Does an Obesity Paradox Really Exist After Cardiovascular Intervention?: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies

Heterogeneous body compositions and all-cause mortality in acute coronary syndrome patients: a ten-year retrospective cohort study

BACKGROUND

The association of different body components, including lean mass and body fat, with the risk of death in acute coronary syndrome (ACS) patients are unclear.

METHODS

We enrolled adults diagnosed with ACS at our center between January 2011 and December 2012 and obtained follow-up outcomes via telephone questionnaires. We used restricted cubic splines (RCS) with the Cox proportional hazards model to analyze the associations between body mass index (BMI), predicted lean mass index (LMI), predicted body fat percentage (BF), and the value of LMI/BF with 10-year mortality. We also examined the secondary outcome of death during hospitalization.

RESULTS

During the maximum 10-year follow-up of 1398 patients, 331 deaths (23.6%) occurred, and a U-shaped relationship was found between BMI and death risk (P nonlinearity = 0.03). After adjusting for age and history of diabetes, the overweight group (24 ≤ BMI < 28 kg/m2) had the lowest mortality (HR = 0.53, 95% CI: 0.29-0.99). Predicted LMI and LMI/BF had an inverse linear relationship with a 10-year death risk (P nonlinearity = 0.24 and P nonlinearity = 0.38, respectively), while an increase in BF was associated with increased mortality (P nonlinearity = 0.64). During hospitalization, 31 deaths (2.2%) were recorded, and the associations of the indicators with in-hospital mortality were consistent with the long-term outcome analyses.

CONCLUSION

Our study provides new insight into the "obesity paradox" in ACS patients, highlighting the importance of considering body composition heterogeneity. Predicted LMI and BF may serve as useful tools for assessing nutritional status and predicting the prognosis of ACS, based on their linear associations with all-cause mortality.

The relation of body adiposity to the outcomes of thoracoscopic lobectomy for lung cancer - a single-center cohort study

Introduction

The outcomes of lung cancer surgery depend on the patients' nutritional status. Body fat percentage (BF%) is one of the indicators of body composition and nutritional status. Direct measurement of BF% is complicated, requires significant resources and is rarely performed. The CUN-BAE (Clínica Universidad de Navarra - Body Adiposity Estimator) index has been shown to accurately predict BF% is several clinical settings, but its relation to the outcomes of lung surgery has not been reported so far.

Aim

To determine the relation of the BF% to the outcomes of thoracoscopic lobectomy.

Material and methods

This retrospective study included 1,183 patients who underwent thoracoscopic lobectomy for non-small cell lung cancer between June 1999, and September 2019 at one department. BF% was calculated according to the Clínica Universidad de Navarra - Body Adiposity Estimator equation. The primary endpoints were postoperative complications and long-term survival.

Results

Univariate analysis showed that higher BF% was related to lower incidence of complications (p = 0.001), including prolonged air leak (p < 0.001), atelectasis (p < 0.05), psychosis (p < 0.001), reoperations (p < 0.05), and shorter chest drainage (p = 0.001) and hospitalization duration (p < 0.001). Multivariate analysis showed that higher BF% was correlated with lower risk of complications (p = 0.005; OR = 0.964; 95% CI: 0.940 to 0.989), including prolonged air leak (p < 0.001; OR = 0.923; 95% CI: 0.886 to 0.962), and shorter duration of chest drainage (p < 0.001; B = -0.046; 95% CI: -0.069 to -0.023) and hospitalization (p < 0.001; B = -0.112; 95% CI: -0.176 to -0.048). Cox proportional hazards regression analysis showed that BF% was not related to long-term survival.

Conclusions

Body fat percentage is a valuable tool that can help predict the short-term outcomes of minimally lobectomy for lung cancer.

Association of body mass index with perioperative blood transfusion and short-term clinical outcomes in patients undergoing isolated coronary artery bypass grafting

BACKGROUND

Few studies have considered outcomes among low body mass index (BMI) cohorts undergoing coronary artery bypass grafting (CABG). This study aims to investigate the effects of low body weight on blood transfusion and perioperative outcomes in patients undergoing isolated CABG.

METHODS

This retrospective study enrolled consecutive cases from a single-center between January 2008 and December 2018. Low body weight/underweight was defined as a BMI < 18.5 kg/m², while normal BMI was defined as 18.5 ≤ BMI < 24.0 kg/m². The primary endpoint was the perioperative red blood cell (RBC) transfusion rate. Secondary endpoints include platelet and plasma transfusion rates, transfusion volume for all blood components, hospital length of stay, and the occurrence of adverse events including prolonged mechanical ventilation, re-intubation, re-operation, acute kidney injury, and 30-day all-cause mortality.

RESULTS

A total of 7,620 patients were included in this study. After 1:1 propensity score matching, 130 pairs were formed, with 61 pairs in the on-pump group and 69 pairs in the off-pump group. Baseline characteristics were comparable between the matched groups. Low body weight independently increased the risk of RBC transfusion (on-pump: OR = 3.837, 95% CI = 1.213-12.144, p = 0.022; off-pump: OR = 3.630, 95% CI = 1.875-5.313, p < 0.001). Moreover, within the on-pump group of the original cohort, BMI of < 18.5 kg/m² was independently correlated with increased risk of re-intubation (OR = 5.365, 95% CI = 1.159 to 24.833, p = 0.032), re-operation (OR = 4.650, 95% CI = 1.019 to 21.210, p = 0.047), and 30-day all-cause mortality (OR = 10.325, 95% CI = 2.011 to 53.020, p = 0.005).

CONCLUSION

BMI < 18.5 kg/m² was identified as an independent risk factor for increased perioperative RBC transfusion rate in patient underwent isolated CABG with or without CPB. Only on-pump underweight patients in the original cohort exhibited an increased risk for re-intubation, re-operation, and 30-day all-cause mortality. Physicians and healthcare systems should consider these findings to improve management for this population.

Associations between body mass index and all-cause mortality: A systematic review and meta-analysis

Fasting insulin and c-reactive protein confound the association between mortality and body mass index. An increase in fat mass may mediate the associations between hyperinsulinemia, hyperinflammation, and mortality. The objective of this study was to describe the "average" associations between body mass index and the risk of mortality and to explore how adjusting for fasting insulin and markers of inflammation might modify the association of BMI with mortality. MEDLINE and EMBASE were searched for studies published in 2020. Studies with adult participants where BMI and vital status was assessed were included. BMI was required to be categorized into groups or parametrized as non-first order polynomials or splines. All-cause mortality was regressed against mean BMI squared within seven broad clinical populations. Study was modeled as a random intercept. β coefficients and 95% confidence intervals are reported along with estimates of mortality risk by BMIs of 20, 30, and 40 kg/m2 . Bubble plots with regression lines are drawn, showing the associations between mortality and BMI. Splines results were summarized. There were 154 included studies with 6,685,979 participants. Only five (3.2%) studies adjusted for a marker of inflammation, and no studies adjusted for fasting insulin. There were significant associations between higher BMIs and lower mortality risk in cardiovascular (unadjusted β -0.829 [95% CI -1.313, -0.345] and adjusted β -0.746 [95% CI -1.471, -0.021]), Covid-19 (unadjusted β -0.333 [95% CI -0.650, -0.015]), critically ill (adjusted β -0.550 [95% CI -1.091, -0.010]), and surgical (unadjusted β -0.415 [95% CI -0.824, -0.006]) populations. The associations for general, cancer, and non-communicable disease populations were not significant. Heterogeneity was very large (I2  ≥ 97%). The role of obesity as a driver of excess mortality should be critically re-examined, in parallel with increased efforts to determine the harms of hyperinsulinemia and chronic inflammation.

