Association between body mass index and outcomes after percutaneous coronary intervention in multiethnic South East Asian population: a retrospective analysis of the Malaysian National Cardiovascular Disease Database-Percutaneous Coronary Intervention (NCVD-PCI) registry

The obesity paradox exists in Asia: A systematic review and meta-analysis of body mass index effects on clinical outcomes following percutaneous coronary intervention in Asia

Cardiovascular diseases (CVDs) are major contributors to illness and death globally. Body mass index (BMI) is a well-established prognostic factor on cardiovascular risk outcome. Numerous investigations have provided evidence for the existence of the obesity paradox after percutaneous coronary intervention (PCI). However, the association between BMI and the results following PCI has not been extensively investigated in Asian populations. The research aims to fill the current void in understanding by investigating the association between BMI and clinical consequences following PCI, with a particular focus on Asian individuals. A systematic search was conducted through PubMed, ScienceDirect, and Cochrane Library to identify studies examining the effect of BMI on clinical outcome after PCI in Asia. R Studio 4.3.2 software was used to carry out the analysis of the data. A total of 182,110 patients who had gone through PCI were found in the 5 included cohorts. A meta-analysis conducted on the subjects revealed that patients who were overweight (odds ratio [OR] = 0.60, 95% confidence interval [CI] [0.57, 0.63], P < 0.0001) had a lower risk of all-cause mortality compared to individuals with a healthy weight and patients with obesity (OR = 0.65, 95% CI [0.41, 1.05], P = 0.006) had a lower risk of all-cause mortality than healthy weight individuals. The study also found that overweight patients (OR = 0.60, 95% CI [0.39, 0.91], P = 0.02) had a lower risk of cardiac mortality. In addition, obese patients (OR = 0.41, 95% CI [0.19, 0.88], P = 0.02) had a lower risk of noncardiac mortality. However, the study found that there were no differences in major adverse cardiovascular event, myocardial infarction, and bleeding between all patient groups. This meta-analysis supports the presence of an obesity paradox after PCI in Asian populations. The obesity paradox was evident in all-cause mortality, cardiac mortality, and noncardiac mortality.

Body Mass Index and All-Cause Mortality in Elderly Patients with Percutaneous Coronary Intervention: A Meta-Analysis

INTRODUCTION

The "obesity paradox" in elderly patients suffering from percutaneous coronary intervention (PCI) remains a source of controversy. The present meta-analysis focused on exploring the real existence of "obesity paradox" in these patients.

METHODS

As of November 2022, PubMed, Cochrane, and Embase databases were comprehensively searched to identify articles reporting all-cause mortality according to diverse body mass index (BMI) categories after PCI among the old cases developing coronary artery disease (CAD). Summary estimates of relative risks (RRs) were assigned to four BMI groups, including underweight, normal weight, overweight, and obesity groups.

RESULTS

There were altogether nine articles involving 25,798 cases selected for further analysis. Relative to normal weight group, overweight and obesity groups had decreased all-cause mortality (RR: 0.86, 95% CI: 0.77-0.95 for overweight group; RR: 0.57, 95% CI: 0.40-0.80 for obesity group), while underweight group had elevated all-cause mortality (RR: 1.52, 95% CI: 1.01-2.29).

CONCLUSION

Our study revealed an "obesity paradox" relation of BMI with all-cause mortality in elderly cases receiving PCI. In comparison with normal weight group, overweight and obesity groups had decreased all-cause mortality, while underweight group had increased all-cause mortality.

Τhe Burden of Obesity on Adult Survivors of Congenital Heart Disease, Past, and Future Directions

The ongoing obesity epidemic has started to ebb. However, as most children with congenital heart disease survive until adulthood, the burgeoning trend has started to spill over in the adult congenital heart disease population as well. This review aims to decipher the prevalence, outcomes, and future directions of obesity in adult survivors of congenital heart disease.

