Sex-specific differences in mortality and the obesity paradox of patients with myocardial infarction ages >70 y

The challenges of assessing adiposity in a clinical setting

To tackle the burden of obesity-induced cardiometabolic disease, the scientific community relies on accurate and reproducible adiposity measurements in the clinic. These measurements guide our understanding of underlying biological mechanisms and clinical outcomes of human trials. However, measuring adiposity and adipose tissue distribution in a clinical setting can be challenging, and different measurement methods pose important limitations. BMI is a simple and high-throughput measurement, but it is associated relatively poorly with clinical outcomes when compared with waist-to-hip and sagittal abdominal diameter measurements. Body composition measurements by dual energy X-ray absorptiometry or MRI scans would be ideal due to their high accuracy, but are not high-throughput. Another important consideration is that adiposity measurements vary between men and women, between adults and children, and between people of different ethnic backgrounds. In this Perspective article, we discuss how these critical challenges can affect our interpretation of research data in the field of obesity and the design and implementation of clinical guidelines.

The impact of obesity on different glucose tolerance status with incident cardiovascular disease and mortality events over 15 years of follow-up: a pooled cohort analysis

BACKGROUND

The effect of obesity in different glucose tolerance statuses i.e. normoglycemia (NGT), pre-diabetes, and type 2 diabetes (T2DM) on cardiovascular disease (CVD) and mortality has been an area of ongoing debate and uncertainty. In the present study, we aimed to examine the impact of being obese, whether general or central separately, in comparison with non-obese in different glucose tolerance statuses on the above outcomes.

METHODS

The study population included 18,184 participants aged 30-60 years (9927 women) from three longitudinal studies, including Atherosclerosis Risk in Communities, Multi-Ethnic Study of Atherosclerosis, and Tehran Lipid and Glucose Study. Glucose tolerance status was defined as NGT (fasting plasma glucose < 5.55 mmol/L), pre-diabetes (5.55-7.00 mmol/L), and T2DM (≥ 7 mmol/L or taking any medication for diabetes). Moreover, general and central obesity were defined based on body mass index and waist circumference (WC), respectively. Multivariable stratified Cox regression analysis was used to estimate hazard ratios (HRs (95% CI)) for CVD and mortality events.

RESULTS

During a 16-year follow-up, 2733 CVD events, 1101 CV mortality, and 3678 all-cause mortality events were recorded. We observed that being generally obese in comparison with non-obese increased the risk of CV and all-cause mortality in all glucose tolerance statuses; while considering CVD events, only among individuals with T2DM, the presence of general obesity was associated with marginally significant higher risk [1.19 (0.98-1.43); p-value = 0.07]. Regarding central adiposity, multivariate analysis revealed that elevated WC in NGT participants is associated with incident CVD [1.27(1.12-1.46)] and all-cause mortality [1.13(1.00-1.28)]. Moreover, central adiposity increased the risk of CV mortality in pre-diabetes individuals [1.47 (1.11-1.95)].

CONCLUSION

Findings from this pooled prospective cohort studies provide evidence that general obesity shows an unfavorable association with CV and all-cause mortality among the general population irrespective of their glucose tolerance statusThe findings imply that it's important to take into account the requirement and magnitude of weight reduction in people who are obese when offering guidance.

Sex-related differences in the impact of nutritional status on in-hospital mortality in acute coronary syndrome: A retrospective cohort study

BACKGROUND AND AIMS

In patients with some cardiovascular disease conditions the result of Nutritional Risk Screening 2002 (NRS-2002) and body mass index (BMI) is related to the in-hospital mortality. The aim of this study was to assess the prognostic impact of BMI and NRS 2002 on in-hospital mortality among patients with acute myocardial infarction (AMI) in relation to sex.

METHODS AND RESULTS

The study was based on a retrospective analysis of 945 medical records of AMI patients admitted to the Cardiology Department between 2017 and 2019. Patients with a score NRS2002 ≥ 3 are considered to be nutritionally at risk. The WHO BMI criteria were used. The endpoint was in-hospital mortality. Logistic regression was used to analyse the impact of quantitative variables on dichotomous outcome. Odds ratios (OR) with 95% confidence intervals were reported. Female patients were significantly older than male patients (73.24 ± 11.81 vs 67 ± 11.81). In an unadjusted model, the risk of malnutrition was a significant predictor of the odds of in-hospital mortality only in female patients (OR = 7.51, p = 0.001). In a multivariate model adjusted by all variables, heart failure (HF) (OR = 8.408, p = 0.003) and the risk of malnutrition (OR = 6.555, p = 0.007) were independent predictors of the odds of in-hospital mortality in female patients. The only significant independent predictor of the odds of in-hospital mortality in male patients was HF (OR = 3.789 p = 0.006).