Impact of BMI on the Survival of Renal Cell Carcinoma Patients Treated with Targeted Therapy: A Systematic Review and Meta-Analysis

It is unclear whether obese renal cell carcinoma (RCC) patients treated with targeted therapy have better survival. We conducted this meta-analysis to assess the prognostic significance of body mass index (BMI) in RCC patients treated with targeted therapy. We systematically searched PubMed, Embase, Cochrane Library, and Web of Science by November 17, 2021. We calculated effect outcomes using random-effects and fixed-effects models. Fifteen articles were identified. We found that RCC patients treated with targeted therapy with BMI over 25 obtained better overall survival (OS) (hazard ratio [HR] = 0.69, 95% confidence interval [CI] = 0.58-0.82, I2 = 75.5%, p < 0.001) and progression-free survival (PFS) (HR = 0.71, 95%CI = 0.55-0.92, I2 = 69.7%, p = 0.006) than patients with BMI below 25. Obese (BMI over 30) patients had remarkably better OS (HR = 0.77, 95%CI = 0.70-0.85, I2 = 0.0%, p = 0.439) and PFS (HR = 0.86, 95%CI = 0.77-0.97, I2 = 0.0%, p = 0.934) than patients with BMI below 25. Overweight (BMI over 25 but below 30) patients also had better OS (HR = 0.86, 95%CI = 0.79-0.93, I2 = 17.7%, p = 0.295) and PFS (HR = 0.82, 95%CI = 0.74-0.90, I2 = 0.0%, p = 0.904) than patients with BMI below 25. When using BMI as continuous variable, patients with high BMI also obtained significantly better OS (HR = 0.92, 95%CI = 0.88-0.96, I2 = 0.0%, p = 0.806). Therefore, higher BMI was associated with greater OS and PFS in RCC patients treated with targeted therapy.

Comparison of Body Mass Index (Four Categories) to In-Hospital Outcomes in Patients Who Underwent Transcatheter Aortic Valve Implantation

Although obesity is often associated with adverse outcomes in cardiovascular diseases, studies have demonstrated a beneficial effect on patients who underwent transcatheter aortic valve implantation (TAVI), coining the term "obesity paradox." We sought to determine if the obesity paradox is valid when patients are studied in body mass index (BMI) groups versus simplified classification of obese and nonobese. We examined the National Inpatient Sample database from 2016 to 2019 for all patients who underwent TAVI >18 years of age using the International Classification of Diseases, 10th edition procedure codes. Patients were grouped by BMI categories of underweight, overweight, obese, and morbidly obese. They were compared with normal-weight patients to assess the relative risk of in-hospital mortality, cardiogenic shock, ST-elevation myocardial infarction, bleeding complications requiring transfusions, and complete heart blocks requiring permanent pacemaker. A logistic regression model was constructed to account for potential confounders. Of the 221,000 patients who underwent TAVI, 42,315 patients with appropriate BMI designation were stratified into BMI groups. Compared to the normal-weight group, overweight, obese, and morbid-obese TAVI patients were associated with a lower risk of in-hospital mortality (relative risk [RR] 0.48, confidence interval [CI] 0.29 to 0.77, p <0.001), (RR 0.42, CI 0.28 to 0.63, p <0.001), (RR 0.49, CI 0.33 to 0.71, p <0.001 respectively), cardiogenic shock (RR 0.27, CI 0.20 to 0.38, p <0.001), (RR 0.21, CI 0.16 to 0.27, p <0.001), (RR 0.21, CI 0.16 to 0.26, p <0.001), and blood transfusions (RR 0.63, CI 0.50 to 0.79, p <0.001), (RR 0.47, CI 0.39 to 0.58, p <0.001), (RR 0.61, CI 0.51 to 0.74, p <0.001). This study indicated that obese patients were at a significantly lower risk of in-hospital mortality, cardiogenic shock, and bleeding complications requiring transfusions. In conclusion, our study supported the existence of the obesity paradox in TAVI patients.

Does the "obesity paradox" exist after transcatheter aortic valve implantation?

Background

Transcatheter aortic valve implantation (TAVI) for symptomatic aortic stenosis is considered a minimally invasive procedure. Body mass index (BMI) has been rarely evaluated for pulmonary complications after TAVI. This study aimed to assess the influence of BMI on pulmonary complications and other related outcomes after TAVI.

Methods

The clinical data of 109 patients who underwent TAVI in our hospital from May 2018 to April 2021 were retrospectively analyzed. Patients were divided into three groups according to BMI: low weight (BMI < 21.9 kg/m², n = 27), middle weight (BMI 21.9–27.0 kg/m², n = 55), and high weight (BMI > 27.0 kg/m², n = 27); and two groups according to vascular access: through the femoral artery (TF-TAVI, n = 94) and through the transapical route (TA-TAVI, n = 15). Procedure endpoints, procedure success, and adverse outcomes were evaluated according to the Valve Academic Research Consortium (VARC)-2 definitions.

Results

High-weight patients had a higher proportion of older (p < 0.001) and previous percutaneous coronary interventions (p = 0.026), a higher percentage of diabetes mellitus (p = 0.026) and frailty (p = 0.032), and lower glomerular filtration rate (p = 0.024). Procedure success was similar among the three groups. The 30-day all-cause mortality of patients with low-, middle-, and high weights was 3.7% (1/27), 5.5% (3/55), and 3.7% (1/27), respectively. In the multivariable analysis, middle- and high-weight patients exhibited similar overall mortality (middle weight vs. low weight, p = 0.500; high weight vs. low weight, p = 0.738) and similar intubation time compared with low-weight patients (9.1 ± 7.3 h vs. 8.9 ± 6.0 h vs. 8.7 ± 4.2 h in high-, middle-, and low-weight patients, respectively, p = 0.872). Although high-weight patients had a lower PaO₂/FiO₂ ratio than low-weight patients at baseline, transitional extubation, and post extubation 12th hour (p = 0.038, 0.030, 0.043, respectively), there were no differences for post extubation 24th hour, post extubation 48th hour, and post extubation 72nd hour (p = 0.856, 0.896, 0.873, respectively). Chronic lung disease [odds ratio (OR) 8.038, p = 0.001] rather than high weight (OR 2.768, p = 0.235) or middle weight (OR 2.226, p = 0.157) affected postoperative PaO₂/FiO₂ after TAVI.

Conclusions

We did not find the existence of an obesity paradox after TAVI. BMI had no effect on postoperative intubation time. Patients with a higher BMI should be treated similarly without the need to deliberately extend the intubation time for TAVI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01910-x.

