An obesity paradox with myocardial infarction in the elderly

Pharmacotherapy for older people with obesity

Rates of obesity continue to rise, including in older adults. Use of medication for obesity in the elderly has been considered controversial, due to concerns around potential progression of age-related sarcopenia and a general lack of evidence for its use in this age group. Within this review, we describe the general considerations when prescribing obesity pharmacotherapy for older adults living with obesity. We evaluate in detail the anti-obesity medications currently licenced in Europe, with emphasis on the available efficacy, safety and cardiovascular outcome data gathered from study of older people. Finally, we discuss future directions and avenues of research.

Underweight and obesity are related to higher mortality in patients undergoing coronary angiography: The KARDIO invasive cardiology register study

BACKGROUND

In patients with some cardiovascular disease conditions, slightly elevated body mass index (BMI) is associated with a lower mortality risk (termed "obesity paradox"). It is uncertain, however, if this obesity paradox exists in patients who have had invasive cardiology procedures. We evaluated the association between BMI and mortality in patients who underwent coronary angiography.

METHODS

We utilised the KARDIO registry, which comprised data on demographics, prevalent diseases, risk factors, coronary angiographies, and interventions on 42,636 patients. BMI was categorised based on WHO cut-offs or transformed using P-splines. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated for all-cause mortality.

RESULTS

During a median follow-up of 4.9 years, 4688 all-cause deaths occurred. BMI was nonlinearly associated with mortality risk: compared to normal weight category (18.5-25 kg/m² ), the age-adjusted HRs (95% CIs) for all-cause mortality were 1.90 (1.49, 2.43), 0.96 (0.92, 1.01), 1.04 (0.99, 1.09), 1.08 (0.96, 1.20), and 1.45 (1.22, 1.72) for underweight (<18.5 kg/m² ), preobesity (25 to <30 kg/m² ), obesity class I (30 to <35 kg/m² ), obesity class II (35 to <40 kg/m² ), and obesity class III (>40 kg/m² ), respectively. The corresponding multivariable adjusted HRs (95% CIs) were 2.00 (1.55, 2.58), 0.92 (0.88, 0.97) 1.01 (0.95, 1.06), 1.10 (0.98, 1.23), and 1.49 (1.26, 1,78), respectively.

CONCLUSIONS

In patients undergoing coronary angiography, underweight and obesity class III are associated with increased mortality risk, and the lowest mortality was observed in the preobesity class. It appears the obesity paradox may be present in patients who undergo invasive coronary procedures.

Obesity Paradox in Coronary Thrombus Burden of Patients with Acute Coronary Syndrome

Background: Acute coronary syndrome (ACS) remains a major cause of morbidity and mortality worldwide. Although obesity is a risk factor for ACS, decreased mortality has been shown in overweight individuals. This study aims to determine the association of body fat parameters such as body fat percentage (BFP), relative fat mass (RFM), and coronary thrombus burden with angiographic thrombotic grade in a series of patients presenting with ACS. Methods: Three hundred ninety patients who underwent percutaneous coronary intervention were enrolled in the study. BFP was calculated using the U.S. Navy formula. RFM index was calculated using gender, height, and waist circumference regardless of weight. Body mass index (BMI) is calculated as the weight in kilograms divided by the square of body length in meters (kg/m²). Two experienced interventional cardiologists reviewed coronary angiograms according to the TIMI thrombus scale. Patients were divided into groups according to thrombus classification and clinical status. Results: RFM, which is an anthropometric measurement parameter for obesity, was inversely related to thrombus burden in patients with ACS. There were no significant differences between ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) groups according to demographic, clinical characteristics, and coronary risk factors. Likewise, RFM, BFP, and BMI were comparable between the two groups. BFP and RFM were lower in patients with thrombus present STEMI group compared with no thrombus group. Thrombus presence was also compared in the NSTEMI group, and BMI, BFP, and RFM were lower in patients with thrombus present NSTEMI group. Conclusions: Our analysis demonstrated that RFM was better than BFP and BMI for predicting thrombus presence in patients with ACS.

Heart failure with preserved ejection fraction in Belgium: characteristics and outcome of a real-life cohort

BACKGROUND

Due to aging of the population and the increase of cardiovascular risk factors, heart failure and preserved ejection fraction (HFpEF) is a rising health issue. Few data exist on the phenotype of HFpEF patients in Belgium and on their prognosis.