CONCLUSIONS

Only in the case of female patients with AMI, the risk of malnutrition was independently associated with the odds of in-hospital mortality. There was no effect of BMI on in-hospital mortality in both sexes.

Sex differences in the relationship between body mass index and outcome in myocardial infarction

BACKGROUND

The data on sex-related differences regarding the body mass index (BMI) in patients with myocardial infarction (MI) are rare and inconclusive. We aimed to assess sex differences in the relationship between BMI and 30-day mortality in men and women with MI.

METHODS

A single-center retrospective study of 6453 patients with MI who underwent PCI was performed. Patients were divided into five BMI categories and these were compared. The relationship between BMI and 30-day mortality was assessed in men and women.

RESULTS

An L-shaped relationship between BMI and mortality was observed in men (p=0.003) with the highest mortality rate (9.4%) in normal weight patients and the lowest in patients with obesity grade I (5.3%). In women, similar mortality was found in all BMI categories (p=0.42). After adjustment for potential confounders, the negative association between BMI category and 30-day mortality was found in men, but not in women (p=0.033 and p=0.13, respectively). Overweight men had a 33% lower risk of death within 30 days compared to normal weight patients (OR 0.67,95%CI 0.46-0.96;p=0.03). Other BMI categories in men had a similar mortality risk to the normal weight category.

CONCLUSIONS

Our results suggest that the relationship between BMI and outcome in patients with MI is different in men and women. We found an L-shaped relationship between BMI and 30-day mortality in men, but no relationship was observed in women. The obesity paradox was not found in women. Sex itself could not explain this differential relationship, and the underlying cause is likely multifactorial.

The Obesity Paradox and Mortality in Older Adults: A Systematic Review

“Obesity paradox” describes the counterintuitive finding that aged overweight and obese people with a particular disease may have better outcomes than their normal weight or underweight counterparts. This systematic review was performed to summarize the publications related to the obesity paradox in older adults, to gain an in-depth understanding of this phenomenon. PubMed©, Embase©, and Scopus© were used to perform literature search for all publications up to 20 March 2022. Studies were included if they reported data from older adults on the relation between BMI and mortality. The following article types were excluded from the study: reviews, editorials, correspondence, and case reports and case series. Publication year, study setting, medical condition, study design, sample size, age, and outcome(s) were extracted. This review has been registered with PROSPERO (no. CRD42021289015). Overall, 2226 studies were identified, of which 58 were included in this systematic review. In all, 20 of the 58 studies included in this review did not find any evidence of an obesity paradox. Of these 20 studies, 16 involved patients with no specific medical condition, 1 involved patients with chronic diseases, and 2 involved patients with type 2 diabetes mellitus. Seven out of the nine studies that looked at short-term mortality found evidence of the obesity paradox. Of the 28 studies that examined longer-term mortality, 15 found evidence of the obesity paradox. In the studies that were conducted in people with a particular medical condition (n = 24), the obesity paradox appeared in 18 cases. Our work supports the existence of an obesity paradox, especially when comorbidities or acute medical problems are present. These findings should help guide strategies for nutritional counselling in older populations.

Survival benefit of overweight patients undergoing MitraClip® procedure in comparison to normal-weight patients

BACKGROUND

The number of MitraClip® implantations increased significantly in recent years. Data regarding the impact of weight class on survival are sparse.

HYPOTHESIS

We hypothesized that weight class influences survival of patients treated with MitraClip® implantation.

METHODS

We investigated in-hospital, 1-year, 3-year, and long-term survival of patients successfully treated with isolated MitraClip® implantation for mitral valve regurgitation (MR) (June 2010-March 2018). Patients were categorized by weight classes, and the impact of weight classes on survival was analyzed.