Impact of body mass index on the outcome of elderly patients treated with transcatheter aortic valve implantation

Underweight or overweight patients with cardiovascular diseases are associated with different outcomes. However, the data on the relation between body mass index (BMI) and outcomes after transcatheter aortic valve implantation (TAVI) are not homogeneous. The aim of this study was to assess the role of low BMI on short and long-term mortality in real-world patients undergoing TAVI. We retrospectively included patients undergoing TAVI for severe aortic valve stenosis. Patients were classified into three BMI categories: underweight (< 20 kg/m²), normal weight (20-24.9 kg/m²) and overweight/obese (≥ 25 kg/m²). Our primary endpoint was long-term all-cause mortality. The secondary endpoint was 30-day all-cause mortality. A total of 794 patients were included [mean age 82.3 ± 5.3, 53% females]. After a median follow-up of 2.2 years, all-cause mortality was 18.1%. Patients in the lowest BMI group showed a higher mortality rate as compared to those with higher BMI values. At the multivariate Cox regression analysis, as compared to the normal BMI group, BMI < 20 kg/m² was associated with long-term mortality independently of baseline risk factors and postprocedural adverse events (hazard ratio [HR] 2.29, 95% confidence interval [CI] 1.30-4.03] and HR 2.61, 95% CI 1.48-4.60, respectively). The highest BMI values were found to be protective for both short- and long-term mortality as compared to lower BMI values even after applying the same adjustments. In our cohort, BMI values under 20 kg/m² were independent predictors of increased long-term mortality. Conversely, the highest BMI values were associated with lower mortality rates both at short- and long-term follow-up.

Impact of BMI on Long-Term Outcomes in Patients with ST-Segment Elevation Myocardial Infarction after Primary Percutaneous Coronary Intervention

AIM

Obesity paradox remains a point of debate in ST-segment elevation myocardial infarction (STEMI) patients. The aim of this study was to examine the relationship between body mass index (BMI) and clinical outcomes in STEMI patients undergoing primary percutaneous coronary intervention (PPCI).

METHODS

Outcomes were assessed in 1429 STEMI patients undergoing PPCI between January 2009 and January 2010 in Beijing. Patients were classified into 6 groups according to age (the younger and elderly groups consisting of patients ≤65 and > 65 years old) and baseline BMI (normal weight, BMI < 24 kg/m²; overweight, 24 kg/m² ≤BMI < 28 kg/m²; obese, BMI ≥ 28 kg/m²). The primary outcome was death, acute myocardial infarction (AMI), or revascularization.

RESULTS

On long-term follow-up (mean follow-up of 59 months), 13.9% of patients experienced the adverse event. Multivariate logistic regression analyses showed that low BMI was a significant predictor of the primary outcome only in the younger group. The odds ratio for overweight in comparison with normal weight was 0.741 (95% CI: 0.413-0.979; p = 0.038), the odds radio for obesity in comparison with normal-weight patients was 0.508 (95% CI: 0.344-0.750; p = 0.016) in the younger group. In the elderly group, diabetes, hypertension, triple disease, regular exercise, angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blockers (ARBs) use after discharge, and bleeding complication were associated with primary outcome.

CONCLUSION

The obesity paradox was recognized only in the younger age group in STEMI patients undergoing PPCI.

The Association of Body Mass Index with Outcomes after Carotid Endarterectomy

BACKGROUND

Patients who are obese or underweight are traditionally at higher risk for perioperative morbidity and mortality. The effect of body mass index (BMI) on outcomes after carotid endarterectomy (CEA) is unclear. Our goal was to analyze the association of BMI with perioperative and long-term outcomes after elective CEA.

METHODS

The Vascular Quality Initiative (VQI) database was queried from 2003-2018 for patients undergoing elective CEAs. Patients were categorized into 5 BMI cohorts - underweight (UW, BMI < 18.5 kg/m²), normal weight (NW, BMI 18.5-24.9 kg/m²), overweight (OW, BMI 25-29.9 kg/m²), obese (OB, BMI 30-39.9 kg/m²), and morbidly obese (MO, BMI ≥ 40 kg/m²). Perioperative and long-term outcomes were assessed with univariable and multivariable analyses.

RESULTS

There were 89,079 patients included: 2% UW, 26% NW, 38.4% OW, 29.9% OB, and 3.6% MO. Overall, the mean age was 70.6 years, 60% were male, and 91.8% were of white race. There were significant differences among the BMI cohorts in regards to age, sex, smoking status, and comorbidities (all P < 0.05). For perioperative outcomes, the BMI cohorts differed significantly in reoperation for bleeding and 30-day mortality. On multivariable analysis, BMI was not associated with stroke or perioperative mortality. MO was associated with perioperative cardiac complications (Odds Ratios [OR] 1.26, 95% CI 1-1.57, P = 0.05). UW status was associated with increased return to the operating room (OR 1.89, 95% confidence interval [95% CI] 1.28-2.78, P = 0.001), 30-day mortality (OR 1.68, 95% CI 1-2.86, P =0.05), 1-year mortality (Hazard ratio [HR] 1.37, 95% CI 1.08-1.74, P = 0.01), and 5-year mortality (HR 1.22, 95% CI 1.06-1.41, P =0.005).

CONCLUSIONS

BMI status was not associated with perioperative stroke, cranial nerve injury, or surgical site infections. Patients with MO had higher perioperative cardiac complications. UW patients have lower short and long-term survival and should be a focus for long-term targeted risk factor stratification and modification.

The Obesity Paradox in Spontaneous Intracerebral Hemorrhage: Results from a Retrospective Analysis of the Nationwide Inpatient Sample

BACKGROUND/OBJECTIVE

Mild obesity is associated with a survival benefit in cardiovascular and cerebrovascular disease. Only a few studies have analyzed the effect of obesity on outcomes after spontaneous intracerebral hemorrhage (ICH), and none have used a national US database. We sought to determine whether or not obesity was associated with outcomes and in-hospital complications following ICH.

METHODS

The Nationwide Inpatient Sample was used to identify patients with ICH in the USA who were discharged between 2002 and 2011. The presence of obesity (body mass index [BMI] 30-39.9) or morbid obesity (BMI ≥ 40) was noted. The primary outcome of interest was in-hospital mortality, and secondary outcomes included non-routine discharge disposition, tracheostomy or gastrostomy placement, length of stay (LOS), inflation-adjusted hospital charges, and in-hospital complications.

RESULTS

A total of 123,415 patients with ICH met the inclusion criteria, and the 10-year overall incidence of obesity was 4.5%. Between 2002 and 2011, the incidence of obesity increased from 1.9 to 4.4% and the incidence of morbid obesity increased from 0.7 to 3.2%. Both obese (OR 0.62, 95% CI 0.56-0.69) and morbidly obese (OR 0.76, 95% CI 0.66-0.88) patients had lower odds of inpatient mortality. Obese (OR 0.85, 95% CI 0.78-0.93) but not morbidly obese patients had lower odds of non-routine discharge. Morbidly obese patients were twice as likely to require a tracheostomy than non-obese patients (OR 2.07, 95% CI 1.62-2.66). Both obese and morbidly obese patients had higher total hospital charges and rates of pulmonary, renal, and venous thromboembolic complications. There was no difference in LOS according to body habitus.

CONCLUSIONS

In patients with spontaneous ICH, obesity is associated with decreased in-hospital mortality but higher rates of in-hospital complications and greater total hospital charges. Non-morbid obesity carries lower odds of non-routine hospital discharge.

Extended intensive care correlates with worsening of surgical outcome after elective abdominal aortic reconstruction

BACKGROUND

The aim of this study was to evaluate the impact of extended postoperative intensive care on short- and long-term patient outcome after elective abdominal aortic surgery and to assess the risk factors for patient survival after extended intensive care unit (ICU) treatment.

