Association between triglyceride glucose-body mass index and all-cause mortality in critically ill patients with acute myocardial infarction: retrospective analysis of the MIMIC-IV database

Background

Insulin resistance (IR) is closely related to the development of cardiovascular diseases. Triglyceride-glucose-body mass index (TyG-BMI) has been proven to be a reliable surrogate of IR, but the relationship between TyG-BMI and acute myocardial infarction (AMI) is unknown. The present study aims to determine the effects of TyG-BMI on the clinical prognosis of critically ill patients with AMI.

Methods

The data of AMI patients were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. All patients were divided into four groups according to the TyG-BMI quartile. Outcomes were defined as 30-, 90-, 180-, and 365-day all-cause mortality. Kaplan-Meier (K-M) curve was used to compare survival rate between groups. Meanwhile, Cox regression analysis and restricted cubic splines (RCS) were used to explore the relationship between TyG-BMI index and outcome events.

Results

A total of 1,188 critically ill patients with AMI were included in this study. They were divided into four groups according to TyG-BMI quartiles, there were significant differences in 90-, 180-, and 365-day all-cause mortality while there was no difference in 30-day all-cause mortality. Interestingly, with the increase of TyG-BMI, the 90-, 180-, and 365-day survival rate increased first and then gradually decreased, but the survival rate after decreasing was still higher than that in the group with the lowest TyG-BMI. U-shaped relationships between TyG-BMI index and 90-, 180-, and 365-day all-cause mortality were identified using RCS curve and the inflection point was 311.1, 316.5, and 320.1, respectively, whereas the TyG-BMI index was not non-linearly associated with 30-day all-cause mortality. The results of Cox proportional hazard regression analysis are consistent with those of RCS analysis.

Conclusion

U-shaped relationships are existed between the TyG-BMI index and 90-, 180-, and 365-day all-cause mortality in critically ill patients with AMI, but not 30-day all-cause mortality. The TyG-BMI index can be used as an effective index for early prevention of critically ill patients with AMI.

BMI-Stratified Exploration of the 'Obesity Paradox': Heart Failure Perspectives from a Large German Insurance Database

Background: The global rise of obesity and its association with cardiovascular risk factors (CVRF) have highlighted its connection to chronic heart failure (CHF). Paradoxically, obese CHF patients often experience better outcomes, a phenomenon known as the 'obesity paradox'. This study evaluated the 'obesity paradox' within a large cohort in Germany and explored how varying degrees of obesity affect HF outcome. Methods: Anonymized health claims data from the largest German insurer (AOK) for the years 2014-2015 were utilized to analyze 88,247 patients hospitalized for myocardial infarction. This analysis encompassed baseline characteristics, comorbidities, interventions, complications, and long-term outcomes, including overall survival, freedom from CHF, and CHF-related rehospitalization. Patients were categorized based on body mass index. Results: Obese patients encompassed 21.3% of our cohort (median age 68.69 years); they exhibited a higher prevalence of CVRF (p < 0.001) and comorbidities than non-obese patients (median age 70.69 years). Short-term outcomes revealed lower complication rates and mortality (p < 0.001) in obese compared to non-obese patients. Kaplan-Meier estimations for long-term analysis illustrated increased incidences of CHF and rehospitalization rates among the obese, yet with lower overall mortality. Multivariable Cox regression analysis indicated that obese individuals faced a higher risk of developing CHF and being rehospitalized due to CHF but demonstrated better overall survival for those classified as having low-level obesity (p < 0.001). Conclusions: This study underscores favorable short-term outcomes among obese individuals. The 'obesity paradox' was confirmed, with more frequent CHF cases and rehospitalizations in the long term, alongside better overall survival for certain degrees of obesity.

J-shaped association between LDL cholesterol and cardiovascular events: A longitudinal primary prevention cohort of over 2.4 million people nationwide

INTRODUCTION

Low-density lipoprotein (LDL) cholesterol-lowering treatment is beneficial for the secondary or primary prevention of high-risk atherosclerotic cardiovascular disease (ASCVD). However, the prognostic implications of low LDL cholesterol levels in patients without previous ASCVD and without statin use remain elusive.

METHODS

From a nationwide cohort, 2,432,471 participants without previous ASCVD or statin use were included. For myocardial infarction (MI) and ischemic stroke (IS), participants were followed-up from 2009 to 2018. They were stratified according to 10-year ASCVD risk (<5 %, 5 %-<7.5 %, 7.5 %-<20 %, and ≥20 %) and LDL cholesterol level (<70, 70-99, 100-129, 130-159, 160-189, and ≥190 mg/dL).

RESULTS

The relationship between LDL cholesterol levels and ASCVD events exhibited a J-shaped curve for both MI and IS. After classification according to the ASCVD risk, this J-shaped relationship was consistently observed for the composite of MI and IS. Participants with an LDL cholesterol level <70 mg/dL showed a higher MI risk than those with a level of 70-99 mg/dL or 100-129 mg/dL in the low-ASCVD risk group. The J-shaped curve between LDL cholesterol levels and MI risk was attenuated across ASCVD risk groups. For IS, participants with an LDL cholesterol level <70 mg/dL demonstrated increased risks compared with those with a level of 70-99 mg/dL, 100-129 mg/dL, or 130-159 mg/dL in the borderline, intermediate, and high ASCVD risk groups, respectively. In contrast, a linear association was observed in participants taking statins. Interestingly, a J-shaped association was observed between LDL cholesterol and high-sensitivity C-reactive protein (hs-CRP) levels; the mean hs-CRP level and the proportion of individuals with increased hs-CRP levels were relatively high among individuals with an LDL cholesterol level <70 mg/dL.

CONCLUSIONS

Although high LDL cholesterol levels increase the risk of ASCVD, low LDL cholesterol levels do not warrant safety from ASCVD. Therefore, individuals with low LDL cholesterol levels should be carefully monitored.

