The Association of Differing Measures of Overweight and Obesity With Prevalent Atherosclerosis

Association of Anthropometric and CT-Based Obesity Indices with Subclinical Atherosclerosis

AIM

Few studies have compared the strength in the associations of anthropometric and computed tomography (CT)-based obesity indices with coronary artery calcification (CAC), aortic artery calcification (AoAC), and aortic valve calcification (AVC).

METHODS

We assessed cross-sectcional associations of anthropometric and CT-based obesity indices with CAC, AoAC, and AVC. Anthropometric measures included body mass index (BMI), waist circumference, hip ircumference, waist-to-hip circumference ratio, and waist-to-height ratio in 931 men (mean age, 63.7 years) from a population-based cohort. CT images at the L4/5 level were obtained to calculate the areas of abdominal visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), total adipose tissue (TAT), VAT-to-SAT ratio (VSR), and VAT-to-TAT ratio (VTR). CAC, AoAC, and AVC were quantified using the Agatston score based on CT scanning.

RESULTS

CAC, AVC, and AoAC were present in 348 (62.6%), 173 (18.6%), and 769 (82.6%) participants, respectively. In multivariable models adjusting for age, lifestyle factors, and CT types (electron beam CT and multidetector row CT), anthropometric and CT-based obesity indices were positively associated with CAC (p＜0.01). Conversely, VAT-to-SAT ratio and VAT-to-TAT ratio were positively associated with AoAC (p＜0.01). Any obesity indices were not associated with AVC.

CONCLUSIONS

The strength of the associations of obesity indices with subclinical atherosclerosis varied according to the anatomically distinct atherosclerotic lesions, among men.

Urinary cortisol and cardiovascular events in women vs. men: The multi-ethnic study of atherosclerosis

Research suggests that women experience greater cardiovascular ischemic effects from stress than men. Visceral adiposity is an endocrine tissue that differs by sex and interacts with stress hormones. We hypothesized that urinary cortisol would be associated with increased cardiovascular events and change in coronary artery calcium score (CAC) in women, and these relationships would vary by central obesity. In the Multi-Ethnic Study of Atherosclerosis Stress Ancillary study, cortisol was quantified by 12-h overnight urine collection. Central obesity was estimated by waist-hip ratio (WHR). Multivariable Cox models estimated the relationship between cortisol and cardiovascular events and assessed for moderation by WHR. The relationship between cortisol and change in CAC Agatston score was assessed by Tobit regression models. 918 patients were analyzed with median follow up of 11 years. There was no association between urinary cortisol and cardiovascular events in the cohort. However, in individuals with below median WHR, higher urinary cortisol levels (upper tertile) were associated with higher cardiovascular event rates in the full cohort, women, and men, but not in groups with above median WHR. There was significant moderation by WHR in women, but not men, whereby the association between elevated cortisol and increased cardiovascular events diminished as WHR increased. Urinary cortisol was associated with increased change in CAC in women (P = 0.003) but not men, without moderation by WHR. Our study highlights associations between cortisol and subclinical atherosclerosis in women, and moderation of the relationship between cortisol and cardiovascular events by central obesity in both genders.

How does obesity affect mortality through blood pressure and blood glucose in Chinese and US citizens? Insights from a causal mediation analysis of two large cohorts

Background

Obesity, which has reached the scale of a global pandemic, is a leading cause of premature death. It is unclear to what extent its effect on mortality was driven by blood pressure or glucose levels in people of different ethnicities.

Methods

We conducted a causal mediation analysis to estimate the mediation effect of blood pressure and glucose between body mass index (BMI) or waist-hip ratio (WHR) on mortality based on data from the China Kadoorie Biobank (CKB) (n = 458 385) and US National Health and Nutrition Examination Survey (NHANES) (1999-2008, n = 20 726).

Results

The WHR's effect on mortality was mediated by blood pressure and glucose in the CKB data set by 38.7% (95% confidence interval (CI) = 34.1, 43.2) and 36.4% (95% CI = 31.6, 42.8), whereas in NHANES by 6.0% (95% CI = 2.3, 8.3) and 11.2% (95% CI = 4.7, 22.7), respectively. For associations between BMI and mortality in subjects with overweight or obesity, the mediator proportion of blood glucose and pressure was 49.4% (95% CI = 40.1, 62.5) and 16.9% (95% CI = 13.6, 22.9) in CKB and 9.10% (95% CI = 2.2, 25.9) and 16.7% (95% CI = 7.3, 49.0) in NHANES, respectively. We stratified the patients by their blood glucose, blood pressure level, or both into four groups. The effect of WHR on mortality was comparable across subgroups in either cohort. The associations between BMI and mortality were stronger in patients with higher blood pressure in CKB (P = 0.011) and blood glucose in NHANES (P = 0.035) in patients with overweight and obesity.

Conclusions

The relationship between WHR and mortality in the CKB data set was potentially caused by blood pressure and glucose to a much greater extent than in the NHANES one. The effect of BMI influenced by blood pressure was significantly higher among Chinese individuals with overweight and obesity. These results implicate a different intervention strategy is required for blood pressure and blood glucose in China and US to prevent obesity and obesity-related premature death.

Efficacy of traditional Chinese exercises in improving anthropometric and biochemical indicators in overweight and obese subjects: A systematic review and meta-analysis

BACKGROUND

The efficacy of traditional Chinese exercise (TCE)-based intervention in the improvement of anthropometric and biochemical indicators in overweight and obese patients is controversial. In this regard, the aim of this review was to summarize the evidence of TCE interventions to evaluate their effectiveness on the anthropometric and biochemical indicators of overweight and obese patients.

METHOD

Five databases were systematically searched for relevant articles published from inception to October 2022. Randomized controlled trials examining TCE intervention in overweight and obese patients The treatment effects were estimated using a random-effect meta-analysis model with standardized mean differences (Hedges' g). The categorical and continuous variables were used to conduct moderator analyses. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (identifier CRD42022377632).

RESULT

Nine studies involving a total of 1297 participants were included in the final analysis. In the anthropometric indicators outcomes, the meta-analytic findings revealed large and significant improvements in body mass index (g = 1.44, 95% confidence interval [CI] = 1.27-1.61, P = .000, I2 = 99%), weight (g = 1.47, 95% CI = 1.25-1.68, P = .000, I2 = 95%), fat percentage (g = 1.22, 95% CI = 0.52-1.93, P = .000, I2 = 93%), and small and significant improvements in waist circumference (g = 0.38, 95% CI = 0.21-0.54, P = .000, I2 = 99%). In the biochemical indicators outcomes, the findings revealed large and significant improvements in low density lipoprotein (g = 2.08, 95% CI = 1.80-2.37, P = .000, I2 = 98%), moderate and significant improvements in triglyceride (g = 0.69, 95% CI = 0.56-0.81, P = .000, I2 = 96%), small and significant improvements in total cholesterol (g = 0.37, 95% CI = 0.19-0.54, P = .000, I2 = 77%), and high-density lipoprotein (g = -0.71, 95% CI = -0.86 to 0.57, P = .000, I2 = 99%). The moderator shows that the effects of TCE on anthropometric and biochemical indicators were moderated by frequency of exercise, exercise duration, and type of control group.

CONCLUSION

TCE intervention is a beneficial non-pharmacological approach to improving anthropometric and biochemical indicators in overweight and obese subjects, especially in body mass index, weight, fat percentage, triglyceride, and low-density lipoprotein. The clinical relevance of our findings is pending more extensive trials and more rigorous study designs to strengthen the evidence.