METHODS

The data of 231 patients that underwent open or endovascular abdominal aortic surgery were retrospectively analysed with regard to extended postoperative intensive care, defined as ICU treatment for more than 24 consecutive hours. Pre- and intraoperative factors were evaluated. The endpoints of the study were postoperative complications, mortality, and long-term follow-up. Univariate and multivariate Cox proportional regression analyses were performed to identify risk factors of worse overall survival.

RESULTS

Extended postoperative intensive care was needed in 84 patients (63 after open and 21 after endovascular surgery). The period of ICU treatment was similar in both groups. Only the wound complications (31.8% vs. 9.5%, p=.0498; OR 4.42 (0.94-20.84)) and the rate of acute kidney injury (82.5% vs. 57.1%, p=.0352; OR 3.55 (1.20-0.46)) were more frequent after open surgery, whereas brief reactive psychosis (38.1% vs. 14.3%, p=.0281; OR 0.27 (0.09- 0.84)) was more frequent after endovascular surgery. ICU stay of ≥8 days correlated with significantly lower survival rates compared to a shorter ICU stay (p=.0034), independent of open or endovascular techniques. Other multivariate risk factors for worse survival were the absence of preoperative aspirin medication, a body mass index (BMI) of <25, chronic renal insufficiency (CRI), and coronary artery disease (CAD). Endovascular therapy was a positive predictive factor of short ICU stay of ≤3 days.

CONCLUSIONS

The outcome after extended intensive care following elective aortic surgery is strongly dependent on the length of ICU stay.

Obesity cardiomyopathy: evidence, mechanisms, and therapeutic implications

The prevalence of heart failure is on the rise and imposes a major health threat, in part, due to the rapidly increased prevalence of overweight and obesity. To this point, epidemiological, clinical, and experimental evidence supports the existence of a unique disease entity termed “obesity cardiomyopathy,” which develops independent of hypertension, coronary heart disease, and other heart diseases. Our contemporary review evaluates the evidence for this pathological condition, examines putative responsible mechanisms, and discusses therapeutic options for this disorder. Clinical findings have consolidated the presence of left ventricular dysfunction in obesity. Experimental investigations have uncovered pathophysiological changes in myocardial structure and function in genetically predisposed and diet-induced obesity. Indeed, contemporary evidence consolidates a wide array of cellular and molecular mechanisms underlying the etiology of obesity cardiomyopathy including adipose tissue dysfunction, systemic inflammation, metabolic disturbances (insulin resistance, abnormal glucose transport, spillover of free fatty acids, lipotoxicity, and amino acid derangement), altered intracellular especially mitochondrial Ca²⁺ homeostasis, oxidative stress, autophagy/mitophagy defect, myocardial fibrosis, dampened coronary flow reserve, coronary microvascular disease (microangiopathy), and endothelial impairment. Given the important role of obesity in the increased risk of heart failure, especially that with preserved systolic function and the recent rises in COVID-19-associated cardiovascular mortality, this review should provide compelling evidence for the presence of obesity cardiomyopathy, independent of various comorbid conditions, underlying mechanisms, and offer new insights into potential therapeutic approaches (pharmacological and lifestyle modification) for the clinical management of obesity cardiomyopathy.

Relation of Body Mass Index to Outcomes in Acute Coronary Syndrome

We assessed the association of BMI with all-cause and cardiovascular (CV) mortality in a contemporary acute coronary syndrome cohort. Patients from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events and Global Registry of Acute Coronary Events between 2009 and 2019, were divided into BMI subgroups (underweight: <18.5, healthy: 18.5 to 24.9, overweight: 25 to 29.9, obese: 30 to 39.9, extremely obese: >40). Logistic regression was used to determine the association between BMI group and outcomes of all cause and CV death in hospital, and at 6 months. 8,503 patients were identified, mean age 64 ± 13, 72% male. The BMI breakdown was: underweight- 95, healthy- 2,140, overweight- 3,258, obese- 2,653, extremely obese- 357. Obese patients were younger (66 ± 12 vs 67 ± 13), with more hypertension, diabetes, and dyslipidemia vs healthy (all p < 0.05). Obese had lower hospital mortality than healthy: all-cause: 1% versus 4%, aOR (95% CI): 0.49(0.27, 0.87); CV: 1% versus 3%, 0.51(0.27, 0.96). At 6-month underweight had higher mortality than healthy: all-cause: 11% versus 4%, 2.69(1.26, 5.76); CV: 7% versus 1%, 3.54(1.19, 10.54); whereas obese had lower mortality: all-cause: 1% versus 4%, 0.48(0.29, 0.77); CV: 0.4% versus 1%, 0.42(0.19, 0.93). When BMI was plotted as a continuous variable against outcome a U-shaped relationship was demonstrated, with highest event rates in the most obese (>60). In conclusion, BMI is associated with mortality following an acute coronary syndrome. Obese patients had the best outcomes, suggesting persistence of the obesity paradox. However, there was a threshold effect, and favorable outcomes did not extend to the most obese.

Association of obesity indices with in-hospital and 1-year mortality following acute coronary syndrome

BACKGROUND/OBJECTIVES

According to the "obesity paradox", adults with obesity have a survival advantage following acute coronary syndrome, compared with those without obesity. Previous studies focused on peripheral obesity and whether this advantage is conferred by central obesity is unknown. The objective of this study was to describe the association of peripheral and central obesity indices with risk of in-hospital and 1-year mortality following acute coronary syndrome (ACS).

SUBJECTS/METHODS

Gulf COAST is a prospective ACS registry that enrolled 4044 patients age ≥18 years from January 2012 through January 2013, across 29 hospitals in four Middle Eastern countries. Associations of indices of peripheral obesity (body-mass index, [BMI]) and central obesity (waist circumference [WC] and waist-to-height ratio [WHtR]) with mortality following ACS were analyzed in logistic regression models (odds ratio, 95% CI) with and without adjustment for Global Registry of Acute Coronary Events risk score.

RESULTS

Of 3882 patients analyzed (mean age: 60 years; 33.3% women [n = 1294]), the prevalence of obesity was 34.5% (BMI ≥ 30.0 kg/m²), 72.2% (WC ≥ 94.0 cm [men] or ≥80.0 cm [women]) and 90.0% (WHtR ≥ 0.5). In adjusted models, deciles of obesity indices showed higher risk of mortality at extreme versus intermediate deciles (U-shaped). When defined by conventional cut-offs, peripheral obesity (BMI ≥ 30.0 versus 18.5-29.9 kg/m²) showed inverse association with risk of in-hospital mortality (0.64; 95% CI, 0.42-0.99; P = 0.04; central obesity showed trend toward reduced mortality). In contrast, for risk of 1-year mortality, all indices showed inverse association. Obesity, defined by presence of all three indices, versus nonobesity showed inverse association with risk of 1-year mortality (0.52; 95% CI, 0.35-0.75; P = 0.001). Results were similar among men and women.

CONCLUSION

The degree of obesity paradox following ACS depends on the obesity index and follow-up time. Obesity indices may aid in risk stratification of mortality following ACS.

