in LVEF. However, the specific mechanism still needs further study.

Safety of Bariatric Surgery in Patients With Congestive Heart Failure: Results of an 11-Year Retrospective Study

INTRODUCTION

Congestive heart failure (CHF) is a known risk factor for increased postoperative morbidity. However, the safety in patients with CHF has not been well established. The objective of this study was to assess the safety of surgery in patients with a history of CHF undergoing bariatric surgical procedures.

METHODS

Retrospective review of a prospectively maintained Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Center of Excellence database. Patients with known CHF undergoing bariatric procedures over an 11-year period were reviewed.

RESULTS

Over the 11-year period, 4470 total bariatric surgeries were performed, of which 41 (.92%) patients had known CHF. Twenty-one patients were men (51.2%) with a mean age of 55.8 years and mean body mass index (BMI) of 51.9. Comorbidities included hypertension (87.8%), obstructive sleep apnea (80.5%), osteoarthritis (63.4%), gastroesophageal reflux disease (56%), and diabetes (53.7%). Surgical procedures included 16 sleeve gastrectomies (SGs) (39%), 11 Roux-en-Y gastric bypasses (RYGBs) (26.8%), 10 laparoscopic adjustable gastric bands (LAGBs) (24.4%), 1 removal of a gastric band and conversion to SG (2.4%), 1 removal of a gastric band to RYGB (2.4%), 1 gastric band over RYGB pouch (2.4%), and 1 gastric band replacement (2.4%). All cases were performed minimally invasively (73.2% laparoscopic and 26.8% robotic). Mean LOS was 2.53 days. Thirty-day complications included 2 readmissions (4.9% [1 small bowel obstruction and 1 pulmonary edema]), 1 reoperation (2.4% [small bowel obstruction]), and 1 mortality (2.4%) on postoperative day 30 unrelated to the surgery.

CONCLUSIONS

Bariatric surgery can be performed safely in patients with CHF.

Cardiovascular and systemic determinants of exercise capacity in people with type 2 diabetes mellitus

The global burden of heart failure (HF) is on the rise owing to an increasing incidence of lifestyle related diseases, predominantly type 2 diabetes mellitus (T2D). Diabetes is an independent risk factor for cardiovascular disease, and up to 75% of those with T2D develop HF in their lifetime. T2D leads to pathological alterations within the cardiovascular system, which can progress insidiously and asymptomatically in the absence of conventional risk factors. Reduced exercise tolerance is consistently reported, even in otherwise asymptomatic individuals with T2D, and is the first sign of a failing heart. Because aggressive modification of cardiovascular risk factors does not eliminate the risk of HF in T2D, it is likely that other factors play a role in the pathogenesis of HF. Early identification of individuals at risk of HF is advantageous, as it allows for modification of the reversible risk factors and early initiation of treatment with the aim of improving clinical outcomes. In this review, cardiac and extra-cardiac contributors to reduced exercise tolerance in people with T2D are explored.

Diabesity: the combined burden of obesity and diabetes on heart disease and the role of imaging

Diabesity is a term used to describe the combined adverse health effects of obesity and diabetes mellitus. The worldwide dual epidemic of obesity and type 2 diabetes is an important public health issue. Projections estimate a sixfold increase in the number of adults with obesity in 40 years and an increase in the number of individuals with diabetes to 642 million by 2040. Increased adiposity is the strongest risk factor for developing diabetes. Early detection of the effects of diabesity on the cardiovascular system would enable the optimal implementation of effective therapies that prevent atherosclerosis progression, cardiac remodelling, and the resulting ischaemic heart disease and heart failure. Beyond conventional imaging techniques, such as echocardiography, CT and cardiac magnetic resonance, novel post-processing tools and techniques provide information on the biological processes that underlie metabolic heart disease. In this Review, we summarize the effects of obesity and diabetes on myocardial structure and function and illustrate the use of state-of-the-art multimodality cardiac imaging to elucidate the pathophysiology of myocardial dysfunction, prognosticate long-term clinical outcomes and potentially guide treatment strategies.