Different Patterns in Ranking of Risk Factors for the Onset Age of Acute Myocardial Infarction between Urban and Rural Areas in Eastern Taiwan

This cross-sectional study aimed to investigate the difference in ranking of risk factors of onset age of acute myocardial infarction (AMI) between urban and rural areas in Eastern Taiwan. Data from 2013 initial onset of AMI patients living in the urban areas (n = 1060) and rural areas (n = 953) from January 2000 to December 2015, including onset age, and conventional risk factors including sex, smoking, diabetes, hypertension, dyslipidemia, and body mass index (BMI). The results of multiple linear regressions analysis showed smoking, obesity, and dyslipidemia were early-onset reversible risk factors of AMI in both areas. The ranking of impacts of them on the age from high to low was obesity (β = −6.7), smoking (β = −6.1), and dyslipidemia (β = −4.8) in the urban areas, while it was smoking (β = −8.5), obesity (β= −7.8), and dyslipidemia (β = −5.1) in the rural areas. Furthermore, the average onset ages for the patients who smoke, are obese, and have dyslipidemia simultaneously was significantly earlier than for patients with none of these comorbidities in both urban (13.6 years) and rural (14.9 years) areas. The findings of this study suggest that the different prevention strategies for AMI should be implemented in urban and rural areas.

Effect of body mass index and abdominal obesity on mortality after percutaneous coronary intervention: a nationwide, population-based study

BACKGROUND/AIMS

We investigated the impact of obesity on the clinical outcomes following percutaneous coronary intervention (PCI).

METHODS

We included South Koreans aged > 20 years who underwent the Korean National Health Screening assessment between 2009 and 2012. Obesity was defined using the body mass index (BMI), according to the World Health Organization's recommendations. Abdominal obesity was defined using the waist circumference (WC), as defined by the Korean Society for Obesity. The odds and hazard ratios in all-cause mortality were calculated after adjustment for multiple covariates. Patients were followed up to the end of 2017.

RESULTS

Among 130,490 subjects who underwent PCI, the mean age negatively correlated with BMI. WC, hypertension, diabetes, dyslipidemia, fasting glucose, total cholesterol, low-density lipoprotein cholesterol, and triglyceride levels correlated with the increased BMI. The mortality rates were higher in the lower BMI and WC groups than the higher BMI and WC groups. The non-obese with abdominal obesity group showed a mortality rate of 2.11 per 1,000 person-years. Obese with no abdominal obesity group had the lowest mortality rate (0.88 per 1,000 person-years). The mortality showed U-shaped curve with a cut-off value of 29 in case of BMI and 78 cm of WC.

CONCLUSION

The mortality showed U-shaped curve and the cut-off value of lowest mortality was 29 in case of BMI and 78 cm of WC. The abdominal obesity may be associated with poor prognosis in Korean patients who underwent PCI.

Association of obesity with arterial stiffness: The Multi-Ethnic Study of Atherosclerosis (MESA)

Arterial stiffness (AS) and obesity are recognized as important risk factors of cardiovascular disease (CVD). The purpose of this study was to investigate the relationship between AS and obesity. AS was defined as high augmentation index (AIx) and low elasticity (C1, large artery elasticity; C2, small artery elasticity) in participants enrolled in the Multi-Ethnic Study of Atherosclerosis at baseline. We compared AIx, C1, and C2 by body mass index (BMI) (< 25, 25-29.9, 30-39.9, ⩾ 40 kg/m²) and waist-hip ratio (WHR) (< 0.85, 0.85-0.99, ⩾ 1). The obesity-AS association was tested across 10-year age intervals. Among 6177 participants (62 ± 10 years old, 52% female), a significant inverse relationship was observed between obesity and AS. After adjustments for CVD risk factors, participants with a BMI > 40 kg/m² had 5.4% lower AIx (mean difference [Δ] = -0.82%; 95% CI: -1.10, -0.53), 15.4% higher C1 (Δ = 1.66 mL/mmHg ×10; 95% CI: 1.00, 2.33), and 40.2% higher C2 (Δ = 1.49 mL/mmHg ×100; 95% CI: 1.15, 1.83) compared to those with a BMI < 25 kg/m² (all p for trend < 0.001). Participants with a WHR ⩾ 1 had 5.6% higher C1 (∆ = 0.92 mL/mmHg ×10; 95% CI: 0.47, 1.37) compared to those with a WHR < 0.85. The WHR had a significant interaction with age on AIx and C2, but not with BMI; the inverse relationships of the WHR with AIx and C2 were observed only in participants < 55 years between the normal (WHR < 0.85) and the overweight (0.85 ⩽ WHR < 0.99) groups. Different associations of WHR and BMI with arterial stiffness among older adults should be further investigated.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Body Mass Index and Major Adverse Cardiovascular Events: A Secondary Analysis Based on a Retrospective Cohort Study

