Complex interaction of obesity, intentional weight loss and heart failure: a systematic review and meta-analysis

The interplay between excess weight and hyper-glycemia on NCDs in Italy: results from a cross-sectional study

PURPOSE

To evaluate the prevalence of chronic comorbidities according to BMI classes and assess the interplay between excess body weight and blood glucose abnormalities in increasing the risk of major chronic diseases.

METHODS

The study is based on data from the Health Search/IQVIA Health LPD Longitudinal Patient Database, an Italian general practice registry, with data obtained from electronic clinical records of 800 general practitioners throughout Italy. Data relative to the year 2018 were analyzed. The study population was classified according to BMI (normal weight, overweight, and obesity classes 1, 2 and 3) and glucose metabolism status (normoglycemia-NGT; impaired fasting glucose-IFG; diabetes mellitus-DM). Comorbidities were identified through ICD-9 CM codes.

RESULTS

Data relative to 991,917 adults were analyzed. The prevalence of overweight was 39.4%, while the prevalence of obesity was 11.1% (class 1: 7.9%, class 2: 2.3%, class 3: 0.9%). In the whole population, the prevalence of DM and IFG was 8.9% and 4.2%, respectively. Both overweight and obesity were associated with an increasing prevalence of glucose metabolism alterations and a large array of different chronic conditions, including cardio-cerebrovascular diseases, heart failure, chronic kidney disease, osteoarticular diseases, depression, sleep apnea, and neoplasms of the gastrointestinal tract. Within each BMI class, the presence of IFG, and to a greater extent DM, identified subgroups of individuals with a marked increase in the risk of concomitant chronic conditions.

CONCLUSION

Addressing the double burden of excess weight and hyperglycemia represents an important challenge and a healthcare priority.

Obesity and Weight Loss Strategies for Patients With Heart Failure

Obesity is a common comorbidity among patients with heart failure with reduced ejection fraction (HFrEF) or heart failure with preserved ejection fraction (HFpEF), with the strongest pathophysiologic link of obesity being seen for HFpEF. Lifestyle measures are the cornerstone of weight loss management, but sustainability is a challenge, and there are limited efficacy data in the heart failure (HF) population. Bariatric surgery has moderate efficacy and safety data for patients with preoperative HF or left ventricular dysfunction and has been associated with reductions in HF hospitalizations and medium-term mortality. Antiobesity medications historically carried concerns for cardiovascular adverse effects, but the safety and weight loss efficacy seen in general population trials of glucagon-like peptide 1 (GLP-1) and gastric inhibitory polypeptide/GLP-1 agonists are highly encouraging. Although there are safety concerns regarding GLP-1 agonists in advanced HFrEF, trials of the GLP-1 agonist semaglutide for treatment of obesity have confirmed safety and efficacy in patients with HFpEF.

Clinical Outcomes of Metabolic Surgery on Diuretic Use in Patients With Heart Failure

The beneficial impacts of metabolic surgery (MS) on patients with heart failure (HF) are incompletely characterized. We aimed to describe the cardiac and metabolic effects of MS in patients with HF and hypothesized that patients with HF would experience both improved metabolic and HF profiles using glycemic control and diuretic dependency as surrogate markers. In this single-center, university-affiliated academic study in the United States, a review of 2,342 hospital records of patients who underwent MS (2017 to 2023) identified 63 patients with a medical history of HF. Preoperative characteristics, 30-day outcomes, and up to 2-year biometric and metabolic outcomes, medication usage, and emergency department utilization were collected. At 24 months, mean body mass index change was -16 kg/m2 (p <0.001) that corresponded to a mean percentage total body weight loss of 29% (p <0.001). Weight loss was accompanied by significant reductions in hemoglobin A1c (p <0.001) and a 65% decrease in diuretic use at 24 months after surgery (p <0.001). Similarly, emergency visits for cardiac conditions (p = 0.06) and intravenous diuresis (p = 0.07) trended favorably at 1 year after surgery compared with 1 year before surgery but were not statistically significant. In conclusion, in patients with HF who were carefully selected, MS appears to provide significant reduction in oral diuretic dependency, and metabolic improvements with trends toward lower rates of emergency department utilization.

Obesity and 1-year all-cause survival of adult intensive care patients with heart failure: data from the MIMIC-IV

BACKGROUND

Heart failure is a disease that threatens global public safety. In recent years, the obesity paradox has been studied in cardiovascular disease and other fields. With the progress of aging, metabolic changes and regulation of fat function, it also provides many bridges for the dialogue between disease and molecular metabolism. The purpose of this study is to investigate the effect of obesity on the outcome of adult intensive care patients with heart failure combined with age factors.

METHOD

Data were derived from the fourth-generation Medical Information Marketplace for Intensive Care (MIMIC-IV version2.1) using structured query language on the Navicat (12.0.11) platform. People were divided into two groups based on the body mass index (BMI), one group with BMI ≥ 30 kg/m² and another group with BMI < 30 kg/m². Afterwards, the patients were divided into two subgroups based on their ages. One group included patients aged<60, and the other included patients aged ≥ 60. The extracted information includes demographic characteristics, laboratory findings, comorbidities, scores. Main results included in-hospital mortality, ICU mortality, and 1-year mortality. Secondary outcomes included hospital interval and ICU interval, use of renal replacement therapy, and rates of noninvasive and invasive ventilation support.

RESULT

In this cohort study, 3390 people were in the BMI<30 group, 2301 people were in the BMI ≥ 30 group, 960 people were in the age<60 group, and 4731 people were in the age ≥ 60 group, including 3557 patients after propensity score matching in high age group. Among patients aged ≥ 60, BMI ≥ 30 group vs. BMI<30 group showed significantly lower in-hospital mortality (13% vs. 16%) and one-year mortality (41% vs. 55%), respectively. Neither primary nor secondary outcomes were significantly described in the competition among patients aged under 60. Restricted cubic spline reveals a J-shaped nonlinear association between BMI and clinical endpoints within the entire cohort. Kaplan-Meier curves revealed a survival advantage in BMI ≥ 30 group (p < 0.001). Following age stratification, a beneficial effect of BMI categories on one-year mortality risk was observed in heart failure patients aged ≥ 60 (Univariable HR, 0.71, 95% CI, 0.65-0.78, p < 0.001; Multivariable HR, 0.74, 95% CI, 0.67-0.81, p < 0.001), but not in those under 60 years old.

OUTCOME

In ICU patients with heart failure, obesity offers a survival benefit to those aged ≥ 60. No obesity paradox was observed in patients younger than 60 years old. The obesity paradox applies to patients aged ≥ 60 with heart failure.

Obesity, Challenges, and Weight-Loss Strategies for Patients With Ventricular Assist Devices

For adults with advanced heart failure, class II/III obesity (body mass index ≥35 kg/m2) represents major challenges, and it is even considered a contraindication for heart transplantation (HT) at many centers. This has led to growing interest in preventing and treating obesity to help patients with advanced heart failure become HT candidates. Among all weight-loss strategies, bariatric surgery (BSx) has the greatest weight loss efficacy and has shown value in enabling select patients with left ventricular assist devices (LVADs) and obesity to lose sufficient weight to access HT. Nevertheless, both BSx and antiobesity medications warrant caution in the LVAD population. In this review, the authors describe and interpret the available published reports on the impact of obesity and weight-loss strategies for patients with LVADs from general and HT candidacy standpoints. The authors also provide an overview of the journey of LVAD recipients who undergo BSx and review major aspects of perioperative protocols.

A second chance for a new heart? The role of metabolic and bariatric surgery in patients with end-stage heart failure

BACKGROUND

Obesity is an independent risk factor for heart failure (HF). Substantial weight loss has been shown to reverse obesity-related cardiomyopathy. This study aimed to report our institution's experience with laparoscopic sleeve gastrectomy (LSG) in patients with morbid obesity and end-stage HF.

METHODS

Between 2018 and 2022, 26 patients with end-stage HF were referred for LSG. Of 26 patients, 16 underwent an operation, and 10 did not. After institutional review board approval, a retrospective electronic medical record review was performed to evaluate (i) age, (ii) preoperative weight, (iii) decrease in body mass index (BMI) score, (iv) whether the patient underwent heart transplantation, and (v) mortality. Data analysis was performed using Stata/SE (version 17.0; StataCorp). The Wilcoxon rank-sum test was used to compare continuous variables between the cohorts, and the Pearson chi-square test was used for binary variables with Bonferroni correction applied.

