Body mass index and vigorous physical activity and the risk of heart failure among men

High Throughput Plasma Proteomics and Risk of Heart Failure and Frailty in Late Life

Importance

Heart failure (HF) and frailty frequently coexist and may share a common pathobiology, although the underlying mechanisms remain unclear. Understanding these mechanisms may provide guidance for preventing and treating both conditions.

Objective

To identify shared pathways between incident HF and frailty in late life using large-scale proteomics.

Design, Setting, and Participants

In this cohort study, 4877 aptamers (Somascan v4) were measured among participants in the community-based longitudinal Atherosclerosis Risk In Communities (ARIC) cohort study at visit 3 (V3; 1993-1995; n = 10 638) and at visit 5 (V5; 2011-2013; n = 3908). Analyses were externally replicated among 3189 participants in the Cardiovascular Health Study (CHS). Data analysis was conducted from February 2022 to June 2023.

Exposures

Protein aptamers, measured at study V3 and V5.

Main Outcomes and Measures

Outcomes assessed included incident HF hospitalization after V3 and after V5, prevalent frailty at V5, and incident frailty between V5 and visit 6 (V6; 2016-2017; n = 4131). Frailty was assessed using the Fried criteria. Analyses were adjusted for age, gender, race, field center, hypertension, diabetes, smoking status, body mass index, estimated glomerular filtration rate, prevalent coronary heart disease, prevalent atrial fibrillation, and history of myocardial infarction. Mendelian randomization (MR) analysis was performed to assess potential causal effects of candidate proteins on HF and frailty.

Results

A total of 4877 protein aptamers were measured among 10 638 participants at V3 (mean [SD] age, 60 [6] years; 4886 [46%] men). Overall, 286 proteins were associated with incident HF after V3 (822 events; P < 1.0 × 10-5), 83 of which were also associated with incident after V5 (336 events; P < 1.7 × 10-4). Among HF-free participants at V5 (n = 3908; mean [SD] age, 75 [5] years; 1861 [42%] men), 48 of 83 HF-associated proteins were associated with prevalent frailty (223 cases; P < 6.0 × 10-4), 18 of which were also associated with incident frailty at V6 (152 cases; P < 1.0 × 10-3). These proteins enriched fibrosis and inflammation pathways and demonstrated stronger associations with incident HF with preserved ejection fraction (HFpEF) than HF with reduced ejection fraction. All 18 proteins were associated with both prevalent frailty and incident HF in CHS. MR identified potential causal effects of several proteins on frailty and HF.

Conclusions and Relevance

In this study, the proteins associated with risk of HF and frailty enrich for pathways related to inflammation and fibrosis as well as risk of HFpEF. Several of these proteins could potentially contribute to the shared pathophysiology of frailty and HF.

Association between oxidative balance score and heart failure in the older adults: Results from the NHANES 2005-2018

BACKGROUND

Heart failure (HF) imposes a substantial burden on older adults, and healthy diets and lifestyles may bring with benefits. However, quantifiable studies on the dietary and lifestyle risk factors for HF are scant. The Oxidative Balance Score (OBS) reflects the oxidative stress status of dietary components and lifestyle factors, but its relationship with HF risk is unclear.

OBJECTIVE

We aims to explore the association between OBS and the prevalence of HF.

METHODS

Using data from the National Health and Nutrition Examination Survey (NHANES) 2005-2018, the association between OBS and the HF prevalence was analyzed by weighted logistic regression and restricted cubic splines (RCS). Subgroup and sensitivity analyses assessed the stability of the results.

RESULTS

The prevalence of HF in the cohort of 6238 older adults was 5.55 %. Compared to the lowest quintile, the adjusted ORs for HF in the highest quintile of OBS and lifestyle OBS were 0.57 (95 % CI: 0.33,0.97) and 0.21 (95 %CI: 0.09,0.50), respectively. The association between OBS and HF prevalence remained stable across different models and subgroups. RCS revealed a potential inflection point. Sensitivity analysis validated the negative association between OBS and HF prevalence, and the correlation analysis between OBS and serum γ-glutamyltransferase (γ-GGT) confirmed the reliability of the study design.

