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Pandey A, Kitzman DW. Searching for the Optimal Exercise Training Regimen in Heart Failure With Preserved Ejection Fraction. JAMA 2021; 325:537-539. [PMID: 33560307 PMCID: PMC8261711 DOI: 10.1001/jama.2020.26347] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Dalane W Kitzman
- Cardiovascular Medicine and Geriatrics Sections, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
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5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2021. Diabetes Care 2021; 44:S53-S72. [PMID: 33298416 DOI: 10.2337/dc21-s005] [Citation(s) in RCA: 169] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Arroyave F, Montaño D, Lizcano F. Diabetes Mellitus Is a Chronic Disease that Can Benefit from Therapy with Induced Pluripotent Stem Cells. Int J Mol Sci 2020; 21:ijms21228685. [PMID: 33217903 PMCID: PMC7698772 DOI: 10.3390/ijms21228685] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/20/2020] [Accepted: 10/31/2020] [Indexed: 12/17/2022] Open
Abstract
Diabetes mellitus (DM) is one of the main causes of morbidity and mortality, with an increasing incidence worldwide. The impact of DM on public health in developing countries has triggered alarm due to the exaggerated costs of the treatment and monitoring of patients with this disease. Considerable efforts have been made to try to prevent the onset and reduce the complications of DM. However, because insulin-producing pancreatic β-cells progressively deteriorate, many people must receive insulin through subcutaneous injection. Additionally, current therapies do not have consistent results regarding the prevention of chronic complications. Leveraging the approval of real-time continuous glucose monitors and sophisticated algorithms that partially automate insulin infusion pumps has improved glycemic control, decreasing the burden of diabetes management. However, these advances are facing physiologic barriers. New findings in molecular and cellular biology have produced an extraordinary advancement in tissue development for the treatment of DM. Obtaining pancreatic β-cells from somatic cells is a great resource that currently exists for patients with DM. Although this therapeutic option has great prospects for patients, some challenges remain for this therapeutic plan to be used clinically. The purpose of this review is to describe the new techniques in cell biology and regenerative medicine as possible treatments for DM. In particular, this review highlights the origin of induced pluripotent cells (iPSCs) and how they have begun to emerge as a regenerative treatment that may mitigate the pathology of this disease.
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Affiliation(s)
- Felipe Arroyave
- Doctoral Program in Biosciences, Universidad de La Sabana, Chía 250008, CU, Colombia;
| | - Diana Montaño
- Center of Biomedical Investigation (CIBUS), Universidad de La Sabana, Chía 250008, CU, Colombia;
| | - Fernando Lizcano
- Doctoral Program in Biosciences, Universidad de La Sabana, Chía 250008, CU, Colombia;
- Center of Biomedical Investigation (CIBUS), Universidad de La Sabana, Chía 250008, CU, Colombia;
- Correspondence: ; Tel.: +57-3144120052 or +57-18615555 (ext. 23906)
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Patel KV, Bahnson JL, Gaussoin SA, Johnson KC, Pi-Sunyer X, White U, Olson KL, Bertoni AG, Kitzman DW, Berry JD, Pandey A. Association of Baseline and Longitudinal Changes in Body Composition Measures With Risk of Heart Failure and Myocardial Infarction in Type 2 Diabetes: Findings From the Look AHEAD Trial. Circulation 2020; 142:2420-2430. [PMID: 33164570 DOI: 10.1161/circulationaha.120.050941] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intentional weight loss is associated with lower risk of heart failure (HF) and atherosclerotic cardiovascular disease among patients with type 2 diabetes. However, the contribution of baseline measures and longitudinal changes in fat mass (FM), lean mass (LM), and waist circumference (WC) to the risk of HF and myocardial infarction (MI) in type 2 diabetes is not well established. METHODS Adults from the Look AHEAD trial (Action for Health in Diabetes) without prevalent HF were included. FM and LM were predicted using validated equations and compared with dual-energy x-ray absorptiometry measurements in a subgroup. Adjusted Cox models were used to evaluate the associations of baseline and longitudinal changes in FM, LM, and WC over 1- and 4-year follow-up with risk of overall HF, HF with preserved ejection fraction (EF; EF ≥50%), HF with reduced EF (EF <50%), and MI. RESULTS Among 5103 participants, there were 257 incident HF events over 12.4 years of follow-up. Predicted and measured FM/LM were highly correlated (R2=0.87-0.90; n=1369). FM and LM decreased over 4-year follow-up with greater declines in the intensive lifestyle intervention arm. In adjusted analysis, baseline body composition measures were not significantly associated with HF risk. Decline in FM and WC, but not LM, over 1 year were each significantly associated with lower risk of overall HF (adjusted hazard ratio per 10% decrease in FM, 0.80 [95% CI, 0.68-0.95]; adjusted hazard ratio per 10% decrease in WC, 0.77 [95% CI, 0.62-0.95]). Decline in FM was significantly associated with lower risk of both HF subtypes. In contrast, decline in WC was significantly associated with lower risk of HF with preserved EF but not HF with reduced EF. Similar patterns of association were observed for 4-year changes in body composition and HF risk. Longitudinal changes in body composition were not significantly associated with risk of MI. CONCLUSIONS In adults with type 2 diabetes, a lifestyle intervention is associated with significant loss of FM and LM. Declines in FM and WC, but not LM, were each significantly associated with lower risk of HF but not MI. Furthermore, decline in WC was significantly associated with lower risk of HF with preserved EF but not HF with reduced EF. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00017953.