RESULTS

The LSG and non-LSG cohorts had comparable ages (P = .088) and starting BMI score (P = .918), and a proportion of patients had a ventricular assist device (P = .191). Patients who underwent LSG lost significantly more weight than the patients who did not, with an average decrease in BMI score of 8.9 kg/m2 (SD, ±6.13) and 1.1 kg/m2 (SD, ±4.10), respectively (P = .040). Of note, 6 patients (37.5%) who underwent LSG eventually underwent transplantation, compared with 2 patients (20.0%) from the matched cohort (P = .884). Of the 26 patients, there were 6 deaths: 2 (12.5%) in the LSG cohort and 4 (40.0%) in the non-LSG cohort (P = .525).

CONCLUSION

LSG may be safe and effective for weight loss in patients with HF. This operation may provide patients affected by obesity with end-stage HF the lifesaving opportunity to achieve transplant candidacy.

Impact of Body Mass Index on outcomes in hospitalized heart failure patients with reduced versus preserved ejection fraction: a 1,699,494-individual analysis from the United States National Inpatient Sample

BACKGROUND

Obesity's effect on outcomes in heart failure (HF) patients with reduced versus maintained ejection fraction (HFrEF and HFpEF) remains debatable. We evaluated hospital outcomes and healthcare expenditures in these patients based on their Body Mass Index (BMI).

METHODS

Using the USA National Inpatient Sample (NIS) database, patients >18 years admitted with a primary diagnosis of HFrEF or HFpEF between January 1, 2004, and August 31, 2015, were studied. Patients were stratified into the following BMI categories: underweight, normal weight, overweight, obese, and morbidly obese. Adjusted multivariable analyses using Poisson regression models were used to study the association between BMI and hospital outcomes and healthcare costs.

RESULTS

Overall, 1,699,494 patients were included. After full adjustment, obesity (OR=1.84; 95% CI: 1.22-2.76) and morbid obesity (OR=1.81; 95% CI: 1.22-2.70) increased the odds of in-hospital mortality compared with normal weight. When stratified per ejection fraction, underweight patients had higher odds of in-hospital mortality in HFrEF (OR=1.46; 95% CI: 1.06-2.01). Obese and morbidly obese patients had higher odds of in-hospital mortality in both HFrEF and HFpEF. Furthermore, obese and morbidly obese patients had a longer mean adjusted length of stay and higher health care expenses.

CONCLUSIONS

Being underweight is associated with increased risk of in-hospital mortality in HFrEF patients. Obesity and morbid obesity increase the risk of in-hospital mortality and higher healthcare costs in both HFrEF and HFpEF. These findings have clinical significance for HF patients, and further research is needed to investigate the ideal weight for HF patients.

Effects of childhood obesity on heart failure and its associated risk factors in the European population: A Mendelian randomization study

BACKGROUND AND AIMS

Observational studies have shown that obesity considerably affects the cardiovascular system. Thus we conducted this Mendelian randomization (MR) analysis to evaluate the causal effect of childhood obesity on heart failure (HF) and its risk factors.

METHODS AND RESULTS

We obtained genetic instruments from genome-wide association studies (GWAS) that investigated childhood obesity, HF, type 2 diabetes mellitus (T2DM), atrial fibrillation (AF), coronary artery disease (CAD), myocardial infarction (MI), chronic kidney disease (CKD), valvular heart disease, myocarditis, hypertrophic cardiomyopathy, and hyperthyroidism. Inverse variance weighting (IVW), weighted median analysis, MR-Egger, and MR-pleiotropy residual sum and outlier (MR-PRESSO) were employed for MR analyses. In addition, the leave-one-out sensitivity test, MR-PRESSO global test, and Cochran's Q test were used for sensitivity analyses. Genetic evaluations showed that childhood obesity increases the risk of HF (odds ratio [OR] = 1.11, 95%CI: 1.05-1.17, p = 1.26 × 10-4), T2DM (OR = 1.17, 95%CI: 1.12-1.23, p = 8.80 × 10-12), AF (OR = 1.08, 95%CI: 1.05-1.12, p = 2.66 × 10-7), MI (OR = 1.08, 95%CI: 1.04-1.13, p = 3.35 × 10-4), and CAD (OR = 1.08, 95%CI: 1.03-1.13, p = 1.48 × 10-3). We found no association between childhood obesity and CKD, valvular heart disease, myocarditis, hypertrophic cardiomyopathy, or hyperthyroidism. Sensitivity analysis and Bonferroni's correction showed consistent results.

CONCLUSIONS

Our study provides new evidence for the relationship between childhood obesity and HF and its risk factors. The results indicate that individuals with a history of childhood obesity require more clinical attention to prevent the development of HF.

Case report of belt electrode-skeletal muscle electrical stimulation for acute heart failure with severe obesity: a novel therapeutic option for acute phase rehabilitation

Background

Belt electrode skeletal muscle electrical stimulation (B-SES) is an emerging therapy anticipated to yield more favorable outcomes than conventional neuromuscular electrical stimulation (NMES), owing to its larger stimulation area. However, information on its efficacy and safety in patients with heart failure remains limited.

Case presentation

A 43-year-old man with a body mass index of 41 kg/m2 was admitted to our hospital for acute heart failure due to dilated cardiomyopathy. The patient required prolonged catecholamine support owing to poor cardiac function, and heart transplantation was considered. We initiated a mobilization program, but the patient's mobility was highly limited due to severe obesity and symptomatic orthostatic hypotension. B-SES was introduced to accomplish weight loss and early ambulation. We applied an intensive monitoring program for safe use and modulated the intensity of B-SES according to physical function. During the B-SES program, the patient's body weight decreased from 89.6 kg to 78.6 kg. Sequential evaluations of body composition and skeletal muscle ultrasonography revealed improved muscle mass, quality, and physical function. Furthermore, we explored the workload of B-SES using expiratory gas analysis. No adverse events were observed during B-SES.

Discussion

We successfully used B-SES to improve muscle function and morbidity in the treatment of acute heart failure. B-SES could be an option for patients with heart failure who have limited mobility and obesity.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Harmony in Chaos: Deciphering the Influence of Ischemic Cardiomyopathy and Non-Cardiac Comorbidities on Holter ECG Parameters in Chronic Heart Failure Patients: A Pilot Study

Background and Objective: In the landscape of heart failure, non-cardiac comorbidities represent a formidable challenge, imparting adverse prognostic implications. Holter ECG monitoring assumes a supplementary role in delineating myocardial susceptibility and autonomic nervous system dynamics. This study aims to explore the potential correlation between Holter ECG parameters and comorbidities in individuals with ischemic cardiomyopathy experiencing heart failure (HF), with a particular focus on the primary utility of these parameters as prognostic indicators. Materials and Methods: In this prospective inquiry, a cohort of 60 individuals diagnosed with heart failure underwent stratification into subgroups based on the presence of comorbidities, including diabetes, chronic kidney disease, obesity, or hyperuricemia. Upon admission, a thorough evaluation of all participants encompassed echocardiography, laboratory panel analysis, and 24 h Holter monitoring. Results: Significant associations were uncovered between diabetes and unconventional physiological indicators, specifically the Triangular index (p = 0.035) and deceleration capacity (p = 0.002). Pertaining to creatinine clearance, notable correlations surfaced with RMSSD (p = 0.026), PNN50 (p = 0.013), and high-frequency power (p = 0.026). An examination of uric acid levels and distinctive Holter ECG patterns unveiled statistical significance, particularly regarding the deceleration capacity (p = 0.045). Nevertheless, in the evaluation of the Body Mass Index, no statistically significant findings emerged concerning Holter ECG parameters. Conclusions: The identified statistical correlations between non-cardiac comorbidities and patterns elucidated in Holter ECG recordings underscore the heightened diagnostic utility of this investigative modality in the comprehensive evaluation of individuals grappling with HF. Furthermore, we underscore the critical importance of the thorough analysis of Holter ECG recordings, particularly with regard to subtle and emerging parameters that may be overlooked or insufficiently acknowledged.