Improvement of Cardiac Function After Roux-en-Y Gastric Bypass in Morbidly Obese Patients Without Cardiac History Measured by Cardiac MRI

PURPOSE

Metabolic syndrome in patients with morbid obesity causes a higher cardiovascular morbidity, eventually leading to left ventricular hypertrophy and decreased left ventricular ejection fraction (LVEF). Roux-en-Y gastric bypass (RYGB) is considered the gold standard modality for treatment of morbid obesity and might even lead to improved cardiac function. Our objective is to investigate whether cardiac function in patients with morbid obesity improves after RYGB.

MATERIALS AND METHODS

In this single center pilot study, 15 patients with an uneventful cardiac history who underwent RYGB were included from May 2015 to March 2016. Cardiac function was measured by cardiac magnetic resonance imaging (CMRI), performed preoperatively and 3, 6, and 12 months postoperative. LVEF and myocardial mass and cardiac output were measured.

RESULTS

A total of 13 patients without decreased LVEF preoperative completed follow-up (mean age 37, 48.0 ± 8.8). There was a significant decrease of cardiac output 12 months postoperative (8.3 ± 1.8 preoperative vs. 6.8 ± 1.8 after 12 months, P = 0.001). Average myocardial mass declined by 15.2% (P < 0.001). After correction for body surface area (BSA), this appeared to be non-significant (P = 0.36). There was a significant improvement of LVEF/BSA at 6 and 12 months postoperative (26.2 ± 4.1 preoperative vs. 28.4 ± 3.4 and 29.2 ± 3.6 respectively, both P = 0.002). Additionally, there was a significant improvement of stroke volume/BSA 12 months after surgery (45.8 ± 8.0 vs. 51.9 ± 10.7, P = 0.033).

CONCLUSION

RYGB in patients with morbid obesity with uneventful history of cardiac disease leads to improvement of cardiac function.

Obesity-related ventricular remodelling is exacerbated in dilated and hypertrophic cardiomyopathy

Background

Obesity causes significant cardiac remodelling even in health, and yet the contribution of this maladaptation in the setting of an additional cardiomyopathic process is poorly understood. Cardiovascular magnetic resonance is the gold-standard tool for assessing cardiac geometry, especially in an obese population, and hence perfectly suited to investigate this important question.

Methods

Using data from our extensive imaging registry (n=1,554), we documented the relationship between increasing BMI and left ventricular (LV) remodelling in patients with dilated (DCM; n=529) and hypertrophic cardiomyopathy (HCM; n=297), compared to the normal heart (n=728).

Results

Regardless of cardiac status, increasing BMI resulted in similar increases in LV stroke volume (P>0.18). However, there was a difference in the degree of LV cavity dilatation associated with this change in stroke volume; when compared to normal hearts [increase in end-diastolic volume of 0.7 mL per unit of rising BMI (mL/kg/m²)], there was a threefold greater LV cavity dilatation in DCM (+2.2 mL/kg/m²) and twofold greater in HCM (+1.9 mL/kg/m², all P<0.04). Whilst obesity was related to LV hypertrophy in all groups (normal +1.3 g, DCM +2.2g, HCM +2.3 g/kg/m², all P<0.001), additional obesity-related concentric LV remodelling only occurred in normal hearts and DCM (normal +0.006 vs. +0.003 mass:volume ratio, both P<0.001).

Conclusions

In both DCM and HCM, the increase in stroke volume required by obesity appears to be achieved by excessive LV cavity dilatation. The impact of obesity on LV geometry was more pronounced in concomitant cardiovascular disease, and therefore carries potential to become an important therapeutic target in cardiomyopathy.

Obesity Surgery and Anesthesiology Risks: a Review of Key Concepts and Related Physiology

The obesity epidemic is swelling to epic proportions. Obese patients often suffer from a combination of hypertension, dyslipidemia, and type 2 diabetes mellitus (T2DM), also known as the "metabolic syndrome." The metabolic syndrome is an independent predictor of cardiac dysfunction and cardiovascular disease and a risk factor for perioperative morbidity and mortality. In this paper, we discuss the perioperative risk factors and the need for advanced care of obese patients needing general anesthesia for (bariatric) surgical procedures based on physiological principles.