CONCLUSION

The OBS is negatively associated with HF prevalence in older adults, and may help prevent HF in this population.

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.

Association between obesity and new-onset heart failure among patients with hypertension in Thailand

BACKGROUND

In Thailand, the epidemiological data on the relationship between obesity and heart failure (HF) among high-risk populations was limited. We assessed the association between body mass index (BMI) and the new-onset HF among people with hypertension (HTN), and also assessed the effect modifier of uncontrolled HTN on this association.

METHODS

We analyzed the data obtained from the 2018 Thailand DM/HT study database. Thai people with HTN aged 20 years and older receiving continuous care at outpatient clinics in hospitals nationwide were included. The new-onset HF was defined regarding the ICD-10 as I50 in the medical records within 12 months. Obesity was defined as BMI ≥ 25 kg/m2. Multivariable log-binomial regression analysis was used to determine the association between BMI and new-onset HF and presented as the adjusted risk ratio (aRR) and 95% confidence interval (CI).

RESULTS

A total of 35,756 participants were included in the analysis. In all, 50.0% of the participants had BP control for the last two consecutive visits. The mean BMI was 25.1 ± 4.7 kg/m2. New-onset HF occurred in 75 participants (0.21%; 95% CI 0.17-0.26). After adjusting for potential confounders, an elevated BMI was associated with new-onset HF (p value for quadratic trend < 0.001). In comparison with participants with normal BMI (18.5-22.9 kg/m2), the aRR for new-onset HF was 1.57 (95% CI 0.80-3.07) and 3.97 (95% CI 1.95-8.10) in those with BMI 25.0-29.9, and ≥ 30.0 kg/m2. For participants with obesity, aRR for new-onset HF was 2.05 (95% CI 1.24-3.39) compared to non-obese participants. The study found that among patients with control BP, obesity was associated with a higher risk of new-onset HF with an adjusted RR of 2.33 (95% CI 1.12-4.83). For those with uncontrolled BP, the adjusted RR was 1.83 (95% CI 0.93-3.58), but there was no heterogeneity with p value = 0.642.

CONCLUSION

An increased BMI had a higher risk for new-onset HF among Thai people with HTN. Obesity was independently associated with new-onset HF among people with HTN, regardless of uncontrolled HTN. Our findings highlight that weight reduction is crucial for mitigating the risk of HF development in HTN patients, regardless of their BP control status.

The mediation and interaction of the obesity index between moderate-vigorous recreational physical activity and hypertension

Previous studies showed that physical activity (PA) is concerned with hypertension (HTN). However, the mediation and interaction role of the obesity index: body mass index (BMI), waist-hip ratio (WHR), body fat rate (BFR) and visceral fat index (VFI) between PA and HTN has never been studied. Therefore, the purpose of this study was to assess the mediation and interaction of the obesity index between moderate-vigorous recreational physical activity (MVRPA) and HTN. We conducted a cross-sectional study of 4710 individuals aged 41 or older in Torch Development Zone, Zhongshan City. The mediation and interaction of the obesity index were evaluated by a four-way decomposition. 48.07% of participants had HTN among these groups. In the adjusted linear regression model, MVRPA was significantly correlated with WHR (β±SE = -0.005±0.002; P<0.05). Compared to sufficient MVRPA (odds ratio (OR) = 1.35), 95% (confidence interval (CI) = 1.17-1.56), insufficient MVRPA increased the risk of developing HTN. Furthermore, there were associations between BMI, WHR, BFR, VFI and HTN where the adjusted ORs and 95% CIs were 1.11 (1.09-1.13), 6.23 (2.61-14.90), 1.04 (1.03-1.06), 1.07 (1.06-1.09), respectively. The mediation analyses suggested that the impact of MVRPA on HTN risk may partly be explained by changes in obesity index, with a pure indirect mediation of WHR between MVRPA and HTN (P<0.05). Therefore, weight control, especially reducing abdominal obesity and maintaining adequate MVRPA, may lead to more proper control of HTN.