Associations between long-term averages of metabolic parameters in adulthood and cardiac structure and function in later life

The effects of long-term levels of body mass index (BMI), blood pressure (BP), plasma lipids and fasting blood glucose (FBG) on the cardiac structure and function in later life in general population are to evaluate. We included adult participants without heart failure from Framingham Heart Study. The respective averages over a span of 30-36 years of seven parameters were pooled into linear regression models simultaneously to evaluate their associations with subsequent left atrial internal dimension (LAID), left ventricular mass index (LVMi), internal dimension (LVID), ejection fraction (LVEF), global longitudinal strain (GLS) and mitral inflow velocity to early diastolic mitral annular velocity (E/é). In 1838 participants (56.0% female, mean age 66.1 years), per 1-standard deviation (SD) increment of mean BMI correlated with larger LAID and LVID (β 0.05~0.17, standard error [SE] 0.01 for all), greater LVMi (β [SE], 1.49 [0.46]), worse E/é (β [SE], 0.28 [0.05]). Per 1-SD increment of mean systolic BP correlated with greater LVMi (β [SE], 4.70 [0.69]), LVEF (β [SE], 0.73 [0.24]), E/é (β [SE], 0.52 [0.08]), whereas increase of mean diastolic BP correlated with smaller LVMi (β [SE], -1.61 [0.62]), LVEF (β [SE], -0.46 [0.22]), E/é (β [SE], -0.30 [0.07]). Per 1-SD increment of mean high density lipoprotein cholesterol (HDL-c) correlated with smaller LVID (β [SE], -0.03 [0.01]) and better systolic function (LVEF, β [SE], 0.63 [0.19]; GLS, β [SE], -0.20 [0.10]). The variabilities of BMI, BP and HDL-c also correlated with certain cardiac measurements. In long-term, BMI affected the size and mass of heart chambers, systolic and diastolic BP differently influenced left ventricular mass and function, higher HDL-c linked to better systolic function. Clinical trial registration: URL: https://clinicaltrials.gov . Identifier: NCT00005121.

The Interplay of Comorbidities in Chronic Heart Failure: Challenges and Solutions

BACKGROUND

Chronic heart failure (HF) is frequently associated with various comorbidities. These comorbid conditions, such as anemia, diabetes mellitus, renal insufficiency, and sleep apnea, can significantly impact the prognosis of patients with HF.

OBJECTIVE

This review aims to synthesize current evidence on the prevalence, impact, and management of comorbidities in patients with chronic HF.

METHODS

A comprehensive review was conducted, with a rigorous selection process. Out of an initial pool of 59,030 articles identified across various research modalities, 134 articles were chosen for inclusion. The selection spanned various research methods, from randomized controlled trials to observational studies.

RESULTS

Comorbidities are highly prevalent in patients with HF and contribute to increased hospitalization rates and mortality. Despite advances in therapies for HF with reduced ejection fraction, options for treating HF with preserved ejection fraction remain sparse. Existing treatment protocols often lack standardization, reflecting a limited understanding of the intricate relationships between HF and associated comorbidities.

CONCLUSION

There is a pressing need for a multidisciplinary, tailored approach to manage HF and its intricate comorbidities. This review underscores the importance of ongoing research efforts to devise targeted treatment strategies for HF patients with various comorbid conditions.

Preventing new-onset heart failure: Intervening at stage A

Heart failure (HF) prevention is an urgent public health need with national and global implications. Stage A HF patients do not show HF symptoms or structural heart disease but are at risk of HF development. There are no unique recommendations on detecting Stage A patients. Patients in Stage A are heterogeneous; many patients have different combinations of risk factors and, therefore, have markedly different absolute risks for HF. Comprehensive strategies to prevent HF at Stage A include intensive blood pressure lowering, adequate glycemic and lipid management, and heart-healthy behaviors (adopting Life's Essential 8). First and foremost, it is imperative to improve public awareness of HF risk factors and implement healthy lifestyle choices very early. In addition, recognize the HF risk-enhancing factors, which are nontraditional cardiovascular (CV) risk factors that identify individuals at high risk for HF (genetic susceptibility for HF, atrial fibrillation, chronic kidney disease, chronic liver disease, chronic inflammatory disease, sleep-disordered breathing, adverse pregnancy outcomes, radiation therapy, a history of cardiotoxic chemotherapy exposure, and COVID-19). Early use of biomarkers, imaging markers, and echocardiography (noninvasive measures of subclinical systolic and diastolic dysfunction) may enhance risk prediction among individuals without established CV disease and prevent chemotherapy-induced cardiomyopathy. Efforts are needed to address social determinants of HF risk for primordial HF prevention.Central illustrationPolicies developed by organizations such as the American Heart Association, American College of Cardiology, and the American Diabetes Association to reduce CV disease events must go beyond secondary prevention and encompass primordial and primary prevention.

The Effect of Bariatric Surgery on Patients with Heart Failure: a Systematic Review and Meta-analysis

The current study aims to evaluate the effect of bariatric metabolic surgery (BMS) on the New York Heart Association (NYHA) class and left ventricular ejection fraction (LVEF) in patients with diagnosed heart failure (HF). Fourteen related articles with 217 patients were included in the final analysis. LVEF significantly improved after BMS in patients with HF with a mean difference of 7.78% (CI 95%: 3.72, 11.84, I2 = 83.75, p-value < 0.001). Also, the NYHA class significantly decreased after BMS with a mean difference of - 0.40 (CI 95%: - 0.62, - 0.19, I2: 47.03, p-value < 0.001). A total of 27 patients with obesity and HF were listed for cardiac transplantation after BMS. Of those, 20 patients successfully underwent heart transplantation after BMS.

Effects of weight loss in heart failure patients with overweight and obesity: a systematic review and meta-analysis

AIMS

To perform a systematic review and meta-analysis to evaluate the impact of weight loss (WL) on the prognosis of overweight and obese patients with heart failure (HF).

METHODS AND RESULTS

We reviewed the literature up to 1 February 2023 from PubMed, Web of Science, Embase, Cochrane Library, and Chinese databases for cohort studies, and randomized controlled trials (RCTs). Data from eligible studies were extracted, and statistical analyses were performed using Review Manager 5.3. A total of 19 studies (involving 449 882 patients) were included in the systematic review and meta-analyses. The results showed that WL did not reduce the mortality and rehospitalization rates in overweight and obese HF patients, but could improve the quality of life (P = 0.002), cardiac function (P = 0.0001), and exercise capacity (P = 0.03). The subgroup analysis showed that WL from bariatric surgery (BS) reduced the risk of death (P < 0.00001), WL from medication or exercise was not significantly associated with the risk of death (P = 0.18), and WL was associated with a higher mortality in the subgroup with unspecified WL modality or unintentional WL (P < 0.00001). In addition, it did not reduce the risk of short-term rehospitalization (P = 0.11), but reduced the rehospitalization rates over the long-term (P = 0.03).

CONCLUSION

WL improves the long-term rehospitalization (>3 months), quality of life, cardiac function, and exercise capacity in overweight and obese HF patients. Although overall WL is not proven effective, subgroup analysis shows that BS can reduce mortality.

Emerging Medical Therapies for the Treatment of Obesity in Women with Cardiovascular Diseases

PURPOSE OF REVIEW

In this review, the impact of obesity on cardiovascular disease in women and emerging anti-obesity pharmacologic treatments are discussed.

RECENT FINDINGS

Robust evidence demonstrates the burden of obesity across the lifespan in women and links obesity to a diverse set of cardiovascular diseases. Female-specific risk factors including sex hormones and pregnancy factors intersect with obesity and cardiovascular risk. Sustained weight loss has potential for cardiovascular benefits. Recent trials demonstrate cardiovascular benefits of emerging agents with weight loss effects including GLP-1 RA and SGLT2 inhibitors in women. Treatment and prevention strategies for cardiovascular disease in obese women should include integration of weight management strategies including the targeted use of emerging pharmacologic therapies.

What are the outcomes of dietary interventions in Heart Failure with preserved Ejection Fraction? A systematic review and meta-analysis

AIMS

To determine the efficacy of dietary interventions in Heart Failure with preserved Ejection Fraction (HFpEF).