RESULTS

Of 617 patients (aged 79.2 years; 47.3% females) treated with MitraClip® implantation (June 2010-March 2018), 12 patients were underweight (2.2%), 220 normal weight (40.1%), 237 overweight (43.2%), and 64 obesity class I (11.7%), 12 class II (2.2%), and 4 class III (0.7%). Preprocedural Logistic EuroScore (21.1 points [IQR 14.0-37.1]; 26.0 [18.5-38.5]; 26.0 [18.4-39.9]; 24.8 [16.8-33.8]; 33.0 [25.9-49.2]; 31.6 [13.1-47.6]; p = .291) was comparable between groups. Weight class had no impact on in-hospital death (0.0%; 4.1%; 1.5%; 0.0%; 7.7%; 0.0%; p = .189), 1-year survival (75.0%; 72.0%; 76.9%; 75.0%; 75.0%; 33.3%; p = .542), and 3-year survival (40.0%; 36.8%; 38.2%; 48.6%; 20.0%; 33.3%; p = .661). Compared to normal weight, underweight (hazard ratio [HR]: 1.35 [95% confidence interval [CI]: 0.65-2.79], p = .419), obesity-class I (HR: 0.93 [95% CI: 0.65-1.34], p = .705), class II (HR: 0.39 [95% CI: 0.12-1.24], p = .112), and class III (HR: 1.28 [95% CI: 0.32-5.21], p = .726) did not affect long-term survival. In contrast, overweight was associated with better survival (HR: 1.32 [95% CI: 1.04-1.68], p = .023).

CONCLUSION

Overweight affected the long-term survival of patients undergoing MitraClip® implantation beneficially compared to normal weight.

Fat-Free Mass and Body Fat in Patients with Myocardial Infarction Who Underwent Percutaneous Coronary Intervention

There are no data on the effects of fat-free mass (FFM) and body fat (BF) on prognosis in patients with myocardial infarction (MI). We investigated the effects of FFM and BF (which were estimated using formulas rather than direct measurements) on 30-day and long-term all-cause mortality in patients with MI who underwent percutaneous coronary intervention. We analyzed data from 6,453 patients with MI. The patients were divided into 2 categories (high/low) according to the fat-free mass index (FFMI) and 2 categories (low/high) according to the BF. The resultant 4 patient groups: HighFFMI-LowBF, HighFFMI-HighBF, LowFFMI-LowBF, and LowFFMI-HighBF, were compared. The lowest crude mortality after 30 days and in the long term was observed in the HighFFMI-LowBF group (3.0%,9.8%, respectively), followed by the HighFFMI-HighBF group (6.6%, 27.0%, respectively), the LowFFMI-LowBF group (10.4%, 36.0%, respectively), and the LowFFMI-HighBF group (14.7%, 56.8%, respectively). The difference was significant (p <0.0001), as was the difference between groups. After adjustment, the FFMI-BF groups independently predicted 30-day mortality (p = 0.003), but the risk was similar in all groups. Compared with the HighFFMI-LowBF group, the long-term mortality risk was similar in the HighFFMI-HighBF group (hazard ratio [HR] 1.11, 95% confidence interval [CI] 0.84 to 1.47, p = 0.47), but the LowFFMI-LowBF and LowFFMI-HighBF patients had a higher risk (HR 1.59, 95% CI 1.20 to 2.11, p = 0.001, HR 1.40, 95% CI 1.03 to 1.91, p = 0.033, respectively). Body composition predicted mortality better than body mass index in patients with MI. Mortality appeared to be inversely related to FFM, with patients with low FFM and low BF having a particularly high mortality risk. The body composition groups also confirmed the obesity paradox.

Obesity survival paradox in patients hospitalized with community-acquired pneumonia. Assessing sex-differences in a population-based cohort study

AIM

To assess the effect of obesity status (no obesity/obesity/ morbid obesity) on hospital outcomes (length of hospital stay [LOHS] and in-hospital mortality [IHM]), among patients hospitalized with community-acquired pneumonia (CAP) and according to sex.

METHODS

We conducted a retrospective cohort study based on national hospital discharge data of all subjects aged≥ 18 years hospitalized with CAP in Spain from 2016 to 2019.

RESULTS

We identified 519,750 hospital discharges with CAP. The prevalence of obesity was 6.38% and 1.78%. for morbid obesity. The mean age was higher for patients without obesity followed by those with obesity and morbid obesity (74.61, 72.5 and 70.2 years respectively; p<0.001). The mean number of comorbidities was similar for patients with obesity and morbid obesity (2.30 and 2.29) and significantly higher than for non-obese individuals (2.10). The crude IHM was higher among the non-obese patients (12.71%) followed by those with morbid obesity (8.56%) and obesity (7.72%), without finding differences between men and women. Among men, after multivariable logistic regression analysis, the probability of dying in the hospital was significantly lower for those with obesity (Adjusted-OR 0.59;95%CI 0.55-0.63) and morbid obesity (Adjusted-OR 0.62;95%CI 0.54-0.71) compared with non-obese. The protective effect of obesity (Adjusted-OR 0.71;95%CI 0.67-0.75) and morbid obesity (Adjusted OR 0.73;95%CI 0.66-0.8) was also observed among women.