Obesity and Mechanisms of its Negative Impact on the Cardiovascular System

Currently, the number of obese people in the world is constantly increasing. Obesity has a direct negative impact on the heart and blood vessels, which can be considered not only as an appropriate response to an increase in the volume of circulating blood due to an increase in body weight, but also as a side tissue reaction of the myocardium to hormonal and metabolic changes inherent in obesity. Our review is devoted to the description of the mechanisms of influence of obesity on the structural and functional parameters of the heart, which create prerequisites for the development of cardiovascular diseases, as well as the existing contradictions. Currently, the accumulated data suggest that an excessive amount of adipose tissue, in addition to metabolic disorders, including insulin resistance, imbalance of adipokines and inflammation markers, leading to the development of lipotoxicity, can directly penetrate the myocardium and cause violations of its contractile properties, as well as affect the conduction of excitation pulses and provoke the development of rhythm and conduction disorders. The development of endothelial dysfunction in obesity ultimately leads to the development of atherosclerosis and coronary heart disease. In addition, obesity contributes to the emergence of risk factors for hypertension, diabetes, atrial fibrillation, chronic heart failure, obstructive sleep apnea syndrome. Given the differences in the literature on the effect of obesity on long-term outcomes in patients with cardiovascular diseases, it is important to conduct prospective studies on the role of individual factors and their combinations that affect the mortality of patients with cardiovascular diseases.

Cardiac remodeling in obesity and after bariatric and metabolic surgery; is there a role for gastro-intestinal hormones?

Introduction: Obesity is associated with various diseases such as type 2 diabetes, hypertension, obstructive sleep apnea syndrome (OSAS), metabolic syndrome, and cardiovascular diseases. It affects several organ systems, including the pulmonary and cardiac systems. Furthermore, it induces pulmonary and cardiac changes that can result in right and/or left heart failure.Areas covered: In this review, authors provide an overview of obesity and cardiovascular remodeling, the individual actions of the gut hormones (like GLP-1 and PYY), the effects after bariatric/metabolic surgery and its influence on cardiac remodeling. In this review, we focussed and searched for literature in Pubmed and The Cochrane library (from the earliest date until April 2019), regarding cardiac function changes before and after bariatric surgery and literature regarding changes in gastrointestinal hormones.Expert opinion: Regarding the surgical treatment of obesity and metabolic diseases there is recognition of the importance of both weight loss (bariatric surgery) and improvement in metabolic milieu (metabolic surgery). A growing body of evidence further suggests that bariatric surgical procedures [like the Sleeve Gastrectomy (SG), Roux-en Y Gastric Bypass (RYGB), or One Anastomosis Gastric Bypass (OAGB)] have can improve outcomes of patients suffering from a number of cardiovascular diseases, including heart failure.

A Population-Based Study of Early Postoperative Outcomes in Patients with Heart Failure Undergoing Bariatric Surgery

BACKGROUND

Weight loss following bariatric surgery can improve cardiac function among patients with heart failure (HF). However, perioperative morbidity of bariatric surgery has not been evaluated in patients with HF.

STUDY DESIGN

The National Surgical Quality Improvement Project (NSQIP) database for 2006-2014 was queried to identify patients undergoing adjustable gastric band, gastric bypass, sleeve gastrectomy, and biliopancreatic diversion-duodenal switch. Patients with HF were propensity matched to a control group without HF (1:5). Univariate analyses evaluated differences in complications, and multivariate analysis was completed to predict all-cause morbidity.