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Affiliation(s)
- Kershaw V Patel
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (K.V.P., J.D.B., A.P.).,Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, TX (K.V.P.)
| | - Judy L Bahnson
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC (J.L.B., S.A.G.)
| | - Sarah A Gaussoin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC (J.L.B., S.A.G.)
| | - Karen C Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis (K.C.J.)
| | - Xavier Pi-Sunyer
- New York Obesity Research Center, Columbia University Medical Center (X.P.)
| | - Ursula White
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge (U.W.)
| | - KayLoni L Olson
- Department of Psychiatry and Human Behavior, Brown Medical School, Providence, RI (K.L.O.)
| | - Alain G Bertoni
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC (A.G.B.)
| | - Dalane W Kitzman
- Department of Internal Medicine, Sections on Cardiovascular Medicine and Geriatrics, Wake Forest School of Medicine, Winston-Salem, NC (D.W.K.)
| | - Jarett D Berry
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (K.V.P., J.D.B., A.P.)
| | - Ambarish Pandey
- Department of Internal Medicine, Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (K.V.P., J.D.B., A.P.)
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Type 2 diabetes is an independent predictor of lowered peak aerobic capacity in heart failure patients with non-reduced or reduced left ventricular ejection fraction. Cardiovasc Diabetol 2020; 19:142. [PMID: 32950064 PMCID: PMC7502205 DOI: 10.1186/s12933-020-01114-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 09/12/2020] [Indexed: 12/13/2022] Open
Abstract
Background Although type 2 diabetes mellitus (T2DM) is one of the most frequent comorbidities in patients with chronic heart failure (CHF), the effects of T2DM on the exercise capacity of CHF patients are fully unknown. Here, we tested the hypothesis that the coexistence of T2DM lowers CHF patients’ peak aerobic capacity. Methods We retrospectively analyzed the cases of 275 Japanese CHF patients with non-reduced ejection fraction (left ventricular ejection fraction [LVEF] ≥ 40%) or reduced EF (LVEF < 40%) who underwent cardiopulmonary exercise testing. We divided them into diabetic and nondiabetic groups in each CHF cohort. Results The mean peak oxygen uptake (VO2) value was 16.87 mL/kg/min in the non-reduced LVEF cohort and 15.52 mL/kg/min in the reduced LVEF cohort. The peak VO2 was lower in the diabetics versus the nondiabetics in the non-reduced LVEF cohort with the mean difference (95% confidence interval [95% CI]) of − 0.93 (− 1.82 to − 0.04) mL/kg/min and in the reduced LVEF cohort with the mean difference of − 1.05 (− 1.96 to − 0.15) mL/kg/min, after adjustment for age-squared, gender, anemia, renal function, LVEF, and log B-type natriuretic peptide (BNP). The adjusted VO2 at anaerobic threshold (AT), a submaximal aerobic capacity, was also decreased in the diabetic patients with both non-reduced and reduced LVEFs. Intriguingly, the diabetic patients had a lower adjusted peak O2 pulse than the nondiabetic patients in the reduced LVEF cohort, but not in the non-reduced LVEF cohort. A multivariate analysis showed that the presence of T2DM was an independent predictor of lowered peak VO2 in CHF patients with non-reduced LVEF and those with reduced LVEF. Conclusions T2DM was associated with lowered peak VO2 in CHF patients with non-reduced or reduced LVEF. The presence of T2DM has a negative impact on CHF patients’ exercise capacity, and the degree of impact is partly dependent on their LV systolic function.