Background

The association between body mass index (BMI) and major adverse cardiovascular events (MACE) has not been clarified and is controversial. Therefore, the purpose of present study is to explore the association between BMI and MACE.

Material/Methods

This was a secondary analysis of a retrospective cohort study in which 204 participants who were diagnosed with stable coronary artery disease (CAD) and received elective percutaneous coronary intervention (PCI) were recruited. According to the BMI, patients were divided into 3 categories – underweight (BMI <18.5 kg/m²), normal BMI (18.5 ≤BMI <25 kg/m²), and overweight (BMI ≥25 kg/m²)], and the patients were followed up. The primary endpoint was MACE.

Results

After a median follow-up of 783 days, MACE events had occurred in 18 participants. After controlling for potential confounding factors, no difference was observed in MACE between the underweight group and the normal BMI group (OR=1.73, 95% CI 0.42 to 7.17); but there were significantly fewer MACE in the overweight group than in the normal BMI group (OR=0.17; 95% CI: 0.03 to 0.84). Pearson correlation analysis showed that BMI was positively correlated with hemoglobin (r=0.2102) and albumin (r=0.2780), but negatively correlated with high-density lipoprotein cholesterol (r=−0.2052). The receiver operating characteristic curve (ROC) showed that the best threshold for BMI to predict MACE was 24.23, the area under the curve was 0.729, sensitivity was 0.893, and the specificity was 0.460.

Conclusions

Our study shows that overweight patient with stable CAD have lower risk of MACE after PCI, and the optimal threshold for predicting MACE is 24.23.

Relationship of obesity to adverse events in myocardial infarction patients without primary percutaneous coronary intervention: results from the Occluded Artery Trial (OAT)

Objective: Our goal was to investigate the "obesity paradox" in myocardial infarction populations without primary percutaneous coronary intervention (PPCI).Methods: The Occluded Artery Trial (OAT, Clinicaltrials.gov: NCT00004562) is a randomized, multicenter study to investigate the influence of routine percutaneous coronary intervention (PCI) on the clinical outcomes of myocardial infarction patients without PPCI. We stratified these patients into three groups according to body mass index (BMI): normal, 18.5 kg/m² ≤ BMI < 25 kg/m²; overweight, 25 kg/m² ≤ BMI < 30 kg/m²; obese, BMI ≥ 30 kg/m². The purpose of our study was to investigate the effects of BMI on the primary endpoint (all-cause mortality) and the secondary endpoint (cardiac death, non-cardiac death or New York Heart Association [NYHA] class IV heart failure) in the population enrolled in the OAT.Results: A total of 2153 patients (99.4%) constituted the final study population. We found that obese patients were younger and were more likely to have cardiovascular risk factors compared with other BMI groups. A U-shaped relationship was observed between BMI and all-cause mortality. The adjusted hazard ratios (HRs) were 0.892 (95% CI: 0.658-1.210, p = .460) for normal weight patients and 0.671 (95% CI: 0.508-0.888, p = .013) for overweight patients compared with obese patients. The same pattern was also observed for non-cardiac death. The adjusted HRs were 0.919 (95% CI: 0.601-1.40, p = .663) for normal weight patients and 0.524 (95% CI: 0.346-0.792, p = .004) for overweight patients compared with obese patients. We did not find any statistical differences among BMI categories in terms of cardiac death or NYHA class IV heart failure.Conclusions: A U-shaped relationship was observed between BMI and all-cause mortality or non-cardiac death. Overweight patients have the lowest risk of all-cause mortality, which may be attributed to their having the lowest risk of non-cardiac death of the groups studied.