Associations between Body Mass Index, Waist Circumference, and Myocardial Infarction in Older Adults Aged over 75 Years: A Population-Based Cohort Study

Background and Objectives: Body mass index (BMI) is widely used as a standard screening method for obesity and an indicator of related diseases. However, its inability to distinguish between lean body mass and body fat limits its utility. This limitation may be more prominent in older populations, wherein age-related sarcopenia and increased visceral fat due to the redistribution of adipose tissue may preclude a precise estimation of obesity. Many studies suggest that waist circumference (WC) is more strongly related to obesity-related diseases. There are also different opinions on whether the obesity paradox is real or a result of confusing interpretations. This study seeks to determine the association between myocardial infarction (MI), BMI, and WC in older adults and to determine if BMI and WC can reliably predict the risk of cardiovascular disease. Materials and Methods: We conducted a cohort study of older Korean adults aged over 75 years registered in the National Health Insurance System Senior database. Results: The results from the analysis using model 5, which was adjusted for each study variable, showed that the lower the BMI, the higher the hazard ratio (HR) of MI and vice versa. On the other hand, groups with lower than normal WC showed lower HR; even if it was higher, the difference was not statistically significant. Those with abdominal obesity tended to have an increased HR of MI. Conclusions: This study found that HR for MI has a negative relationship with BMI, whereas it has a positive relationship with WC. Furthermore, WC is a more appropriate indicator for predicting the risk of MI in the older population.

Time-restricted eating with or without low-carbohydrate diet reduces visceral fat and improves metabolic syndrome: A randomized trial

Overconsumption of carbohydrate-rich food combined with adverse eating patterns contributes to the increasing incidence of metabolic syndrome (MetS) in China. Therefore, we conducted a randomized trial to determine the effects of a low-carbohydrate diet (LCD), an 8-h time-restricted eating (TRE) schedule, and their combination on body weight and abdominal fat area (i.e., primary outcomes) and cardiometabolic outcomes in participants with MetS. Compared with baseline, all 3-month treatments significantly reduce body weight and subcutaneous fat area, but only TRE and combination treatment reduce visceral fat area (VFA), fasting blood glucose, uric acid (UA), and dyslipidemia. Furthermore, compared with changes of LCD, TRE and combination treatment further decrease body weight and VFA, while only combination treatment yields more benefits on glycemic control, UA, and dyslipidemia. In conclusion, without change of physical activity, an 8-h TRE with or without LCD can serve as an effective treatment for MetS (ClinicalTrials.gov: NCT04475822).

BMI is not independently associated with coronary artery calcification in a large single‐center CT cohort

Objective

Obesity is associated with cardiovascular disease (CVD) and CVD mortality. However, previous reports showed a paradoxical protective effect in patients with known CVD referred as "obesity paradox". Therefore, the aim of the present study was to investigate the association of body mass index (BMI) with coronary artery calcification (CAC) in a large outpatient cardiac CT cohort.

Methods

4.079 patients who underwent cardiac CT between December 2007-May 2014 were analyzed. BMI and clinical risk factors (current smoking, diabetes mellitus type 2, family history, systolic blood pressure, lipid spectrum) were assessed. Missing values were imputed using multiple imputation. CAC extent was categorized as absent (0), mild (>0-100), moderate (>100-400) and severe (>400).

Results

Multivariable multinomial logistic regression analysis, including all risk factors as independent variables, showed no association between BMI and CAC. Using absence of calcification as reference category, the odds ratios per unit increase in BMI were 1.01 for mild; 1.02 for moderate; and 1.00 for severe CAC (p-values ≥0.103).

Conclusions

No statistically significant association was observed between BMI and CAC after adjustment for other risk factors.

A Bibliometric Analysis of Research on the Links Between Gut Microbiota and Atherosclerosis

Background

Emerging evidence has linked gut microbiota (GM) and its related metabolites to atherosclerosis (AS). This study aimed to analyze the evolution of GM in AS in the past decades, and provide valuable insights in this field.

Methods

Web of Science Core Collection (WoSCC) was applied to retrieve the publications related to GM in AS from their inception until 2 December 2021, and the data was analyzed in Microsoft Excel, Scimago Graphica, CiteSpace, and VOSviewer.

Results

In total, 560 documents were extracted from the WoSCC databases. The publications have shown rapid growth since 2008. China and Cleveland Clin were the most prolific country and institution, respectively. The journal with the most publications is Nutrients, and Nature was the most co-cited journal. Among 3556 related authors, Hazen, Stanley L., Tang, W. H. Wilson, and Wang, Zeneng were the top 3 contributing authors in this field. Aside from “gut microbiota,” “atherosclerosis,” the terms “TMAO,” “metabolite,” “obesity,” and “phosphatidylcholine” were frequently occurred in the abstract and title of articles. Burst detection of keywords indicated that “metabolic syndrome,” “acid,” and “bile acid” were hot topics in recent years. According to the co-citation analysis of references, the research focus in this area has changed over time, and recent researches focus on choline, hypertension, butyrate, and berberine.

Conclusion

Our study showed that the researches of GM in AS have been flourishing, and the content themes were constantly deepened. Human GM is critical to atherosclerotic diseases, and this hot topic is still worthy of more focus in the future.

Is Obesity a Risk Factor for Carotid Atherosclerotic Disease?—Opportunistic Review

Obesity is a risk factor for coronary atherosclerosis. However, the influence of adipose tissue in carotid atherosclerosis is not completely understood. No systematic review/meta-analysis was previously performed to understand if obesity is a risk factor for carotid atherosclerosis. This paper aims to provide an opportunistic review of the association between obesity and carotid atherosclerosis and define the role of the different adipose tissue depots in the characteristics of carotid stenosis. The databases PubMed and Cochrane Library were searched on 15–27 April and 19 May 2021. A total of 1750 articles published between 1985 and 2019 were identified, 64 were preselected, and 38 papers (35,339 subjects) were included in the final review. The most frequent methods used to determine obesity were anthropometric measures. Carotid plaque was mostly characterized by ultrasound. Overall obesity and visceral fat were not associated with the presence of carotid plaque when evaluated separately. Waist-hip ratio, however, was a significant anthropometric measure associated with the prevalence of carotid plaques. As it reflected the ratio of visceral and subcutaneous adipose tissue, the balance between these depots could impact the prevalence of carotid plaques.

Influence of Waist-to-Hip Ratio on the Prognosis of Heart Failure Patients With Revascularized Coronary Heart Disease

Background: Heart failure (HF) is considered one of the most common complications of coronary heart disease (CHD), with a higher incidence of readmission and mortality. Thus, exploring the risk factors related to the prognosis is necessary. Moreover, the effect of the waist-to-hip ratio (WHR) on HF patients with revascularized CHD is still unclear. Thus, we aimed to assess the influence of WHR on the prognosis of HF patients with revascularized CHD. Methods: We collected data of HF patients with revascularized CHD who were referred to the Cardiac Rehabilitation Clinic of PLA Hospital from June 30, 2015, to June 30, 2019. Cox proportional hazard regression analysis was used to determine the relationship between WHR and prognosis of HF patients with revascularized CHD. Patients were divided into higher and lower WHR groups based on the cutoff WHR value calculated by the X-tile software. Cox regression analysis was used to analysis the two groups. We drew the receiver operating characteristic curve (ROC) of WHR and analyzed the differences between the two groups. Endpoints were defined as major adverse cardiac events (MACE) (including all-cause mortality, non-fatal myocardial infarction, unscheduled revascularization, and stroke). Results: During the median follow-up of 39 months and maximum follow-up of 54 months, 109 patients were enrolled, of which 91.7% were males, and the mean age was 56.0 ± 10.4 years. WHR was associated with the incidence of MACE in the Cox regression analysis (p = 0.001); an increase in WHR of 0.01 unit had a hazard ratio (HR) of 1.134 (95%CI: 1.057-1.216). The WHR cutoff value was 0.93. Patients in the higher WHR group had a significantly higher risk of MACE than those in the lower WHR group (HR = 7.037, 95%CI: 1.758-28.168). The ROC area under the curve was 0.733 at 4 years. Patients in the higher WHR group had a higher body mass index (BMI; 26.7 ± 3.5 vs. 25.4 ± 2.4, P = 0.033) than patients in the lower WHR group. Conclusions: WHR is an independent risk factor of the long-term prognosis of Chinese HF patients with revascularized CHD. Patients with WHR ≥ 0.93 require intensified treatment. Higher WHR is related to higher BMI and ΔVO2/ΔWR.

Association Between a Body Shape Index and Subclinical Carotid Atherosclerosis in Population Free of Cardiovascular and Cerebrovascular Diseases

AIM

We used a dataset from a cross-sectional survey conducted in China to determine which of the anthropometric indices of obesity are important in terms of carotid atherosclerosis free of cardiovascular and cerebrovascular diseases.