CONCLUSIONS

Obese and obesity morbid patients with CAP have a lower risk of IHM than non-obese patients, without sex differences in this association. These data confirm the existence of the obesity paradox in this patient population.

Obesity and Its Impact on Adverse In-Hospital Outcomes in Hospitalized Patients With COVID-19

BACKGROUND

An increasing level of evidence suggests that obesity not only is a major risk factor for cardiovascular diseases (CVDs) but also has adverse outcomes during COVID-19 infection.

METHODS

We used the German nationwide inpatient sample to analyze all hospitalized patients with confirmed COVID-19 diagnosis in Germany from January to December 2020 and stratified them for diagnosed obesity. Obesity was defined as body mass index ≥30 kg/m² according to the WHO. The impact of obesity on in-hospital case fatality and adverse in-hospital events comprising major adverse cardiovascular and cerebrovascular events (MACCE), acute respiratory distress syndrome (ARDS), venous thromboembolism (VTE), and others was analyzed.

RESULTS

We analyzed data of 176,137 hospitalizations of patients with confirmed COVID-19 infection; among them, 9,383 (5.3%) had an additional obesity diagnosis. Although COVID-19 patients without obesity were older (72.0 [interquartile range (IQR) 56.0/82.0] vs. 66.0 [54.0/76.0] years, p < 0.001), the CVD profile was less favorable in obese COVID-19 patients (Charlson comorbidity index 4.44 ± 3.01 vs. 4.08 ± 2.92, p < 0.001). Obesity was independently associated with increased in-hospital case fatality (OR 1.203 [95% CI 1.131-1.279], p < 0.001) and MACCE (OR 1.168 [95% CI 1.101-1.239], p < 0.001), ARDS (OR 2.605 [95% CI 2.449-2.772], p < 0.001), and VTE (OR 1.780 [95% CI 1.605-1.973], p < 0.001) and also associated with increased necessity of treatment on intensive care unit (OR 2.201 [95% CI 2.097-2.310], p < 0.001), mechanical ventilation (OR 2.277 [95% CI 2.140-2.422], p < 0.001), and extracorporeal membrane oxygenation (OR 3.485 [95% CI 3.023-4.017], p < 0.001).

CONCLUSIONS

Obesity independently affected case fatality, MACCE, ARDS development, VTE, and other adverse in-hospital events in patients with COVID-19 infection. Obesity should be taken into account regarding COVID-19 prevention strategies, risk stratification, and adequate healthcare planning. Maintaining a healthy weight is important not only to prevent cardiometabolic diseases but also for better individual outcomes during COVID-19 infection.

Total numbers and in-hospital mortality of patients with myocardial infarction in Germany during the FIFA soccer world cup 2014

Environmental stress like important soccer events can induce excitation, stress and anger. We aimed to investigate (i) whether the FIFA soccer world cup (WC) 2014 and (ii) whether the soccer games of the German national team had an impact on total numbers and in-hospital mortality of patients with myocardial infarction (MI) in Germany. We analyzed data of MI inpatients of the German nationwide inpatient sample (2013-2015). Patients admitted due to MI during FIFA WC 2014 (12th June-13th July2014) were compared to those during the same period 2013 and 2015 (12th June-13th July). Total number of MI patients was higher during WC 2014 than in the comparison-period 2013 (18,479 vs.18,089, P < 0.001) and 2015 (18,479 vs.17,794, P < 0.001). WC was independently associated with higher MI numbers (2014 vs. 2013: OR 1.04 [95% CI 1.01-1.07]; 2014 vs. 2015: OR 1.07 [95% CI 1.04-1.10], P < 0.001). Patient characteristics and in-hospital mortality rate (8.3% vs. 8.3% vs. 8.4%) were similar during periods. In-hospital mortality rate was not affected by games of the German national team (8.9% vs. 8.1%, P = 0.110). However, we observed an increase regarding in-hospital mortality from 7.9 to 9.3% before to 12.0% at final-match-day. Number of hospital admissions due to MI in Germany was 3.7% higher during WC 2014 than during the same 31-day period 2015. While in-hospital mortality was not affected by the WC, the in-hospital mortality was highest at WC final.

Sex Difference in the Case Fatality of Older Myocardial Infarction Patients

Background

The female sex is associated with poorer outcomes after myocardial infarction (MI), although current evidence in older patients is limited and mixed. We sought to evaluate sex-based differences in outcome after MI in older patients.

Method

Consecutive older (≥70 years) all-comer patients with out-of-hospital MI admitted to 20 hospitals in Finland between 2005 and 2014 were studied using national registries (n = 40 654, mean age 80 years, 50% women). The outcome of interest was death within 1 year after MI. Differences between sexes (age, baseline features, medication, comorbidities, revascularization, and treating hospital) were balanced by inverse probability weighting.