RESULTS

There were 237 patients identified with HF (mean age 52.8 years, 59.9% female, mean body mass index 50.6 kg/m²) matched to 1185 controls without HF who underwent bariatric surgery. Preoperatively, patients with HF were more likely to be taking antihypertensive medication and have undergone prior percutaneous cardiac intervention and cardiac surgery. There was no difference in operative time, surgical site infections, acute renal failure, re-intubation, or myocardial infarction. HF was associated with increased likelihood of length of stay more than 7 days, likelihood to remain ventilated > 48 h, venous thromboembolism, and reoperation. For patients with HF, the adjusted odds ratio for all-cause morbidity was 2.09 (1.32-3.22).

CONCLUSION

The NSQIP definition of HF, which includes recent hospitalization for HF exacerbation or new HF diagnosis 30 days prior to surgery, predicts a more than two-fold increase in odds of morbidity following bariatric surgery. This must be balanced with the longer-term potential benefits of weight loss and associated improvement in cardiac function in this population.

Obesity and its cardiovascular effects

Obesity is described in terms of body fat percentage or body mass index (BMI), despite the fact that these measures do not give full insight about the body fat distribution. It is presently a consistently growing universal challenge since it has tripled in the last 10 years, killing approximately 28 million people each year. In this review, we aim to clarify the different results of obesity on the working and physiology of the cardiovascular system and to reveal changes in the obesity "paradox"-a variety of cardiovascular outcomes in typical/overweight people. Central fat build-up in ordinary/overweight populaces has been related to expanded occurrences of myocardial infarction, heart failure, or all-cause mortality when contrasted with the obese populace. These discoveries are additionally clarified as the abundance and prolonged vulnerability to free fatty acids (FFAs) in obesity. This has been believed to cause the myocardial substrate to move from glucose to FFAs digestion, which causes lipid gathering in cardiomyocytes, spilling over to other lean tissues, and prompting a general atherogenic impact. This cardiomyocyte lipid aggregation has been demonstrated to cause insulin resistance and cardiovascular hypertrophy, and to lessen the heart functions in general. There is a proof backing the fact that fat tissue is not only an energy reservoir, it also coordinates hormones and proinflammatory cytokines and deals with the energy transition of the body by putting away abundant lipids in diverse tissues.

Activation of the sympathetic nervous system suppresses mouse white adipose tissue hyperplasia through the β1 adrenergic receptor

Adipose tissue (AT) expands via both hypertrophy and hyperplasia during the development of obesity. While AT hypertrophy involves the increase in size of existing adipocytes, hyperplasia is the process of creating new adipocytes from the pool of adipocyte precursor cells (APCs), which includes adipocyte progenitor cells and preadipocytes. Prior studies have implicated a role of the sympathetic nervous system (SNS) in regulation of hyperplasia in white adipose tissue (WAT). Here, we aimed to determine the mechanisms underlying SNS regulation of APC proliferation in mouse WAT. Using flow cytometry with antibodies against various cell surface markers, along with an intracellular marker of proliferation (Ki67), we quantitated the percentages and proliferative status of adipocyte progenitor cells and preadipocytes in the stromal vascular fraction (SVF) of WAT. In vivo SNS activation through cold exposure, as well as in vitro adrenergic stimulation via exposure to the canonical SNS neurotransmitter norepinephrine (NE), inhibited preadipocyte proliferation. Pretreatment with propranolol, a β1‐ and β2‐adrenergic receptor (AR) antagonist, trended toward rescuing the inhibitory effects of NE in primary cell culture. The selective β1‐AR agonist dobutamine diminished preadipocyte proliferation both in vivo and in vitro, whereas the selective β2‐AR agonist, salbutamol, promoted proliferation in vitro, suggesting that the β1‐AR may mediate the inhibitory effect of NE on preadipocyte proliferation. Taken together, we conclude that SNS activation suppresses preadipocyte proliferation via activation of the β1 AR in WAT.

Rationale, design and study protocol of the randomised controlled trial: Diabetes Interventional Assessment of Slimming or Training tO Lessen Inconspicuous Cardiovascular Dysfunction (the DIASTOLIC study)

INTRODUCTION

Despite their young age and relatively short duration of disease, younger adults with type 2 diabetes (T2D) already have diastolic dysfunction and may be at risk of incipient heart failure. Whether weight loss or exercise training improve cardiac dysfunction in people with T2D remains to be established.

