Emerging markers of atherosclerosis before and after bariatric surgery

Association of prior bariatric surgery with financial and clinical outcomes of acute myocardial infarction

BACKGROUND

Superior clinical outcomes after hospitalization for cardiovascular-related disease such as acute heart failure have been linked with prior history of bariatric surgery, but similar analyses in acute myocardial infarction (MI) are currently limited.

OBJECTIVE

This work examines clinical outcomes and resource utilization in patients with acute MI hospitalizations with a prior history of bariatric surgery.

SETTING

Academic university-affiliated hospital in the United States.

METHODS

All adult patients with hospitalizations with a primary diagnosis of acute MI were queried using the 2016-2020 Nationwide Readmissions Database. The study population was comprised of patients with an International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code for obesity (body mass index ≥35 kg/m2) as well as those with a prior history of bariatric surgery regardless of their body mass index status. Comparison was made between those with a prior history of bariatric surgery and those without. Univariate analysis and multivariate regression models were used to examine the association between bariatric surgery and outcomes of interest, which included in-hospital mortality, medical complications, and resource utilization.

RESULTS

Of an estimated 2,736,606 hospitalizations for acute MI, 296,902 patients (10.8%) had a diagnosis of obesity and/or a prior history of bariatric surgery. The bariatric cohort was more frequently female and had a lower prevalence of congestive heart failure, chronic lung disease, diabetes, and electrolyte derangements than the nonbariatric cohort. After risk adjustment, prior history of bariatric surgery was associated with significantly lower odds of in-hospital mortality, cardiogenic shock, and acute kidney injury. Additionally, prior history of bariatric surgery was linked to a decreased duration of hospital stay and lower hospitalization costs as well as lower odds of nonhome discharge.

CONCLUSION

Among acute MI patients with obesity, prior history of bariatric surgery was associated with decreased odds of in-hospital mortality, improved clinical outcomes, and lower resource utilization. Expansion of bariatric surgery programs may provide improved access to a medical intervention that is intertwined with cardiovascular health.

New perspectives on obesity-induced adipose tissue fibrosis and related clinical manifestations

Adipose tissue is a complex heterogeneous tissue composed of adipocytes along with several non-adipocyte populations, including blood, stromal, endothelial, and progenitor cells, as well as extracellular matrix (ECM) components. As obesity progresses, the adipose tissue expands dynamically through adipocyte hypertrophy and/or hyperplasia. This expansion requires continuous ECM remodeling to properly accommodate the size increase as well as functional changes. Upon reaching a hypertrophic threshold beyond the adipocyte buffering capacity, excess ECM components are deposited, causing fibrosis and ultimately resulting in unhealthy metabolic maladaptation. These complex ECM remodeling processes in adipose tissues are regulated by the local environment, several key mediators, and genetic factors that are closely linked to insulin sensitivity. It is crucial to understand how adipocytes interact with nonadipocyte populations and various mediators (i.e., immune cells, ECM components, and adipokines) during these processes. This mini-review provides an overview of the latest research into the biology of obesity-induced adipose tissue fibrosis and its related clinical manifestations, providing insight for further studies aimed at controlling metabolic syndrome and its comorbidities.

Changes in adipokine levels and metabolic profiles following bariatric surgery

BACKGROUND

Bariatric surgery is considered to be the most effective treatment option for weight reduction in obese patients. Abdominal obesity is frequently accompanied by metabolic syndrome (MS). Adipokines are cell signaling proteins that have direct impact upon the metabolic homeostasis. The purpose of this analysis was to evaluate the effect of bariatric surgery, including laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LRYGB) on the adipokine levels and metabolic profile as well as MS and status of type 2 diabetes (T2D).

METHODS

We analyzed anthropometric parameters, blood levels of adipokines, vitamins, lipids and inflammatory markers in 30 bariatric surgery patients with obesity of class II or III 1 month before and 1 year after surgery as well as in 60 obese patients from general practice (GP) and 15 patients with normal body mass (control).