Impact of Body Mass Index on Mortality in Hospitalized Patients With Hypertrophic Cardiomyopathy

Although obesity is associated with increased phenotypic expression in patients with hypertrophic cardiomyopathy (HC), the effect of body mass index (BMI) on in-hospital mortality in hospitalized patients with HC has not been established. We evaluated the National Inpatient Sample in the United States to identify all adults with HC hospitalized for cardiac illnesses between 2008 and 2017. Using International Classification of Diseases codes, the study cohort was stratified into underweight (BMI ≤19.9 kg/m²), normal weight (BMI 20.0 to 24.9 kg/m²), overweight (BMI 25.0 to 29.9 kg/m²), class I (BMI 30.0 to 34.9 kg/m²), class II (BMI 35.0 to 39.9 kg/m²), and class III (BMI ≥40.0 kg/m²) obesity. Multiple logistic regression analysis was used to analyze the independent association of various BMI categories and mortality. The study included a total of 2,392,325 hospitalizations (mean age-66.1 ± 12.2 years; 42.0% female). The patients with class III obesity (adjusted mortality rate [AMR] 3.3%, adjusted odds ratio [AOR] 1.53, 95% confidence interval [CI] 1.29 to 1.82, p <0.001) and underweight patients (AMR 4.4%, AOR 2.07, 95% CI 1.74-2.46, p <0.001) had higher in-hospital mortality whereas overweight patients (AMR 1.6%, AOR 0.26, 95% CI 0.19 to 0.34, p <0.001), patients with class I obesity (AMR 0.8%, AOR 0.35, 95% CI 0.27 to 0.45, p <0.001) and patients with class II obesity (AMR 0.8%, AOR 0.34, 95% CI 0.26 to 0.45, p <0.001) had lower mortality compared with patients with normal BMI (AMR 2.9%). In conclusion, BMI has a nonlinear U-shaped relation with in-hospital mortality in patients with HC. The patients who were underweight and morbidly obese had significantly higher mortality, whereas those patients with overweight, class I, and class II obesity had lower mortality than normal BMI.

Relationship of lipid metabolism disorders with the development of fatal and non-fatal cardiovascular events in residents of the Chui region of the Kyrgyz Republic of varying sex and ethnicity

Aim. To study the relationship of lipid metabolism disorders (overweight, general and abdominal obesity (AO)) with the development of fatal and non-fatal cardiovascular events (CVEs) among residents of the Chui region of the Kyrgyz Republic of varying sex and ethnicity.

Material and methods. This study was performed as part of the international prospective epidemiological project “Interepid”. The total follow-up period was 7 years. Vital status at the end of the follow-up period was monitored in 1096 respondents from 1341 initial cohorts. Response rate was 82,1%. As an endpoint, the analysis included cases of fatal and non-fatal CVEs. The prevalence of events was assessed by survival analysis methods (Cox proportional hazard regression model, parametric survival models, Kaplan-Meier estimator).

Results. In total, 181 (16,44%) cases of fatal and non-fatal CVEs were recorded during the follow-up period. In individuals with normal body weight, the incidence of CVEs was 10%. In overweight persons, it increased and reached 17,99% (p<0,001), while in those with obesity — 24,5% (p<0.0001). An increase in CVE rate with an increase in body mass index was recorded in all analyzed subgroups (men, women, Russians, Kyrgyz). Cox regression model with a logistic regression analysis made it possible to confirm the independent role of general and AO in the development of fatal and non-fatal cardiac and cerebral accidents in both ethnic groups in women, but not in men.

Conclusion. An increase in body mass index >25 kg/m2 and the presence of AO are independent risk factors for fatal and non-fatal CVEs in the analyzed cohort of residents of the Chui region in women (but not men) of both ethnic groups.

Absence of Obesity Paradox in All-Cause Mortality Among Chinese Patients With an Implantable Cardioverter Defibrillator: A Multicenter Cohort Study

Background: The results of studies on the obesity paradox in all-cause mortality are inconsistent in patients equipped with an implantable cardioverter-defibrillator (ICD). There is a lack of relevant studies on Chinese populations with large sample size. This study aimed to investigate whether the obesity paradox in all-cause mortality is present among the Chinese population with an ICD.

Methods: We conducted a retrospective analysis of multicenter data from the Study of Home Monitoring System Safety and Efficacy in Cardiac Implantable Electronic Device–implanted Patients (SUMMIT) registry in China. The outcome was all-cause mortality. The Kaplan–Meier curves, Cox proportional hazards models, and smooth curve fitting were used to investigate the association between body mass index (BMI) and all-cause mortality.

Results: After inclusion and exclusion criteria, 970 patients with an ICD were enrolled. After a median follow-up of 5 years (interquartile, 4.1–6.0 years), in 213 (22.0%) patients occurred all-cause mortality. According to the Kaplan–Meier curves and multivariate Cox proportional hazards models, BMI had no significant impact on all-cause mortality, whether as a continuous variable or a categorical variable classified by various BMI categorization criteria. The fully adjusted smoothed curve fit showed a linear relationship between BMI and all-cause mortality (p-value of 0.14 for the non-linearity test), with the curve showing no statistically significant association between BMI and all-cause mortality [per 1 kg/m² increase in BMI, hazard ratio (HR) 0.97, 95% CI 0.93–1.02, p = 0.2644].

Conclusions: The obesity paradox in all-cause mortality was absent in the Chinese patients with an ICD. Prospective studies are needed to further explore this phenomenon.

Age and gender aspects of the association of generalized obesity with development of fatal and nonfatal cardiovascular events (results of the prospective cohort study “Interepepid”)

Background. Currently, obesity has become one of the most important medical and social problems in the world due to its high prevalence. Numerous literature data indicate that high BMI is associated with increased mortality from cardiovascular diseases.

The aim: to study the relationship between overweight and generalized obesity with the development of fatal and non-fatal cardiovascular events among residents of the Chui region of the Kyrgyz Republic, taking into account gender and age.

Material and methods. This study was carried out as part of the international crosssectional epidemiological study “Interepid”. The total follow-up period was 7 years. Life status at the end of the follow-up period was monitored in 1096 respondents out of 1341 initial cohorts (response – 82.1 %). The endpoints were cases of fatal and non-fatal cardiovascular events. The frequency of events was assessed using methods of analysis of survival (Cox proportional hazard regression model, parametric survival models, survival by the Kaplan – Meier method).