Exploring the Mechanistic Link Between Obesity and Heart Failure

PURPOSE OF REVIEW

Among subtypes of cardiovascular disease, obesity has a potent and unique association with heart failure (HF) that is unexplained by traditional cardiovascular risk mediators. The concomitant rise in the prevalence of obesity and HF necessitates better understanding of their relationship to develop effective prevention and treatment strategies. The purpose of this review is to provide mechanistic insight regarding the link between obesity and HF by elucidating the direct and indirect pathways linking the two conditions.

RECENT FINDINGS

Several direct pathophysiologic mechanisms contribute to HF risk in individuals with excess weight, including hemodynamic alterations, neurohormonal activation, hormonal effects of dysfunctional adipose tissue, ectopic fat deposition with resulting lipotoxicity and microvascular dysfunction. Obesity further predisposes to HF indirectly through causal associations with hypertension, dyslipidemia, and most importantly, diabetes via insulin resistance. Low levels of physical activity and fitness further influence HF risk in the context of obesity. These various processes lead to myocardial injury and cardiac remodeling that are reflected by abnormalities in cardiac biomarkers and cardiac function on myocardial imaging. Understanding and addressing obesity-associated HF is a pressing clinical and public health challenge which can be informed by a deeper understanding of the complex pathways linking these two conditions together.

Non-occupational physical activity and risk of cardiovascular disease, cancer and mortality outcomes: a dose-response meta-analysis of large prospective studies

OBJECTIVE

To estimate the dose-response associations between non-occupational physical activity and several chronic disease and mortality outcomes in the general adult population.

DESIGN

Systematic review and cohort-level dose-response meta-analysis.

DATA SOURCES

PubMed, Scopus, Web of Science and reference lists of published studies.

ELIGIBILITY CRITERIA

Prospective cohort studies with (1) general population samples >10 000 adults, (2) ≥3 physical activity categories, and (3) risk measures and CIs for all-cause mortality or incident total cardiovascular disease, coronary heart disease, stroke, heart failure, total cancer and site-specific cancers (head and neck, myeloid leukaemia, myeloma, gastric cardia, lung, liver, endometrium, colon, breast, bladder, rectum, oesophagus, prostate, kidney).

RESULTS

196 articles were included, covering 94 cohorts with >30 million participants. The evidence base was largest for all-cause mortality (50 separate results; 163 415 543 person-years, 811 616 events), and incidence of cardiovascular disease (37 results; 28 884 209 person-years, 74 757 events) and cancer (31 results; 35 500 867 person-years, 185 870 events). In general, higher activity levels were associated with lower risk of all outcomes. Differences in risk were greater between 0 and 8.75 marginal metabolic equivalent of task-hours per week (mMET-hours/week) (equivalent to the recommended 150 min/week of moderate-to-vigorous aerobic physical activity), with smaller marginal differences in risk above this level to 17.5 mMET-hours/week, beyond which additional differences were small and uncertain. Associations were stronger for all-cause (relative risk (RR) at 8.75 mMET-hours/week: 0.69, 95% CI 0.65 to 0.73) and cardiovascular disease (RR at 8.75 mMET-hours/week: 0.71, 95% CI 0.66 to 0.77) mortality than for cancer mortality (RR at 8.75 mMET-hours/week: 0.85, 95% CI 0.81 to 0.89). If all insufficiently active individuals had achieved 8.75 mMET-hours/week, 15.7% (95% CI 13.1 to 18.2) of all premature deaths would have been averted.

CONCLUSIONS

Inverse non-linear dose-response associations suggest substantial protection against a range of chronic disease outcomes from small increases in non-occupational physical activity in inactive adults. PROSPERO registration number CRD42018095481.

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.

Association between visceral adiposity index and heart failure: A cross-sectional study

BACKGROUND

Obesity is an important risk factor for heart failure (HF).

HYPOTHESIS

Visceral adiposity index (VAI) is a simple metric for assessing obesity; however, the association between VAI and risk for HF has not been studied.