RESULTS

The BMI was significantly higher among patients before surgery and GP patients in comparison to control and post-surgery patients. The levels of glucose, cholesterol and LDL-cholesterol, triglyceride and hs-CRP were the highest in patients before surgery but decreased significantly after surgery, while the level of HDL-cholesterol increased after surgery. The levels of adiponectin increased and that of leptin decreased after surgery. The significant difference in the concentration of resistin was revealed between LSG and LRYGB methods. The relationship between resistin and vitamin D was also found. The patients with MS and T2D displayed significantly greater reduction in lipid markers and adipokine levels than the rest of patients.

CONCLUSION

Remarkable changes in levels of adipokines after bariatric surgery appear like increase in adiponectin and decrease in leptin levels. Significant improvement in anthropometric parameters, metabolic and inflammatory markers occurs, suggesting high potential for reduction of metabolic syndrome and risk for type 2 diabetes. We have shown for the first time ever that level of vitamin D may be involved in resistin regulation.

Relation of Bariatric Surgery to Inpatient Cardiovascular Outcomes (from the National Inpatient Sample)

Approximately one in 3 patients in the United States are obese. There is a strong association between obesity and an increased rate of cardiovascular disease (CVD)-related mortality. Bariatric surgery (BS) has emerged as an effective strategy to achieve reduction of excess weight. Our study aims to explore the relationship between BS and major adverse cardiovascular events (MACE) among obese hospitalized patients in the United States. This is a retrospective study of all obese adult patients with BMI ≥35 kg/m² (n= 1,700,943) in the National Inpatient Sample between 2012 and 2016. Differences in the clinical characteristics of obese patients with a history of BS versus obese patients without a history of BS were analyzed as well as the association between BS and MACE after adjusting for CVD risk factors. Among 50,296 obese patients with a history of BS (2.96%), the mean age was 53 ± 12 years with the majority being female (75.32%) and Caucasian (71.85%). Multivariate analysis revealed that obese patients with a history of BS had a1.6-fold decrease odds of MACE compared with patients without BS (OR 0.62; 95% CI, 0.60 to 0.65; p <0.001). In conclusion, this study illustrates that among obese patients with BMI ≥35 kg/m², history of BS was associated with a significantly lower odds of inpatient MACE, after adjusting for CVD risk factors.

Differential Expression of MMP2 and TIMP2 in Peripheral Blood Mononuclear Cells After Roux-en-Y Gastric Bypass

Matrix metalloproteinases (MMP) and their endogenous inhibitor, the tissue inhibitor of metalloproteinases (TIMP), are expressed in many different cell types and play an important role in physiologic and pathological degradation of extracellular matrix (ECM). Starting from these observations and considering the activation state of peripheral blood mononuclear cells (PBMCs) in obesity, we investigated the gene expression of metalloproteinases before and after Roux-en-Y gastric bypass (RYBG). The study was performed in the Ribeirão Preto Medical School University Hospital. Seventy-three women were divided into a study group (SG), composed of 53 individuals with severe obesity before and after 6 months of RYGB, and a control group (CG), composed of 20 normal-weight individuals. Anthropometric and body composition data were collected, and peripheral blood for ribonucleic acid (RNA) extraction. The biological samples were submitted to a quantitative real-time polymerase chain reaction to evaluate the expression of MMP2 and TIMP2 genes. Alterations in weight loss, body mass index (BMI), and fat mass (FM) were observed after 6 months of RYGB (p < 0.05). A reduction of gene expression of TIMP2 was observed after 6 months of RYGB, contributing positively to the weight loss (R ² = 0.33 p = 0.04). The enrichment analyses highlighted the interaction between TIMP2 and MMP2 genes and the molecular pathways involving the ECM remodeling in the obesity condition. RYGB contributes significantly to weight loss, improved BMI, reduced FM, and reduced TIMP2 expression in PBMCs, which might contribute to the ECM remodeling in the obesity and could be useful as a circulating biomarker.