Results. A total of 181 cases of fatal and non-fatal cardiovascular events (16.44 %) were recorded during the follow-up. In persons with normal body weight, the incidence of cardiovascular complications was 10 %. In overweight individuals, the value of this indicator increased and reached 17.99 % (p˂ 0.001), and in individuals with obesity – 24.5 % (p˂ 0.0001). The increase in the frequency of events with the increase in body mass index did not depend on the gender of the respondents but was typical only for people under 60 years of age. For elderly patients, there was no relationship between BMI and the development of cardiovascular complications. In contrast, the relative risk had an insignificant tendency to decrease by 2.6 % for every 1 kg/m2 increase in body mass index (RR – 0.974; 95% CI: 0.924–1.025).

Conclusion. The increase of body mass index above 25 kg/m2 is an independent risk factor for the development of fatal and non-fatal cardiovascular events in the analyzed cohort of the Chui region residents, regardless of gender, but only in persons under 60 years of age. 

Assessment of Cardiovascular Risk Factors and Their Interactions in the Risk of Coronary Heart Disease in Patients with Type 2 Diabetes with Different Weight Levels, 2013-2018

PURPOSE

In addition to hyperglycemia and hyperlipidemia, obesity and hypertension are important cardiovascular risk factors for coronary heart disease (CHD) in patients with type 2 diabetes mellitus (T2DM). This study aims to explore the interaction of these risk factors.

PATIENTS AND METHODS

Data of hospitalized patients with T2DM from 2013 to 2018 were collected. A multivariate logistic regression model was established. Patients with normal weight and blood pressure were recruited as controls. The interaction on the risk of CHD was evaluated by relative excess risk due to interaction (RERI).

RESULTS

Among the 30,693 patients with T2DM, 7202 (23.5%) had CHD. In the low weight group, the prevalence of CHD in patients with hypertension was nearly four times higher than that in patients without hypertension (42.7% vs 11.3%, P < 0.01). The OR value of hypertension alone on CHD increased from 1.29 (95% CI 1.06-1.56) in the body mass index (BMI) 30.0-34.9 kg/m² group to 1.35 (95% CI 1.11-1.62) in the BMI ≤ 18.5 kg/m² group. Additive interaction was observed between hypertension and BMI in CHD risk, especially in the low weight group (RERI:2.2, 95% CI 0.9-3.5). BMI and CHD risk showed a smile curve relationship. The attributive proportion in the low weight group was higher than that in the severe obesity group, that is, 0.52 (95% CI 0.35-0.69) vs 0.18 (95% CI -0.59 to 0.95).

CONCLUSION

Maintaining normal weight and avoiding low weight are particularly important for patients with co-occurring diabetes and hypertension to prevent the risk of CHD.

Clinical Implication of 'Obesity Paradox' in Elderly Patients With Acute Myocardial Infarction

BACKGROUND

The clinical impact of body mass index (BMI), especially in the elderly with acute myocardial infarction (AMI), has not been sufficiently evaluated. The purpose of this study was to elucidate the clinical impact of BMI in very old patients (≥80 years) with AMI.

METHODS

The study analysed 2,489 AMI patients aged ≥80 years from the Korea Acute Myocardial Infarction Registry and the Korea Working Group on Myocardial Infarction (KAMIR/KorMI) registries between November 2005 and March 2012. The study population was categorised into four groups based on their BMI: underweight (n=301), normal weight (n=1,150), overweight (n=890), and obese (n=148). The primary endpoint was major adverse cardiovascular event (MACE), a composite of cardiac death, myocardial infarction, target lesion revascularisation, and target vessel revascularisation.

RESULTS

Baseline characteristics among the four groups were similar, except for hypertension (45.1 vs 58.4 vs 66.2 vs 69.9%, respectively; p<0.001) and diabetes (16.6 vs 23.6 vs 30.7 vs 35.1%, respectively; p<0.001). Coronary care unit length of stay was significantly different among the four groups during hospitalisation (5.3±5.9 vs 4.8±6.8 vs 4.2±4.0 vs 3.5±2.1 days; p=0.007). MACE (16.9 vs 14.9 vs 13.7 vs 8.8%; p=0.115) and cardiac death (10.3 vs 8.4 vs 7.9 vs 4.1%; p=0.043) less frequently occurred in the obese group than in other groups during the 1-year follow-up. A multivariate regression model showed obese status (BMI ≥27.5 kg/m²) as an independent predictor of reduced MACE (hazard ratio [HR], 0.20; 95% confidence interval [CI], 0.06-0.69; p=0.010) along with reduced left ventricular ejection fraction (≤40%) as a predictor of increased MACE (HR,1.87; 95% CI, 1.31-2.68; p=0.001).

CONCLUSION

Body mass index in elderly patients with acute myocardial infarction was significantly associated with coronary care unit stay and clinical cardiovascular outcomes.

Overweight and obesity as protective factors against mortality in nonischemic cardiomyopathy patients with an implantable cardioverter defibrillator

Background

Previous studies have reported inconsistent results on the relationship between body mass index (BMI) and clinical outcomes in implantable cardioverter defibrillator (ICD) patients. Additionally, research on ICD patients with nonischemic cardiomyopathy (NICM) is lacking.

Hypothesis

This study aimed to investigate the impact of BMI on mortality and ventricular arrhythmias (VAs) in NICM patients with an ICD.

Methods

This study retrospectively analyzed the data from the Study of Home Monitoring System Safety and Efficacy in Cardiac Implantable Electronic Device‐implanted patients (SUMMIT) in China. Four hundred and eighty NICM patients with an ICD having BMI data were enrolled. Patients were divided into two groups: underweight and normal range group (BMI < 24 kg/m²), overweight and obese group (BMI≥24 kg/m²). The primary endpoint was all‐cause mortality. The secondary endpoint was the first occurrence of VAs requiring appropriate ICD therapy or shock.