METHODS

A total of 5,245 participants who were volunteering for carotid ultrasound unit in this cross-sectional survey were included in the present analysis. All subjects were free of angina, myocardial infarction, heart failure and stroke, and cancer. A low-risk subgroup was defined as people free of hypertension, diabetes, and hyperlipidemia. All analyses based on logistic regression were gender-specific.

RESULTS

The present study consisted of 2,501 males and 2,744 females, with 776 (31.03%) diagnosed as carotid artery plaque in males and 550 (20.04%) in females. Univariable analyses in unadjusted logistic model showed significant associations between disease presence and all central obesity indices. After adjusting for more variables, only a body shape index (ABSI) was associated with the presence of disease in both males and females. Moreover, stepwise regression approaches revealed that ABSI was always an independent determinant of the presence of subclinical carotid plaque. Multiple regression shows a linear and significant increase in the prevalence of atherosclerosis in males and females as ABSI decile levels increased. Similar results were obtained when the association between ABSI and carotid plaque was studied in this low-risk subgroup.

CONCLUSIONS

ABSI, as a novel anthropometric indicator compared with traditional indices, was found to have a closer relationship with subclinical carotid atherosclerosis, even in populations free of hypertension, diabetes, and hyperlipidemia.

Cardiovascular disease in obesity hypoventilation syndrome - A review of potential mechanisms and effects of therapy

Cardiovascular disease is common in patients with obesity hypoventilation syndrome (OHS) and accounts in part for their poor prognosis. This narrative review article examines the epidemiology of cardiovascular disease in obesity hypoventilation syndrome, explores possible contributing factors and the effects of therapy. All studies that included cardiovascular outcomes and biomarkers were included. Overall, there is a higher burden of cardiovascular disease and cardiovascular risk factors among patients with obesity hypoventilation syndrome. In addition to obesity and sleep-disordered breathing, there are several other pathophysiological mechanisms that contribute to higher cardiovascular morbidity and mortality in OHS. There is evidence emerging that positive airway pressure therapy and weight loss have beneficial effects on the cardiovascular system in obesity hypoventilation syndrome patients, but further research is needed to clarify whether this translates to clinically important outcomes.

The impact of visceral fat and levels of vitamin D on coronary artery calcification

OBJECTIVE

To evaluated calcification of the coronary arteries and its association with visceral fat and 25-hydroxyvitamin D (25(OH)D) serum levels.

METHODS

A cross sectional study involving 140 individuals without any previous diagnosis of cardiovascular disease. A biochemical analysis of vitamin D serum levels was carried out, as well as computed tomography to measure coronary artery calcium score and visceral adipose tissue.

RESULTS

The mean age of the individuals was 55.9 (±12.4). Coronary artery calcium was observed in 40.7% of the population. Vitamin D presented median serum levels of 30.4 ng/ml (IQ24.5-39.1), with 14,1 and 33.7% of the individuals presenting deficiency and insufficiency, respectively. In the univariate analysis, the calcium score was more prevalent in aged patients (p<0.01), in hypertensive individuals (p<0.01), in diabetics (p=0.02), and in those with a higher concentration of VAT (p=0.02). In the adjusted analysis, it was found that the highest concentration of VAT (OR: 4.0; 95%CI 1.4-11.7), hypertension (OR: 4.8; 95%CI 1.5-15.3), and age (OR: 10.4; 95%CI 3.9-27.6) were predictors of subclinical atherosclerosis, regardless of body mass index, diabetes, and 25OHD.

CONCLUSIONS

Excess visceral fat was associated with subclinical atherosclerosis, regardless of other risk factors for cardiovascular disease. Serum levels of 25OHD were not associated with CAD in its early stages.

Obesity and Cardiovascular Disease: A Scientific Statement From the American Heart Association

The global obesity epidemic is well established, with increases in obesity prevalence for most countries since the 1980s. Obesity contributes directly to incident cardiovascular risk factors, including dyslipidemia, type 2 diabetes, hypertension, and sleep disorders. Obesity also leads to the development of cardiovascular disease and cardiovascular disease mortality independently of other cardiovascular risk factors. More recent data highlight abdominal obesity, as determined by waist circumference, as a cardiovascular disease risk marker that is independent of body mass index. There have also been significant advances in imaging modalities for characterizing body composition, including visceral adiposity. Studies that quantify fat depots, including ectopic fat, support excess visceral adiposity as an independent indicator of poor cardiovascular outcomes. Lifestyle modification and subsequent weight loss improve both metabolic syndrome and associated systemic inflammation and endothelial dysfunction. However, clinical trials of medical weight loss have not demonstrated a reduction in coronary artery disease rates. In contrast, prospective studies comparing patients undergoing bariatric surgery with nonsurgical patients with obesity have shown reduced coronary artery disease risk with surgery. In this statement, we summarize the impact of obesity on the diagnosis, clinical management, and outcomes of atherosclerotic cardiovascular disease, heart failure, and arrhythmias, especially sudden cardiac death and atrial fibrillation. In particular, we examine the influence of obesity on noninvasive and invasive diagnostic procedures for coronary artery disease. Moreover, we review the impact of obesity on cardiac function and outcomes related to heart failure with reduced and preserved ejection fraction. Finally, we describe the effects of lifestyle and surgical weight loss interventions on outcomes related to coronary artery disease, heart failure, and atrial fibrillation.

Endurance exercise and the risk of cardiovascular pathology in men: a comparison between lifelong and late-onset endurance training and a non-athletic lifestyle - rationale and design of the Master@Heart study, a prospective cohort trial

Introduction

Low and moderate endurance exercise is associated with better control of cardiovascular risk factors, a decreased risk of coronary artery disease and atrial fibrillation (AF). There is, however, a growing proportion of individuals regularly performing strenuous and prolonged endurance exercise in which the health benefits have been challenged. Higher doses of endurance exercise have been associated with a greater coronary atherosclerotic plaque burden, risk of AF and myocardial fibrosis (MF).

Methods and analysis

Master@Heart is a multicentre prospective cohort study aiming to assess the incidence of coronary atherosclerosis, AF and MF in lifelong endurance athletes compared to late-onset endurance athletes (initiation of regular endurance exercise after the age of 30 years) and healthy non-athletes.

The primary endpoint is the incidence of mixed coronary plaques. Secondary endpoints include coronary calcium scores, coronary stenosis >50%, the prevalence of calcified and soft plaques and AF and MF presence. Tertiary endpoints include ventricular arrhythmias, left and right ventricular function at rest and during exercise, arterial stiffness and carotid artery intima media thickness.

Two hundred male lifelong athletes, 200 late-onset athletes and 200 healthy non-athletes aged 45–70 will undergo comprehensive cardiovascular phenotyping using CT, coronary angiography, echocardiography, cardiac MRI, 12-lead ECG, exercise ECG and 24-hour Holter monitoring at baseline. Follow-up will include online tracking of sports activities, telephone calls to assess clinical events and a 7-day ECG recording after 1 year.

Ethics and dissemination

Local ethics committees approved the Master@Heart study. The trial was launched on 18 October 2018, recruitment is complete and inclusions are ongoing.

Trial registration number

NCT03711539.