Results

Adjusted all-cause case fatality was lower in women than in men at 30 days (16.0% vs 19.0%, respectively) and at 1 year (27.7% vs 32.4%, respectively) after MI (hazard ratio: 0.83; confidence interval [CI]: 0.80–0.86; p < .0001). Excess 1-year case fatality after MI compared to the corresponding general population was 22.1% (CI: 21.4%–22.8%) in women and 24.1% (CI: 23.4%–24.9%) in men. Women had a lower adjusted hazard of death after MI in subgroups of patients aged 70–79 years and ≥80 years, patients with and without ST elevation MI, revascularized and non-revascularized patients, patients with and without atrial fibrillation, and patients with and without diabetes. The sex difference in case fatality remained similar during the study period.

Conclusions

Older women were found to have a lower hazard of death after an out-of-hospital MI when compared to older men with similar features and treatments. This finding was consistent in several subgroups.

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.

Adiposity and Outcome After Ischemic Stroke: Obesity Paradox for Mortality and Obesity Parabola for Favorable Functional Outcomes

BACKGROUND AND PURPOSE

A survival advantage among individuals with higher body mass index (BMI) has been observed for diverse acute illnesses, including stroke, and termed the obesity paradox. However, prior ischemic stroke studies have generally tested only for linear rather than nonlinear relations between body mass and outcome, and few studies have investigated poststroke functional outcomes in addition to mortality.

METHODS

We analyzed consecutive patients with acute ischemic stroke enrolled in a 60-center acute treatment trial, the NIH FAST-MAG acute stroke trial. Outcomes at 3 months analyzed were (1) death; (2) disability or death (modified Rankin Scale score, 2-6); and (3) low stroke-related quality of life (Stroke Impact Scale<median). Relations with BMI were analyzed univariately and in multivariate models adjusting for 14 additional prognostic variables.

RESULTS

Among 1033 patients with acute ischemic stroke, average age was 71 years (±13), 45.1% female, National Institutes of Health Stroke Scale 10.6 (±8.3), and BMI 27.5 (±5.6). In both unadjusted and adjusted analysis, increasing BMI was linearly associated with improved 3-month survival (P=0.01) odds ratios in adjusted analysis for mortality declined across the BMI categories of underweight (odds ratio, 1.7 [CI, 0.6-4.9]), normal (odds ratio, 1), overweight (0.9 [CI, 0.5-1.4]), obese (0.5, [CI, 0.3-1.0]), and severely obese (0.4 [CI, 0.2-0.9]). In unadjusted analysis, increasing BMI showed a U-shaped relation to poststroke disability or death (modified Rankin Scale score, 2-6), with odds ratios of modified Rankin Scale score, 2 to 6 for underweight, overweight, and obese declined initially when compared with normal weight patients, but then increased again in severely obese patients, suggesting a U-shaped or J-shaped relation. After adjustment, including for baseline National Institutes of Health Stroke Scale, modified Rankin Scale score 2 to 6 was no longer related to adiposity.

CONCLUSIONS

Mortality and functional outcomes after acute ischemic stroke have disparate relations with patients' adiposity. Higher BMI is linearly associated with increased survival; and BMI has a U-shaped or J-shaped relation to disability and stroke-related quality of life. Potential mechanisms including nutritional reserve aiding survival during recovery and greater frequency of atherosclerotic than thromboembolic infarcts in individuals with higher BMI.

Predicted Skeletal Muscle Mass and 4-Year Cardiovascular Disease Incidence in Middle-Aged and Elderly Participants of IKARIA Prospective Epidemiological Study: The Mediating Effect of Sex and Cardiometabolic Factors

The sex-specific effect of skeletal muscle mass (SMM) index (SMI) on 4-year first fatal/non-fatal cardiovascular disease (CVD) event in free-of-disease individuals was examined. In 2009, n = 1411 inhabitants (mean age = 64(12)) from Ikaria were selected. Follow-up was performed in 2013. SMI was created to reflect SMM through appendicular skeletal muscle mass (indirectly calculated through formulas) divided by body mass index (BMI). Fifteen and six tenths percent of participants exhibited CVD (19.8% in men/12% in women, p = 0.002). Significant U-shape trends were observed in participants >65 years old and women irrespective to age confirmed through multi-adjusted Cox regression analysis; in age >65 years, Hazard Ratio (HR)_{(2nd vs. 1st SMI tertile)} = 0.80, 95% Confidence Interval (95%CI) (0.45, 0.96) and in women HR_{(2nd vs. 1st SMI tertile)} = 0.71, 95% CI (0.33, 0.95), while, as for the 3rd SMI tertile, no significant trends were observed. Mediation analysis revealed that mediators of the aforementioned associations in men were the arterial distensibility and total testosterone, while, in women, inflammation, insulin resistance, and arterial distensibility. High SMM accompanied by obesity may not guarantee lower CVD risk. Specific cardiometabolic factors seem to explain this need for balance between lean and fat mass.