Association of Body Mass Index and Extreme Obesity With Long-Term Outcomes Following Percutaneous Coronary Intervention

Background

Previous studies have reported a protective effect of obesity compared with normal body mass index (BMI) in patients undergoing percutaneous coronary intervention (PCI). However, it is unclear whether this effect extends to the extremely obese. In this large multicenter registry‐based study, we sought to examine the relationship between BMI and long‐term clinical outcomes following PCI, and in particular to evaluate the association between extreme obesity and long‐term survival after PCI.

Methods and Results

This cohort study included 25 413 patients who underwent PCI between January 1, 2005 and June 30, 2017, who were prospectively enrolled in the Melbourne Interventional Group registry. Patients were stratified by World Health Organization–defined BMI categories. The primary end point was National Death Index–linked mortality. The median length of follow‐up was 4.4 years (interquartile range 2.0‐7.6 years). Of the study cohort, 24.8% had normal BMI (18.5‐24.9 kg/m²), and 3.3% were extremely obese (BMI ≥40 kg/m²). Patients with greater degrees of obesity were younger and included a higher proportion of diabetics (P<0.001). After adjustment for age and comorbidities, a J‐shaped association was observed between different BMI categories and adjusted hazard ratio (HR) for long‐term mortality (normal BMI, HR 1.00 [ref]; overweight, HR 0.85, 95% CI 0.78‐0.93, P<0.001; mild obesity, HR 0.85, 95% CI 0.76‐0.94, P=0.002; moderate obesity, HR 0.95, 95% CI 0.80‐1.12, P=0.54; extreme obesity HR 1.33, 95% CI 1.07‐1.65, P=0.01).

Conclusions

An obesity paradox is still apparent in contemporary practice, with elevated BMI up to 35 kg/m² associated with reduced long‐term mortality after PCI. However, this protective effect appears not to extend to patients with extreme obesity.

A risk score model for predicting cardiac rupture after acute myocardial infarction

Background:

Cardiac rupture (CR) is a major lethal complication of acute myocardial infarction (AMI). However, no valid risk score model was found to predict CR after AMI in previous researches. This study aimed to establish a simple model to assess risk of CR after AMI, which could be easily used in a clinical environment.

Methods:

This was a retrospective case-control study that included 53 consecutive patients with CR after AMI during a period from January 1, 2010 to December 31, 2017. The controls included 524 patients who were selected randomly from 7932 AMI patients without CR at a 1:10 ratio. Risk factors for CR were identified using univariate analysis and multivariate logistic regression. Risk score model was developed based on multiple regression coefficients. Performance of risk model was evaluated using receiver-operating characteristic (ROC) curves and internal validity was explored using bootstrap analysis.

Results:

Among all 7985 AMI patients, 53 (0.67%) had CR (free wall rupture, n = 39; ventricular septal rupture, n = 14). Hospital mortalities were 92.5% and 4.01% in patients with and without CR (P < 0.001). Independent variables associated with CR included: older age, female gender, higher heart rate at admission, body mass index (BMI) <25 kg/m², lower left ventricular ejection fraction (LVEF) and no primary percutaneous coronary intervention (pPCI) treatment. In ROC analysis, our CR risk assess model demonstrated a very good discriminate power (area under the curve [AUC] = 0.895, 95% confidence interval: 0.845–0.944, optimism-corrected AUC = 0.821, P < 0.001).

Conclusion:

This study developed a novel risk score model to help predict CR after AMI, which had high accuracy and was very simple to use.

Nutritional risk index is a better predictor of early mortality than conventional nutritional markers after transcatheter aortic valve replacement: A prospective cohort study

BACKGROUND

Nutritional risk index (NRI) has been shown to better predict survival than body mass index (BMI) or albumin after several cardiovascular interventions. Under assessment herein is whether NRI can have higher predictive value than conventional parameters for short-term survival after transcatheter aortic valve replacement (TAVR).

METHODS

A prospective cohort study was performed. In-hospital, 1-month and 3-month survival was evaluated. Since most patients undergoing TAVR are over 65, the NRI definition for a geriatric population (GNRI) was used. The impact of baseline BMI, albumin levels, and GNRI on in-hospital and short-term survival was assessed.

RESULTS

One hundred fifty two patients aged 82 ± 5.4 were included. In-hospital, 1-month, and 3-month mortality was 5.3%, 5.9%, and 9.2%, respectively. Mean GNRI was 112.7 ± 11.9, and was significantly lower in patients who died in-hospital (101.0 ± 8.8 vs. 113.3 ± 11.7), at 30 days (103.4 ± 10.9 vs. 113.3 ± 11.7), and at 90 days (104.0 ± 9.6 vs. 113.6 ± 11.8) than in survivors (all, p < 0.05). Three-month mortality in patients with no nutritional risk was 6.8% (9/132) vs. 25% (5/20) in patients with malnutrition (p = 0.022). In univariate analysis, GNRI predicted in-hospital, 30-day, and 90-day mortality (all, p < 0.05). Predictive value remained significant after adjusting for age, EuroSCORE II, and STS-Score (p < 0.05). Based on receiver operating curves, GNRI (AUC: 0.73) showed a better discrimination for 3-month mortality than albumin (0.69), weight (0.67) or BMI (0.62). The optimal cut-off value was 109.8.

CONCLUSIONS

The geriatric nutritional risk index predicts short-term mortality after TAVR and has a higher discriminating ability than other commonly used nutritional variables. It is a simple parameter that identifies those patients who could benefit from pre-procedural nutritional therapy.

Mental illness and obesity among Veterans undergoing percutaneous coronary intervention: Insights from the VA CART program

Mental illness and obesity are highly prevalent in patients with coronary disease and are frequently comorbid. While mental illness is an established risk factor for major adverse cardiac and cerebrovascular events (MACCEs), prior studies suggest improved outcomes in people with obesity. It is unknown if obesity and mental illness interact to affect cardiac outcomes or if they independently influence MACCE. We identified 55 091 patients undergoing percutaneous coronary intervention (PCI) between 2009 and 2014, using the Veterans Affairs (VA) Clinical Assessment Reporting and Tracking (CART) program. Cox methods were used to assess the risk of MACCE by weight status and psychiatric diagnosis, and assessed for interaction. Compared to normal weight status, higher weight was associated with reduced MACCE events after PCI (mean follow-up of 2 years) for both stable angina and acute coronary syndromes (ACSs; reduction of >13% in stable angina, >17% in ACS; P < 0.01 for both after adjustment). Having a non-substance abuse mental illness diagnosis increased risk of MACCE compared to patients without mental illness in stable angina over 17%; P < 0.05, but not in ACS. When analysed for interaction, obesity and mental illness did not significantly impact MACCE over their independent influences. These results suggest that mental illness along with weight status have significant impact on MACCE, post-PCI. Clinicians should be aware of patients' mental health status as a significant cardiovascular risk factor after PCI, independent of weight status.

Association Trends Between Antihypertensive Drug Therapies and Diastolic Hypotension in Emirati Patients with Type 2 Diabetes: A Single-Center Retrospective Longitudinal Study

INTRODUCTION

Diabetes mellitus (DM) is associated with multiple complications, including cardiovascular diseases. Previously, it was believed that the latter are mainly caused by hypertension and increased systolic blood pressure. However, recent studies have challenged this concept, by showing that diastolic dysfunction may also be involved in the cardiovascular events that are associated with DM. Pharmacologic management of hypertension in patients with type 2 DM appears to adversely influence diastolic function.