Current Progress and Future Directions in the Double Burden of Malnutrition among Women in South and Southeast Asian Countries

BACKGROUND

In order to combat the double burden of malnutrition the UN General Assembly has established under its Sustainable Development Goal-2 (SDG2) a set of nutritional targets that member countries need to achieve by 2030, with the goal of eradicating all forms of malnutrition worldwide.

OBJECTIVES

In order to understand progress towards this goal, we reviewed recent trends and forecast future trends to examine the likelihood of South and Southeast Asian countries achieving the SDG2 target by 2030. We also considered how inequalities based on wealth, education, and urban/rural dwelling influence the current and future prevalence of underweight, overweight, and obesity.

METHODS

We used population-representative cross-sectional data from the Demographic and Health Survey, conducted between 1996 and 2016, for 8 South and Southeast Asian countries. We used a Bayesian linear regression model to estimate trends and to forecast the prevalence of underweight, overweight, and obesity by 2030.

RESULTS

The overall pooled prevalence of underweight, overweight, and obesity in the South and Southeast Asian region was 22.9%, 21.3%, and 8.6%, respectively. Regional average annual rate of reduction and average annual rate of increase for the period 1996 to 2016 were 1.3% and 8.4% for underweight and overweight/obesity respectively. We estimate that if current trends continue as projected, the proportion of underweight and overweight/obesity will be 6.6% (95% CI: 3.9%, 11.1%) and 76.6% (95% CI: 64.3%, 85.7%) in 2030, respectively. Specific projections based on the wealth index suggested that by 2030 the prevalence of underweight would be highest among the poorest sector of society, and overweight and obesity highest among the richest sector.

CONCLUSIONS

We found that despite progress in reducing underweight, nearly two-thirds of the South and Southeast Asian population will be overweight or obese by 2030. Our findings suggest that countries in this region will not achieve the 2030 SDG2 target.

The influence of Elixhauser comorbidity index on percutaneous coronary intervention outcomes

BACKGROUND

Clinical outcomes with respect to the evolution of comorbidity burden in national cohorts of patients undergoing PCI have not been reported.

OBJECTIVES

We sought to explore the association between comorbidity burden and periprocedural outcomes in patients treated with PCI in the National Inpatient Sample.

METHODS

6,601,526 PCI procedures were identified between 2004 and 2014 and comorbidities were defined by the Elixhauser classification system (ECS) consisting of 30 comorbidity measures. Endpoints included in-hospital mortality, periprocedural complications, length of stay and cost. Patients were classified based on their ECS in five categories (ECS I < 0, ECS II = 0, ECS III = 1-5, ECS IV = 6-13, and ECS V ≥ 14).

RESULTS

Patients with a score over 13 had a fivefold increase in the odds of mortality (OR: 5.13, 95% CI: 4.76-5.54), major bleeding (OR: 11.46, 95% CI: 10.66-12.33) and doubled the hospitalization costs ($31,452 vs $17.566).

CONCLUSIONS

Our study of over six million PCI procedures demonstrates that patients with the greatest comorbid burden (as defined by an ECS of >13) have a fivefold increase risk of in-hospital mortality, a fourfold increase in in-hospital periprocedural complications and an 11-fold increase in major bleeding events once differences in baseline patient characteristics are adjusted for. In addition, ECS significantly impacts the length of stay and doubles the healthcare costs. Comorbid burden is an important predictor of poor outcomes after PCI and should be considered as part of the decision-making processes in patients undergoing PCI.