Body mass index and in-hospital outcomes in patient's ≥80 years with ST Elevation Myocardial Infarction. Results from low income country without coronary intervention

BACKGROUND

In most scenarios from low/middle income countries, pharmacological approach for ST elevation Myocardial Infarction is still use. In these setting and increase proportion of elderly patients is awaited. So it is also expected to have older patients with suboptimal treatment and risk stratification.

OBJECTIVE

To investigate the impact of the body mass index (BMI) on in-hospital outcomes in a cohort of elderly (≥80 years) patients, from a center without coronary intervention.

METHODS

Patient's ≥80 years of age admitted to our institution between June 2014 and May 2019 with STEMI, were divided according BMI tertiles (BMI tertile 1: ≪22.36 kg/m2, BMI tertile2: 22.36-25.71 kg/m2, and BMI tertile 3: ≫25.71 kg/m2). The primary endpoint was all-cause in-hospital mortality RESULTS: Out of 118 patients, 41 (34.74%) were women. Median age was 84.4 ± 3.5 years and median BMI 24.1 ± 3.7 kg/m2. Women had a higher BMI than men (24.4 ± 4.0 vs 24.0 ± 3.6; p: 0.535). All-cause mortality was 33.3%, 2.5%, and 15% for lower, middle, and higher BMI tertiles (p=0.002). To belong to BMI tertile 1 was associated with an increased all-cause mortality (OR: 5.15, 95% CI 1.84-14.28, p = 0.001); and in patients without administration of streptokinase (OR: 9.52, 95% CI 2.34-38.45, p = 0.001).

CONCLUSION

This study reports association between lower BMI values and increased mortality in elderly patients with and without pharmacological reperfusion with streptokinase.

Association of Body Mass Index and Outcome in Acutely Ill Patients With Chronic Kidney Disease Requiring Intensive Care Therapy

OBJECTIVE

An association of body mass index (BMI) and outcome, the "obesity paradox," has been described in patients with chronic kidney disease (CKD) and end-stage renal disease. We sought to assess whether a potential beneficial effect of a high body mass is also seen in CKD patients with critical illness.

METHODS

In a retrospective analysis of a prospectively collected database of 123,416 patients from 107 Austrian intensive care units (ICUs) in whom BMI was available, the association of 6 groups of BMI and hospital mortality was assessed in 12,206 patients with CKD 3-5 by univariate and multivariate logistic regression analyses.

RESULTS

Patients with CKD were sicker, had a longer ICU stay, and had a higher ICU and hospital mortality than those without. The association of BMI and outcome in CKD patients indicated a U-shaped curve with the highest mortality in patients with BMI <20 and ≥40, and the lowest with a BMI between ≥25 and <40. This relationship was also significant in a multivariate analysis adjusted for severity of illness assessed by Simplified Acute Physiology Score III score, age, gender, admission diagnosis, and pre-existing comorbidities. It was not found in patients with CKD 5 on renal replacement therapy, in patients below 60 years of age, and those with diabetes mellitus requiring insulin treatment.

CONCLUSIONS

BMI is associated with better outcomes in CKD 3-5 patients who have acquired acute intermittent diseases and are admitted to an ICU, but not those requiring renal replacement therapy. This higher tolerance to acute disease processes may in part explain the "obesity paradox" observed in CKD patients.

Survival Benefit of Obese Patients With Pulmonary Embolism

OBJECTIVE

To investigate the impact of obesity and underweight on adverse in-hospital outcomes in pulmonary embolism (PE).

PATIENTS AND METHODS

Patients diagnosed as having PE based on International Statistical Classification of Diseases and Related Health Problems, 10th Revision, German Modification code I26 in the German nationwide inpatient database were stratified for obesity, underweight, and normal weight/overweight (reference group) and compared regarding adverse in-hospital outcomes.

