Improvement in cardiovascular risk in women after bariatric surgery as measured by carotid intima-media thickness: comparison of sleeve gastrectomy versus gastric bypass

Impact of bariatric surgery on carotid intima-media thickness, flow-mediated dilation, and nitrite-mediated dilation: a systematic review and meta-analysis

Obesity is considered one of the independent risk factors for atherosclerosis and is strongly correlated with cardiovascular morbidity and mortality. Previous studies showed carotid intima-media thickness (CIMT), flow-mediated dilation (FMD), and nitrite-mediated dilatation (NMD) are reliable non-invasive markers of arterial damage and dysfunction. The aim of this study was to evaluate the effect of bariatric surgery on CIMT, FMD, and NMD markers in patients with obesity. A systematic search was performed in the PubMed, Embase, Scopus, and Web of Science databases until May 2022. All the English-published studies on the effect of bariatric surgery on CIMT, FMD, and NMD were included. A quantitative meta-analysis was performed, as well as subgroup analyses for the type of procedure and duration of follow-up. Meta-analysis of 41 studies with 1639 patients showed CIMT was significantly reduced by .11 mm after bariatric surgery (95% CI, -.14 to -.08; P < .001; mean follow-up = 10.8 mo). The pooled analysis of 23 studies with 1106 patients showed an increase of FMD by 4.57% after bariatric surgery (95% CI, 2.69-6.44; P < .001; mean follow-up = 11.5 mo). The results of a pooled analysis of 12 studies with 346 patients showed a significant increase of NMD by 2.46% after bariatric surgery (95% CI, .99-3.94; P < .001; mean follow-up = 11.4 mo). The random effect meta-regression demonstrated that baseline CIMT and FMD significantly affect the changes in CIMT and FMD. This meta-analysis showed bariatric surgery can improve CIMT, FMD, and NMD markers in patients with obesity. These improvements show the known effect of metabolic surgery in decreasing cardiovascular risk.

Bariatric surgery prevents carotid wall thickness progression

BACKGROUND

Bariatric surgery is a treatment option for patients with severe obesity and improves parameters of cardiovascular and/or metabolic disease. Carotid intima media thickness (C-IMT) is a surrogate measure of subclinical atherosclerosis. Previous studies showed short to mid-term arrest and even regression of C‑IMT progression following bariatric surgery. We aimed to investigate the long-term effect of weight loss on C‑IMT progression 10 years after bariatric surgery in comparison to a population-based control cohort.

METHODS

In total, 21 eligible patients were examined preoperatively, at 5 and 10 years after bariatric surgery. Anthropometric parameters, plasma triglycerides, total cholesterol, high-density lipoprotein cholesterol (HDL-C), insulin, and glucose were assessed at all three study visits. C‑IMT was measured via B‑mode scans of the common carotid artery. C‑IMT progression was measured in an age-matched and BMI-matched cohort selected from the population-based Bruneck study to compare with changes in C‑IMT progression after bariatric surgery.

RESULTS

C‑IMT remained stable over the 10-year observation period after bariatric surgery. The control cohort showed a significant C‑IMT progression over 10 years. The difference in C‑IMT progression over 10 years was significant (p < 0.01) between both cohorts.

CONCLUSION

Weight loss induced by bariatric surgery halts the natural progression of C‑IMT over a 10-year observation period.

The Beneficial Changes on Inflammatory and Endothelial Biomarkers Induced by Metabolic Surgery Decreases the Carotid Intima-Media Thickness in Men

Obesity increases cardiovascular risk in men through several mechanisms. Among them, low-grade chronic inflammation and obesity-associated hypogonadism have been described. We aimed to study the effects of metabolic surgery on the carotid-intima media thickness through changes in inflammatory, endothelial biomarkers, and testosterone. We included 60 men; 20 submitted to laparoscopic Roux-en-Y gastric bypass (RYGB), 20 to sleeve gastrectomy (SG), and 20 to lifestyle modification (controls). Several inflammatory and endothelial biomarkers and total testosterone (TT) were measured at baseline and six months after surgery. Free testosterone (FT) was calculated, and carotid intima-media thickness (cIMT) was measured by ultrasonography. Compared to controls, cIMT decreased after surgery concomitantly with CRP, PAI-1, sICAM-1, and IL-18 (p < 0.01) and with an increase in sTWEAK (p = 0.027), with no differences between RYGB and SG. The increase in TT and FT after surgery correlated with the changes in cIMT (p = 0.010 and p = 0.038, respectively), but this association disappeared after multivariate analysis. Linear regression showed that sTWEAK (ß = -0.245, p = 0.039), PAI-1 (ß = 0.346, p = 0.005), and CRP (ß = 0.236, p = 0.049) were associated with the changes in cIMT (R² = 0.267, F = 6.664, p = 0.001). In conclusion, both RYGB and SG induced improvements in inflammation and endothelial biomarkers that drove a decrease in cIMT compared to men with obesity who submitted to diet and exercise.