METHOD AND RESULTS

Keyword searches were performed in five bibliographic databases to identify randomized or controlled studies of dietary interventions conducted in HFpEF or mixed heart failure (HF) samples published in the English language. Studies were appraised for bias and synthesized into seven categories based on the similarity of the intervention or targeted population. The quality of the body of evidence was assessed via the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework. Twenty-five unique interventions were identified; 17 were considered for meta-analysis. Most studies were judged to be at high risk of bias. There was moderate-quality evidence that caloric restriction led to clinically meaningful improvements in blood pressure and body weight. There was moderate-quality evidence that carbohydrate restriction resulted in meaningful reductions in blood pressure. There was very low-quality evidence that protein supplementation improved blood pressure and body weight and moderate-quality evidence for clinically meaningful improvements in function.

CONCLUSIONS

While some types of dietary interventions appeared to deliver clinically meaningful change in critical outcomes; the study heterogeneity and overall quality of the evidence make it difficult to make firm recommendations. Greater transparency when reporting the nutritional composition of interventions would enhance the ability to pool studies.

REGISTRATION

PROSPERO CRD42019145388.

Effect of bariatric surgery on cardio-psycho-metabolic outcomes in severe obesity: A randomized controlled trial

OBJECTIVE

Randomized evidence comparing the cardiovascular effects of surgical and conservative weight management is lacking.

PATIENTS & METHODS

In this single-center, open-label randomized trial, obese patients with indication for Roux-en-Y gastric bypass (RYGB) and able to perform treadmill cardiopulmonary exercise testing (CPET) were included. After a 6-12 month run-in phase of multimodal anti-obesity treatment, patients were randomized to RYGB or psychotherapy-enhanced lifestyle intervention (PELI) and co-primary endpoints were assessed 12 months later. Thereafter, PELI patients could opt for surgery and patients were reassessed 24 months after randomization. Co-primary endpoints were mean change (95 % confidence intervals) in peak VO2 (ml/min/kg body weight) in CPET and the physical functioning scale (PFS) of the Short Form health survey (SF-36).

RESULTS

Of 93 patients entering the study, 60 were randomized. Among these (median age 38 years; 88 % women; mean BMI 48·2 kg/m2), 46 (RYGB: 22 and PELI: 24) were evaluated after 12 months. Total weight loss was 34·3 % after RYGB vs. 1·2 % with PELI, while peak VO2 increased by +4·3 ml/min/kg (2·7, 5·9) vs +1·1 ml/min/kg (-0·2, 2·3); p < 0·0001. Respective improvement in PFS score was +40 (30, 49) vs +10 (1, 15); p < 0·0001. 6-minute walking distance also favored the RYGB group: +44 m (17, 72) vs +6 m (-14, 26); p < 0·0001. Left ventricular mass decreased after RYGB, but not with PELI: -32 g (-46, -17) vs 0 g (-13,13); p < 0·0001. In the non-randomized follow-up, 34 patients were assessed. Favorable changes were sustained in the RYGB group and were repeated in the 15 evaluated patients that opted for surgery after PELI.

CONCLUSIONS

Among adults with severe obesity, RYGB in comparison to PELI resulted in improved cardiopulmonary capacity and quality of life. The observed effect sizes suggest that these changes are clinically relevant.

Body mass index and survival in people with heart failure

AIMS

In people with heart failure (HF), a high body mass index (BMI) has been linked with better outcomes ('obesity paradox'), but there is limited evidence in community populations across long-term follow-up. We aimed to examine the association between BMI and long-term survival in patients with HF in a large primary care cohort.

METHODS

We included patients with incident HF aged ≥45 years from the Clinical Practice Research Datalink (2000-2017). We used Kaplan-Meier curves, Cox regression and penalised spline methods to assess the association of pre-diagnostic BMI, based on WHO classification, with all-cause mortality.

RESULTS

There were 47 531 participants with HF (median age 78.0 years (IQR 70-84), 45.8% female, 79.0% white ethnicity, median BMI 27.1 (IQR 23.9-31.0)) and 25 013 (52.6%) died during follow-up. Compared with healthy weight, people with overweight (HR 0.78, 95% CI 0.75 to 0.81, risk difference (RD) -4.1%), obesity class I (HR 0.76, 95% CI 0.73 to 0.80, RD -4.5%) and class II (HR 0.76, 95% CI 0.71 to 0.81, RD -4.5%) were at decreased risk of death, whereas people with underweight were at increased risk (HR 1.59, 95% CI 1.45 to 1.75, RD 11.2%). In those underweight, this risk was greater among men than women (p value for interaction=0.02). Class III obesity was associated with increased risk of all-cause mortality compared with overweight (HR 1.23, 95% CI 1.17 to 1.29).

CONCLUSION

The U-shaped relationship between BMI and long-term all-cause mortality suggests a personalised approach to identifying optimal weight may be needed for patients with HF in primary care. Underweight people have the poorest prognosis and should be recognised as high-risk.

Body Composition and Risk of Incident Heart Failure in 1 Million Adults: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies

Background The aim of this systematic review was to quantify the associations between body composition measures and risk of incident heart failure (HF) and its subtypes in the general population. Methods and Results We searched Medline, Embase, and Global Health databases from each database inception to January 19, 2023 for prospective studies reporting on body composition and HF risk. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The Newcastle-Ottawa scale was used to assess the risk of bias of included studies. Fixed-effects models were used for meta-analysis. Thirty-five studies were included (ntotal=1 137 044; ncases=34 422). Summary relative risk (RR) per 5-kg/m2 higher body mass index was 1.42 (95% CI, 1.40-1.42; 𝜁2=0.02, I2=94.4%), 1.28 (95% CI, 1.26-1.31; 𝜁2=0.01, I2=75.8%) per 10-cm higher waist circumference, and 1.33 (95% CI, 1.28-1.37; 𝜁2=0.04, I2=94.9%) per 0.1-unit higher waist-hip ratio. Pooled estimates of the few studies that reported on regional fat suggested significant positive association between HF risk and both visceral fat (RR, 1.08 [95% CI, 1.04-1.12]) and pericardial fat (RR, 1.08 [95% CI, 1.06-1.10]). Among HF subtypes, associations were stronger for HF with preserved ejection fraction than HF with reduced ejection fraction. No study reported on lean mass. Conclusions Pooled data suggested strong associations between adiposity and HF. The association with adiposity is stronger for HF with preserved ejection fraction than HF with reduced ejection fraction, indicating that different mechanisms may be at play in etiopathogenesis of HF subtypes. Future studies are needed to investigate role of regional fat mass and lean mass in HF risk. Registration Information REGISTRATION: URL: www.crd.york.ac.uk/prospero/. Unique identifier: CRD42020224584.

Body mass index and clinical outcomes in patients with heart failure with preserved ejection fraction mediated by diastolic blood pressure status?

Background

The "obesity paradox" has been elucidated in patients with heart failure (HF). Current guidelines introduce a target diastolic blood pressure (DBP) < 80 mmHg but >70 mmHg in HF patients. Due to reduced coronary perfusion, low DBP has a deleterious impact on cardiovascular outcomes. This present study aimed to assess the relationship between BMI and adjudicated clinical outcomes in HFpEF patients according to the status of DBP.

Methods

We analyzed the data in 1749 HFpEF patients from the Americas of the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) Trial. The population was stratified by DBP (<70 mmHg, and ≥70 mmHg) and BMI strata (normal weight, overweight, and obesity). Cox proportional hazards models and competing-risks regression analysis were performed.

Results

At baseline, the median BMI and DBP were 32.9 kg/m² (interquartile range 28.0-38.5 kg/m²) and 70 mmHg (interquartile range 62-80 mmHg), respectively. In the multivariable analysis, obesity was associated with better survival rates in the total HFpEF population (all-cause death: HR = 0.439, 95% CI 0.256-0.750; and cardiovascular death: HR = 0.378, 95% CI 0.182-0.787). In patients with DBP<70 mmHg, obesity was not significantly associated with reduced risks for all-cause death (HR = 0.531, 95% CI: 0.263-1.704) and cardiovascular death (HR = 0.680, 95% CI: 0.254-1.819). However, multivariate analyses for cardiovascular death (HR = 0.339, 95% CI: 0.117-0.983) and all-cause death (HR = 0.389, 95% CI: 0.156-0.969) were significant in patients with DBP≥70 mmHg. Nevertheless, there were no interactions between DBP and BMI.

Conclusions

The obesity paradox was observed in patients with HFpEF, regardless of DBP strata (<70 mmHg, and ≥70 mmHg).