Cardiometabolic-Based Chronic Disease, Addressing Knowledge and Clinical Practice Gaps: JACC State-of-the-Art Review

In the second part of this JACC State-of-the-Art Review, an early and sustainable preventive care plan is described for cardiometabolic-based chronic disease. This plan can improve cardiometabolic health by targeting early mechanistic events to decrease the risk for certain cardiovascular diseases (e.g., coronary heart disease, heart failure, and atrial fibrillation). Included are various prevention modalities, intensive lifestyle interventions, pharmacotherapy and cardiovascular outcome trial evidence, and bariatric/metabolic procedures. A tactical approach of implementing published clinical practice guidelines/algorithms for early behavioral, adiposity, and dysglycemia targeting is emphasized, as well as relevant educational and research implications.

Increased PON lactonase activity in morbidly obese patients is associated with impaired lipid profile

AIMS

The paraoxonase-1 (PON1) enzyme could play an important role in the anti-oxidant capacity of high-density lipoprotein. However, there are no studies which analyse the evolution of the three activities of PON1 (PON arylesterase, PON paraoxonase and PON lactonase) after Roux-en-Y Gastric Bypass (RYGB) in morbidly obese subjects. We analysed the association of PON concentration and activities with the evolution of morbidly obese subjects who underwent RYGB, and its relationship with biochemical variables and different atherogenic indices.

METHODS

Twenty-seven non-obese and 82 morbidly obese subjects were studied before and 6 months after RYGB.

RESULTS

Before RYGB, morbidly obese subjects had a lower PON1 concentration (P < 0.05) and higher PON lactonase activity (P < 0.001) than non-obese subjects, with no differences in PON arylesterase and PON paraoxonase activities. After RYGB, PON1 concentration (P < 0.05) and PON lactonase activity (P < 0.001) decreased with regard to the presurgery state. PON lactonase activity correlated with the atherogenic index of plasma before (r = 0.19, P = 0.047) and after RYGB (r = 0.27, P = 0.035). In different multiple lineal regression analysis models, presurgery PON lactonase activity was associated with total cholesterol (β = 0.909, P < 0.001), LDL (β = 0.632, P = 0.006) and DBP (β = 0.230, P = 0.030) (R²  = 0.295), postsurgery PON lactonase activity was associated with esterified cholesterol (β = 0.362, P = 0.011) (R²  = 0.131), and the change (Δ) in PON lactonase activity after RYGB was associated with Δesterified cholesterol (β = 0.304, P = 0.030) (R²  = 0.093).

CONCLUSIONS

PON lactonase activity is associated with the presence of morbid obesity and with an impaired lipid profile. All associations found could indicate the relationship between PON lactonase activity and the development of atherosclerosis.

Behavior of Metalloproteinases in Adipose Tissue, Liver and Arterial Wall: An Update of Extracellular Matrix Remodeling

Extracellular matrix (ECM) remodeling is required for many physiological and pathological processes. Metalloproteinases (MMPs) are endopeptidases which are able to degrade different components of the ECM and nucleus matrix and to cleave numerous non-ECM proteins. Among pathological processes, MMPs are involved in adipose tissue expansion, liver fibrosis, and atherosclerotic plaque development and vulnerability. The expression and the activity of these enzymes are regulated by different hormones and growth factors, such as insulin, leptin, and adiponectin. The controversial results reported up to this moment regarding MMPs behavior in ECM biology could be consequence of the different expression patterns among species and the stage of the studied pathology. The aim of the present review was to update the knowledge of the role of MMPs and its inhibitors in ECM remodeling in high incidence pathologies such as obesity, liver fibrosis, and cardiovascular disease.

Gastric Bypass Surgery Produces a Durable Reduction in Cardiovascular Disease Risk Factors and Reduces the Long-Term Risks of Congestive Heart Failure

Background

Obesity and its association with reduced life expectancy are well established, with cardiovascular disease as one of the major causes of fatality. Metabolic surgery is a powerful intervention for severe obesity, resulting in improvement in comorbid diseases and in cardiovascular risk factors. This study investigates the relationship between metabolic surgery and long‐term cardiovascular events.