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Nesti L, Pugliese NR, Sciuto P, Natali A. Type 2 diabetes and reduced exercise tolerance: a review of the literature through an integrated physiology approach. Cardiovasc Diabetol 2020; 19:134. [PMID: 32891175 PMCID: PMC7487838 DOI: 10.1186/s12933-020-01109-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 08/29/2020] [Indexed: 12/14/2022] Open
Abstract
The association between type 2 diabetes mellitus (T2DM) and heart failure (HF) is well established. Early in the course of the diabetic disease, some degree of impaired exercise capacity (a powerful marker of health status with prognostic value) can be frequently highlighted in otherwise asymptomatic T2DM subjects. However, the literature is quite heterogeneous, and the underlying pathophysiologic mechanisms are far from clear. Imaging-cardiopulmonary exercise testing (CPET) is a non-invasive, provocative test providing a multi-variable assessment of pulmonary, cardiovascular, muscular, and cellular oxidative systems during exercise, capable of offering unique integrated pathophysiological information. With this review we aimed at defying the cardiorespiratory alterations revealed through imaging-CPET that appear specific of T2DM subjects without overt cardiovascular or pulmonary disease. In synthesis, there is compelling evidence indicating a reduction of peak workload, peak oxygen assumption, oxygen pulse, as well as ventilatory efficiency. On the contrary, evidence remains inconclusive about reduced peripheral oxygen extraction, impaired heart rate adjustment, and lower anaerobic threshold, compared to non-diabetic subjects. Based on the multiparametric evaluation provided by imaging-CPET, a dissection and a hierarchy of the underlying mechanisms can be obtained. Here we propose four possible integrated pathophysiological mechanisms, namely myocardiogenic, myogenic, vasculogenic and neurogenic. While each hypothesis alone can potentially explain the majority of the CPET alterations observed, seemingly different combinations exist in any given subject. Finally, a discussion on the effects -and on the physiological mechanisms-of physical activity and exercise training on oxygen uptake in T2DM subjects is also offered. The understanding of the early alterations in the cardiopulmonary response that are specific of T2DM would allow the early identification of those at a higher risk of developing HF and possibly help to understand the pathophysiological link between T2DM and HF.
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Affiliation(s)
- Lorenzo Nesti
- Metabolism, Nutrition and Atherosclerosis Lab, Dietologia Universitaria, Pisa, Italy. .,Cardiopulmonary Test Lab, Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy.
| | - Nicola Riccardo Pugliese
- Cardiopulmonary Test Lab, Department of Clinical and Experimental Medicine, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Paolo Sciuto
- Metabolism, Nutrition and Atherosclerosis Lab, Dietologia Universitaria, Pisa, Italy
| | - Andrea Natali
- Metabolism, Nutrition and Atherosclerosis Lab, Dietologia Universitaria, Pisa, Italy
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Segar MW, Patel KV, Vaduganathan M, Caughey MC, Butler J, Fonarow GC, Grodin JL, McGuire DK, Pandey A. Association of Long-term Change and Variability in Glycemia With Risk of Incident Heart Failure Among Patients With Type 2 Diabetes: A Secondary Analysis of the ACCORD Trial. Diabetes Care 2020; 43:1920-1928. [PMID: 32540922 PMCID: PMC7876556 DOI: 10.2337/dc19-2541] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 05/04/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the associations between long-term change and variability in glycemia with risk of heart failure (HF) among patients with type 2 diabetes mellitus (T2DM). RESEARCH DESIGN AND METHODS Among participants with T2DM enrolled in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, variability in HbA1c was assessed from stabilization of HbA1c following enrollment (8 months) to 3 years of follow-up as follows: average successive variability (ASV) (average absolute difference between successive values), coefficient of variation (SD/mean), and SD. Participants with HF at baseline or within 3 years of enrollment were excluded. Adjusted Cox models were used to evaluate the association of percent change (from baseline to 3 years of follow-up) and variability in HbA1c over the first 3 years of enrollment and subsequent risk of HF. RESULTS The study included 8,576 patients. Over a median follow-up of 6.4 years from the end of variability measurements at year 3, 388 patients had an incident HF hospitalization. Substantial changes in HbA1c were significantly associated with higher risk of HF (hazard ratio [HR] for ≥10% decrease 1.32 [95% CI 1.08-1.75] and for ≥10% increase 1.55 [1.19-2.04]; reference <10% change in HbA1c). Greater long-term variability in HbA1c was significantly associated with higher risk of HF (HR per 1 SD of ASV 1.34 [95% CI 1.17-1.54]) independent of baseline risk factors and interval changes in cardiometabolic parameters. Consistent patterns of association were observed with use of alternative measures of glycemic variability. CONCLUSIONS Substantial long-term changes and variability in HbA1c were independently associated with risk of HF among patients with T2DM.