Functional outcomes after Medial Patellofemoral Ligament Reconstruction show inverted J-shaped relation with Body Mass Index

PURPOSE

Medial patellofemoral ligament reconstruction (MPFL-R) is a recognised surgical procedure for the treatment of recurrent patellofemoral instability with excellent outcomes reported. The aim of this study is to determine if body mass index can influence these outcomes.

METHODS

This is a single-centre retrospective analysis of a longitudinal patellofemoral database. Patients with recurrent patellar instability, without patellar alta or severe trochlear dysplasia were treated using a MPFL-R between 2015 and 2019 at The Robert Jones & Agnes Hunt Orthopaedic Hospital. The clinical efficacy following surgery was assessed by Kujula, International Knee Documentation Committee Score (IKDC), and EuroQol-5 score (EQ-5D) at baseline and up to 26 months post-operatively; their safety assessed by complication rate and requirement for further surgery. The effect of Body Mass Index (BMI) on clinical outcome was analysed using linear, curvilinear, and segmented models following propensity score weighting.

RESULTS

A total of 97 patients (97 Knees, mean age 25y) were analysed. Of these, 61 patients had a BMI < 30 kg/m² (mean age 23y, mean BMI 24) of which 7 patients (12.3%) required additional surgery. A further 36 patients had a BMI > 30 kg/m² (mean age 27y, mean BMI 36) of which 2 patients (5.6%) required additional surgery. The re-dislocation rate was 0% in each BMI group. Both groups had a significantly improved mean outcome following surgery, with improvements in mean IKDC above the minimum clinical important differences (MCID) of 20.5. BMI had an inverted J-shaped association with functional outcome, showing peak outcomes at BMI of 20.5 (95% CI 18.5 to 22.4; IKDC and Kujala) or BMI of 28 (EQ-5D index). No evidence for an association between BMI and complication risk was found.

CONCLUSION

BMI influences the functional outcomes in MPFL-R with an inverted J-shaped relation, without evidence it affected the complication or re-dislocation rate. In the absence of patella alta and severe trochlear dysplasia, an isolated MPFL reconstruction is a safe and effective procedure to treat patellar instability, with the best functional outcome in patients with a BMI around 20 to 21.

LEVEL OF EVIDENCE

Level III.

Association between body mass index and long-term clinical outcomes in patients with non-valvular atrial fibrillation taking oral anticoagulants

BACKGROUND AND AIMS

The association between body mass index (BMI) and clinical outcomes of patients with non-valvular atrial fibrillation (NVAF) taking oral anticoagulants (OACs) are controversial, and we thus analyzed the large registry data to elucidate them.

METHODS AND RESULTS

We conducted a historical cohort study at 71 centers in Japan and included outpatients with NVAF taking vitamin K antagonists (VKAs). Physicians in charge could change VKAs to direct OACs based on their judgement during follow-up period. We categorized patients into four BMI groups (kg/m²): underweight (BMI < 18.5), normal weight (18.5 ≤ BMI < 25), overweight (25 ≤ BMI < 30), and obese (30 ≤ BMI). The effects of each BMI group relative to the normal weight group on clinical outcomes consisting of all-cause death, ischemic events, and bleeding events were estimated using Cox proportional hazard models adjusting for potential confounders. We also constructed restricted cubic spline regression model adjusted by multivariable Cox proportional hazard models. We included 6927 patients consisting of an underweight (n = 386), normal weight (n = 3785), overweight (n = 2174), and obese (n = 582) groups. The median follow-up period was 3.9 years. In the underweight group, the adjusted hazard ratios (HRs) for all-cause death and ischemic events were 1.75 (1.30-2.34) and 1.61 (1.04-2.50). The HR for all-cause death was 0.63 (0.49-0.82) in the overweight group. Restricted cubic spline regression models confirmed that lower BMI showed significantly higher risks for all-cause death and ischemic events.

CONCLUSION

Among NVAF patients taking OACs, underweight patients had higher risks of all-cause death and ischemic events than other patients. Overweight patients had lower risk of all-cause death.

Ranking of cardiovascular risk factors in Romania- regional epidemiological approach

An extensive epidemiological investigation was applied regarding the risk factors, to a cohort of patients with pre-existing heart disease, hospitalized for tertiary prophylaxis in a rehabilitation hospital. The group of 499 patients from all regions of the country respected the proportions of gender and environment of origin for the general population of Romania and was adjusted according to regional proportions. The ranking of risk factors and protection factors present in the studied population was made, at the level of each of the 8 regions of the country and for the whole country consolidated. The profile of the cardiovascular patient was identified. We used risk factors for population characterization, not for aggregation into tools for assessing total cardiovascular risk (as is the trend in large cohort studies since Framingham) The data processing was done to be able to develop prevention strategies in the interest of the specific individual, not to standardize population characteristics and translate them to the individual thus decreasing their appropriateness. Keywords: 1 cardiovascular risk-factors, 2 cardiovascular diseases prevention , 3 cardiovascular rehabilitation.

Consequences of Obesity on Short-Term Outcomes in Patients Who Underwent Off-Pump Coronary Artery Bypass Grafting Surgery

The correlation between off-pump coronary artery bypass (OPCAB) surgery and obesity-related outcomes is still uncertain. The aim of our study was to analyse the pre-, intra-, and postoperative short-term outcomes between obese and non-obese patients after off-pump bypass surgery. We performed a retrospective analysis from January 2017 until November 2022, including a total of 332 (non-obese (n = 193) and obese (n = 139)) patients who underwent an OPCAB procedure due to coronary artery disease (CAD). The primary outcome was all-cause in-hospital mortality. Our results showed no difference regarding mean age of the study population between both groups. The use of the T-graft technique was significantly higher (p = 0.045) in the non-obese group compared to the obese group. The dialysis rate was significantly lower in non-obese patients (p = 0.019). In contrast, the wound infection rate was significantly higher (p = 0.014) in the non-obese group compared to the obese group. The all-cause in-hospital mortality rate did not differ significantly (p = 0.651) between the two groups. Furthermore, ST-elevation myocardial infarction (STEMI) and reoperation were relevant predictors for in-hospital mortality. Therefore, OPCAB surgery remains a safe procedure even in obese patients.

Heart failure treatment in patients with and without obesity with an ejection fraction below 50

BACKGROUND

The aim of this study was to assess heart failure (HF) treatment in patients with and without obesity in a large contemporary real-world Western European cohort.

METHODS

Patients with a left ventricular ejection fraction (LVEF) <50% and available information on body mass index (BMI) were selected from the CHECK-HF registry. The CHECK-HF registry included chronic HF patients in the period between 2013 and 2016 in 34 Dutch outpatient clinics. Patients were divided into BMI categories. Differences in HF medical treatment were analysed, and multivariable logistic regression analysis (dichotomized as BMI <30 kg/m² and ≥30 kg/m² ) was performed.

RESULTS

Seven thousand six hundred seventy-one patients were included, 1284 (16.7%) had a BMI ≥30 kg/m² , and 618 (8.1%) had a BMI ≥35 kg/m² . Median BMI was 26.4 kg/m² . Patients with obesity were younger and had a higher rate of comorbidities such as diabetes mellitus, hypertension and obstructive sleep apnoea (OSAS). Prescription rates of guideline-directed medical therapy (GDMT) increased significantly with BMI. The differences were most pronounced for mineralocorticoid receptor antagonists (MRAs) and diuretics. Patients with obesity more often received the guideline-recommended target dose. In multivariable logistic regression, obesity was significantly associated with a higher likelihood of receiving ≥100% of the guideline-recommended target dose of beta-blockers (OR 1.34, 95% CI 1.10-1.62), renin-angiotensin system (RAS)-inhibitors (OR 1.34, 95% CI 1.15-1.57) and MRAs (OR 1.40, 95% CI 1.04-1.87).

CONCLUSIONS

Guideline-recommended HF drugs are more frequently prescribed and at a higher dose in patients with obesity as compared to HF patients without obesity.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Obesity increases heart failure incidence and mortality: observational and Mendelian randomization studies totalling over 1 million individuals

AIMS

Whether high body mass index (BMI) causally influences development and prognosis of heart failure has implications for clinical practice. We tested the hypotheses that high BMI causally influences heart failure incidence and mortality.