Results

During a median follow‐up of 61 (1‐95) months, 70 patients (14.6%) died, 173 patients (36%) experienced VAs requiring appropriate ICD therapy, and 112 patients (23.3%) were treated with ICD shock. Multivariate Cox regression modeling indicated a decreased mortality risk in the overweight and obese group compared with the underweight and normal range group (hazard ratio = 0.44, 95% confidence interval 0.26‐0.77, P = .003). However, the risk of VAs was similar in both groups in univariate and multivariate Cox models.

Conclusions

Compared with underweight and normal weight, overweight and obesity are protective against mortality but have only a neutral impact on VAs risk in NICM patients with an ICD.

Predicting the Development of Myocardial Infarction in Middle-Aged Adults with Type 2 Diabetes: A Risk Model Generated from a Nationwide Population-Based Cohort Study in Korea

BACKGROUND

Most of the widely used prediction models for cardiovascular disease are known to overestimate the risk of this disease in Asians. We aimed to generate a risk model for predicting myocardial infarction (MI) in middle-aged Korean subjects with type 2 diabetes.

METHODS

A total of 1,272,992 subjects with type 2 diabetes aged 40 to 64 who received health examinations from 2009 to 2012 were recruited from the Korean National Health Insurance database. Seventy percent of the subjects (n=891,095) were sampled to develop the risk prediction model, and the remaining 30% (n=381,897) were used for internal validation. A Cox proportional hazards regression model and Cox coefficients were used to derive a risk scoring system. Twelve risk variables were selected, and a risk nomogram was created to estimate the 5-year risk of MI.

RESULTS

During 7.1 years of follow-up, 24,809 cases of MI (1.9%) were observed. Age, sex, smoking status, regular exercise, body mass index, chronic kidney disease, duration of diabetes, number of anti-diabetic medications, fasting blood glucose, systolic blood pressure, total cholesterol, and atrial fibrillation were significant risk factors for the development of MI and were incorporated into the risk model. The concordance index for MI prediction was 0.682 (95% confidence interval [CI], 0.678 to 0.686) in the development cohort and 0.669 (95% CI, 0.663 to 0.675) in the validation cohort.

CONCLUSION

A novel risk engine was generated for predicting the development of MI among middle-aged Korean adults with type 2 diabetes. This model may provide useful information for identifying high-risk patients and improving quality of care.

Effects of body mass index on the safety and effectiveness of direct oral anticoagulants: a retrospective review

BACKGROUND

The International Society on Thrombosis and Haemostasis recommends avoiding the use of direct oral anticoagulants (DOACs) in patients with a body mass index (BMI) greater than 40 kg/m² or weight greater than 120 kg.

HYPOTHESIS

Higher BMI is associated with altered pharmacokinetics which may affect the safety and effectiveness for DOACs.

METHODS

Data were collected on 3458 patients taking a DOAC prior to admission to a Midwestern health system between February 2013 and August 2016. Of these, 43 patients had a thrombotic event and 70 patients had an overt bleeding event. Patients were stratified among the following three BMI groups: BMI < 30 kg/m², BMI 30-40 kg/m², and BMI > 40 kg/m².

RESULTS

There was no statistically significant difference between BMI groups for thrombotic events (p = 0.598) or for overt bleeding events (p = 0.065). The BMI < 30 kg/m² had the highest occurrence rate of bleeding events. It was observed that bleeding occurrence decreased as the BMI groups increased. The BMI > 40 kg/m² group had the lowest risk of bleeding events, and was the only group to have a higher occurrence rate of thrombotic events compared to bleeding events.

CONCLUSIONS

Among patients admitted to a single health system on DOAC therapy over a three-and-a-half-year period, obesity did not significantly correlate with thrombotic or overt bleeding complications. This study is limited as a single health system study with low overall event rates. A preliminary finding of this study showed a trend towards decreased bleeding frequency as BMI increased.

Abdominal obesity and the risk of recurrent atherosclerotic cardiovascular disease after myocardial infarction

BACKGROUND

The association between abdominal obesity and recurrent atherosclerotic cardiovascular disease after myocardial infarction remains unknown.

OBJECTIVE

The purpose of this study was to investigate the prevalence of abdominal obesity and its association with recurrent atherosclerotic cardiovascular disease in patients after a first myocardial infarction.

DESIGN AND METHODS

In this register-based observational cohort, 22,882 patients were identified from the national Swedish Web-system for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry at a clinical revisit 4-10 weeks after their first myocardial infarction 2005-2014. Patients were followed for recurrent atherosclerotic cardiovascular disease defined as non-fatal myocardial infarction, coronary heart disease death, non-fatal or fatal ischaemic stroke. Univariate and multivariable-adjusted Cox regression models were used to calculate hazard ratios and 95% confidence intervals in quintiles of waist circumference as well as three categories of body mass index including normal weight, overweight and obesity.

RESULTS

The majority of patients had abdominal obesity. During a median follow-up time of 3.8 years, 1232 men (7.3%) and 469 women (7.9%) experienced a recurrent atherosclerotic cardiovascular disease event. In the univariate analysis, risk was elevated in the fifth quintile (hazard ratio 1.22, 95% confidence interval 1.07-1.39) compared with the first. In the multivariable-adjusted analysis, risk was elevated in the fourth and fifth quintiles (hazard ratio 1.21, confidence interval 1.03-1.43 and hazard ratio 1.25, confidence interval 1.04-1.50), respectively. Gender-stratified analyses showed similar associations in men, while U-shaped associations were observed in women and the body mass index analyses.

CONCLUSIONS

Abdominal obesity was common in post-myocardial infarction patients and larger waist circumference was independently associated with recurrent atherosclerotic cardiovascular disease, particularly in men. We recommend utilising waist circumference to identify patients at increased risk of recurrent atherosclerotic cardiovascular disease after myocardial infarction.

Skeletal muscle mass in acute coronary syndrome prognosis: Gender-based analysis from Hellenic Heart Failure cohort

BACKGROUND AND AIMS

Predictive and prognostic ability of muscle mass in CVD settings is increasingly discussed. The gender-specific effect of skeletal muscle mass index (SMI) on 10-year recurrent fatal/non fatal cardiovascular disease (CVD) event of acute coronary syndrome (ACS) patients was evaluated.