OBJECTIVES

We describe clinical characteristics and outcomes of Belgian HFpEF patients.

METHODS

We prospectively enrolled 183 HFpEF patients. They underwent clinical examination, comprehensive biological analysis and echocardiography, and were followed for a combined outcome of all-cause mortality and first HF hospitalisation.

RESULTS

Belgian patients with HFpEF were old (78 ± 8 years), predominantly females (62%) with multiple comorbidities. Ninety-five per cent were hypertensive, 38% diabetic and 69% overweight. History of atrial fibrillation was present in 63% of population, chronic kidney disease in 60% and anaemia in 58%. Over 30 ± 9 months, 55 (31%) patients died, 87 (49%) were hospitalised and 111 (63%) reached the combined outcome. In multivariate Cox analysis, low body mass index (BMI), NYHA class III and IV, diabetes, poor renal function and loop diuretic intake were independent predictors of the combined outcome (p < .05). BMI and renal function were also independent predictors of mortality, as were low haemoglobin, high E/e' and poor right ventricular function.

CONCLUSION

Belgian patients with HFpEF are elderly patients with a high burden of comorbidities. Their prognosis is poor with high rates of hospitalisation and mortality. Although obesity is a risk factor for developing HFpEF, low BMI is the strongest independent predictor of mortality in those patients.

Obesity paradox in joint replacement for osteoarthritis - truth or paradox?

Obesity is associated with an increased risk of cardiovascular disease (CVD) and other adverse health outcomes. In patients with pre-existing heart failure or coronary heart disease, obese individuals have a more favourable prognosis compared to individuals who are of normal weight. This paradoxical relationship between obesity and CVD has been termed the 'obesity paradox'. This phenomenon has also been observed in patients with other cardiovascular conditions and diseases of the respiratory and renal systems. Taking into consideration the well-established relationship between osteoarthritis (OA) and CVD, emerging evidence shows that overweight and obese individuals undergoing total hip or knee replacement for OA have lower mortality risk compared with normal weight individuals, suggesting an obesity paradox. Factors proposed to explain the obesity paradox include the role of cardiorespiratory fitness ("fat but fit"), the increased amount of lean mass in obese people, additional adipose tissue serving as a metabolic reserve, biases such as reverse causation and confounding by smoking, and the co-existence of older age and specific comorbidities such as CVD. A wealth of evidence suggests that higher levels of fitness are accompanied by prolonged life expectancy across all levels of adiposity and that the increased mortality risk attributed to obesity can be attenuated with increased fitness. For patients about to have joint replacement, improving fitness levels through physical activities or exercises that are attractive and feasible, should be a priority if intentional weight loss is unlikely to be achieved.

US Obesity Mortality Trends and Associated Noncommunicable Diseases Contributing Conditions Among White, Black, and Hispanic Individuals by Age from 1999 to 2017

This study aims to assess the effect of obesity as an underlying cause of death in association with four main noncommunicable diseases (NCDs) as contributing causes of mortality on the age of death in White, Black, and Hispanic individuals in the USA. To estimate mortality hazard ratios, we ran a Cox regression on the US National Center for Health Statistics mortality integrated datasets from 1999 to 2017, which included almost 48 million cases. The variable in the model was the age of death in years as a proxy for time to death. The cause-of-death variable allowed for the derivation of predictor variables of obesity and the four main NCDs. The overall highest obesity mortality HR when associated with NCD contributing conditions for the year 1999-2017 was diabetes (2.15; 95% CI: 2.11-2.18), while Whites had the highest HR (2.46; 95% CI: 2.41-2.51) when compared with Black (1.32; 95% CI: 1.27-1.38) and Hispanics (1.25; 95% CI: 1.18-1.33). Hispanics had lower mortality HR for CVD (1.21; 95% CI: 1.15-1.27) and diabetes (1.25; 95% CI: 1.18-1.33) of the three studied groups. The obesity death mean was 57.3 years for all groups. People who die from obesity are, on average, 15.4 years younger than those without obesity. Although Hispanics in the USA have a higher prevalence of diabetes and cardiovascular disease (CVD), they also have the lowest mortality HR for obesity as an underlying cause of death when associated with CVD and cancer. While there is no obvious solution for obesity and its complications, continued efforts to address obesity are needed.