[Influence of age factor and age-associated predictors on remote results of coronary artery bypass grafting]

This study was undertaken to analyse long-term survival and its predictors, depending on age of patients who underwent isolated coronary aortic bypass grafting. Our study included a total of 177 consecutive patients operated on during 2014. For the purpose of statistical analysis, the patients were divided into two groups according to their age at the time of surgery: <60 years (n=96) and >60 years (n=81). The mean age in the groups <60 years and >60 years amounted to 54.5±2.9 years and 63.5±2.5 years, respectively. All data were obtained from the patients' medical histories, outpatient follow-up records, and operative reports. The average duration of follow-up in the overall cohort amounted to 5.1±1.7 years. Chronic obstructive pulmonary disease, peripheral artery disease, and acute impairment of cerebral circulation were of significantly less common occurrence in the younger patient cohort. However, the frequency of a body mass index of ≥30 kg/m2, unstable angina, previously endured myocardial infarction and left ventricular systolic dysfunction in the preoperative period appeared to be significantly higher in this population. At 5 years after surgery, freedom from survival amounted to 94.8% in patients younger than 60 years (5 patients) and to 90.1% (8 patients) in those aged 60 years and older (p<0.001). Based on the findings of a multivariate analysis, independent predictors of mortality turned out to be a history of myocardial infarction, chronic kidney disease, diabetes mellitus, chronic obstructive pulmonary disease, lesions of peripheral arteries and the trunk of the left coronary artery. The area under the receiver operating characteristic curve was 0.834 (p<0.001, 95% CI: 0.724-0.902). Despite the fact that coronary artery bypass grafting is an effective method of treatment of ischaemic heart disease for both groups, special attention should be paid to the development and improvement of preventive strategies aimed at decreasing the impact of specific risk factors for cardiovascular diseases such as diet, lifestyle, weight control, and more aggressive medical therapy in younger patients. It is necessary to elaborate a reasonable strategy and optimization of the choice of an optimal approach to myocardial revascularization for elderly patients with multivessel and truncal lesions of coronary arteries, which are potential risk factors of death in the postoperative period.

Obesity and Coronary Heart Disease: Epidemiology, Pathology, and Coronary Artery Imaging

Overweight and obesity contribute to the development of cardiovascular disease (CVD) in general and coronary heart disease (CHD) in particular in part by their association with traditional and nontraditional CVD risk factors. Obesity is also considered to be an independent risk factor for CVD. The metabolic syndrome, of which central obesity is an important component, is strongly associated with CVD including CHD. There is abundant epidemiologic evidence of an association between both overweight and obesity and CHD. Evidence from postmortem studies and studies involving coronary artery imaging is less persuasive. Recent studies suggest the presence of an obesity paradox with respect to mortality in persons with established CHD. Physical activity and preserved cardiorespiratory fitness attenuate the adverse effects of obesity on CVD events. Information concerning the effect of intentional weight loss on CVD outcomes in overweight and obese persons is limited.

Association between anthropometric indicators of obesity and cardiovascular risk factors among adults in Shanghai, China

Background

To determine the optimal cut-off values and evaluate the associations of body mass index (BMI), waist circumference (WC) and waist-height ratio (WHtR) with cardiovascular disease (CVD) risk factors.

Methods

A large-scale cross-sectional survey was conducted among 35,256 adults aged 20–74 years in Shanghai between June 2016 and December 2017. Receiver operating characteristic (ROC) analyses were conducted to assess the optimal cut-off anthropometric indices of CVD risk factors including hypertension, diabetes, dyslipidemia and hyperuricemia. Multivariate Logistic regression models were preformed to evaluate the odds ratio of CVD risk factors.

Results

The area under the curve (AUC) of WHtR was significantly greater than that of BMI or WC in the prediction of hypertension and diabetes, and AUCs were higher in women than men. The optimal cut-off values of WHtR were approximately 0.51 in both sexes, while the cut-off values of BMI and WC were higher for men compared with women. The optimal cutoff values of BMI and WC varied greatly across different age groups, but the difference in WHtR was relatively slight. Among women, the optimal threshold of anthropometric indices appeared to increase with age for hypertension and diabetes. The odds ratio between anthropometric indices and CVD risk factors were attenuated with age. WHtR had the greatest odds ratio for CVD risk factors among adults under 60 years old except for women with hypertension, while among 60–74 years, BMI yielded the greatest odds ratio in terms of all CVD outcomes except for women with diabetes.

Conclusions

WHtR had the best performance for discriminating hypertension and diabetes and potentially be served as a standard screening tool in public health. The associations between three anthropometric indices and CVD risk factors differed by sex and decreased with age. These findings indicated a need to develop age- and gender-specific difference and make effective strategies for primary prevention of CVDs.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7366-0) contains supplementary material, which is available to authorized users.

Multi-compartment mesenchymal tissue segmentation in pelvic MRI examinations of women: Anthropomorphic and clinical correlations

AIM

To investigate the reliability of multicompartmental volumetric mesenchymal segmentations on MRI and their correlations with anthropomorphic and clinical parameters.

MATERIALS AND METHODS

A consecutive series of middle-age (35-50 year old) female volunteers with variable body mass index (BMI) and MRI scans performed as a part of the Dallas Heart Study were included. A semi-automatic segmentation tool was used to partition different mesenchymal tissues- fat, muscle, and bone on MRI of pelvis. Total volumes of each compartment were calculated and compared between overweight/obese (BMI> = 25 kg/m2) and non-obese (BMI < 25 kg/m2) groups, and with physical performance measurements, i.e. mean activity counts per minute (MVPA) and cardiorespiratory fitness (CRF) estimated by submaximal treadmill test (TT). Kruskal Wallis, Mann-Whitney U test, intraclass correlation coefficient (ICC) and Spearman correlations were used. P value <0.05 was considered statistically significant.

RESULTS

There were statistically significant positive correlations between fat volume and BMI (p < 0.0001), muscle volume and height (p = 0.03), and bone volume and height (p < 0.0001). Significant inverse correlations were found between bone volume and BMI (p = 0.002). Fair to good interobserver reliability was seen with muscle and fat volumes (ICC = 0.43-0.64) and excellent reliability was seen with bone volumes (ICC = 0.78-0.79). Statistically significant inverse correlations were found between MVPA and age (p = 0.01), and TT with BMI and weight (p = 0.01, 0.03).

CONCLUSION

Multi-compartment mesenchymal tissue volume quantification on pelvic MRI is reliable in females. Inverse correlation of bone volume with BMI has potential implications for future risk of fracture.

Central and peripheral pulse wave velocity and subclinical myocardial stress and damage in older adults

Background

Arterial stiffness independently predicts cardiovascular disease. However, few studies have evaluated the associations of central and peripheral pulse wave velocity (PWV) with biomarkers of both myocardial stress (natriuretic peptide [NT-proBNP]) and damage (high-sensitivity cardiac troponin-T [hs-cTnT]) among persons without cardiac disease.

Methods

We examined 3,348 participants (67–90 years) without prevalent cardiac disease in the Atherosclerosis Risk in Communities (ARIC) Study (2011–13). The cross-sectional associations of PWV quartiles for central arterial segments (carotid-femoral, heart-carotid, heart-femoral) and peripheral artery (femoral-ankle) with NT-proBNP and hs-cTnT were evaluated accounting for potential confounders.

Results

Most PWV measures demonstrated J- or U-shaped associations with the two cardiac biomarkers. The highest (Q4) vs. second lowest (Q2) quartile of central PWV measures (carotid-femoral, heart-carotid, heart-femoral PWV) were associated with higher levels of NT-proBNP independently of demographic characteristics. The associations were less evident for hs-cTnT. These associations were attenuated after adjusting for traditional cardiovascular risk factors, but the heart-carotid PWV-NT-proBNP relationship remained borderline significant (difference in log-NT-proBNP = 0.08 [-0.01, 0.17] in Q4 vs. Q2, p = 0.07). Peripheral PWV demonstrated inverse associations. Higher values of NT-proBNP were seen in the lowest vs. second lowest quartile of all PWV measures.

Conclusions

Central stiffness measures showed stronger associations with cardiac biomarkers (particularly NT-proBNP) than peripheral measures among older adults without cardiac disease. Our findings are consistent with the concept of ventricular-vascular coupling and suggest that central rather than peripheral arterial hemodynamics are more closely related to myocardial stress rather than damage.

Assessment of adiposity distribution and its association with diabetes and insulin resistance: a population-based study

BACKGROUND

Rational measures in estimating adiposity distribution in diabetic patients has yet to be validated. This study aims to provide insight about the possible links between routinely available body adiposity parameters and the development of both diabetes and insulin resistance.

METHODS

We performed a population-based cross-sectional study in 9496 subjects aged 40 years or older. All of the body adiposity measures including body mass index (BMI), waist circumference (WC), waist-hip ratio (WHR), waist-height ratio (WHtR), visceral adiposity index (VAI), body adiposity index (BAI) and lipid accumulation product index (LAP) were separately evaluated according to standard measurement methods. Diabetes was diagnosed according to the American Diabetes Association 2010 criteria.