METHODS AND RESULTS

In 2006-2009, n = 1000 consecutive patients (n = 222 women), hospitalized at the First Cardiology Clinic of Athens with ACS diagnosis and with symptoms and left ventricular function indicative of heart failure were selected. SMI was created to reflect skeletal muscle mass through appendicular skeletal muscle mass (indirectly calculated through population formulas) divided by body mass index (BMI). In the 10-year follow-up (2016), 55% of ACS patients experienced recurrent fatal/non fatal CVD events (53% in women vs.62% in men, p = 0.04). Patients in the 2nd SMI tertile (mostly overweight) had 10% lower risk for CVD recurrence (women:men rate ratio = 0.87) over their counterparts in the 1st (mostly normalweight) and 3rd tertile (mostly obese). Multivariate analysis revealed that ACS patients in the 2nd SMI tertile presented 46% and 85% lower CVD event risk over their counterparts in the 1st tertile (Hazard Ratio (HR) = 0.54, 95% Confidence Interval (95% CI) 0.30, 0.96, p = 0.002) and 3rd tertile (HR = 1.85, 95%CI 1.05, 2.94, p = 0.03). Gender-based analysis revealed that this trend remained significant only in women. Inflammatory markers had strong confounding effect.

CONCLUSION

A U-shape association between SMI and 10-year CVD event especially in women was highlighted. This work reveals gender-specific remarks for "obesity-lean paradox" in secondary prevention, implying that high muscle mass accompanied by obesity and excess adiposity may not guarantee better prognosis.

Outcomes in Cardiogenic Shock from Acute Coronary Syndrome Depending on Severity of Obesity

We reviewed 54,044 adult cases of cardiogenic shock (CS) accompanying acute coronary syndrome from the 2005 to 2014 Nationwide Inpatient Sample. We evaluated outcomes among patients who were nonobese, obese (body mass index 30.0 to 39.9 kg/m²) and extremely-obese (body mass index ≥40 kg/m²). A multivariate analysis was performed to assess their impact on in-hospital mortality. There were 3,602 (6.6%) and 1,610 (2.9%) admissions among patients who were obese and extremely-obese. Those obese and extremely-obese were younger compared with the nonobese (62.7 vs 61.2 vs 68.8 years, respectively; p <0.01) but had significantly greater comorbidity burden. CS patients who were not-obese were most likely to have an associated ST elevation myocardial infarction, compared with the obese and extremely-obese (67.7% vs 65.9% vs 60.7%; p <0.01). Compared to the nonobese, patients who were obese had higher rates of percutaneous coronary intervention (55.8% vs 51.5%; p <0.01) and coronary artery bypass grafting (24.0% vs 16.0%; p <0.01) whereas those extremely-obese had higher coronary artery bypass grafting rates (23.9% vs 16.0%; p <0.01) but similar percutaneous coronary intervention rates (51.1% vs 51.5%; p = 0.74). Short-term mechanical support use was lowest among the nonobese followed by the extremely-obese and obese. Adjusted analysis revealed that obesity predicted less (adjusted odd ratio 0.82, 95% confidence interval 0.76 to 0.90) and extreme-obesity predicted higher in-hospital mortality (adjusted odds ratio 1.17, 95% confidence interval 1.05 to 1.32) compared with the nonobese. In conclusion, obesity and extreme-obesity are associated with greater comorbidity burden among ACS related CS admissions. Obesity predicted less in-hospital mortality, whereas extreme obesity was associated with elevated in-hospital mortality.

Association of Body Mass Index With Risk Factor Optimization and Guideline-Directed Medical Therapy in US Veterans With Cardiovascular Disease

BACKGROUND

Obesity is a growing epidemic that has been linked to the development of cardiovascular disease (CVD). Guideline-directed medications for secondary prevention and risk factor control are recommended for patients with all forms of CVD. The association of body mass index (BMI) with use of medications for secondary prevention and risk factor control in patients with CVD are poorly understood.

METHODS AND RESULTS

We identified 1 122 567 patients with CVD receiving care in 130 Veterans Affairs facilities from October 1, 2013, to September 30, 2014. Five groups were stratified by BMI-underweight (BMI, <18.5 kg/m²), normal (BMI, 18.5-24.9 kg/m²), overweight (BMI, 25-29.9 kg/m²), obese (BMI, 30-39.9 kg/m²), and extremely obese (BMI, ≥40 kg/m²). A composite of 4 measures-blood pressure <140/90 mm Hg, hemoglobin A1c ≤9% in diabetic patients, statin use, and antiplatelet use-termed optimal medial therapy (OMT) was compared among groups. Multivariable logistic regression was performed with normal BMI as the referent category. Underweight patients comprised 12 623 (1.1%), normal BMI 230 471 (20.5%), overweight 413 590 (36.8%), obese 404 105 (36%), and extremely obese 61 778 (5.5%) of the cohort. Only 43.7% of the entire cohort received OMT, and this was the highest in the overweight group. Adjusted odds ratios for receiving OMT were 0.81 (95% CI, 0.77-0.85), 1.11 (95% CI, 1.10-1.13), 1.08 (95% CI, 1.06-1.09), and 0.87 (95% CI, 0.85-0.89), for patients who were underweight, overweight, obese, and extremely obese, respectively, compared with normal BMI.

CONCLUSIONS

OMT was low in the entire cohort. There is an inverse U-shaped relationship between OMT and BMI with patients who are underweight and extremely obese less likely to receive OMT compared with patients with normal BMI.

“Obesity paradoxes”: main causes of an “inverse” cardiovascular epidemiology

Taken the continuous increase of obesity prevalence, most countries in the world deal with an epidemy, one of the main healthcare concerns. In the structure of nosology associated with overweight and obesity, cardiovascular is leading. Also, in the recent trials and meta analyses there is negative correlation found for body mass index and clinical outcomes characterizing better survival and lower events rate in those with higher BMI, as less chronic diseases. Such facts facilitated a number of discussions on the predictive value of overweight and obesity and consideration whether to correct those in cardiovascular patients as secondary prevention. Current article is focused on the main causes for an “inverse” cardiovascular epidemiology in overweight and obesity.