METHODS

Four hundred and eight medical records of hypertensive and obese Emirati patients with type 2 DM were included in the present retrospective study. The main objectives of the present study were (1) to determine the prevalence of low diastolic blood pressure (DBP) and diastolic hypotension in this group of patients and (2) to investigate the associations, if any, between the use of various antihypertensive medications and low DBP and diastolic hypotension.

RESULTS

The results of the present study showed that low DBP (< 70 mmHg) was experienced by 40% of the hypertensive type 2 DM patients, whereas diastolic hypotension (< 60 mmHg) was reported to occur in about 10% of the patients. Another important factor that has been significantly correlated with diastolic hypotension is age (p < 0.01). Association trends have been reported between low DBP and diastolic hypotension and several antihypertensive therapies, including (1) monotherapies such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs), (2) dual therapies such as ACE inhibitors in combination with thiazide-like diuretics (THLDs) or beta blockers, and (3) triple therapy combinations of ACE inhibitors with THLDs and potassium-sparing diuretics.

CONCLUSION

The use of antihypertensive medications, in particular ACE inhibitors and ARBs, appears to be a risk factor for the development of low DBP and diastolic hypotension in obese hypertensive Emirati patients with type 2 DM, whereas calcium channel blockers seem to be a safer option for this group of patients.

Obesity paradox in the era of percutaneous coronary intervention with 2nd-generation drug-eluting stents: an analysis of a multicenter PCI registry

Being overweight has been identified as independent risk factors for coronary artery disease. However, overweight patients have been reported frequently to have better mortality outcomes, and there is little data showing they are at a disadvantage regarding secondary prevention of cardiovascular events. We analyzed the influence of being overweight (defined as body mass index > 25 kg/m²) on adverse events in patients who underwent everolimus-eluting stent (EES) implantation using a multicenter registry with a maximum follow-up of 3 years. Propensity score matching was done for adjusting baseline characteristics. We defined primary end points as major adverse cardiac and cerebrovascular events (MACCE: a composite of mortality from all causes, nonfatal myocardial infarction, and nonfatal stroke) and "MACCE excluding non-cardiac mortality". Other adverse events were analyzed as key secondary end points. Out of 1918 patients, 450 pairs were obtained through propensity score matching. Overweight patients were superior to non-overweight patients regarding MACCE (event rates: 8.2 vs. 13.8% in overweight vs. non-overweight, respectively; log-rank p = 0.009) and "MACCE excluding non-cardiac mortality" (5.9 vs. 10.1%, p = 0.03). On secondary end points, not only did overweight patients have significantly fewer major bleeding events (2.2 vs. 4.8%, p = 0.02), but they also had smaller adverse event rates for almost all such events; the differences were not statistically significant. Overweight patients had better outcomes for MACCE, even on excluding non-cardiac mortalities. No result was supportive of an evident advantage to non-overweight EES-implanted patients in terms of secondary prevention of cardiovascular events.

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.

The Relationship of Body Mass Index to Percutaneous Coronary Intervention Outcomes: Does the Obesity Paradox Exist in Contemporary Percutaneous Coronary Intervention Cohorts? Insights From the British Cardiovascular Intervention Society Registry

OBJECTIVES

The aims of this study were to examine the relationship between body mass index (BMI) and clinical outcomes following percutaneous coronary intervention (PCI) and to determine the relevance of different clinical presentations requiring PCI to this relationship.

BACKGROUND

Obesity is a growing problem, and studies have reported a protective effect from obesity compared with normal BMI for adverse outcomes after PCI.

METHODS

Between 2005 and 2013, 345,192 participants were included. Data were obtained from the British Cardiovascular Intervention Society registry, and mortality data were obtained through the U.K. Office of National Statistics. Multiple logistic regression was performed to determine the association between BMI group (<18.5, 18.5 to 24.9, 25 to 30 and >30 kg/m²) and adverse in-hospital outcomes and mortality.

RESULTS

At 30 days post-PCI, significantly lower mortality was seen in patients with elevated BMIs (odds ratio [OR]: 0.86 [95% confidence interval (CI): 0.80 to 0.93] 0.90 [95% CI: 0.82 to 0.98] for BMI 25 to 30 and >30 kg/m², respectively). At 1 year post-PCI, and up to 5 years post-PCI, elevated BMI (either overweight or obese) was an independent predictor of greater survival compared with normal weight (OR: 0.70 [95% CI: 0.67 to 0.73] and 0.73 [95% CI: 0.69 to 0.77], respectively, for 1 year; OR: 0.78 [95% CI: 0.75 to 0.81] and 0.88 [95% CI: 0.84 to 0.92], respectively, for 5 years). Similar reductions in mortality were observed for the analysis according to clinical presentation (stable angina, unstable angina or non-ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction).

CONCLUSIONS

A paradox regarding the independent association of elevated BMI with reduced mortality after PCI is still evident in contemporary U.K. practice. This is seen in both stable and more acute clinical settings.

Systematic review of prognostic roles of body mass index for patients undergoing lung cancer surgery: does the 'obesity paradox' really exist?

Summary

The paradoxical benefit of obesity, the 'obesity paradox', has been recently identified in surgical populations. Our goal was to evaluate by a systematic review with meta-analysis the prognostic role of body mass index (BMI) and to identify whether the 'obesity paradox' exists in lung cancer surgery. Comprehensive literature retrieval was conducted in PubMed to identify the eligible articles. The odds ratios (OR) and hazard ratios (HR) with the corresponding 95% confidence intervals (CI) were used to synthesize in-hospital and long-term survival outcomes, respectively. The heterogeneity level and publication bias between studies were also estimated. Finally, 25 observational studies with 78 143 patients were included in this review. The pooled analyses showed a significantly better long-term survival rate in patients with higher BMI, but no significant benefit of increased BMI was found for in-hospital morbidity. The pooled analyses also showed that overall morbidity (OR: 0.84; 95% CI: 0.73-0.98; P  =   0.025) and in-hospital mortality (OR: 0.78; 95% CI: 0.63-0.98; P  =   0.031) were significantly decreased in obese patients. Obesity could be a strong predictor of the favourable long-term prognosis of lung cancer patients (HR: 0.69; 95% CI: 0.56-0.86; P  =   0.001). The robustness of these pooled estimates was strong. No publication bias was detected. In summary, obesity has favourable effects on in-hospital outcomes and long-term survival of surgical patients with lung cancer. The 'obesity paradox' does have the potential to exist in lung cancer surgery.

Influence of Body Mass Index on Long-Term Survival After Cardiac Catheterization

We examined 18,654 patients who underwent cardiac catheterization in a single center to clarify the association between catheterization indication, body mass index (BMI), and long-term survival over a mean follow-up of 81 months. Patients were grouped by indication for catheterization: (a) acute coronary syndromes (ACS), 7,426 patients; (b) coronary artery disease (CAD) evaluation in stable clinical presentation, 6,911 patients; and (c) primarily non-CAD cardiac evaluations, 4,317 patients. Compared with normal weight, overweight and obesity (but not morbid obesity) was associated with lower risk of long-term mortality. Underweight patients had the greatest risk of mortality. After multivariate adjustment, survival benefit of the overweight and obese was retained in the ACS group [hazard ratio 0.86, 95% confidence interval (0.77-0.96), p = 0.006 and 0.79, (0.68-0.91), p = 0.001, respectively] and in overweight patients in the stable presentation CAD group [0.83, (0.72-0.94), p = 0.005], whereas there was no survival benefit in any of the BMI categories in those catheterized primarily for non-CAD indications. Further analysis of matched cohorts showed similar patterns of survival benefit of the overweight/obese. In conclusion, among patients who underwent cardiac catheterization, an inverse association between BMI and long-term mortality was observed, with the lowest risk noted in the overweight and obese population; the obesity paradox was principally demonstrated in patients with ACS, and was eliminated after covariate adjustment in those catheterized primarily for non-CAD indications.