Cross-sectional and prospective follow-up study to detect early signs of cardiac dysfunction in obesity: protocol of the CARDIOBESE study

INTRODUCTION

In view of the increasing occurrence of both obesity and heart failure, a growing overlap of these two clinical entities in the near future is expected. Significant advances in our understanding of the pathophysiological consequences of obesity for the cardiovascular system have been made over the past two decades. However, to optimise management and treatment of obesity patients, further research is required to improve early identification of cardiac dysfunction in obesity and to gain insight in the underlying pathophysiology. The CARdiac Dysfunction In OBesity - Early Signs Evaluation (CARDIOBESE) study has been designed to address these issues.

METHODS AND ANALYSIS

CARDIOBESE is a cross-sectional multicentre study of 100 obesity patients scheduled for bariatric surgery (body mass index (BMI) ≥35 kg/m²) without known cardiovascular disease, and 50 age-matched and gender-matched non-obese controls (BMI <30 kg/m²). Echocardiography, blood and urine biomarkers and Holter monitoring will be used to identify parameters that are able to show cardiac dysfunction at a very early stage in obesity patients (primary objective). Furthermore, a prospective follow-up study of obesity patients before and 1 year after bariatric surgery will be done to gain insight in the pathophysiology of obesity causing cardiac dysfunction (secondary objective).

ETHICS AND DISSEMINATION

The study was approved by the Medical Ethics Committee Toetsingscommissie Wetenschappelijk Onderzoek Rotterdam e.o. (TWOR). Inclusion of patients and controls is almost complete. Analyses of the investigations are currently being performed, and dissemination through peer-reviewed publications and conference presentations is expected from the first quarter of 2019. By identifying early markers of cardiac dysfunction in obesity, and by understanding the underlying pathophysiology of the abnormalities of these markers, the CARDIOBESE study may provide guidance for risk stratification, monitoring and treatment strategies for obesity patients.

Does body mass index truly affect mortality and cardiovascular outcomes in patients after coronary revascularization with percutaneous coronary intervention or coronary artery bypass graft? A systematic review and network meta-analysis

BACKGROUND

Obesity, a comorbid medical condition, is usually observed in patients with established coronary artery disease. Paradoxically, patients with a higher body mass index (BMI) usually have better clinical outcomes after coronary revascularization.

METHODS

We searched five online databases through December 2017. We identified studies reporting the rate of all-cause mortality or cardiovascular-related outcomes among patients after coronary revascularization with percutaneous coronary intervention or coronary artery bypass graft based on various BMI categories. Network meta-analysis was performed using Bayesian methods.

RESULTS

Sixty-five records involving 865,774 participants were included in our study. A U-shaped association was observed across BMI categories for all-cause mortality. Using normal weight as the reference, all-cause mortality was increased for (relative risk [RR]: 2.4; 95% credibility interval [CrI]: 2.1-2.7) patients with underweight, whereas it was lowered in patients with overweight, obese, and severely obese. This association remained significant in many subgroups. We also observed that the risk of major adverse cardiovascular events (MACE) was lowest among patients with overweight. Furthermore, patients with underweight were associated with greater risks of myocardial infarction (RR: 1.9; 95% CrI: 1.4-2.5), cardiovascular-related mortality (RR: 2.8; 95% CrI: 1.6-4.7), stroke (RR: 2.0; 95% CrI: 1.3-3.3) and heart failure (RR: 1.7; 95% CrI: 1.1-2.7) compared with normal weight patients; no significant association was observed among individuals with higher BMI.

CONCLUSIONS

The 'obesity paradox' does exist in patients after coronary revascularization, especially for patients with post-percutaneous coronary intervention. All-cause mortality in patients with high BMI is significantly lower compared with patients with normal weight. Furthermore, patients with underweight experience higher rates of cardiovascular outcomes compared with patients with normal weight.