Neurocalcin-delta: a potential memory-related factor in hippocampus of obese rats induced by high-fat diet

Introduction

Aberrant protein expression within the hippocampus has recently been implicated in the pathogenesis of obesity-induced memory impairment.

Objectives

The objective of the current study was to search for specific memory-related factors in the hippocampus in obese rats.

Methods

Sprague-Dawley (SD) rats were fed either a high-fat (HF) diet or normal-fat (NF) diet for 10 weeks to obtain the control (CON), diet-induced obese rats (DIO) and diet-resistant (DR) rats. D-galactose was injected subcutaneously for 10 weeks to establish model (MOD) rats with learning and memory impairment. After the hippocampus of the rats sampling, the proteome analysis was conducted using two-dimensional get electrophoresis (2-DE) combined with peptide mass fingerprinting (PMF).

Results

We found 15 differential proteins that expressed in the hippocampus in rats induced by HF diet from the 2-DE map. In addition, Neurocalcin-delta (NCALD) was nearly down-regulated in the DR rats compared with CON rats and MOD rats, which was further confirmed by Western blot, real-time PCR and ELISA results.

Conclusion

Our data demonstrates that the differential memory-related proteins were a reflection of the HF diet, but not potential factors in obesity proneness or obesity resistance. Furthermore, NCALD is proved to be a potential hippocampus-memory related factor related to obesity.

Joint statement of the European Association for the Study of Obesity and the European Society of Hypertension: obesity and heart failure

Obese individuals are more likely to develop heart failure. Yet, once heart failure is established, the impact of overweight and obesity on prognosis and survival is unclear. The purpose of this joint scientific statement of the European Association for the Study of Obesity and the European Society of Hypertension is to provide an overview on the current scientific literature on obesity and heart failure in terms of prognosis, mechanisms, and clinical management implications. Moreover, the document identifies open questions that ought to be addressed. The need for more tailored weight management recommendations in heart failure will be emphasized and, in line with the emerging evidence, aims to distinguish between primary disease and secondary outcome prevention. In the primary prevention of heart failure, it appears prudent advising obese individuals to lose or achieve a healthy body weight, especially in those with risk factors such as hypertension or type 2 diabetes. However, there is no evidence from clinical trials to guide weight management in overweight or obese patients with established heart failure. Prospective clinical trials are strongly encouraged.

Recognized Obstructive Sleep Apnea is Associated With Improved In-Hospital Outcomes After ST Elevation Myocardial Infarction

BACKGROUND

Obstructive sleep apnea (OSA) is an independent risk factor for many cardiovascular conditions such as coronary artery disease, myocardial infarction, systemic hypertension, pulmonary hypertension, and stroke. However, the association of OSA with outcomes in patients hospitalized for ST-elevation myocardial infarction remains controversial.

METHODS AND RESULTS

We used the nation-wide inpatient sample between 2003 and 2011 to identify patients with a primary discharge diagnosis of ST-elevation myocardial infarction and then used the International Classification of Diseases, Clinical Modification code 327.23 to identify a group of patients with OSA. The primary outcome of interest was in-hospital mortality, and secondary outcomes were in-hospital cardiac arrest, length of stay and hospital charges. Our cohort included 1 850 625 patients with ST-elevation myocardial infarction, of which 1.3% (24 623) had documented OSA. OSA patients were younger and more likely to be male, smokers, and have chronic pulmonary disease, depression, hypertension, known history of coronary artery disease, dyslipidemia, obesity, and renal failure (P<0.001 for all). Patients with OSA had significantly decreased in-hospital mortality (adjusted odds ratio, 0.78 [95% CI, 0.73-0.84]), longer hospital stay (5.00±4.68 versus 4.85±5.96 days), and incurred greater hospital charges ($79 460.12±70 621.91 versus $62 889.91±69 124.15). There was no difference in incidence of in-hospital cardiac arrest (adjusted odds ratio, 0.93 [95% CI, 0.84-1.03]) between these 2 groups.

CONCLUSION

ST-elevation myocardial infarction patients with recognized OSA had significantly decreased mortality compared with patients without OSA. Although patients with OSA had longer hospital stays and incurred greater hospital charges, there was no difference in incidence of in-hospital cardiac arrest.

Association of Obesity With In-Hospital Mortality of Cardiogenic Shock Complicating Acute Myocardial Infarction

Several previous studies have shown obesity to be counterintuitively associated with more favorable mortality in patients with acute myocardial infarction (AMI); however, the association of obesity with in-hospital mortality of cardiogenic shock complicating AMI has not been previously examined. We queried the 2004 to 2013 National Inpatient Sample databases to identify all patients ≥18 years hospitalized with the principal diagnosis of AMI. Multivariable regression models adjusting for demographics, hospital characteristics, and co-morbidities were used to examine differences in incidence and in-hospital mortality of cardiogenic shock complicating AMI between obese and nonobese patients. Of 6,097,817 patients with AMI, 290,894 (4.8%) had cardiogenic shock. There was no difference in risk-adjusted incidence of cardiogenic shock between obese and nonobese patients (adjusted odds ratio 1.00, 95% CI 0.98 to 1.01; p = 0.46). Of the patients with cardiogenic shock complicating AMI, 8.9% had a documented diagnosis of obesity. Obese patients were on average 6 years younger and had higher prevalence of most cardiovascular co-morbidities. Obese patients were more likely to receive revascularization (73.0% vs 63.4%, p <0.001) and had lower risk-adjusted in-hospital mortality compared with nonobese patients (28.2% vs 36.5%; adjusted odds ratio 0.89, 95% CI 0.86 to 0.92; p <0.001). Similar findings were seen in subgroups of patients with cardiogenic shock complicating ST elevation or non-ST elevation MI. In conclusion, this large retrospective analysis of a nationwide cohort of patients with cardiogenic shock complicating AMI demonstrated that obese patients were younger, more likely to receive revascularization, and had modestly lower risk-adjusted in-hospital mortality compared with nonobese patients.