RESULTS

All tested body adiposity measurements were significantly associated with fasting plasma glucose (FPG), oral glucose tolerance test (OGTT) 2 h glucose, HbA1c and fasting insulin. Compared with other adiposity phenotypes, LAP have shown the relatively strongest while BAI have shown the relatively weakest association with increased odds of both diabetes and insulin resistance across all logistic regression models. Additionally, LAP provided the best discrimination accuracy for diabetes [area under the curve (AUC): 0.658 95% confidence intervals (CI) 0.645-0.671] and insulin resistance (AUC: 0.781 95% CI 0.771-0.792) when compared with other body adiposity parameters.

CONCLUSIONS

The LAP index seems to be a better indicator than other adiposity measures tested in the study to evaluate the association of visceral fat mass with diabetes and insulin resistance, which should be given more consideration in the clinical practice.

An increased waist-to-hip ratio is a key determinant of atherosclerotic burden in overweight subjects

AIMS

The association of overweight status and cardiovascular disease is not clear. In this study we aimed to investigate coronary atherosclerotic disease, evaluated as coronary artery calcium score (CACs), in overweight patients with or without abdominal obesity as defined by waist-to-hip ratio (WHR).

METHODS

We enrolled 276 patients aged between 40 and 70 years, with a body mass index of 25-29.9 kg/m² and at least one cardiovascular risk factor. Exclusion criteria were history of diabetes, cardiovascular or renal disease. Patients were stratified in high WHR (H-WHR) or low WHR (L-WHR) group according to WHR (≥ 0.85 for women and ≥ 0.90 for men) and underwent multi-detector computed tomography for CACs. Mean carotid intima-media thickness (IMT) and plaque presence were equally assessed.

RESULTS

CACs was higher in the H-WHR group compared to L-WHR (9.05 [0.0-83.48] vs 0.0 [0.0-64.7] AU, p < 0.01); the prevalence of CACs > 0 in the H-WHR group was significantly higher than subjects with L-WHR (59.6% vs 38.5%, p < 0.001). Moreover, H-WHR group had higher mean IMT (0.64 [0.56-0.72] vs 0.59 [0.55-0.67] mm, p < 0.05) and higher carotid plaque prevalence (63.7% vs 50.8%, p < 0.05) compared to subjects with L-WHR. Logistic regression showed that H-WHR was associated with presence of CACs and carotid plaque (p < 0.01). In a multiple linear regression, WHR was positively associated with CACs and IMT (p < 0.01).

CONCLUSIONS

H-WHR is a marker of coronary and peripheral atherosclerotic burden in overweight patients.

Overview of Epidemiology and Contribution of Obesity and Body Fat Distribution to Cardiovascular Disease: An Update

Obesity is recognized as a heterogeneous condition in which individuals with similar body mass index may have distinct metabolic and cardiovascular risk profiles. Susceptibility to obesity-related cardiometabolic complications is not solely mediated by overall body fat mass, but is largely dependent upon individual differences in regional body fat distribution and ability of subcutaneous adipose tissue to expand. The present review will discuss to what extent the individual variation in body fat distribution is one of the clinical key variables explaining the metabolic heterogeneity of obesity and its related cardiovascular risk. We will present the evidence for the complex nature of the relationship between obesity and cardiovascular disease, outline our current understanding of the mechanisms involved, and identify future direction of research pertinent to this interaction.

Obesity and metabolic features associated with long-term developing diastolic dysfunction in an initially healthy population-based cohort

BACKGROUND

Diastolic dysfunction (DD) is increasingly common. However, its metabolic determinants are poorly known. This study aims to determine which metabolic and inflammatory features predict DD in initially healthy adults.

METHODS

We prospectively analyzed the association between metabolic features and DD in 728 initially healthy adults aged 30-60 from Eastern France enrolled in the STANISLAS population-based cohort. Clinical and biological cardiovascular features were collected at baseline (1994-1995). DD was assessed twenty years later (2011-2016) by echocardiography using current international guidelines. For replication purposes, 1463 subjects from the Malmö Preventive Project cohort were analyzed.

RESULTS

In the STANISLAS cohort, 191 subjects (26.2%) developed DD. In age-sex-adjusted logistic models, significant predictors of DD were body mass index (BMI, odds ratio for 1-standard-deviation increase (OR) 1.28, 95% CI 1.08-1.52), waist circumference (WC, OR 1.48, 95% CI 1.18-1.84), waist-hip ratio (OR 1.53, 95% CI 1.16-2.02), systolic blood pressure (OR 1.19, 95% CI 1.00-1.43) and triglycerides (TG, OR 1.18, 95% CI 1.00-1.40). Subjects with elevated WC (> 80th percentile) and TG (> 50th percentile) had a twofold higher DD risk (age-sex-adjusted odds ratio 2.00, 95% CI 1.20-3.31, P = 0.008), whereas no such interplay was observed for BMI. In the Malmö cohort, BMI was similarly associated with DD; participants with both elevated BMI and TG were at higher DD risk (age-sex-adjusted odds ratio 1.61, 95% CI 1.18-2.20, P = 0.002).

CONCLUSIONS

Subjects with elevated WC and TG may have a higher long-term DD risk. Prevention targeting visceral obesity may help reduce the incidence of DD.

Relation of Waist-Hip Ratio to Long-Term Cardiovascular Events in Patients With Coronary Artery Disease

We aimed to assess the association between measures of obesity and outcomes in coronary artery disease (CAD) patients. We included consecutive patients referred to cardiac rehabilitation for previous CAD events, who were classified using body mass index (BMI) groups and gender-specific tertiles of waist-to-hip ratio (WHR). Follow-up was ascertained using a population-based, record linkage system. Major cardiovascular event (MACE) was defined as the composite outcome including acute coronary syndromes, coronary revascularization, ventricular arrhythmias, stroke, or death from any cause. We used Cox proportional hazards models adjusted for potential confounders. The cohort included 1,529 patients (74% men), 63.1 ± 12.5 years (mean age ± SD), of whom 40% were obese by BMI. Eighty-eight percent of men and 57% of women were classified as having central obesity by WHR. Median follow-up was 5.7 years and 415 patients had MACE. After adjustment, a high WHR tertile was a significant predictor for MACE in women (hazard ratio [HR] 1.85, 95% confidence interval [CI] 1.16, 2.94, p = 0.01) but not in men (HR 0.92, 95% CI 0.69, 1.22, p = 0.54). This relation in women persisted after further adjustment for BMI (HR 1.75, 95% CI 1.07, 2.87, p = 0.03). Obesity by BMI was not associated with MACE in either men (HR 1.07, 95% CI 0.76, 1.51, p = 0.69) or women (HR 0.98, 95% CI 0.62, 1.56, p = 0.95). In conclusion, WHR is associated with a higher risk of MACE among women with CAD but not in men. There was no obesity paradox when assessing obesity by BMI in patients with CAD when including nonfatal events.

Bushenkangshuai Tablet Reduces Atherosclerotic Lesion by Improving Blood Lipids Metabolism and Inhibiting Inflammatory Response via TLR4 and NF-κB Signaling Pathway

Bushenkangshuai tablet (BSKS) is a Chinese herbal compound which has been used for the treatment of cardiovascular and cerebrovascular diseases in China for decades. This study intends to explore the molecular mechanism of BSKS against atherosclerosis in ApoE^−/− mice. ApoE^−/− mice were fed with western-type diet for 6 weeks and then were given BSKS for 6 weeks. The results showed that BSKS attenuated the size of the atherosclerotic lesion, reduced visceral adipose content, and decreased blood lipids. We also found that BSKS promoted the expression of adiponectin and its receptors, inhibited the expression of Toll-like receptor 4 and nuclear factor-kappa B, decreased the levels of interleukin-1 beta, monocyte chemotactic protein-1, and vascular cell adhesion molecule-1, and increased the levels of interleukin-10 and adiponectin. Our data provided evidence that BSKS exerted an antiatherosclerotic effect by lowering blood lipids and inhibiting inflammatory response via TLR4 and NF-κB signaling pathway.