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Affiliation(s)
- Matthew W Segar
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Kershaw V Patel
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Department of Medicine, Harvard Medical School, Boston, MA
| | - Melissa C Caughey
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, Chapel Hill, NC
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Division of Cardiology, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
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Razavi AC, Gingras V, Michos ED, Navar AM, Brown S, Delker E, Foti K, Harrison S, Lu Y, Nierenberg JL, Scott J, Tang O, Thomas AG, Turkson‐Ocran R, Wallace A, Zhang M, Lancaster KJ, Lutsey PL, Selvin E. American Heart Association EPI|Lifestyle Scientific Sessions: 2020 Meeting Highlights. J Am Heart Assoc 2020; 9:e017252. [PMID: 32476542 PMCID: PMC7429023 DOI: 10.1161/jaha.120.017252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alexander C. Razavi
- Department of EpidemiologyTulane University School of Public Health and Tropical MedicineNew OrleansLA
- Department of MedicineTulane University School of MedicineNew OrleansLA
| | - Véronique Gingras
- Department of Population MedicineHarvard Medical School and Harvard Pilgrim Health Care InstituteBostonMA
| | - Erin D. Michos
- Ciccarone Center for the Prevention of Cardiovascular DiseaseJohns Hopkins University School of MedicineBaltimoreMD
| | | | - Sherry‐Ann Brown
- Cardio‐Oncology ProgramDivision of CardiologyMedical College of WisconsinMilwaukeeWI
| | - Erin Delker
- Department of PediatricsSchool of MedicineUniversity of CaliforniaSan DiegoCA
| | - Kathryn Foti
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical ResearchJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Stéphanie Harrison
- School of NutritionUniversité LavalQuebecCanada
- Centre NutritionSanté et SociétéInstitute of Nutrition and Functional FoodsUniversité LavalQuebecCanada
| | - Yifei Lu
- Department of EpidemiologyGillings School of Global Public HealthUniversity of North Carolina at Chapel HillDurhamNC
| | - Jovia L. Nierenberg
- Department of EpidemiologyTulane University School of Public Health and Tropical MedicineNew OrleansLA
| | | | - Olive Tang
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical ResearchJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Alvin G. Thomas
- Department of EpidemiologyGillings School of Global Public HealthUniversity of North Carolina at Chapel HillDurhamNC
| | - Ruth‐Alma Turkson‐Ocran
- American Heart Association Strategically Focused Obesity Research NetworkJohns Hopkins University School of MedicineBaltimoreMD
| | - Amelia Wallace
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical ResearchJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Mingyu Zhang
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical ResearchJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
| | - Kristie J. Lancaster
- Department of Nutrition and Food StudiesSteinhardt School of Culture, Education, and Human DevelopmentNew York UniversityNew YorkNY
| | - Pamela L. Lutsey
- Division of Epidemiology and Community HealthUniversity of Minnesota School of Public HealthMinneapolisMN
| | - Elizabeth Selvin
- Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical ResearchJohns Hopkins Bloomberg School of Public HealthBaltimoreMD
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Pandey A, Kitzman D. Preventing Heart Failure With Habitual Physical Activity: Dependence on Heart Failure Phenotype and Concomitant Cardiovascular Disease. J Am Heart Assoc 2020; 9:e016635. [PMID: 32390493 PMCID: PMC7660885 DOI: 10.1161/jaha.120.016635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Ambarish Pandey
- Division of Cardiology Department of Internal Medicine UT Southwestern Medical Center Dallas TX
| | - Dalane Kitzman
- Sections on Cardiovascular Medicine and Geriatrics Department of Internal Medicine Wake Forest School of Medicine Winston Salem NC
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Abstract
The obesity paradox, which suggests a survival advantage for the obese in heart failure (HF) has sparked debate in the medical community. Studies demonstrate a survival advantage in obese patients with HF, including those with advanced HF requiring continuous inotropic support for palliation or disease modifying therapy with a left ventricular assist device (LVAD) or heart transplantation (HT). Importantly, the obesity paradox is affected by the level of cardiorespiratory fitness (CRF). It is now recommended that HF patients with body mass index ≥35 kg/m2 achieve at least 5-10% weight loss, in order to improve symptoms and cardiac function, though more robust data are urgently needed. CRF may be the single best predictor of overall health and small improvements in fitness levels may lead to improved outcomes in HF. In addition to implications of obesity in chronic HF, we also discuss management of obese patients with advanced HF and their implications for therapies such as LVAD implantation and HT.
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