Is There an Obesity Paradox for Outcomes in Atrial Fibrillation?

Background and Purpose—

Obesity is a risk factor for all-cause and cardiovascular death but, despite this, an inverse relationship between overweight or obesity and a better cardiovascular prognosis in long-term follow-up studies has been observed; this phenomenon, described as obesity paradox, has also been found evident in atrial fibrillation cohorts.

Methods—

We performed a systematic review on the relationship between body mass index and major adverse outcomes in atrial fibrillation patients. Moreover, we provided a meta-analysis of non–vitamin K antagonist oral anticoagulants (NOACs) trials.

Results—

An obesity paradox was found for cardiovascular death and all-cause death in the subgroup analyses of randomized trial cohorts; however, observational studies fail to show this relationship. From the meta-analysis of NOAC trials, a significant obesity paradox was found, with both overweight and obese patients reporting a lower risk for stroke/systemic embolic event (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.66–0.84 and OR, 0.62; 95% CI, 0.54–0.70, respectively). For major bleeding, only obese patients were at lower risk compared with normal weight patients (OR, 0.84; 95% CI, 0.72–0.98). A significant treatment effect of NOACs was found in normal weight patients, both for stroke/systemic embolic event (OR, 0.66; 95% CI, 0.56–0.78) and for major bleeding (OR, 0.72; 95% CI, 0.54–0.95). Major bleeding risk was lower in overweight patients treated with NOACs (OR, 0.84; 95% CI, 0.71–1.00).

Conclusions—

There may be an obesity paradox in atrial fibrillation patients, particularly for all-cause and cardiovascular death outcomes. An obesity paradox was also evident for stroke/systemic embolic event outcome in NOAC trials, with a treatment effect favoring NOACs over warfarin for both efficacy and safety that was significant only for normal weight patients.

Malnutrition is associated with increased mortality in older adults regardless of the cause of death

Malnutrition predicts preterm death, but whether this is valid irrespective of the cause of death is unknown. The aim of the present study was to determine whether malnutrition is associated with cause-specific mortality in older adults. This cohort study was conducted in Sweden and included 1767 individuals aged ≥65 years admitted to hospital in 2008–2009. On the basis of the Mini Nutritional Assessment instrument, nutritional risk was assessed as well nourished (score 24–30), at risk of malnutrition (score 17–23·5) or malnourished (score <17). Cause of death was classified according to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, into twenty different causes of death. Data were analysed using Cox proportional hazards regression models. At baseline, 55·1 % were at risk of malnutrition, and 9·4 % of the participants were malnourished. During a median follow-up of 5·1 years, 839 participants (47·5 %) died. The multiple Cox regression model identified significant associations (hazard ratio (HR)) between malnutrition and risk of malnutrition, respectively, and death due to neoplasms (HR 2·43 and 1·32); mental or behavioural disorders (HR 5·73 and 5·44); diseases of the nervous (HR 4·39 and 2·08), circulatory (HR 1·95 and 1·57) or respiratory system (HR 2·19 and 1·49); and symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (HR 2·23 and 1·43). Malnutrition and risk of malnutrition are associated with increased mortality regardless of the cause of death, which emphasises the need for nutritional screening to identify older adults who may require nutritional support in order to avoid preterm death.

Obesity paradox and mortality in adults with and without incident type 2 diabetes: a matched population-level cohort study

OBJECTIVE

Among adults with type 2 diabetes (T2D), several (but not all) studies show that being overweight (body mass index (BMI): 25.0-29.9 kg/m2) or obese I (BMI: 30.0-34.9 kg/m2) near the time of diagnosis, is unexpectedly associated with reduced all-cause mortality compared with normal weight-the obesity paradox. We addressed whether this observation is causal (eg, a true protective effect); due to confounding (including effect modification); or due to selection ('collider') bias.

RESEARCH DESIGN AND METHODS

We performed a matched population-level cohort study using primary care records from Salford, UK (1995-2012) in 10 464 patients with incident T2D paired (1:3) with 31 020 individuals who never developed T2D. We estimated HRs for associations of BMI with all-cause mortality using Cox models, stratified by smoking status.

RESULTS

Median follow-up was 8.7 years. For never smokers, the hazard of all-cause mortality increased from 25 kg/m2, in a linear manner, with increasing BMI in the T2D cohort (HR per 5 kg/m2: 1.23, ptrend<0.001) and in the non-diabetes cohort (HR per 5 kg/m2: 1.34, ptrend<0.001). In contrast, among ever smokers, BMI-mortality relationships were U-shaped in the T2D and non-diabetes cohorts. Evidence of the obesity paradox in ever smokers, with and without T2D, argued against a selection bias, but supported a contribution of effect modification by smoking (pinteraction=0.009). Results were stable to various sensitivity analyses.

CONCLUSIONS

In this cohort, the obesity paradox is mainly explained by smoking as an effect modifier. These findings indicate that the obesity paradox does not challenge standard weight management recommendations among T2D patients.

All cause mortality and body mass index in a young Asian occupational cohort without baseline metabolic syndrome components

BACKGROUND

The aim was to investigate associations between underweight, overweight and obesity and all cause, cancer and cardiovascular disease (CVD) mortality, excluding subjects with known CVD, diabetes, hypertension and components of the metabolic syndrome (MetS) at baseline.

METHODS

The study population consisted of examinees participating in a health screening in Korea from 2002 to 2013. Data were analyzed in 162,194 subjects (in a retrospective cohort study design-median (interquartile range (IQR) follow-up 4.9 (1.8-8.5years))). The outcomes were all cause mortality, cancer and CVD.