METHODS

A cross-sectional study involving 28 764 participants ≥18 years of age from the National Health and Nutrition Examination Survey (NHANES), 2009-2018, in the United States was performed. VAI was calculated using body mass index (BMI), waist circumference (WC), triglycerides (TG), and high-density lipoprotein cholesterol. VAI was analyzed as a continuous and categorical variable to examine its association with HF. Subgroup analysis was also performed.

RESULTS

The highest VAI (fourth quartile [Q4]) was found among males, BMI, systolic and diastolic blood pressure, WC, hypertension, diabetes, liver disease, coronary heart disease, smoking, total cholesterol, and TG. More participants in Q4 took β-receptor blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers/angiotensin receptor-neprilysin inhibitor, calcium channel blockers, and antidiabetic and antihyperlipidemic medications. Participants with HF exhibited greater VAI. A per-unit increase in VAI resulted in a 4% increased risk for HF (odds ratio [OR] 1.04 [95% confidence interval (CI) 1.02-1.05]). After multivariable adjustment, compared with the lowest quartile, the OR for Q3 was 1.55 (95% CI 1.24-1.94). Subgroup analysis revealed no significant interactions between VAI and specific subgroups.

CONCLUSION

VAI was independently associated with the risk for HF. As a noninvasive index of visceral adiposity, VAI could be used for a "one shot" assessment of HF risk and may serve as a novel marker.

Association between weight-adjusted-waist index and heart failure: Results from National Health and Nutrition Examination Survey 1999-2018

Background

Weight-adjusted waist circumference index (WWI) is a novel index positively associated with excessive fat accumulation. The current study aims to evaluate the association between WWI and the prevalent heart failure (HF), and to assess the value of WWI to improve the detection of HF in the general population.

Methods

A total of 25,509 subjects from National Health and Nutrition Examination Survey 1999-2018 were included into our study. WWI was calculated as WC (cm) divided by the square root of weight (kg). HF was identified according to the subjects' reports.

Results

The prevalence of reported HF was 2.96%. With adjustment of demographic, anthropometric, laboratory, and medical history data, one SD increment of WWI could cast an additional 19.5% risk for prevalent HF. After separating WWI into quartiles, the fourth quartile had a 1.670 times risk of prevalent HF compared to the first quartile. Furthermore, smooth curve fitting suggested that the association was linear in the entire range of WWI. Moreover, the association was robust to subgroups of age, sex, race, obesity, hypertension, and diabetes. Additionally, ROC analysis revealed a significant improvement for the detection of prevalent HF from WWI (0.890 vs. 0.894, P < 0.001); And continuous net reclassification index (0.225, P < 0.001) and integrated discrimination index (0.004, P < 0.001) also supported the improvement from WWI.

Conclusion

Our data demonstrated a significant, linear, and robust association between WWI, a simple surrogate for fat mass accumulation, and the risk for prevalent HF in a representative population. Moreover, our results also suggested the potential value of WWI to refine the detection of prevalent HF in the general population.

Physical Activity and Risk of Major Diabetes-Related Complications in Individuals With Diabetes: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Physical activity is a cornerstone in diabetes management; however, evidence synthesis on the association between physical activity and long-term diabetes-related complications is scarce.

PURPOSE

To summarize and evaluate findings on physical activity and diabetes-related complications, we conducted a systematic review and meta-analysis.

DATA SOURCES

We searched PubMed, Web of Science, and the Cochrane Library for articles published up to 6 July 2021.

STUDY SELECTION

We included prospective studies investigating the association between physical activity and incidence of and mortality from diabetes-related complications, i.e., cardiovascular disease (CVD), coronary heart disease, cerebrovascular events, heart failure, major adverse cardiovascular events, and microvascular complications such as retinopathy and nephropathy, in individuals with diabetes.

DATA EXTRACTION

Study characteristics and risk ratios with 95% CIs were extracted. Random-effects meta-analyses were performed, and the certainty of evidence and risk of bias were evaluated with use of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) and Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tools.