The Role of Adiponectin in the Resolution of Male-Obesity-Associated Secondary Hypogonadism after Metabolic Surgery and Its Impact on Cardiovascular Risk

Male-obesity-associated secondary hypogonadism (MOSH) is a very prevalent entity that may resolve after marked weight loss. Adiponectin (APN) is an adipokine with anti-inflammatory properties that regulates metabolism. Low-circulating APN is associated with obesity, diabetes, and cardiovascular risk, along with circulating testosterone. We aimed to evaluate APN changes in men with MOSH (low circulating free testosterone (FT) with low or normal gonadotropins) and without it after metabolic surgery. We look for their possible association with cardiovascular risk measured by carotid intima-media thickness (cIMT). We included 60 men (20 submitted to lifestyle modification, 20 to sleeve gastrectomy, and 20 to gastric bypass) evaluated at baseline and 6 months after. The increase in APN at follow-up was reduction in patients with persistent MOSH (n = 10) vs. those without MOSH (n = 30) and MOSH resolution (n = 20), and the former did not achieve a decrease in cIMT. The increase in APN correlated positively with FT (r = 0.320, p = 0.013) and inversely with cIMT (r = −0.283, p = 0.028). FT inversely correlated with cIMT (r = −0.269, p = 0.038). In conclusion, men without MOSH or with MOSH resolution showed a high increase in APN after weight loss with beneficial effects on cIMT. Those without MOSH resolution failed to attain these effects.

What Can We Change in Diet and Behaviour in Order to Decrease Carotid Intima-Media Thickness in Patients with Obesity?

Atherosclerosis—considered the major cause of cardiovascular diseases (CVDs)—is strongly associated with obesity, to which it strongly contributes. Moreover, atherosclerosis is characterised by a long asymptomatic phase, and its progression can lead to serious cardiovascular (CV) events. The carotid intima-media thickness (cIMT) has been determined as a predictor of CV events, as well as a marker of subclinical atherosclerosis, and has been used in clinical trials as an alternative assessment method or a surrogate endpoint. It should be noted that several behavioural approaches can directly influence the cIMT values, and decrease or increase the CV risk. In our paper, we aimed to summarize the current knowledge regarding IMT measurement among patients with obesity as a risk group—also in terms of the obesity paradox where the diagnosis of subclinical atherosclerosis is especially essential and implements the early therapeutic approach. We also summarized behavioural, modifiable factors, such as the Mediterranean diet, the Dietary Approach to Stop Hypertension Diets, body weight reduction or the intake of micro- and macronutrients, with a particular focus on the studies where the cIMT values were one of the outcomes. In order to collect the literature data related to the presented topic, the PubMed database was explored.

Changes of Carotid Intima-Media Thickness After Sleeve Gastrectomy in High Cardiovascular Risk Patients: a Prospective Study

PURPOSE

There are insufficient data showing the impact of laparoscopic sleeve gastrectomy (LSG) on carotid intima-media thickness (CIMT). Therefore, in the current work, we investigated the improvement of metabolic syndrome and CIMT in patients with obesity after LSG.

METHODS

This study involved 120 consecutively selected Egyptian patients with a high cardiovascular risk who underwent LSG and were followed up for 12 months.

RESULTS

CIMT declined from 0.95 ± 0.17 mm to 0.83 ± 0.12 (p < 0.001) after 12 months. In addition, the mean fasting blood glucose and fasting inulin level dropped significantly from 153.3 ± 63.6 to 108.8 ± 33.8 mg/dl and from 23.1 ± 7.1 mU/ml to 14.1 ± 6.4 respectively (p < 0.001). Furthermore, glycated hemoglobin (HbA1c) declined from 7.02 ± 1.7 to 5.5 ± 0.96 (p < 0.001). At the end of the follow-up period, metabolic parameters such as HOMA-IR, C-reactive protein (CRP), fibrinogen, total cholesterol, LDL cholesterol, triglycerides, AST, and ALT decreased significantly from their respective baselines (p value < 0.001). Moreover, the reduction in CIMT showed a strong positive correlation with the degree of weight loss at 6 months and 12 months of follow-up.