RESULTS

From January 1, 2011, through December 31, 2014, 345,831 inpatients (53.3% females) 18 years and older were included in this analysis; 8.6% were obese and 0.5% were underweight. Obese patients were younger (67.0 vs 73.0 years), were more frequently female (60.2% vs 52.7%), had a lower cancer rate (13.6% vs 20.5%), and were more often treated with systemic thrombolysis (6.4% vs 4.3%) and surgical embolectomy (0.3% vs 0.1%) vs the reference group (P<.001 for all). Overall, 51,226 patients (14.8%) died during in-hospital stay. Obese patients had lower mortality (10.9% vs 15.2%; P<.001) vs the reference group and a reduced odds ratio (OR) for in-hospital mortality (OR, 0.74; 95% CI, 0.71-0.77; P<.001) independent of age, sex, comorbidities, and reperfusion therapies. This survival benefit of obese patients was more pronounced in obesity classes I (OR, 0.56; 95% CI, 0.52-0.60; P<.001) and II (OR, 0.63; 95% CI 0.58-0.69; P<.001). Underweight patients had higher prevalence of cancer and higher mortality rates (OR, 1.15; 95% CI, 1.00-1.31; P=.04).

CONCLUSION

Obesity is associated with decreased in-hospital mortality rates in patients with PE. Although obese patients were more often treated with reperfusion therapies, the survival benefit of obese patients occurred independently of age, sex, comorbidities, and reperfusion treatment.

Associations of Chronic Inflammation, Insulin Resistance, and Severe Obesity With Mortality, Myocardial Infarction, Cancer, and Chronic Pulmonary Disease

IMPORTANCE

Chronic inflammation and insulin resistance often accompany severe obesity, and all are associated with disease risk.

OBJECTIVE

To examine how the association of severe obesity with adverse outcomes may be modified by the presence of systemic inflammation and/or insulin resistance.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, retrospective cohort study included all residents of Alberta, Canada, aged 18 years and older with at least 1 procedure to ascertain severe obesity and measures of C-reactive protein, fasting glucose, triglyceride, and high-density lipoprotein cholesterol levels. Participants were observed from April 2003 to March 2017, and data analysis was conducted from June 2018 to December 2018.

EXPOSURES

Severe obesity (body mass index ≥35 or ≥40 after January 1, 2017, as indicated with a procedure-fee modifier), chronic inflammation (all measures of C-reactive protein >10 mg/L), and a surrogate measure of insulin resistance.

MAIN OUTCOMES AND MEASURES

All-cause death, first acute myocardial infarction during follow-up, first cancer diagnosis during follow-up, and new chronic pulmonary disease.

RESULTS

Among 420 636 participants, the median age was 45 years (interquartile range, 34-56 years; range, 18-97 years), 157 799 (37.5%) were male, 185 782 (44.2%) had insulin resistance, 71 987 (17.1%) had severe obesity, and 10 770 (2.6%) had inflammation. In women with chronic inflammation, the presence of severe obesity was associated with a lower mortality risk (hazard ratio [HR], 0.75; 95% CI, 0.65-0.86), but there was no difference in risk in men with inflammation (HR, 0.89; 95% CI, 0.78-1.02). In contrast, the presence of severe obesity was associated with a higher mortality risk in men without inflammation (HR, 1.20; 95% CI, 1.13-1.26), but there was no difference in risk in women without inflammation (HR, 1.00; 95% CI, 0.95-1.06). For myocardial infarction, severe obesity was associated with increased risk in both women and men without inflammation (women: HR, 1.26; 95% CI, 1.17-1.36; men: HR, 1.35; 95% CI, 1.27-1.43) but not in women and men with inflammation (women: HR, 0.85; 95% CI, 0.67-1.07; men: HR, 0.90; 95% CI, 0.71-1.14). Severe obesity was associated with increased risk in women and men, irrespective of chronic inflammation, for new chronic pulmonary disease (women with inflammation: HR, 1.34; 95% CI, 1.23-1.46; women without inflammation: HR, 1.58; 95% CI, 1.54-1.62; men with inflammation: HR, 1.41; 95% CI, 1.29-1.54; men without inflammation: HR, 1.65; 95%, CI, 1.60-1.71) and cancer (women with inflammation: HR, 1.16; 95% CI, 1.03-1.30; women without inflammation, HR, 1.32; 95% CI, 1.28-1.36; men with inflammation: HR, 1.17; 95% CI, 1.04-1.32; men without inflammation: HR, 1.33; 95% CI, 1.28-1.39). Similar to chronic inflammation, severe obesity was not always associated with higher risk in participants with insulin resistance.

CONCLUSIONS AND RELEVANCE

The findings suggest that severe obesity with systemic inflammation is associated with a different prognosis than severe obesity without inflammation.