DATA SYNTHESIS

Overall, 31 studies were included. There was moderate certainty of evidence that high versus low levels of physical activity were inversely associated with CVD incidence, CVD mortality (summary risk ratio 0.84 [95% CI 0.77, 0.92], n = 7, and 0.62 [0.55, 0.69], n = 11), and microvascular complications (0.76 [0.67, 0.86], n = 8). Dose-response meta-analyses showed that physical activity was associated with lower risk of diabetes-related complications even at lower levels. For other outcomes, similar associations were observed but certainty of evidence was low or very low.

LIMITATIONS

Limitations include residual confounding and misclassification of exposure.

CONCLUSIONS

Physical activity, even below recommended amounts, was associated with reduced incidence of diabetes-related complications.

Causal association between heart failure and bone mineral density: Insights from a two-sample bidirectional Mendelian randomization study

In recent times, the association between HF and BMD has attracted enormous interest in the scientific community. However, published epidemiological observational studies on the relationship between HF and BMD remain inconclusive. Herein, we evaluated from the analytical perspective a two-sample bidirectional MR study to analyze the causal association between HF and BMD using a summary-level GWAS Catalog. To select instrumental SNPs strongly associated with exposure, we took a series of rigorous quality control steps at the time of analysis. The causal MR assessment of HF on the risk of BMD was performed first and then in the opposite direction. To make the conclusions more reliable and robust, the fixed-effects IVW, weighted median-based method, MR-Egger, simple mode and weighted mode were utilized. A maximum likelihood model was also used if necessary. MR-Egger regression, IVW "leave-one-out" sensitivity analysis, MR-PRESSO, MR-Egger intercept test and Cochran's Q statistic methods were used to assess heterogeneity and pleiotropy. Our MR studies supported a meaningful causal association between HF and TB-BMD (IVW: OR = 0.78, 95% CI: 0.68-0.87, p = 0.00588). At the same time, we did not find a significant causal relationship between HF and FA-BMD, FN-BMD or LS-BMD. No significant causal relationships between BMD and HF were observed. This bidirectional MR analysis suggested a causal association of HF with only low TB-BMD, while the reverse causality hypothesis was not found. Studies of the prevention and treatment of total bone mineral density decline in patients with heart failure need to be performed.

Exercise, Physical Activity, and Cardiometabolic Health: Insights into the Prevention and Treatment of Cardiometabolic Diseases

Physical activity (PA) and exercise are widely recognized as essential components of primary and secondary cardiovascular disease (CVD) prevention efforts and are emphasized in the health promotion guidelines of numerous professional societies and committees. The protean benefits of PA and exercise extend across the spectrum of CVD, and include the improvement and reduction of risk factors and events for atherosclerotic CVD (ASCVD), cardiometabolic disease, heart failure, and atrial fibrillation (AF), respectively. Here, we highlight recent insights into the salutary effects of PA and exercise on the primary and secondary prevention of ASCVD, including their beneficial effects on both traditional and nontraditional risk mediators; exercise "prescriptions" for ASCVD; the role of PA regular exercise in the prevention and treatment of heart failure; and the relationships between, PA, exercise, and AF. While our understanding of the relationship between exercise and CVD has evolved considerably, several key questions remain including the association between extreme volumes of exercise and subclinical ASCVD and its risk; high-intensity exercise and resistance (strength) training as complementary modalities to continuous aerobic exercise; and dose- and intensity-dependent associations between exercise and AF. Recent advances in molecular profiling technologies (ie, genomics, transcriptomics, proteomics, and metabolomics) have begun to shed light on interindividual variation in cardiometabolic responses to PA and exercise and may provide new opportunities for clinical prediction in addition to mechanistic insights.

The Obesity Paradox in Chronic Heart Disease and Chronic Obstructive Pulmonary Disease

Obesity in recent years has become an epidemic. A high body mass index (BMI) is one of today's most crucial population health indicators. BMI does not directly quantify body fat but correlates well with easier body fat measurements. Like smoking, obesity impacts multiple organ systems and is a major modifiable risk factor for countless diseases. Despite this, reports have emerged that obesity positively impacts the prognosis of patients with chronic illnesses such as chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD), a phenomenon known as the Obesity Paradox. This article attempts to explain and summarize this phenomenon.