METHODS AND RESULTS

Using observational and Mendelian randomization causal, genetic analyses, we studied 106 121 individuals from the Copenhagen General Population Study, 18 407 from the Copenhagen City Heart Study, and 977 323 from publicly available databases. In observational analyses in the Copenhagen studies with 10 years of median follow-up, multivariable adjusted hazard ratios per 1 kg/m2 increment of BMI were 1.06 (95% confidence interval: 1.05-1.07; P < 0.001; n = 124 528; events = 6589) for heart failure incidence, 1.04 (1.03-1.06; P < 0.001; n = 124 528; events = 1237) for heart failure mortality, and 1.01 (1.00-1.01; P < 0.001; n = 124 528; events = 24 144) for all-cause mortality. In genetic analyses in the Copenhagen studies, the age and sex adjusted causal risk ratios per 1 kg/m2 increment of BMI were 1.19 (1.05-1.36; P = 0.008; n = 118 200; events = 6541) for heart failure incidence, 1.27 (0.82-1.98; P = 0.28; n = 118 200; events = 889) for heart failure mortality, and 1.11 (1.02-1.22; P = 0.022; n = 118 200; events = 16 814) for all-cause mortality. Finally, combining genetic data from the Copenhagen studies, the Genetic Investigation of ANthropometric Traits, the Heart Failure Molecular Epidemiology for Therapeutic Targets, and the UK Biobank, the unadjusted causal risk ratios per 1 kg/m2 increment of BMI were 1.39 (1.27-1.52; P < 0.001; n = 1 095 523; events = 53 850) for heart failure incidence, 1.18 (1.00-1.38; P = 0.05; n = 576 853; events = 2373) for heart failure mortality, and 1.02 (1.00-1.04; P = 0.03; n = 576 853; events = 44 734) for all-cause mortality.

CONCLUSION

High BMI causally increases the risk of both heart failure incidence and mortality.

Cardiometabolic-based chronic disease: adiposity and dysglycemia drivers of heart failure

Heart failure (HF) is a complex clinical syndrome, associated with high rates of mortality, hospitalization, and impairment of quality of life. Obesity and type 2 diabetes are major cardiometabolic drivers, represented as distinct stages of adiposity- and dysglycemia-based chronic disease (ABCD, DBCD), respectively, and leading to cardiometabolic-based chronic disease (CMBCD). This review focuses on one aspect of the CMBCD model: how ABCD and DBCD influence genesis and progression of HF phenotypes. Specifically, the relationships of ABCD and DBCD stages with structural and functional heart disease, HF risk, and outcomes in overt HF are detailed. Also, evidence-based lifestyle, pharmacological, and procedural interventions that promote or reverse cardiac remodeling and outcomes in individuals at risk or with HF are discussed. In summary, driver-based chronic disease models for individuals at risk or with HF can expose prevention targets for more comprehensive interventions to improve clinical outcomes. Future randomized trials that investigate structured lifestyle, pharmacological, and procedural therapies specifically tailored for the CMBCD model are needed to develop personalized care plans to decrease HF susceptibility and improve outcomes.

Obesity Paradox among Heart Failure with Reduced Ejection Fraction Patients: A Retrospective Cohort Study

Background and Objectives: There is consensus on the negative effects of obesity on the development of heart failure. However, several studies have suggested that obesity may have paradoxical survival benefits in heart failure patients. Therefore, the aim of this study is to investigate whether the obesity paradox exists in heart failure with reduced ejection fraction (HFrEF) patients in Jordan. Materials and Methods: In this retrospective cohort study, data were retrieved from electronic hospital records of heart failure patients admitted to King Abdullah University Hospital between January 2010 and January 2020. Patients were divided into five BMI (kg/m2) subgroups: (1) Less than 25.0, (2) Overweight 25.0−29.9, (3) Obese Class I 30.0−34.9, (4) Obese Class II 35.0−39.9, and (5) Obese Class III ≥40.0. Changes in patients’ clinical and echocardiographic parameters over one year were analyzed. Results: Data of a total of 297 patients were analyzed to determine the effect of obesity on heart failure. The mean age was 64.6 ± 12.4 years, and most patients (65.7%) were male. Among several co-morbidities, diabetes mellitus and hypertension were the most common and were present in 81.8% and 81.1% of patients, respectively. Over all patients, there was no significant change in EF after 1 year compared to baseline. However, only patients in the Obese Class I group had a statistically significant improvement in EF of 38.0 ± 9.81% vs. 34.8 ± 6.35% (p = 0.004) after 1 year. Importantly, among non-diabetic individuals, only Obese Class I patients had a significant (p < 0.001) increase in EF after 1 year compared to other BMI subgroups, a feature that was not observed among patients with diabetes. On the other hand, only Obese Class I patients with hypertension had a significant improvement (p < 0.05) in EF after 1 year compared to other BMI subgroups, a feature that was not observed among patients without hypertension. Conclusions: Our study demonstrates an inverted U-shaped relationship between BMI and EF such that patients with mild obesity (i.e., Obese Class I) had significant improvement in EF compared to those having a lower and higher BMI. We, therefore, suggest the existence of the obesity paradox among HFrEF patients in Jordan.

Impact of Obesity on Early In-Hospital Outcomes after Coronary Artery Bypass Grafting Surgery in Acute Coronary Syndrome: A Propensity Score Matching Analysis

Recent advances in perioperative care have considerably improved outcomes after coronary artery bypass graft (CABG) surgery. However, obesity can increase postoperative complication rates and can lead to increased morbidity and mortality. Between June 2011 and October 2019, a total of 1375 patients with acute coronary syndrome (ACS) underwent cardiac surgery and were retrospectively analyzed. Patients were divided into 2 groups: non-obese (body mass index (BMI) < 30 kg/m2, n = 967) and obese (BMI ≥ 30 kg/m2, n = 379). Underweight patients (n = 29) were excluded from the analysis. To compare the unequal patient groups, a propensity score-based matching (PSM) was applied (non-obese group (n = 372) vs. obese group (n = 372)). The mean age of the mentioned groups was 67 ± 10 (non-obese group) vs. 66 ± 10 (obese group) years, p = 0.724. All-cause in-hospital mortality did not significantly differ between the groups before PSM (p = 0.566) and after PSM (p = 0.780). The median length of ICU (p = 0.306 before PSM and p = 0.538 after PSM) and hospital stay (p = 0.795 before PSM and p = 0.131 after PSM) was not significantly higher in the obese group compared with the non-obese group. No significant differences regarding further postoperative parameters were observed between the unadjusted and the adjusted group. Obesity does not predict increased all-cause in-hospital mortality in patients undergoing CABG procedure. Therefore, CABG is a safe procedure for overweight patients.

Effect of Weight Loss on Early Left Atrial Myopathy in People With Obesity But No Established Cardiovascular Disease

Background Obesity is associated with left atrial (LA) remodeling (ie, dilatation and dysfunction) which is an independent determinant of future cardiovascular events. We aimed to assess whether LA remodeling is present in obesity even in individuals without established cardiovascular disease and whether it can be improved by intentional weight loss. Methods and Results Forty-five individuals with severe obesity without established cardiovascular disease (age, 45±11 years; body mass index; 39.1±6.7 kg/m²; excess body weight, 51±18 kg) underwent cardiac magnetic resonance for quantification of LA and left ventricular size and function before and at a median of 373 days following either a low glycemic index diet (n=28) or bariatric surgery (n=17). Results were compared with those obtained in 27 normal-weight controls with similar age and sex. At baseline, individuals with obesity displayed reduced LA reservoir function (a marker of atrial distensibility), and a higher mass and LA maximum volume (all P<0.05 controls) but normal LA emptying fraction. On average, weight loss led to a significant reduction of LA maximum volume and left ventricular mass (both P<0.01); however, significant improvement of the LA reservoir function was only observed in those at the upper tertile of weight loss (≥47% excess body weight loss). Following weight loss, we found an average residual increase in left ventricular mass compared with controls but no residual significant differences in LA maximum volume and strain function (all P>0.05). Conclusions Obesity is linked to subtle LA myopathy in the absence of overt cardiovascular disease. Only larger volumes of weight loss can completely reverse the LA myopathic phenotype.