Acute Cardiovascular Events Associated With Influenza in Hospitalized Adults : A Cross-sectional Study

BACKGROUND

Influenza may contribute to the burden of acute cardiovascular events during annual influenza epidemics.

OBJECTIVE

To examine acute cardiovascular events and determine risk factors for acute heart failure (aHF) and acute ischemic heart disease (aIHD) in adults with a hospitalization associated with laboratory-confirmed influenza.

DESIGN

Cross-sectional study.

SETTING

U.S. Influenza Hospitalization Surveillance Network during the 2010-to-2011 through 2017-to-2018 influenza seasons.

PARTICIPANTS

Adults hospitalized with laboratory-confirmed influenza and identified through influenza testing ordered by a practitioner.

MEASUREMENTS

Acute cardiovascular events were ascertained using discharge codes from the International Classification of Diseases (ICD), Ninth Revision, Clinical Modification, and ICD, 10th Revision. Age, sex, race/ethnicity, tobacco use, chronic conditions, influenza vaccination, influenza antiviral medication, and influenza type or subtype were included as exposures in logistic regression models, and marginal adjusted risk ratios and 95% CIs were estimated to describe factors associated with aHF or aIHD.

RESULTS

Among 89 999 adults with laboratory-confirmed influenza, 80 261 had complete medical record abstractions and available ICD codes (median age, 69 years [interquartile range, 54 to 81 years]) and 11.7% had an acute cardiovascular event. The most common such events (non-mutually exclusive) were aHF (6.2%) and aIHD (5.7%). Older age, tobacco use, underlying cardiovascular disease, diabetes, and renal disease were significantly associated with higher risk for aHF and aIHD in adults hospitalized with laboratory-confirmed influenza.

LIMITATION

Underdetection of cases was likely because influenza testing was based on practitioner orders. Acute cardiovascular events were identified by ICD discharge codes and may be subject to misclassification bias.

CONCLUSION

In this population-based study of adults hospitalized with influenza, almost 12% of patients had an acute cardiovascular event. Clinicians should ensure high rates of influenza vaccination, especially in those with underlying chronic conditions, to protect against acute cardiovascular events associated with influenza.

PRIMARY FUNDING SOURCE

Centers for Disease Control and Prevention.

Body Mass Index and 1-Year Unplanned Readmission in Chinese Patients with Acute Myocardial Infarction: A Retrospective Cohort Study

BACKGROUND

Evidence regarding the relationship between body mass index (BMI) and 1-year unplanned readmission was limited. Therefore, the objective of this research is to investigate whether BMI was independently related to 1-year unplanned readmission in Chinese patients with acute myocardial infarction (AMI) after percutaneous transluminal coronary intervention (PCI) after adjusting for other covariates.

METHODS

The present study was a cohort study. A total of 214 participants with AMI after PCI were involved in a hospital in China from 1st January 2017 to 1st January 2018. The target independent variable and the dependent variable were BMI measured at baseline and 1-year unplanned readmission, respectively. Covariates involved in this study included age, gender, TC, triglyceride, HDL-C, LDL-C, PT, APTT, INR, creatinine, HGB, LVEF, discharge medication, marital status, educational level, COPD, diabetes mellitus, heart failure, history of ischemic stroke, history of hemorrhagic stroke, arrhythmia, and hypertension.

RESULTS

The average age of 172 selected participants was 60.2 ± 10.8 years old, and about 68.6% of them was male. The rate of readmission in patients with AMI was 26.14%. The result of fully adjusted binary logistic regression showed BMI was negatively associated with risk of readmission after adjusting confounders (hazard ratio (HR) = 1.1, 95% CI 0.93-1.29). Nonlinear relationship was detected between BMI and 1-year unplanned readmission, whose point was 29.3. The effect sizes and the confidence intervals of the left and right sides of inflection point were 0.9 (0.7-1.2, P for nonlinearity = 0.530) and 2.8 (1.3-5.8, P for nonlinearity = 0.530) and 2.8 (1.3-5.8.