As it stands, two theories explain this paradox. The muscle mass hypothesis states that obese patients are better adapted to tide through acute exacerbations due to increased reserve because of greater muscle mass. The other theory focuses on brown adipose tissue and its anti-inflammatory effects on the body.

We performed a literature review on research articles published in English from 1983 to the present in the following databases - PubMed, Elsevier, and Google Scholar. The following search strings and Medical Subject Headings (MeSH) terms were used: "Obesity," "Heart Failure," "COPD," and "Cardio-Respiratory Fitness." In this review, we looked at the obesity paradox in Heart Failure and COPD. We summarized the current literature on the Obesity Paradox and reviewed its relationship with Cardio-Respiratory Fitness.

Risk factor control among heart failure patients in the United States: Results from the NHANES 1999-2018

Background

Compliance with recommended pharmacological and non-pharmacological treatments to modify risk factors is associated with improved outcomes for patients with heart failure (HF).

Methods

We conducted an analysis of the National Health and Nutrition Examination Survey (NHANES) years 1999-2018 to evaluate the adequacy of risk factor control and compliance with recommended lifestyle and medications according to the clinical guidelines for the management of HF. Demographic, clinical, and healthcare-access factors associated with having risk factors uncontrolled or not receiving recommended medications were determined using logistic regression analyses.

Results

We collected 1906 participants aged 18 years or older with a self-reported history of HF. The majority were at target goals for blood pressure (45.07%), low-density lipoprotein cholesterol (22.04%), and glycated hemoglobin (72.15%), whereas only 19.09% and 27.38% were at targets for body mass index and waist circumference respectively. Besides, 79.49% and 67.23% of respondents reported smoking cessation and recommended alcohol consumption, whereas only 11.54% reported adequate physical activity. Proportion of taking beta blockers, angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) and diuretics was 54.77%, 52.62% and 49.37%, respectively. Finally, the logistic regression analysis showed that metabolic syndrome and diabetes mellitus were associated with a higher likelihood of having risk factor uncontrolled, while metabolic syndrome, diabetes mellitus, and chronic kidney disease were predictors for not receiving recommended medications.

Conclusions

Risk factor control and adherence to recommended lifestyle and medications are non-ideal among HF patients in the USA. A systematic approach for risk factor optimization in people with HF is urgently needed.

Relationship of normal-weight central obesity with the risk for heart failure and atrial fibrillation: analysis of a nationwide health check-up and claims database

Aims

There have been scarce data on the relationship of normal-weight central obesity (NWCO) with the subsequent risk for heart failure (HF) and atrial fibrillation (AF). Using a nationwide health check-up and administrative claims database, we sought to clarify whether NWCO would be associated with the incidence of HF and AF.

Methods and results

Medical records of 1 697 903 participants without prior history of cardiovascular disease (CVD) and normal-weight (body mass index of 18.5–23.0 kg/m²) were extracted from the JMDC Claims Database, which is a health check-up and claims database. We defined NWCO as normal-weight and CO (waist circumference ≥ 90 cm for men or ≥ 80 cm for women). The median age was 44.0 (37.0–52.0) years and 872 578 (51.4%) participants were men. Overall, 154 778 individuals (9.1%) had CO. The mean follow-up period was 3.3 ± 2.6 years. Participants with NWCO were older and more likely to be women than those without. HF and AF occurred in 26 936 (1.6%) and 6554 (0.4%) participants, respectively. People having NWCO were associated with a greater risk for HF [hazard ratio (HR): 1.072, 95% confidence interval (CI) 1.026–1.119] and AF (HR: 1.202, 95% CI: 1.083–1.333) compared with those having normal-weight without CO.