Intermittent fasting and exercise therapy abates STZ-induced diabetotoxicity in rats through modulation of adipocytokines hormone, oxidative glucose metabolic, and glycolytic pathway

Diabetes is a global, costly, and growing public health issue. Intermittent fasting (IF) and exercise therapy have been shown to improve insulin sensitivity (IS) in large studies, although the underlying processes are still unknown. The goal of this study, which included both nondiabetic and diabetic rats, was to look at the mechanisms of intermittent fasting and exercise in the management of diabetotoxicity. The effects of starvation and honey on the oral glucose tolerance test, insulin tolerance test, adipocytokines, oxidative glucose metabolic enzymes, glycolytic enzymes, food intake, and body weight in rats with streptozotocin‐induced diabetes were also investigated. In the nondiabetic phase, rats were administered an oral regimen of distilled water (0.5 ml/rat), honey (1 g/kg body weight), and interventions with IF, and starvation for 4 weeks while in the diabetic phase, after STZ or citrate buffer injections, interventions with IF, exercise, starvation, and honey treatment began for 4 weeks. At all OGTT and ITT points, there was a substantial rise in glucose in the STZ group. Adipocytokines hormone, oxidative glucose metabolic enzymes, glycolytic enzymes, and body weight were all affected by STZ when compared to starvation and honey, however, IF and exercise significantly reduced these alterations. In diabetic rats, intermittent fasting and exercise enhanced serum adipocytokines levels. These findings imply that adipokines modulate glycolytic/nonmitochondrial enzymes and glucose metabolic/mitochondrial dehydrogenase to mediate the antidiabetic effects of intermittent fasting and exercise.

Intermittent fasting and exercise therapy abates STZ‐induced diabetotoxicity in rats through modulation of adipocytokines hormone, oxidative glucose metabolic, and glycolytic pathway.

The Nrf2 in Obesity: A Friend or Foe?

Obesity and its complications have become serious global health concerns recently and increasing work has been carried out to explicate the underlying mechanism of the disease development. The recognized correlations suggest oxidative stress and inflammation in expanding adipose tissue with excessive fat accumulation play important roles in the pathogenesis of obesity, as well as its associated metabolic syndromes. In adipose tissue, obesity-mediated insulin resistance strongly correlates with increased oxidative stress and inflammation. Nuclear factor erythroid 2-related factor 2 (Nrf2) has been described as a key modulator of antioxidant signaling, which regulates the transcription of various genes coding antioxidant enzymes and cytoprotective proteins. Furthermore, an increasing number of studies have demonstrated that Nrf2 is a pivotal target of obesity and its related metabolic disorders. However, its effects are controversial and even contradictory. This review aims to clarify the complicated interplay among Nrf2, oxidative stress, lipid metabolism, insulin signaling and chronic inflammation in obesity. Elucidating the implications of Nrf2 modulation on obesity would provide novel insights for potential therapeutic approaches in obesity and its comorbidities.

Initiation of Anti-Hypertensive Drugs and Outcomes in Patients with Heart Failure with Reduced Ejection Fraction

BACKGROUND

In patients with heart failure with reduced ejection fraction (HFrEF) and hypertension, systolic blood pressure is recommended to be maintained below 130 mmHg, although this has not been shown to be associated with improved outcomes. We examined the association between anti-hypertensive drug initiation and outcomes in patients with HFrEF.

METHODS

In the Medicare-linked OPTIMIZE-HF, 7966 patients with HFrEF (ejection fraction ≤40%) without renal failure were not receiving anti-hypertensive drugs before hospitalization, of whom 692 received discharge prescriptions for those drugs (thiazides and calcium channel blockers). We assembled a propensity score-matched cohort of 687 pairs of patients initiated and not initiated on anti-hypertensive drugs, balanced on 38 baseline characteristics. Hazard ratios (HR) and 95% confidence intervals (CIs) for outcomes associated with anti-hypertensive drug initiation were estimated in the matched cohort.

RESULTS

Matched patients (n = 1374) had a mean age of 74 years, 41% were female, 17% were African-American, 66% were discharged on renin-angiotensin system inhibitors and beta blockers, and 10% on aldosterone antagonists. During 6 (median 2.5) years of follow-up, 70% of the patients died and 53% had heart failure readmission. Anti-hypertensive drug initiation was not significantly associated with all-cause mortality (HR, 0.95; 95% CI, 0.83-1.07) or heart failure readmission (HR, 0.93; 95% CI, 0.80-1.07). Similar associations were observed during 30 days and 12 months of follow-up.

CONCLUSIONS

Among hospitalized older patients with HFrEF receiving contemporary treatments for heart failure, initiation of an anti-hypertensive drug was not associated with a lower risk of all-cause mortality or hospital readmission.

Impact of weight loss with diet or diet plus physical activity on cardiac magnetic resonance imaging and cardiovascular disease risk factors: Heart Health Study randomized trial

OBJECTIVE

The primary aim of this study was to examine the change in left ventricular mass (LVM) in adults with overweight or obesity in response to a behavioral weight-loss intervention, with variable physical activity (PA) prescriptions.

METHODS

A total of 383 adults were randomized to a 12-month intervention of diet modification (DIET), DIET plus 150 min/wk of PA (DIET+MODPA), or DIET plus prescription of 250 min/wk of PA (DIET+HIGHPA). LVM was measured with cardiac magnetic resonance imaging.

RESULTS

Twelve-month weight loss was -10.2% (95% CI: -11.7% to -8.8%) in the DIET group, -11.0% (95% CI: -12.4% to -9.5%) in the DIET+MODPA group, and -10.3% (95% CI: -11.8% to -8.9%) in the DIET+HIGHPA group. LVM decreased at 12 months in the DIET group (-2.9 g [95% CI: -5.2 to -0.7]; p = 0.0114), with no change observed in the DIET+MODPA group (-0.8 g [95% CI: -3.0 to 1.5]; p = 0.4979) or the DIET+HIGHPA group (-1.1 g [95% CI: -3.3 to 1.1]; p = 0.3299).

CONCLUSIONS

Weight loss through dietary modification resulted in reduced LVM, whereas, when combined with at least 150 min/wk of prescribed moderate-to-vigorous PA, LVM was preserved. These may both be favorable adaptations to weight loss and PA in adults with overweight or obesity that warrant further investigation to understand the clinical implications of these changes on cardiovascular disease risk.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

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Impact Of Obesity On Cardiac Structural And Functional Changes

The urgency of obesity issue is undeniable. Obesity is now considered the most important risk factor of cardiovascular diseases. Numerous studies have demonstrated the negative effect of excessive adipose tissue on structural and functional changes in the heart that lead to development of left ventricular hypertrophy, arrhythmias and conduction abnormalities, as well as progression of diastolic and systolic heart failure. High prevalence of obesity – so high that it can be called a pandemic – greatly contributes to the increased incidence of cardiovascular diseases. Studying the problem of obesity is a priority area of focus for modern medicine. This article describes hormonal, metabolic and hemodynamic features of obesity impact on cardiovascular system and describes pathogenetic mechanisms of cardiovascular pathology development.

Effects of weight loss after bariatric surgery on atrial electromechanical delay in obese subjects

Background: The authors investigated the relationship between weight loss after sleeve gastrectomy and change in atrial electromechanical delay values. Methods: A total of 41 patients were included. The primary end point was any effect of total weight loss on atrial electromechanical delay parameters. Results: The mean loss of body weight was 25.50 ± 11.07 kg. There was a significant correlation between mean body weight change and change in interatrial and left intra-atrial electromechanical delays (Pearson's correlation coefficient: 0.575 and 0.871, respectively; p < 0.001). Only change in body weight was significantly related to change in interatrial electromechanical delay (regression coefficient: 0.707; p < 0.01). Conclusion: In this study, a significant relationship was found between amount of body weight loss and decrease in atrial electromechanical values.