Anthropometric measures of obesity and renal artery calcification: Results from the Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIMS

Renal artery calcium (RAC) has been linked to several cardiovascular disease (CVD) risk factors, including age, male gender, and hypertension. The purpose of this study was to determine whether anthropometric measures of obesity are associated with presence of RAC.

METHODS

We studied 1287 community-dwelling adults enrolled in the Multi-Ethnic Study of Atherosclerosis. Logistic regression models adjusted for CVD risk factors were used to examine body mass index (BMI), waist circumference (WC), hip circumference (HC), and waist-to-hip ratio (WHR) as primary predictors of RAC.

RESULTS

Study participants had a mean age of 67.7 years, 55.7% were female, and 36.8% were non-Hispanic White. Prevalence of RAC was 33.3%. WC and WHR as continuous variables were not significant with adjustment. Subjects with high WC, as defined by World Health Organization cut-offs, had significantly higher odds for RAC in the fully adjusted model. BMI and HC were not significantly associated with RAC in any models.

CONCLUSIONS

In this community-based sample of older adults, higher levels of WC are significantly associated with RAC independently of CVD risk factors. Adults who meet World Health Organization criteria for high WC may be at higher risk for complications of calcified atherosclerosis in the renal arteries.

The Impact of Age on Clinical Outcomes of Coronary Artery Bypass Grafting: Long-Term Results of a Real-World Registry

The aim of this retrospective multicenter registry study was to investigate age-dependent trends in mortality, long-term survival, and comorbidity over time in patients who underwent isolated CABG from 2003 to 2015. The percentage of patients < 60 years of age was 18.9%. Female sex, chronic pulmonary disease, extracardiac arteriopathy, and neurologic dysfunction disease were significantly less frequent in this younger population. The prevalence of BMI ≥ 30, previous myocardial infarction, preoperative severe depressed left ventricular ejection fraction, and history of previous PCI were significantly higher in this population. After PS matching, at 5 years, patients < 60 years of age reported significantly lower overall mortality (p < 0.0001), cardiac-related mortality (p < 0.0001), incidence of acute myocardial infarction (p = 0.01), and stroke rates (p < 0.0001). Patients < 60 years required repeated revascularization more frequently than older patients (p = 0.05). Patients < 60 who underwent CABG had a lower risk of adverse outcomes than older patients. Patients < 60 have a different clinical pattern of presentation of CAD in comparison with more elderly patients. These issues require focused attention in order to design and improve preventive strategies aiming to reduce the impact of specific cardiovascular risk factors for younger patients, such as diet, lifestyle, and weight control.

Normal body mass index with central obesity has increased risk of coronary artery calcification in Korean patients with chronic kidney disease

In chronic kidney disease (CKD), overweight and mild obesity have shown the lowest cardiovascular (CV) risk. However, central obesity has been directly associated with CV risk in these patients. This bidirectional relationship of body mass index (BMI) and central obesity prompted us to evaluate CV risk based on a combination of BMI and waist-to-hip ratio (WHR) in nondialysis CKD patients. We included 1078 patients with CKD stage 2 through 5 (nondialysis) enrolled in a nationwide prospective cohort of Korea. Patients were divided into 3 groups by BMI (normal BMI, 18.5-22.9; overweight, 23.0-27.4; and obese, 27.5 and over kg/m²) and were dichotomized by a sex-specific median WHR (0.92 in males and 0.88 in females). Coronary artery calcification (CAC) was determined by multislice computed tomography. CAC (score above 10 Agatston units) was found in 477 patients. Multivariate logistic regression analysis indicated that BMI was not independently associated with CAC. However, WHR showed an independent linear and significant association with CAC (odds ratio, 1.036; 95% confidence interval, 1.007-1.065 per 0.01 increase). Furthermore, when patients were categorized into 6 groups according to a combination of BMI and WHR, normal BMI but higher WHR had the highest risk of CAC compared with the normal BMI with lower WHR group (2.104; 1.074-4.121). Thus, a normal BMI with central obesity was associated with the highest risk of CAC, suggesting that considering BMI and WHR, 2 surrogates of obesity, can help to discriminate CV risk in Korean nondialysis CKD patients.

Association between body mass index and osteoporosis in women from northwestern Rio Grande do Sul

OBJECTIVE

To investigate the association between body mass index (BMI) and bone mineral density (BMD) in postmenopausal women.

METHODS

Observational study with postmenopausal women who underwent bone densitometry in Palmeira das Missões - RS. Sociodemographic data, risk for osteoporosis and food intake were assessed through a specific form. BMI was calculated according to WHO criteria. The assessment of BMD was performed by dual-energy X-ray absorptiometry (DXA) and classified according to WHO. Statistical analysis was performed using prevalence ratios (PR) and their respective 95% confidence intervals for the factors studied. Variables associated with p<0.20 with the different outcomes (osteopenia and osteoporosis) were included in a Poisson regression model with robust variance to adjust for potential confounding factors. A 5% significance level was considered.

RESULTS

393 postmenopausal women with a mean age of 59.6±8.2 years participated. After the adjustments, the normal weight women had 1.2 times the prevalence of osteopenia of obese women (PR=1.2; CI 95% 1.3-1.5). Considering osteoporosis, the PR of euthophic women was twice the PR of obese women (PR=2; CI 95% 1.4-2.9) and was 1.7 times greater for overweight group compared to obese category (PR=1.7; CI 95% 1.2-2.5).

CONCLUSION

Obese women had lower prevalence of osteopenia compared with normal weight subjects and also with lower prevalence of osteoporosis as compared to normal- and overweight women.

Relation of Body Circumferences to Cardiometabolic Disease in Overweight-Obese Subjects

Body circumferences have been proposed as potential anthropometric measures for the assessment of cardiometabolic risk as they are independently associated with insulin resistance and diabetes. The aim of this study was to validate neck and wrist circumference and waist-to-hip ratio as practical markers of metabolic dysfunction and atherosclerosis; 120 subjects who underwent coronary angiography and carotid Doppler ultrasound were enrolled in this cross-sectional study. Exclusion criteria were history of diabetes, acute myocardial infarction, body mass index (BMI) <18.5 or ≥45.0 kg/m(2). Metabolic dysfunction was ascertained by the calculation of visceral adiposity index (VAI) and by diagnosis of metabolic syndrome (MS). Advanced atherosclerotic disease was defined as ≥70% coronary lumen and/or ≥50% carotid lumen stenosis. No association between body circumferences and VAI or MS was found in subjects with BMI <25 kg/m(2). VAI was significantly related to waist-to-hip ratio (R(2) = 0.09, p = 0.008), neck (R(2) = 0.09, p = 0.007), and wrist circumferences (R(2) = 0.05, p = 0.041) in subjects with BMI ≥25 kg/m(2). In overweight subjects, higher gender-specific tertiles of wrist circumference were independently associated with an increased risk of MS (odds ratio 2.57, 95% confidence interval 1.11 to 5.96, p = 0.028). VAI was independently associated with carotid intima-media thickness: β = 0.104, R(2) = 0.118, p = 0.003. Carotid intima-media thickness and MS, but not body circumferences, were associated with advanced atherosclerosis. In conclusion, these data indicate that anthropometric measurements, in particular wrist circumference, can be used as practical tools for assessment of metabolic risk in overweight-obese subjects but not as markers of advanced atherosclerosis.

Impact of Body Mass Index on Vascular Calcification and Pericardial Fat Volume Among Patients with Suspected Coronary Artery Disease

OBJECTIVES

This study aimed to assess the effect of body mass index (BMI) on the relationship between pericardial fat volume (PFV), aortic root calcification (ARC) and coronary artery calcification (CAC) among patients with suspected coronary artery disease (CAD).

METHODS

This cross-sectional study took place between January and December 2014 at the Kufa University Teaching Hospital, Najaf, Iraq. A total of 130 consecutive patients with an intermediate pretest probability of ischaemic heart disease who underwent 64-slice multidetector computed tomography (CT) angiography during the study period were recruited. Of these, 111 were included in the study and divided into groups according to BMI. Imaging markers were measured on CT angiography.