CONCLUSION

LSG led to a substantial decrease in CIMT. Moreover, it significantly impacted cardiovascular risk factors such as obesity, hypertension, insulin resistance, lipid profile, and inflammatory markers.

Traditional Risk Factors are Causally Related to Carotid Intima-Media Thickness Progression: Inferences from Observational Cohort Studies and Interventional Trials

In the present review, associations between traditional vascular risk factors (VRFs) and carotid intimamedial thickness progression (C-IMTp) as well as the effects of therapies for VRFs control on C-IMTp were appraised to infer causality between each VRF and C-IMTp. Cohort studies indicate that smoking, binge drinking, fatness, diabetes, hypertension and hypercholesterolemia are associated with accelerated C-IMTp. An exception is physical activity, with mixed data. Interventions for the control of obesity, diabetes, hypertension and hypercholesterolemia decelerate C-IMTp. Conversely, scarce information is available regarding the effect of smoking cessation, stop of excessive alcohol intake and management of the metabolic syndrome. Altogether, these data support a causative role of several traditional VRFs on C-IMTp. Shortcomings in study design and/or ultrasonographic protocols may account for most negative studies, which underlines the importance of careful consideration of methodological aspects in investigations using C-IMTp as the outcome.

Alterations of aorta intima and media transcriptome in swine fed high-fat diet over 1-year follow-up period and of the switch to normal diet

BACKGROUND AND AIM

We previously showed that 12-month high-fat diet (HFD) in pigs led to fattening and increased artery intima-media-thickness, which were partly reversed after 3-month return to control diet (CD). The aim of this study was to decipher underlying mechanism of action by using transcriptomic analyses of intima and media of aorta.

METHODS AND RESULTS

Thirty-two pigs were divided into three groups: CD for 12 months; HFD for 12 months; switch diet group (regression diet; RD): HFD for 9 months followed by CD for 3 months. After 12 months, RNA was isolated from aorta intima and media for nutrigenomic analyses. HFD significantly affected gene expression in intima, while RD gene expression profile was distinct from the CD group. This suggests that switch to CD is not sufficient to correct gene expression alterations induced by HFD but counteracted expression of a group of genes. HFD also affected gene expression in media and as for intima, the expression profile of media of pigs on RD differed from that of these on CD.

CONCLUSIONS

This study revealed nutrigenomic modifications induced by long-term HFD consumption on arterial intima and media. The return to CD was not sufficient to counteract the genomic effect of HFD.

Changes in Soluble TWEAK Concentrations, but Not Those in Amyloid-β(1-40), Are Associated with a Decrease in Carotid Intima-Media Thickness after Bariatric Surgery in Obese Women

BACKGROUND/AIM

Soluble tumor necrosis factor-like weak inducer of apoptosis (sTWEAK) and amyloid-β(1-40) (Aβ40) emerged as markers of cardiovascular risk because of their actions in the endothelium and their role in atherosclerotic progression. The aim of this study was to analyze the association of these two factors with the decrease in carotid intima-media thickness (cIMT) after bariatric surgery in obese women.

METHODS

We studied 60 severely obese women, of whom 20 were submitted to laparoscopic Roux-en-Y gastric bypass (RYGB), 20 to sleeve gastrectomy (SG), and 20 to lifestyle modification therapy. Circulating sTWEAK, Aβ40, high-sensitivity C-reactive protein, plasminogen activator inhibitor type 1, insulin resistance (HOMA-IR), and cIMT were measured at baseline and after 1 year of follow-up.

RESULTS

sTWEAK increased similarly after both surgical procedures, whereas the increase observed after lifestyle intervention did not reach statistical significance. Aβ40 showed no differences between groups of women, nor did it change during follow-up. The decrease in cIMT at 12 months correlated with the decrease in body mass index (BMI) (r = 0.45; p < 0.001) and fasting insulin (r = 0.30; p = 0.038), and also with the increase in sTWEAK (r = -0.43; p = 0.002). Multivariate linear regression showed that only the changes in BMI (β = 0.389; p = 0.005) and sTWEAK (β = -0.358; p = 0.009) were associated with the decrease in cIMT (R2 = 0.313; F = 9.348; p < 0.001).

CONCLUSIONS

One year after bariatric surgery, RYGB and SG induced a similar increase in circulating sTWEAK that occurred in parallel to the decrease observed in cIMT.

Effects of high-intensity interval training on vascular endothelial function and vascular wall thickness in breast cancer patients receiving anthracycline-based chemotherapy: a randomized pilot study

PURPOSE

The purpose of this study was to determine the effects of an 8-week high-intensity interval training (HIIT) intervention on vascular endothelial function, measured as brachial artery flow-mediated dilation (baFMD), and vascular wall thickness measured by carotid intima media thickness (cIMT) in breast cancer patients undergoing anthracycline-based chemotherapy.