Low Body Mass Index Is an Independent Predictive Factor after Surgical Resection in Patients with Non-Small Cell Lung Cancer

Background:

The effect of body mass index (BMI) on postoperative survival in non-small cell lung cancer (NSCLC) has been controversial. We retrospectively analysed the effect of preoperative BMI on postoperative outcomes of NSCLC surgery.

Methods:

Consecutive 384 NSCLC patients were enrolled. Patients were subdivided into 3 groups: low BMI group (BMI<18.5 kg/m²), normal BMI group (BMI=18.5-24.0 kg/m²) and high BMI group (BMI>24.0 kg/m²). The prognostic significance of BMI was examined retrospectively.

Results:

The 5-year survival of patients with low, normal and high BMI groups were 46.3%, 74.3% and 84.3%, respectively. The low BMI group had a poorer prognosis than the other groups (p<0.001). The survival of high BMI group had a more favorable trend than that of normal BMI group, but this did not reach statistical significance (p=0.057). On multivariate analysis, significant risk factors for cancer-specific survival were male gender (p=0.0061), non-adenocarcinoma histology (p=0.0003), pN1-2 status (p=0.0007), high serum CEA level (p<0.0001) and low BMI (low vs. others: p <0.0001).

Conclusions:

Preoperative BMI is an independent prognostic factor for NSCLC patients after surgical resection, with low BMI patients having an unfavorable prognosis.

Body mass index as a biomarker for the evaluation of the "Obesity Paradox" among inpatients

BACKGROUND

Overweight and obesity are, on the one hand, recognized as risk factors for many health-related disorders, and, on the other, as favorable prognostic factors in various patients treated for several different conditions; what is called the "obesity paradox". Until now, the existence of this phenomenon among a general population of consecutive inpatients has not been evaluated. We decided, therefore, to perform an evaluation.

PATIENTS AND METHODS

Historical prospective analysis of the medical documentation of 23 603 hospitalizations during two consecutive years in one center was performed. The outcomes measured were as follows: length of stay, in-hospital all-cause mortality, and non-scheduled readmission in the 14-day, 30-day and one-year periods following discharge.

RESULTS

Overweight and obese patients had a lower or similar prevalence of the measured outcomes than malnourished patients and those of normal weight. Adjustment of the standard WHO BMI ranges for patients aged ≥65 y (normal weight BMI range 23-33 kg/m²) made these differences more apparent. In logistic regression, the ratio of fat to fat-free body mass was a stronger and unfavorable risk factor compared with BMI for the measured outcomes.

CONCLUSIONS

The greatest risk of all-cause in-hospital death and readmission concerned malnourished inpatients. Compared to patients with a normal BMI range, overweight and obesity had a lower or similar (but not greater) risk of the outcomes measured. However, due to several BMI limitations, our observations should be interpreted as suggesting a "BMI paradox", rather than an "obesity paradox".

Biodegradable polymer drug-eluting stents versus first-generation durable polymer drug-eluting stents: A systematic review and meta-analysis of 12 randomized controlled trials

BACKGROUND

Even if drug-eluting stents (DES) showed beneficial effects in patients with coronary artery diseases (CADs), limitations have been observed with the first-generation durable polymer DES (DP-DES). Recently, biodegradable polymer DES (BP-DES) have been approved to be used as an alternative to DP-DES, with potential benefits. We aimed to systematically compare BP-DES with the first-generation DP-DES using a large number of randomized patients.

METHODS

Electronic databases were searched for randomized controlled trials (RCTs) comparing BP-DES with first-generation DP-DES. The main endpoints were the long-term (≥2 years) adverse clinical outcomes that were reported with these 2 types of DES. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) and the analysis was carried out by RevMan 5.3 software.

RESULTS

Twelve trials with a total number of 13,480 patients (7730 and 5750 patients were treated by BP-DES and first-generation DP-DES, respectively) were included. During a long-term follow-up period of ≥2 years, mortality, myocardial infarction (MI), target lesion revascularization (TLR), and major adverse cardiac events (MACEs) were not significantly different between these 2 groups with OR: 0.84, 95% CI: 0.66-1.07; P = .16, I = 0%, OR: 1.01, 95% CI: 0.45-2.27; P = .98, I = 0%, OR: 0.91, 95% CI: 0.75-1.11; P = .37, I = 0% and OR: 0.86, 95% CI: 0.44-1.67; P = .65, I = 0%, respectively. Long-term total stent thrombosis (ST), definite ST, and probable ST were also not significantly different between BP-DES and the first-generation DP-DES with OR: 0.77, 95% CI: 0.50-1.18; P = .22, I = 0%, OR: 0.71, 95% CI: 0.43-1.18; P = .19, I = 0% and OR: 1.31, 95% CI: 0.56-3.08; P = .53, I = 6%, respectively.

CONCLUSION

Long-term mortality, MI, TLR, MACEs, and ST were not significantly different between BP-DES and the first-generation DP-DES. However, the follow-up period was restricted to only 3 years in this analysis.

Effect of body mass index on clinical outcome and all-cause mortality in patients undergoing transcatheter aortic valve implantation

Objectives

To assess the effect of body mass index (BMI) on outcome among patients with severe aortic stenosis (AS) admitted for transcatheter aortic valve implantation (TAVI).

Background

Being overweight or obese is associated with improved outcome following certain medical treatments, suggesting the existence of a BMI paradox. However, the relationship between BMI and mortality after TAVI remains controversial.

Methods

Patients were classified according to World Health Organisation criteria such as normal weight, overweight, or obesity according to their BMI (18.5 to 24.9 kg/m², 25.0 to 29.9 kg/m², and ≥30.0 kg/m², respectively).

Results

A total of 549 consecutive patients (age: 80.2 ± 7.5 years; logistic European system for cardiac operative risk evaluation [EuroSCORE]: 17.3 ± 9.9%) who underwent TAVI for AS were included. Of these patients, 43% (n = 237) had normal weight, 36% (n = 200) were overweight, and 20% (n = 112) were obese. There were no differences in peri-operative bleeding or vascular complication rates between the groups. All-cause mortality after 30 days, and 1 year, were higher in normal weight patients compared with overweight and obese patients (7% vs. 5 and 4%, p = 0.383, and 19% vs. 9 and 10%, p = 0.006, respectively). After adjustment for several confounding factors, overweight was associated with a decreased 30-day and 1‑year all-cause mortality outcome (hazard ratio [HR] 0.69; 95% confidence interval [CI] 0.47–0.99, and HR 0.65; 95% CI 0.45–0.94, respectively).

Conclusions

Despite the well-documented adverse effects of increased body weight on health, being overweight is associated with improved survival following TAVI when compared with normal weight.

Differences in Short- and Long-Term Mortality Associated With BMI Following Coronary Revascularization

BACKGROUND

The association between obesity and mortality risks following coronary revascularization is not clear. We examined the associations of BMI (kg/m2) with short-, intermediate-, and long-term mortality following coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) in patients with different coronary anatomy risks and diabetes mellitus status.