RESULTS

The mean (age range) and median age (IQR) at baseline were 36.9(20.0-85.3) and 35.2 (30.8-40.6) years. There were 436 deaths during follow-up. For men and women together, the fully adjusted HR for underweight and all cause mortality, cancer and CVD was 1.53 (95% CIs 1.06-2.20), 1.21 (95% CIs 0.68-2.14) and 1.34 (95% CIs 0.40-4.49) respectively. In contrast, the fully adjusted HR for overweight/obesity combined and all cause mortality was 0.77 (95%CIs 0.63-0.95) and there were non significant trends towards decreased cancer and CVD mortality. The association between overweight/obesity and all cause mortality was similar for men and women considered separately and for overweight and obesity as separate BMI categories. Smoking did not seem to explain the increased HR in the underweight BMI category.

CONCLUSIONS

In a young metabolically healthy adult cohort, underweight was associated with increased all cause mortality and overweight/obesity was associated with decreased all cause mortality if CVD, diabetes, hypertension and components of the metabolic syndrome (MetS) are excluded.

Relation of Obesity to Survival After In-Hospital Cardiac Arrest

Previous studies have shown that obesity is paradoxically associated with improved outcomes in many cardiovascular (CV) disease states; however, whether obesity affects survival after in-hospital cardiac arrest (IHCA) has not been well examined. We queried the 2003 to 2011 Nationwide Inpatient Sample databases to identify all patients aged ≥18 years who underwent cardiopulmonary resuscitation for IHCA. Obese patients were identified using the co-morbidity variable for obesity, as defined in Nationwide Inpatient Sample databases. Survival to hospital discharge was compared between obese and nonobese patients using multivariate regression models. Of 836,289 patients with IHCA, 67,216 (8.0%) were obese. Obese patients were younger and more likely to be women compared with nonobese patients. Despite being younger, obese patients had significantly higher prevalence of most CV co-morbidities such as dyslipidemia, coronary artery disease, previous myocardial infarction, heart failure, diabetes mellitus, hypertension, peripheral vascular disease, and chronic renal failure (p <0.001 for all). Obese patients were more likely to have ventricular tachycardia or ventricular fibrillation as the initial cardiac arrest rhythm (22.3% vs 20.9%; p <0.001). After multivariate risk adjustment, obese patients had improved survival to hospital discharge compared with nonobese patients (31.4% vs 24.1%; unadjusted odds ratio 1.44, 95% CI 1.42 to 1.47, p <0.001; adjusted odds ratio 1.15, 95% CI 1.13 to 1.17, p <0.001). Similar results were seen in patients with CV or non-CV conditions as the primary diagnosis and in those with ventricular tachycardia/ventricular fibrillation or pulseless electrical activity/asystole as the cardiac arrest rhythm. In conclusion, this large retrospective analysis of a nationwide cohort of patients with IHCA demonstrated higher risk-adjusted odds of survival in obese patients, consistent with an "obesity paradox."

Metabolic consequences of adipose tissue dysfunction and not adiposity per se increase the risk of cardiovascular events and mortality in patients with type 2 diabetes

OBJECTIVES

To quantify the risk of obesity and its associated metabolic dysfunction on the development of cardiovascular events and mortality in patients with type 2 diabetes.

METHODS

In 1827 patients with type 2 diabetes enrolled in the Secondary Manifestations of ARTerial disease (SMART) cohort study, the risk of higher BMI, waist circumference and intra-abdominal fat on the development of cardiovascular events (composite of myocardial infarction, stroke, and vascular mortality) was quantified using Cox regression. Second, risk of cardiovascular events related to obesity associated metabolic dysfunction (≥3 adapted NCEP metabolic syndrome criteria) was quantified for tertiles of intra-abdominal fat.

RESULTS

217 patients died from cardiovascular causes and 338 patients developed the composite endpoint of cardiovascular events during a median follow-up of 7.0years (interquartile range 3.9 to 10.5years). No increased risk for cardiovascular events and mortality was observed per SD higher BMI, waist circumference and intra-abdominal fat (HR varying from 1.00, 95% CI 0.88-1.14 to 1.13, 95% CI 0.96-1.33). Compared to the first tertile of intra-abdominal fat without metabolic dysfunction, the presence of metabolic dysfunction increased the risk of cardiovascular events in all tertiles of intra-abdominal fat with the highest risk observed for metabolic dysfunction in the first tertile of intra-abdominal fat (HR 2.47, 95% CI 1.32-4.62).

CONCLUSIONS

Body-mass index, waist circumference and intra-abdominal fat are not related to the risk of cardiovascular events and mortality in patients with type 2 diabetes. Instead, in these patients the metabolic consequences of adipose tissue dysfunction are more important than strict measures of adiposity when estimating cardiovascular risk.

High aortic pulse-wave velocity may be responsible for elevated red blood cell distribution width in overweight and obese people: a community-based, cross-sectional study

Background:

Obesity and overweight are risk factors for atherosclerosis. Red blood cell distribution width (RDW) is associated with subclinical cardiac diseases. The aim of this study was to investigate the association between RDW and aortic stiffness in overweight or obese subjects.

Methods:

A total of 101 overweight or obese subjects without overt cardiovascular disorders, and 48 healthy controls were enrolled. RDW, aortic pulse-wave velocity (PWV) and augmentation index 75 (Aix75) were evaluated. The case subjects were divided into two sub-groups according to PWV values; ≥ 10 m/s in group I, and < 10 m/s in group II. Bivariate correlation and multiple regression analyses (stepwise) were performed.

Results

RDW and PWV were considerably increased in the case groups compared with the controls. RDW was significantly increased in group I compared with group II and the controls [median 12.0 m/s, interquartile range (IQR): 10.5–17.5; median 11.7 m/s, IQR: 10.2–14.2, and median 11.4 m/s, IQR: 9.6–15.5, p < 0.05, respectively]. Resting heart rate and age were higher in group I than group II (81 ± 11 vs 74 ± 12 beats/min and 41 ± 120 vs 36 ± 9 years, respectively, p < 0.05). Regression analyses revealed that while log-RDW, age and resting heart rate were independent predictors for aortic PWV, log-RDW was the most important predictor in the final model.

Conclusions:

RDW, resting heart rate and age independently predicted arterial stiffness, and RDW may be useful to provide an early recognition of subclinical atherosclerosis in overweight and obese individuals.