METHODS

Thirty women were randomized to either HIIT or non-exercise control groups (CON). The HIIT group participated in an 8-week HIIT intervention occurring three times per week on a cycle ergometer. The CON group was offered the HIIT intervention after 8 weeks. baFMD was measured from the brachial artery diameter at baseline (D0) and 1 min after cuff deflation (D1); percent change was calculated by measuring brachial artery diameter after cuff deflation relative to the baseline [baFMD = (D1 - D0)/D0 × 100]. The cIMT was obtained from the posterior wall of common carotid artery 10 mm below the carotid bulb. Paired t test and repeated measures ANCOVA were performed to assess changes in baFMD and cIMT.

RESULTS

At baseline, the HIIT (n = 15) and CON (n = 15) groups did not differ by age (46.9 ± 9.8 years), BMI (31.0 ± 7.5 kg/m2), and blood pressure (123.4 ± 16.8/72.3.9 ± 5.6 mmHg). Post-exercise, baFMD significantly increased [4.3; 95% confidence interval (CI): (1.5, 7.0), p = 0.005] in HIIT versus CON group. cIMT did not significantly change [0.003, 95% CI - 0.004, 0.009), p = 0.40] in HIIT group, while IMT significantly increased from baseline to post-intervention (0.009, 95% CI 0.004, 0.010, p = 0.003) in CON group.

CONCLUSION

This study may suggest that HIIT improved vascular endothelial function and maintained wall thickness in breast cancer patients undergoing anthracycline-based chemotherapy.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02454777.

Comparison of Cardiovascular Benefits of Bariatric Surgery and Abdominal Lipectomy

PURPOSE OF REVIEW

The purpose of this review is to examine recent evidence supporting effectiveness of bariatric surgery and abdominal lipectomy as interventional strategies aimed at reduction in incidence of cardiovascular disease (CVD) and related morbidity and mortality in obese and metabolic syndrome patients.

RECENT FINDINGS

While several studies show reduction in CVD risk factors in patients who have undergone both the Roux-en-Y gastric bypass and sleeve gastrectomy, very few demonstrate actual improvements in cardiovascular function, or a decrease in CVD events or CVD-related mortality. Consequently, the cardiovascular benefits of the less invasive sleeve gastrectomy in comparison to the gastric bypass are also unclear. Striking new data on large patient samples demonstrate significant positive correlation between gastric bypass and CVD risk factor reduction only in patients who are diabetic or > 50 years of age at the time of surgery, with no significant differences in non-diabetic and younger patients and with significant side effects. On the other hand, a markedly less invasive removal of abdominal subcutaneous adipose tissue via lipectomy consistently and significantly improved CVD risk factors as well as cardiovascular function in the very few studies available. Overall, neither the potential nor the definitive cardiovascular benefits of either of the commonly used bariatric surgical or the various lipectomy procedures have been adequately explored. Future basic science and clinical studies have the opportunity to understand the mechanisms and long-term consequences of both approaches and develop personalized approaches with higher benefit to side effect ratios.

Beneficial changes on plasma apolipoproteins A and B, high density lipoproteins and oxidized low density lipoproteins in obese women after bariatric surgery: comparison between gastric bypass and sleeve gastrectomy

Background

The beneficial effects in lipid profiles after obesity surgery might be associated with the decrease in cardiovascular risk. However, direct comparison between different surgical techniques has not been extensively performed.

Methods

In the present study we compare 20 obese women submitted to laparoscopic Roux en Y gastric bypass (RYGB) with 20 women submitted to sleeve gastrectomy (SG). Twenty control women matched for age and baseline cardiovascular risk were also included. Both patients and controls were followed up for 1 year after surgery or conventional treatment with diet and exercise, respectively. Lipid profiles were measured at baseline, 6 and 12 months later. Carotid intima-media thickness was measured by ultrasonography at baseline and at the end of the study.

Results

Women submitted to bariatric surgery showed a decrease in total cholesterol, triglycerides, oxidized-LDL and ApoB, and an increase in HDL and ApoA concentrations that occurred regardless of the surgical procedure. LDL concentrations, however, decreased only after RYGB whereas Lp(a) showed no changes. We did not observe any correlation between the changes in serum lipid concentrations and those in carotid intima-media thickness.

Conclusions

Sleeve gastrectomy and gastric bypass induce a similar beneficial effect on serum lipids in women with high cardiovascular risk 1 year after surgery.