RESULTS

A total of 28 patients were obese, while 42 and 41 were overweight and normal weight, respectively. The median PFV, CAC and ARC was 109 cm(3) (interquartile range [IQR]: 52-176 cm(3)), 0 Agatston score (IQR: 0-52 Agatston score) and 0 Agatston score (IQR: 0-15 Agatston score), respectively, in the normal weight group in comparison to 79 cm(3) (IQR: 43-138 cm(3)), 0 Agatston score (IQR: 0-54 Agatston score) and 0 Agatston score (IQR: 0-0 Agatston score), respectively, in the obese group. Significant correlations were observed between PFV and CAC (r(2) = 0.22; P = 0.002) and ARC and CAC (r(2) = 0.37; P <0.001) in the normal weight group. However, no significant correlations were observed for obese and overweight patients.

CONCLUSION

These findings indicate that BMI may not be an accurate tool for measuring adiposity or assessing subclinical coronary atherosclerosis in patients with suspected CAD.

Association Between Body Mass Index and Age of Presentation With Symptomatic Coronary Artery Disease

BACKGROUND

Obesity is increasingly recognized as an important risk factor for coronary artery disease (CAD).

HYPOTHESIS

Patients with increased body mass index (BMI) present at a younger age with symptomatic CAD.

METHODS

We analyzed data on 2137 consecutive patients admitted for treatment of CAD proven on angiography from 2010 to 2013, excluding those with prior coronary intervention or bypass surgery.

RESULTS

Mean age was 64.1 ± 12.4 years; 75% were male; 43.6% were overweight (BMI 25-29.9 kg/m² ) and 31.6% were obese (BMI ≥30 kg/m² ). Patients with BMI ≥25 kg/m² compared with <25 kg/m² were more likely to have diabetes (24.5% vs 13.6%), hypertension (56.2% vs 45.5%), and hyperlipidemia (42.4% vs 31.6%; P < 0.0001 for all). On multivariate analysis adjusted for sex and cardiovascular risk factors, patients in higher BMI categories had lower mean age in a linear and stepwise fashion compared with those with normal BMI (P < 0.0001). For example, compared with patients with normal BMI, those with BMI of 35 to 39.9 kg/m² were on average 9.2 years younger (P < 0.0001). Multivariate analysis examining the interaction between sex and BMI produced similar results for effect of BMI on age of presentation (P = 0.97 for interaction).

CONCLUSIONS

After multivariate adjustment, patients with increased BMI presented at an earlier age with symptomatic CAD compared with patients with normal BMI. Primary prevention efforts in those with increased BMI to reduce risk-factor burden, including evidence-based treatments for weight reduction, promise to reduce risk or delay onset of CAD.

Waist-hip ratio and 1-year clinical outcome in patients with non-ST-elevation myocardial infarctions

OBJECTIVES

Obesity is a well-known cardiovascular disease risk factor. We evaluated the relationship between the waist-hip ratio (WHR), as a surrogate marker of central obesity, and clinical outcomes in patients with non-ST-segment elevation myocardial infarctions (NSTEMIs) undergoing percutaneous coronary interventions (PCIs).

METHODS

Between 2008 and 2010, NSTEMI patients who underwent PCI and who had available anthropometric data were divided into three groups according to their WHR tertile range. Clinical outcomes in the groups were analyzed.

RESULTS

Increasing incidences of hypertension and diabetes mellitus were associated with increasing WHR. As the WHR increased, a disintegration of patient metabolic patterns was documented in laboratory findings. There was no difference in the 1-year mortality rates between the three groups. However, increasing 1-year major adverse cardiovascular event rates were documented as the WHR increased (13, 14.7, and 19.4% in tertile groups 1-3, respectively; P=0.005). After adjusting for confounding variables, the highest tertile group was associated with increased 1-year mortality and major adverse cardiovascular event rates compared with the lowest tertile group. These differences arose from the female subgroup, suggesting that the magnitude of the central obesity effect might be greater in female than in male patients.

CONCLUSION

Central obesity, represented by WHR, was associated with poor clinical outcomes in NSTEMI patients undergoing PCI, particularly among women.

The CardioMetabolic Health Alliance: Working Toward a New Care Model for the Metabolic Syndrome

The Cardiometabolic Think Tank was convened on June 20, 2014, in Washington, DC, as a "call to action" activity focused on defining new patient care models and approaches to address contemporary issues of cardiometabolic risk and disease. Individual experts representing >20 professional organizations participated in this roundtable discussion. The Think Tank consensus was that the metabolic syndrome (MetS) is a complex pathophysiological state comprised of a cluster of clinically measured and typically unmeasured risk factors, is progressive in its course, and is associated with serious and extensive comorbidity, but tends to be clinically under-recognized. The ideal patient care model for MetS must accurately identify those at risk before MetS develops and must recognize subtypes and stages of MetS to more effectively direct prevention and therapies. This new MetS care model introduces both affirmed and emerging concepts that will require consensus development, validation, and optimization in the future.

STAT4 contributes to adipose tissue inflammation and atherosclerosis

Adipose tissue (AT) inflammation is an emerging factor contributing to cardiovascular disease. STAT4 is a transcription factor expressed in adipocytes and in immune cells and contributes to AT inflammation and insulin resistance in obesity. The objective of this study was to determine the effect of STAT4 deficiency on visceral and peri-aortic AT inflammation in a model of atherosclerosis without obesity. Stat4(-/-)Apoe(-/-) mice and Apoe(-/-) controls were kept either on chow or Western diet for 12 weeks. Visceral and peri-aortic AT were collected and analyzed for immune composition by flow cytometry and for cytokine/chemokine expression by real-time PCR. Stat4(-/-)Apoe(-/-) and Apoe(-/-) mice had similar body weight, plasma glucose, and lipids. Western diet significantly increased macrophage, CD4+, CD8+, and NK cells in peri-aortic and visceral fat in Apoe(-/-) mice. In contrast, in Stat4(-/-)Apoe(-/-) mice, a Western diet failed to increase the percentage of immune cells infiltrating the AT. Also, IL12p40, TNFa, CCL5, CXCL10, and CX3CL1 were significantly reduced in the peri-aortic fat in Stat4(-/-)Apoe(-/-) mice. Importantly, Stat4(-/-)Apoe(-/-) mice on a Western diet had significantly reduced plaque burden vs Apoe(-/-) controls. In conclusion, STAT4 deletion reduces inflammation in peri-vascular and visceral AT and this may contribute via direct or indirect effects to reduced atheroma formation.

Higher association of coronary artery calcification with non-alcoholic fatty liver disease than with abdominal obesity in middle-aged Korean men: the Kangbuk Samsung Health Study

BACKGROUND

It is uncertain whether non-alcoholic fatty liver disease (NAFLD) or abdominal obesity is more associated with atherosclerosis. The aim of this study was to determine whether NAFLD or abdominal obesity is more strongly associated with subclinical atherosclerosis represented by coronary artery calcification (CAC).

METHODS

A total of 21,335 male participants in a health screening program (mean age 41 years) were enrolled. Ultrasonographic measurements of fatty liver and multi-detector computed tomography were performed to determine the coronary artery calcium score (CACS). The presence of CAC was defined as CACS > 0. Subjects were divided into four groups according to the presence or absence of NAFLD and/or abdominal obesity as assessed by waist-hip ratio (WHR) > 0.9.

RESULTS

The presence of CAC was detected in 2,385 subjects (11.2%). The proportion of subjects with CAC was highest in the abdominal obesity only group (23.2%). After adjustment for age, diabetes history, hypertension, cigarette smoking, and physical inactivity, the odds ratio (OR) for CAC was the highest in the group with both abnormalities [1.465 (1.324-1.623)]. The NAFLD only group showed significantly increased OR for CAC compared to that in the abdominal obesity only group [1.286 (1.151-1.436) vs. 1.076 (0.939-1.233)].

CONCLUSION

Non-alcoholic fatty liver disease is more closely associated with CAC than abdominal obesity as assessed by the WHR. NAFLD could be considered an independent determinant of subclinical atherosclerosis as assessed by CAC.