METHODS AND RESULTS

Data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry were analyzed. Using normal BMI (18.5-24.9) as a reference, multivariable-adjusted hazard ratios for all-cause mortality within 6 months, 1 year, 5 years, and 10 years were individually calculated for CABG and PCI with 4 prespecified BMI categories: overweight (25.0-29.9), obese class I (30.0-34.9), obese class II (35.0-39.9), and obese class III (≥40.0). The analyses were repeated after stratifying for coronary risks and diabetes mellitus status. The cohorts included 7560 and 30 258 patients for CABG and PCI, respectively. Following PCI, overall mortality was lower in patients with overweight and obese class I compared to those with normal BMI; however, 5- and 10-year mortality rates were significantly higher in patients with obese class III with high-risk coronary anatomy, which was primarily driven by higher mortality rates in patients without diabetes mellitus (5-year adjusted hazard ratio, 1.78 [95% CI, 1.11-2.85] and 10-year adjusted hazard ratio, 1.57 [95% CI, 1.02-2.43]). Following CABG, overweight was associated with lower mortality risks compared with normal BMI.

CONCLUSIONS

Overweight was associated with lower mortality following CABG and PCI. Greater long-term mortality in patients with obese class III following PCI, especially in those with high-risk coronary anatomy without diabetes mellitus, warrants further investigation.

Body mass index is inversely associated with mortality in patients with acute kidney injury undergoing continuous renal replacement therapy

BACKGROUND

Many epidemiologic studies have reported on the controversial concept of the obesity paradox. The presence of acute kidney injury (AKI) can accelerate energy-consuming processes, particularly in patients requiring continuous renal replacement therapy (CRRT). Thus, we aimed to investigate whether obesity can provide a survival benefit in this highly catabolic condition.

METHODS

We conducted an observational study in 212 patients who had undergone CRRT owing to various causes of AKI between 2010 and 2014. The study end point was defined as death that occurred within 30 days after the initiation of CRRT.

RESULTS

Patients were categorized into three groups according to tertiles of body mass index (BMI). During ≥30 days after the initiation of CRRT, 39 patients (57.4%) in the highest tertile died, as compared with 58 patients (78.4%) in the lowest tertile (P = 0.02). In a multivariable analysis adjusted for cofounding factors, the highest tertile of BMI was significantly associated with a decreased risk of death (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.37-0.87; P = 0.01). This significant association remained unaltered for 60-day (HR, 0.64; 95% CI, 0.43-0.94; P = 0.03) and 90-day mortality (HR, 0.66; 95% CI, 0.44-0.97; P = 0.03).

CONCLUSION

This study showed that a higher BMI confer a survival benefit over a lower BMI in AKI patients undergoing CRRT.

From the BMI paradox to the obesity paradox: the obesity-mortality association in coronary heart disease

Despite a strong association between body weight and mortality in the general population, clinical evidence suggests better clinical outcome of overweight or obese individuals with established coronary heart disease. This finding has been termed the 'obesity paradox', but its existence remains a point of debate, because it is mostly observed when body mass index (BMI) is used to define obesity. Inherent limitations of BMI as an index of adiposity, as well as methodological biases and the presence of confounding factors, may account for the observed findings of clinical studies. In this review, our aim is to present the data that support the presence of a BMI paradox in coronary heart disease and then explore whether next to a BMI paradox a true obesity paradox exists as well. We conclude by attempting to link the obesity paradox notion to available translational research data supporting a 'healthy', protective adipose tissue phenotype. © 2016 World Obesity.

Prolonged and intensive medication use are associated with the obesity paradox after percutaneous coronary intervention: a systematic review and meta-analysis of 12 studies

Background

Obesity paradox is defined as the unexpected decrease in the total number of death which has been observed among patients who are overweight and obese compared to patients with normal weight after undergoing revascularization by percutaneous coronary intervention (PCI). Despite of so many recent studies which showed the existence of this phenomenon, prolonged and intensive medication use were only suggested to be among the reasons responsible for this ‘obesity paradox’ but it was never confirmed whether this hypothesis should really be considered true or not. Therefore, this study aimed to investigate whether prolonged and intensive medication use were associated with this obesity paradox after PCI.

Methods

Medline, PubMed, EMBASE and the Cochrane Library were searched for studies showing the existence of this ‘obesity paradox’ in patients who underwent coronary revascularization by PCI and only articles comprising of medication use among the patients analyzed were considered relevant for this research. Medication use among the different subgroups of patients was calculated. Mortality was considered as the clinical endpoint in this study. Risk Ratio (RR) with 95 % Confidence Interval (CI) was used to express the pooled effect on discontinuous variables and the pooled analyses were performed with RevMan 5.3.

Results

Twelve studies consisting of a total number of 91,582 patients was included in this meta-analysis. An intensive medication use after the hospital discharge and during the follow up period after PCI was observed in the subgroup of obese patients, followed by the overweight patients and the normal weight patients respectively. Our results showed that the short-term (30 days) mortality in overweight and obese patients was significantly lower compared to the normal weight patients with RR: 0.72; 95 % CI: 0.56-0.92, p = 0.008 and RR: 0.47, 95 % CI: 0.34-0.65; p < 0.00001 respectively. The long-term (≥ one year) mortality was also significantly lower in the overweight and the obese groups with RR: 0.74, 95 % CI: 0.67-0.82; p < 0.00001 and RR: 0.63, 95 % CI: 0.55-0.72; p < 0.00001 respectively.

Conclusion

Our study has confirmed to some extent, that prolonged and intensive use of medications which were more prominent in patients who were overweight and obese during the follow up period, might apparently be among the reasons responsible for this obesity paradox after PCI.

Epigenetics and obesity cardiomyopathy: From pathophysiology to prevention and management

Uncorrected obesity has been associated with cardiac hypertrophy and contractile dysfunction. Several mechanisms for this cardiomyopathy have been identified, including oxidative stress, autophagy, adrenergic and renin-angiotensin aldosterone overflow. Another process that may regulate effects of obesity is epigenetics, which refers to the heritable alterations in gene expression or cellular phenotype that are not encoded on the DNA sequence. Advances in epigenome profiling have greatly improved the understanding of the epigenome in obesity, where environmental exposures during early life result in an increased health risk later on in life. Several mechanisms, including histone modification, DNA methylation and non-coding RNAs, have been reported in obesity and can cause transcriptional suppression or activation, depending on the location within the gene, contributing to obesity-induced complications. Through epigenetic modifications, the fetus may be prone to detrimental insults, leading to cardiac sequelae later in life. Important links between epigenetics and obesity include nutrition, exercise, adiposity, inflammation, insulin sensitivity and hepatic steatosis. Genome-wide studies have identified altered DNA methylation patterns in pancreatic islets, skeletal muscle and adipose tissues from obese subjects compared with non-obese controls. In addition, aging and intrauterine environment are associated with differential DNA methylation. Given the intense research on the molecular mechanisms of the etiology of obesity and its complications, this review will provide insights into the current understanding of epigenetics and pharmacological and non-pharmacological (such as exercise) interventions targeting epigenetics as they relate to treatment of obesity and its complications. Particular focus will be on DNA methylation, histone modification and non-coding RNAs.