Methods and Results

A cohort of Roux‐en‐Y gastric bypass surgery (RYGB) patients was tightly matched by age, body mass index, sex, Framingham Risk Score, smoking history, use of antihypertension medication, diabetes mellitus status, and calendar year with a concurrent cohort of nonoperated control patients. The primary study end points of major cardiovascular events (myocardial infarction, stroke, and congestive heart failure) were evaluated using Cox regression. Secondary end points of longitudinal cardiovascular risk factors were evaluated using repeated‐measures regression. The RYGB and matched controls (N=1724 in each cohort) were followed for up to 12 years after surgery (overall median of 6.3 years). Kaplan–Meier analysis revealed a statistically significant reduction in incident major composite cardiovascular events (P=0.017) and congestive heart failure (0.0077) for the RYGB cohort. Adjusted Cox regression models confirmed the reductions in severe composite cardiovascular events in the RYGB cohort (hazard ratio=0.58, 95% CI=0.42–0.82). Improvements of cardiovascular risk factors (eg, 10‐year cardiovascular risk score, total cholesterol, high‐density lipoprotein, systolic blood pressure, and diabetes mellitus) were observed within the RYGB cohort after surgery.

Conclusions

Gastric bypass is associated with a reduced risk of major cardiovascular events and the development of congestive heart failure.

Does bariatric surgery improve adipose tissue function?

Bariatric surgery is currently the most effective treatment for obesity. Not only do these types of surgeries produce significant weight loss but also they improve insulin sensitivity and whole body metabolic function. The aim of this review is to explore how altered physiology of adipose tissue may contribute to the potent metabolic effects of some of these procedures. This includes specific effects on various fat depots, the function of individual adipocytes and the interaction between adipose tissue and other key metabolic tissues. Besides a dramatic loss of fat mass, bariatric surgery shifts the distribution of fat from visceral to the subcutaneous compartment favoring metabolic improvement. The sensitivity towards lipolysis controlled by insulin and catecholamines is improved, adipokine secretion is altered and local adipose inflammation as well as systemic inflammatory markers decreases. Some of these changes have been shown to be weight loss independent, and novel hypothesis for these effects includes include changes in bile acid metabolism, gut microbiota and central regulation of metabolism. In conclusion bariatric surgery is capable of improving aspects of adipose tissue function and do so in some cases in ways that are not entirely explained by the potent effect of surgery. © 2016 World Obesity.

Association between obesity and lower urinary tract symptoms: propensity score matching study between healthy controls and obese patients seeking bariatric surgery

BACKGROUND

To date, the association between obesity and lower urinary tract symptoms (LUTS) is controversial.

OBJECTIVE

To overcome the current inconsistent results regarding the association between obesity and LUTS and to investigate the association between obesity and LUTS using propensity score matching analysis.

SETTING

Bariatric center of excellence and health promotion center at university hospital.

METHODS

From August 2012 to December 2014, a total of 260 obese patients (77 men and 180 women) visited to our bariatric center to undergo bariatric surgery. Patients' International Prostate Symptom Score (IPSS) and overactive bladder symptom score were compared with those of 844 healthy controls who had visited our health center during the same period. To control for the effects of age, 1:1 propensity score matching was used.

RESULTS

After matching propensity score forage, 73 male patients and 176 female patients were included in our study. In men, all IPSS items except "frequency" were significantly different between obese patients and controls; median scores were higher in the obese group. In women, all IPSS items except "feeling of incomplete emptying" were significantly different between the 2 groups. Both voiding and storage subscores also had marked differences in both genders (P<.001). Total IPSS, quality of life, and total overactive bladder symptom score were significantly different in both genders (P< .001).

CONCLUSION

There were marked differences in LUTS between obese and nonobese patients, including in voiding and storage symptoms. Considering the relatively young age of both groups, this case-control study supports the hypothesis of a relationship between obesity and bladder pathophysiology.