Compliance to exercise-oncology guidelines in prostate cancer survivors and associations with psychological distress, unmet supportive care needs, and quality of life

OBJECTIVE

The purpose of this study was to determine prevalence of Australian prostate cancer survivors meeting contemporary exercise-oncology guidelines and identify associations with distress, unmet supportive care needs, and quality of life.

METHODS

A population-based cohort of 463 prostate cancer survivors who were on 10.8 months post-curative therapy was assessed for compliance with current exercise guidelines for cancer survivors, motivational readiness for physical activity, psychological distress, unmet supportive care needs, and quality of life.

RESULTS

Only 57 men (12.3%) reported sufficient exercise levels (150 min of moderate intensity or 75 min of strenuous exercise per week and twice weekly resistance exercise), 186 (40.2%) were insufficiently active, and 220 (47.5%) were inactive. Among inactive men, 99 (45.0%) were in the contemplation or preparation stage of motivation readiness. Inactive men had higher global distress (p = 0.01) and Brief Symptom Inventory-Anxiety (p < 0.05) than those who were insufficiently active. Total Supportive Care Needs and International Prostate Cancer Symptom scores were higher in inactive than insufficiently and sufficiently active men (p < 0.05). Lack of physical activity contributed to poorer quality of life.

CONCLUSIONS

Only a small proportion of Australian prostate cancer survivors met contemporary exercise-oncology recommendations despite increasing recognition of exercise to improve patient outcomes. Strategies are urgently required to increase prostate cancer survivors' participation in aerobic and resistance exercise training.Copyright © 2015 John Wiley & Sons, Ltd.

Meta-analysis of the relation of body mass index to all-cause and cardiovascular mortality and hospitalization in patients with chronic heart failure

Clinical studies have indicated the existence of an "obesity paradox" in patients with chronic heart failure (HF), that is, reduced mortality in patients who have elevated body mass index (BMI) scores compared with normal-weight reference groups. The aim of this study was to investigate the relation of BMI with all-cause and cardiovascular (CV) mortality and hospitalization in patients with chronic HF though a systematic review and meta-analysis of published research. PubMed, the Cumulative Index to Nursing and Allied Health Literature, Cochrane Central, Scopus, web of science and Embase were searched for studies reporting rates of total mortality, cardiac mortality, and risk for hospitalization in patients with HF in various BMI categories (<20 kg/m(2) [low], 20 to 24.9 kg/m(2) [normal reference], 25 to 29.9 kg/m(2) [overweight], 30 to 34.9 [obese], and ≥35 kg/m(2) [severely obese]). Event rates were compared using a forest plot of relative risk (RR) using a random-effects model assuming interstudy heterogeneity. Two study investigators independently reviewed the 124 reports retrieved and identified 6 for final analyses (n = 22,807). After a mean follow-up period of 2.85 years, the risk for adverse events was highest in patients with low BMIs: total mortality RR 1.27 (95% confidence interval [CI] 1.17 to 1.37), CV mortality RR 1.20 (95% CI 1.01 to 1.43), and hospitalization RR 1.19 (95% CI 1.09 to 1.30). Risk for CV mortality and hospitalization was lowest in overweight patients (RR 0.79, 95% CI 0.70 to 0.90, and RR 0.92, 95% CI 0.86 to 0.97, respectively). Increasing degree of obesity failed to achieve a statistically significant effect on CV mortality (RR 0.82, 95% CI 0.64 to 1.05, and RR 0.71, 95% CI 0.50 to 1.01, for obese and severely obese, respectively) and on hospitalization (RR 0.99, 95% CI 0.92 to 1.07, and RR 1.28, 95% CI 0.88 to 1.87, for obese and severely obese, respectively). In conclusion, risk for total mortality and CV mortality and hospitalization was highest in patients with chronic HF who were underweight as defined by low BMI, whereas risk for CV mortality and hospitalization was lowest in overweight subjects.

Lutein prevents high fat diet-induced atherosclerosis in ApoE-deficient mice by inhibiting NADPH oxidase and increasing PPAR expression

Epidemiological and experimental studies provide supportive evidence that lutein, a major carotenoid, may act as a chemopreventive agent against atherosclerosis, although the underlying molecular mechanisms are not well understood. The main aim of this study was to investigate the effects of lutein on the alleviation of atherosclerosis and its molecular mechanisms involved in oxidative stress and lipid metabolism. Male apolipoprotein E knockout mice (n = 55) were fed either a normal chow diet or a high fat diet (HFD) supplemented with or without lutein for 24 weeks. The results showed that a HFD induced atherosclerosis formation, lipid metabolism disorders and oxidative stress, but noticeable improvements were observed in the lutein treated group. Additionally, lutein supplementation reversed the decreased protein expression of aortic heme oxygenase-1 and increased the mRNA and protein expressions of aortic nicotinamide-adenine dinucleotide phosphate oxidase stimulated by a HFD. Furthermore, the decreased mRNA and protein expression levels of hepatic peroxisome proliferator-activated receptor-α, carnitine palmitoyltransferase 1A, acyl CoA oxidase 1, low density lipoprotein receptors and scavenger receptor class B type I observed in mice with atherosclerosis were markedly enhanced after treatment with lutein. Taken together, these data add new evidence supporting the anti-atherogenic properties of lutein and describing its mechanisms of action in atherosclerosis prevention, including oxidative stress and lipid metabolism improvements.

How to choose and use bariatric surgery in 2015

Severe obesity is associated with increased morbidity and mortality and represents a major health care problem with increasing incidence worldwide. Bariatric surgery, through its efficacy and improved safety, is emerging as an important available treatment for patients with severe obesity. Classically, bariatric surgery has been described as either a restrictive or a hybrid surgery, which is a combination of restriction and malabsorption. For most severely obese patients, bariatric surgery results in the remission of major obesity-related comorbidities including type 2 diabetes mellitus, sleep apnea, hypertension, and dyslipidemia. Thus, bariatric surgery reduces cardiovascular risk burden, and overall mortality risk. Early complications (< 30 days) after bariatric surgery were reported to be < 10% and tend to be lower in restrictive surgeries compared with hybrid surgeries. Most common early complications reported are gastric and anastomosis leak (1.6%-5.1%), bleeding (0.5%-3.5%), and pulmonary embolism (0.2%-1%). Long-term complications (> 30 days) might differ depending on the type of bariatric surgery. According to the type of surgery and the type of study, the 30-day operative mortality rates differ from 0.1% to 1.2%. Studies on postoperative outcomes, investigations on weight loss physiology, and mechanism of action after bariatric surgery provide a better understanding of the bariatric surgery metabolic benefits. In this article, we present an overview of bariatric procedures with their effects, including risks and benefits, on the severely obese patients' health. It provides evidence to support surgical treatment of severe obesity to achieve cardiovascular disease risk reduction in severely obese patients.

Obesity and coronary artery disease: evaluation and treatment

With the increasing prevalence of obesity, clinicians are now facing a growing population of patients with specific features of clinical presentation, diagnostic challenges, and interventional, medical, and surgical management. After briefly discussing the effect of obesity on atherosclerotic burden in this review, we will focus on strategies clinicians might use to ensure better outcomes when performing revascularization in obese and severely obese patients. These patients tend to present comorbidities at a younger age, and their anthropometric features might limit the use of traditional cardiovascular risk stratification approaches for ischemic disease. Alternative techniques have emerged, especially in nuclear medicine. Positron emission tomography-computed tomography might be the diagnostic imaging technique of choice. When revascularization is considered, features associated with obesity must be considered to guide therapeutic strategies. In percutaneous coronary intervention, a radial approach should be favoured, and adequate antiplatelet therapy with new and more potent agents should be initiated. Weight-based anticoagulation should be contemplated if needed, with the use of drug-eluting stents. An "off-pump" approach for coronary artery bypass grafting might be preferable to the use of cardiopulmonary bypass. For patients who undergo bilateral internal thoracic artery grafting, harvesting using skeletonization might prevent deep sternal wound infections. In contrast to percutaneous coronary intervention, lower surgical bleeding has been observed when lean body mass is used for perioperative heparin dose determination.