CONCLUSION

BMI has a nonlinear relationship with 1-year unplanned readmission in patients with myocardial infarction. The 1-year unplanned readmission rate of overweight patients (BMI > 29.3 kg/m2) has increased significantly. Obesity paradox does not exist in terms of readmission of Chinese patients with myocardial infarction after PCI.

Effects of Physical Activity, Exercise, and Fitness on Obesity-Related Morbidity and Mortality

Obesity is associated with increased prevalence of cardiovascular (CV) disease (CVD) risk factors, which may adversely impact CV structure and function and may increase the prevalence of most CVD, particularly heart failure (HF) and coronary heart disease (CHD). Physical activity (PA), exercise training (ET) and cardiorespiratory fitness (CRF) are all associated with marked reductions in most CVD, including HF and CHD. Additionally, PA/ET and, especially CRF, markedly alter the relationship between adiposity and subsequent major CVD outcomes and dramatically impact the "obesity paradox," which are all reviewed, including attention to the debate regarding "fitness versus fatness" for long-term prognosis, including in patients with established CVD.

Obesity paradox in cardiovascular disease: where do we stand?

Obesity is associated with an increased risk of developing cardiovascular disease (CVD), particularly heart failure (HF) and coronary heart disease (CHD). The mechanisms through which obesity increases CVD risk involve changes in body composition that can affect hemodynamics and alters heart structure. Pro-inflammatory cytokines produced by the adipose tissue itself which can induce cardiac dysfunction and can promote the formation of atherosclerotic plaques. When obesity and HF or CHD coexist, individuals with class I obesity present a more favorable prognosis compared to individuals who are normal or underweight. This phenomenon has been termed the “obesity paradox.” Obesity is defined as an excess fat mass (FM), but individuals with obesity typically also present with an increased amount of lean mass (LM). The increase in LM may explain part of the obesity paradox as it is associated with improved cardiorespiratory fitness (CRF), a major determinant of clinical outcomes in the general population, but particularly in those with CVD, including HF. While increased LM is a stronger prognosticator in HF compared to FM, in patients with CHD excess FM can exert protective effects particularly when not associated with increased systemic inflammation. In the present review, we discuss the mechanisms through which obesity may increase the risk for CVD, and how it may exert protective effects in the setting of established CVD, with a focus on body composition. We also highlight the importance of measuring or estimating CRF, including body composition-adjusted measures of CRF (ie, lean peak oxygen consumption) for an improved risk status stratification in patients with CVD and finally, we discuss the potential non-pharmacologic therapeutics, such as exercise training and dietary interventions, aimed at improving CRF and perhaps clinical outcomes.

Relation of Obesity to Outcomes of Hospitalizations for Atrial Fibrillation

Obesity has been linked with increased incidence of atrial fibrillation (AF), but impact of presence of obesity on outcomes of hospitalizations for AF has not been investigated. We used the National Inpatient Sample database 2010 to 2014 to identify all adult hospitalizations aged ≥18years with a primary diagnosis of AF. Obese patients were identified using the co-morbidity variable for obesity, as defined in National Inpatient Sample databases. Multivariable logistic regression was used to compare in-hospital outcomes (mortality, acute stroke events) between obese and non-obese patients with AF. Of 431, 734 hospitalizations for AF, 66,138 (15.3%) were obese. Obese patients were younger and more likely to be African-Americans compared with non-obese patients. Despite being younger, obese patients had significantly higher prevalence of cardiovascular co-morbidities such as hypertension, diabetes mellitus, dyslipidemia, smoking, heart failure, and chronic renal failure (p <0.001 for all). After multivariate risk-adjustment, obese patients had a lower observed in-hospital mortality (0.5% vs 1.0%; unadjusted odds ratio = 0.52, 95% confidence interval [CI] 0.46 to 0.58, p <0.001; adjusted odds ratio = 0.83, 95% CI 0.73 to 0.94, p <0.001) and acute stroke events (0.4% vs 0.7%, unadjusted odds ratio = 0. 65, 95% CI 0.57 to 0.73, p < 0.001; adjusted odds ratio = 0.82, 95% CI 0.72 to 0.94) compared with non-obese patients. In conclusion, in this large retrospective analysis of an unselected nationwide cohort of patients hospitalized for AF, obese patients demonstrated lower risk-adjusted odds of in-hospital mortality and stroke events, consistent with an "obesity paradox."