Cardio-psycho-metabolic outcomes of bariatric surgery: design and baseline of the WAS trial

Obesity is a rapidly emerging health problem and an established risk factor for cardiovascular diseases. Bariatric surgery profoundly reduces body weight and mitigates sequelae of obesity. The open, randomized controlled Würzburg Adipositas Studie (WAS) trial compares the effects of Roux-en-Y gastric bypass (RYGB) vs psychotherapy-supported lifestyle modification in morbidly obese patients. The co-primary endpoint addresses 1-year changes in cardiovascular function (peak VO2 during cardiopulmonary exercise testing) and the quality of life (QoL) (Short-Form-36 physical functioning scale). Prior to randomization, all included patients underwent a multimodal anti-obesity treatment for 6-12 months. Thereafter, the patients were randomized and followed through month 12 to collect the primary endpoints. Afterwards, patients in the lifestyle group could opt for surgery, and final visit was scheduled for all patients 24 months after randomization. Sample size calculation suggested to enroll 90 patients in order to arrive at minimally 22 patients per group evaluable for the primary endpoint. Secondary objectives were to quantify changes in body weight, left ventricular hypertrophy, systolic and diastolic function (by echocardiography and cardiac MRI), functional brain MRI, psychometric scales, and endothelial and metabolic function. WAS enrolled 93 patients (72 women, median age 38 years, BMI 47.5 kg/m2) exhibiting a relevantly compromised exercise capacity (median peakVO2 18.3 mL/min/kg) and the QoL (median physical functioning scale 50). WAS is the first randomized controlled trial focusing on the effects of RYGB on cardiovascular function beyond hypertension. In addition, it will provide a wealth of high-quality data on the cerebral, psychiatric, hepatic, and metabolic function in obese patients after RYGB.

Role of confirmed and potential predictors of an unfavorable outcome in heart failure in everyday clinical practice

Heart failure (HF) is the only cardiovascular disease with an ever increasing incidence. HF, through reduced functional capacity, frequent exacerbations of disease, and repeated hospitalizations, results in poorer quality of life, decreased work productivity, and significantly increased costs of the public health system. The main challenge in the treatment of HF is the availability of reliable prognostic models that would allow patients and doctors to develop realistic expectations about the prognosis and to choose the appropriate therapy and monitoring method. At this moment, there is a lack of universal parameters or scales on the basis of which we could easily capture the moment of deterioration of HF patients' condition. Hence, it is crucial to identify such factors which at the same time will be widely available, cheap, and easy to use. We can find many studies showing different predictors of unfavorable outcome in HF patients: thorough assessment with echocardiography imaging, exercise testing (e.g., 6-min walk test, cardiopulmonary exercise testing), and biomarkers (e.g., N-terminal pro-brain type natriuretic peptide, high-sensitivity troponin T, galectin-3, high-sensitivity C-reactive protein). Some of them are very promising, but more research is needed to create a specific panel on the basis of which we will be able to assess HF patients. At this moment despite identification of many markers of adverse outcomes, clinical decision-making in HF is still predominantly based on a few basic parameters, such as the presence of HF symptoms (NYHA class), left ventricular ejection fraction, and QRS complex duration and morphology.

A Dose Response Association Between Body Mass Index and Mortality in Patients with Peripheral Artery Disease: A Meta-analysis Including 5 729 272 Individuals

OBJECTIVE

Obesity is a significant risk factor for atherosclerotic cardiovascular disease; however, the "obesity paradox", in which obese patients enjoy superior survival, has been observed in various cardiovascular conditions. Whether this phenomenon exists for peripheral artery disease (PAD) remains uncertain. The goal of this study was to evaluate the relationship between body mass index (BMI) and mortality in patients with PAD.

METHODS

A comprehensive literature search identified seven eligible cohort studies that reported the association between BMI and all cause mortality in patients with PAD. A dose response meta-analysis was done for all cause mortality, short term (30 day or in hospital) mortality and long term mortality. The dose response association between BMI and mortality was also assessed in patients who received endovascular therapy (EVT).

RESULTS

The non-linear dose response analysis showed that higher BMI values were associated with a lower mortality risk from the range between 15 kg/m² to approximately 33 - 34 kg/m². The risk of mortality increased slightly thereafter. This relationship was consistent with that of long term mortality but was not apparent in short term mortality. A U shaped relationship was also observed between BMI and mortality in patients who received EVT with the lowest mortality observed at around 30 kg/m².

CONCLUSION

The obesity paradox was evident in the analysis of long term survival among patients with PAD, with the lowest mortality rates observed in obese patients. However, this association was not observed for short term or in hospital mortality.

Prevalence of Obesity and Overweight among Adults in the Middle East Countries from 2000 to 2020: A Systematic Review and Meta-Analysis

BACKGROUND

Obesity has become a significant public health issue worldwide, and it is a major risk factor for many noncommunicable diseases. This systematic review aimed to identify the prevalence of obesity and overweight in the Middle East region and different countries in this region.

MATERIALS AND METHODS

PubMed, Google Scholar, and MEDLINE databases were searched from 2000-2020 to identify relevant studies in the Middle East area. The survey was carried out using combinations of Medical Subject Headings (Mesh) keywords like "body mass index", "obesity", "overweight", "prevalence", "Middle-East", and "Countries in the Middle East area". Analysis of the data was done using STATA-14, and a random-effects model was used to estimate the pooled prevalence.

RESULTS

A total of 101 studies with 698905 participants have been identified that met inclusion criteria for this meta-analysis. The pooled estimates of the prevalence of obesity and overweight in the Middle East area were 21.17 (95% CI: 17.05-26.29) and 33.14 (95% CI: 26.87-40.87), respectively. The findings showed that obesity prevalence increased with age so that the highest prevalence of obesity and overweight was observed in people >40 years old. Obesity prevalence in the Middle East area remained steady between 2000-2006 and 2014-2020 (23%). During these time intervals, the prevalence of overweight decreased from 34.83 (95% CI: 32.40-37.45) to 32.85 (95% CI: 31.39-34.38).

CONCLUSIONS

Despite the relative stabilization of the overweight and obesity trend in the Middle East, current interventions to combat the overweight epidemic need to be maintained and strengthened because the prevalence of overweight and obesity in this region is still very high. The prevalence of obesity increases with age so that people over 40 have the highest percentage of obesity and overweight. Therefore, implementing intervention programs to prevent and control obesity and overweight in the Middle East is essential.

Parallel improvement of systolic function with surgical weight loss in patients with heart failure and reduced ejection fraction: a systematic review and patient-level meta-analysis

BACKGROUND

Morbid obesity (MO) is an increasingly common condition in patients with heart failure with reduced ejection fraction (HFrEF). Although substantial weight loss in morbidly obese patients has proved to slow the progression of heart failure, parallel alteration of ejection fraction (EF) and New York Heart Association (NYHA) functional class along with post-bariatric surgery weight loss is yet to be determined.

OBJECTIVES

This systematic review aimed to measure the effect of bariatric weight loss on EF and NYHA functional class in patients with HFrEF.

METHODS

A systematic literature review was performed in Medline/PubMed to identify studies in patients with MO and pre-existing HFrEF, who underwent bariatric surgery.

RESULTS

A total of 11 studies encompassing 136 patients with HFrEF undergoing bariatric surgery for MO were included. Six studies provided patient-level data on 37 cases. Patients lost an average body mass index (BMI) of 12.9 ± 4.2 kg/m² (5.1 to 23 kg/m²) after an average follow up of 22.43 ± 18.6 months (2-89 mo). There was a direct correlation between BMI loss and EF improvement (r = 0.61, P < .0001), but not between BMI loss and NYHA functional class changes (r = 0.17, P = .4).

CONCLUSION

Weight loss induced by bariatric surgery results in parallel EF increase in patients with MO and HFrEF. However, current data does not indicate a parallel improvement of clinical symptoms (NYHA functional class) along with such an increase in EF in this population of patients.

Dietary Management of Heart Failure: DASH Diet and Precision Nutrition Perspectives

Heart failure (HF) is a major health care burden increasing in prevalence over time. Effective, evidence-based interventions for HF prevention and management are needed to improve patient longevity, symptom control, and quality of life. Dietary Approaches to Stop Hypertension (DASH) diet interventions can have a positive impact for HF patients. However, the absence of a consensus for comprehensive dietary guidelines and for pragmatic evidence limits the ability of health care providers to implement clinical recommendations. The refinement of medical nutrition therapy through precision nutrition approaches has the potential to reduce the burden of HF, improve clinical care, and meet the needs of diverse patients. The aim of this review is to summarize current evidence related to HF dietary recommendations including DASH diet nutritional interventions and to develop initial recommendations for DASH diet implementation in outpatient HF management. Articles involving human studies were obtained using the following search terms: Dietary Approaches to Stop Hypertension (DASH diet), diet pattern, diet, metabolism, and heart failure. Only full-text articles written in English were included in this review. As DASH nutritional interventions have been proposed, limitations of these studies are the small sample size and non-randomization of interventions, leading to less reliable evidence. Randomized controlled interventions are needed to offer definitive evidence related to the use of the DASH diet in HF management.