Obesity paradox in peripheral artery disease

BACKGROUND & AIMS

Previous studies have suggested an obesity survival paradox in patients with peripheral artery disease (PAD). We investigated the influence of obesity and underweight on adverse in-hospital outcomes in PAD.

METHODS

Patients diagnosed with PAD based on ICD-code I70.2 of the German nationwide database were stratified for obesity, underweight and a reference group with normal-weight/over-weight and compared regarding adverse in-hospital outcomes.

RESULTS

Between 01/2005-12/2015, 5,611,484 inpatients (64.8% males) were diagnosed with PAD; of those, 8.9% were coded with obesity and 0.3% with underweight. Obese patients were younger (70 (IQR 63/76) vs. 73 (66/80) years, P < 0.001), more frequently female (36.7% vs. 35.1%, P < 0.001), had less cancer (4.9% vs. 7.9%, P < 0.001) and had less treatment with major amputation (2.6% vs. 3.2%, P < 0.001) compared to the reference group. Overall, 277 876 (5.0%) patients died in-hospital. Obese patients showed lower mortality rate (3.2% vs. 5.1%, P < 0.001) compared to the reference group and reduced risk of in-hospital mortality (OR, 0.617 [95%CI 0.607-0.627], P < 0.001). This "obesity paradox" was demonstrated in obesity classes I (OR, 0.475 [95%CI 0.461-0.490], P < 0.001), II (OR, 0.580 [95%CI 0.557-0.605], P < 0.001), and III (OR, 0.895 [95%CI 0.857-0.934], P < 0.001) and was independent of age, sex and comorbidities. Underweight patients revealed higher in-hospital mortality (6.0% vs. 5.1%, P < 0.001) compared to the reference group (OR, 1.179 [95%CI 1.106-1.257], P < 0.001) and showed higher prevalence of cancer (22.0% vs. 7.9%, P < 0.001).

CONCLUSIONS

Coding for obesity is associated with lower in-hospital mortality in PAD patients relative to those with normal-weight/over-weight. This obesity survival paradox was independent of age, gender and comorbidities and observed for all obesity classes.

Obesity Paradox in Aging: From Prevalence to Pathophysiology

Recent advances in medical technology and health care have greatly improved the management for chronic diseases and prolonged human lifespan. Unfortunately, increased lifespan and the aging population impose a major challenge on the ever-rising prevalence of chronic diseases, in particular cardiometabolic stress associated with the pandemic obesity in our modern society. Although overweight and obesity are associated with incident cardiovascular diseases (CVD), including heart failure (HF), it paradoxically leads to a more favorable prognosis in patients with chronic HF, a phenomenon commonly defined as "obesity paradox". Numerous population-based and clinical studies have suggested possible explanations such as better metabolic reserve, smoking and disease-associated weight loss for obesity paradox. Recent evidence noticed a shift in obesity paradox with aging. While some studies have reported a more pronounced "obesity paradox" in the older patients, others have seen diminished cardiac benefits with overweight and obesity in the elderly patients with CVD. These findings suggested that a complex relationship among aging, metabolism, and HF severity/chronicity, which may explain the shift in obesity paradox in the elderly. Aging negatively affects body metabolism and cardiac function although its precise impact on obesity paradox remains elusive. To develop new strategies for cardiovascular health in the elderly, it is imperative to understand the precise role for aging on obesity-related CVD.

Data Talks: Obesity-Related Influences on US Mortality Rates

BACKGROUND

In the US, obesity is an epidemiologic challenge and the population fails to comprehend this complex public health issue. To evaluate underlying obesity-impact patterns on mortality rates, we data-mined the 1999-2016 Center for Disease Control WONDER database's vital records.

METHODS

Adopting SAS programming, we scrutinized the mortality and population counts. Using ICD-10 diagnosis codes connected to overweight and obesity, we obtained the obesity-related crude and age-adjusted causes of death. To understand divergent and prevalence trends we compared and contrasted the tabulated obesity-influenced mortality rates with demographic information, gender, and age-related data.

KEY RESULTS

From 1999 to 2016, the obesity-related age-adjusted mortality rates increased by 142%. The ICD-10 overweight and obesity-related death-certificate coding showed clear evidence that obesity factored in the male age-adjusted mortality rate increment to 173% and the corresponding female rate to 117%. It also disproportionately affected the nation-wide minority population death rates. Furthermore, excess weight distributions are coded as contributing features in the crude death rates for all decennial age-groups.

CONCLUSIONS

The 1999-2016 data from ICD-10 death certificate coding for obesity-related conditions indicate that it is affecting all segments of the US population.