METHODS AND ANALYSIS

Prospective, randomised, open-label, blind endpoint trial. The primary aim of the study is to determine if diastolic function can be improved by either a meal replacement plan or a supervised exercise programme, compared with guideline-directed care. A total of 90 obese participants with T2D (aged 18-65 years), diabetes duration <12 years and not on insulin treatment will be randomised to either guideline-directed clinical care with lifestyle coaching, a low-energy meal replacement diet (average ≈810 kcal/day) or a supervised exercise programme for 12 weeks. Participants undergo glycometabolic profiling, cardiopulmonary exercise testing, echocardiography and MRI scanning to assesses cardiac structure and function and dual-energy X-ray absorptiometry scanning for body composition. Key secondary aims are to assess the effects of the interventions on glycaemic control and insulin resistance, exercise capacity, blood pressure, changes in body composition and association of favourable cardiac remodelling with improvements in weight loss, exercise capacity and glycometabolic control.

ETHICS AND DISSEMINATION

The study has full ethical approval, and data collection was completed in August 2018. The study results will be submitted for publication within 6 months of completion.

TRIAL REGISTRATION NUMBER

NCT02590822; Pre-results.

Diabetic cardiomyopathy: prevalence, determinants and potential treatments

The prevalence of type 2 diabetes (T2D) has reached a pandemic scale. These patients are at a substantially elevated risk of developing cardiovascular disease, with heart failure (HF) being a leading cause of morbidity and mortality. Even in the absence of traditional risk factors, diabetes still confers up to a twofold increased risk of developing HF. This has led to identifying diabetes as an independent risk factor for HF and recognition of the distinct clinical entity, diabetic cardiomyopathy. Despite a wealth of research interest, the prevalence and determinants of diabetic cardiomyopathy remain uncertain. This limited understanding of the pathophysiology of diabetic heart disease has also hindered development of effective treatments. Tight blood-glucose and blood-pressure control have not convincingly been shown to reduce macrovascular outcomes in T2D. There is, however, emerging evidence that T2D is reversible and that the metabolic abnormalities can be reversed with weight loss. Increased aerobic exercise capacity is associated with significantly lower cardiovascular and overall mortality in diabetes. Whether such lifestyle modifications as weight loss and exercise may ameliorate the structural and functional derangements of the diabetic heart has yet to be established. In this review, the link between T2D and myocardial dysfunction is explored. Insights into the structural and functional perturbations that typify the diabetic heart are first described. This is followed by an examination of the pathophysiological mechanisms that contribute to the development of cardiovascular disease in T2D. Lastly, the current and emerging therapeutic strategies to prevent or ameliorate cardiac dysfunction in T2D are evaluated.

Heart Failure With Preserved Ejection Fraction: Prevention and Management

Heart failure with preserved ejection fraction (HFpEF) is a complex clinical syndrome that constitutes nearly half of all heart failure cases. Because of lack of effective pharmacological targets to improve outcomes, the emphasis of the management and prevention of HFpEF should be through control of risk factors. This review will use the framework proposed by the American Heart Association on 7 simple measures ("Life's Simple 7") that involves diet and lifestyle changes to achieve ideal cardiovascular health. These 7 measures include (1) smoking, (2) obesity, (3) exercise, (4) diet, (5) blood pressure, (6) cholesterol, and (7) glucose control, which can help control the most common comorbidities and risk factors associated with HFpEF, such as hypertension, diabetes, and obesity. Therefore, application of these 7 simple measures would be a patient-centered and cost-effective way of prevention and management of HFpEF.

Cardiac structure and function before and after bariatric surgery: a clinical overview

Obesity, defined as a body mass index of ≥30 kg/m² , is the most common chronic metabolic disease worldwide and its prevalence has been strongly increasing. Obesity has deleterious effects on cardiac function. The purpose of this review is to evaluate the effects of obesity and excessive weight loss due to bariatric surgery on cardiac function, structural changes and haemodynamic responses of both the left and right ventricle.