Conclusion

Our analysis of a nationwide health check-up and administrative claims database including ∼1.7 million participants without prevalent CVD history demonstrated the potential impact of NWCO on the risk for HF and AF, suggesting the importance of abdominal obesity in the developing HF and AF even in normal-weight individuals.

MCC950, a Selective NLRP3 Inhibitor, Attenuates Adverse Cardiac Remodeling Following Heart Failure Through Improving the Cardiometabolic Dysfunction in Obese Mice

Obesity is often accompanied by hypertension. Although a large number of studies have confirmed that NLRP3 inhibitors can improve cardiac remodeling in mice with a normal diet, it is still unclear whether NLRP3 inhibitors can improve heart failure (HF) induced by pressure overload in obese mice. The purpose of this study was to explore the role of MCC950, a selective NLRP3 inhibitor, on HF in obese mice and its metabolic mechanism. Obese mice induced with a 10-week high-fat diet (HFD) were used in this study. After 4 weeks of HFD, transverse aortic constriction (TAC) surgery was performed to induce a HF model. MCC950 (10 mg/kg, once/day) was injected intraperitoneally from 2 weeks after TAC and continued for 4 weeks. After echocardiography examination, we harvested left ventricle tissues and performed molecular experiments. The results suggest that in obese mice, MCC950 can significantly improve cardiac hypertrophy and fibrosis caused by pressure overload. MCC950 ameliorated cardiac inflammation after TAC surgery and promoted M2 macrophage infiltration in the cardiac tissue. MCC950 not only restored fatty acid uptake and utilization by regulating the expression of CD36 and CPT1β but also reduced glucose uptake and oxidation via regulating the expression of GLUT4 and p-PDH. In addition, MCC950 affected the phosphorylation of AKT and AMPK in obese mice with HF. In summary, MCC950 can alleviate HF induced by pressure overload in obese mice via improving cardiac metabolism, providing a basis for the clinical application of NLRP3 inhibitors in obese patients with HF.

Diabetes Status Modifies the Association Between Different Measures of Obesity and Heart Failure Risk Among Older Adults: A Pooled Analysis of Community-Based NHLBI Cohorts

BACKGROUND

Obesity and diabetes are associated with a higher risk of heart failure (HF). The interrelationships between different measures of adiposity-overall obesity, central obesity, fat mass (FM)-and diabetes status for HF risk are not well-established.

METHODS

Participant-level data from the ARIC study (Atherosclerosis Risk in Communities; visit 5) and the CHS (Cardiovascular Health Study; visit 1) cohorts were obtained from the National Heart, Lung, and Blood Institute Biologic Specimen and Data Repository Information Coordinating Center, harmonized, and pooled for the present analysis, excluding individuals with prevalent HF. FM was estimated in all participants using established anthropometric prediction equations additionally validated using the bioelectrical impedance-based FM in the ARIC subgroup. Incident HF events on follow-up were captured across both cohorts using similar adjudication methods. Multivariable-adjusted Fine-Gray models were created to evaluate the associations of body mass index (BMI), waist circumference (WC), and FM with risk of HF in the overall cohort as well as among those with versus without diabetes at baseline. The population attributable risk of overall obesity (BMI≥30 kg/m²), abdominal obesity (WC>88 and 102 cm in women and men, respectively), and high FM (above sex-specific median) for incident HF was evaluated among participants with and without diabetes.

RESULTS

The study included 10 387 participants (52.9% ARIC; 25.1% diabetes; median age, 74 years). The correlation between predicted and bioelectrical impedance-based FM was high (R²=0.90; n=5038). During a 5-year follow-up, 447 participants developed HF (4.3%). Higher levels of each adiposity measure were significantly associated with higher HF risk (hazard ratio [95% CI] per 1 SD higher BMI=1.15 [1.05, 1.27], WC=1.22 [1.10, 1.36]; FM=1.13 [1.02, 1.25]). A significant interaction was noted between diabetes status and measures of BMI (P interaction=0.04) and WC (P interaction=0.004) for the risk of HF. In stratified analysis, higher measures of each adiposity parameter were significantly associated with higher HF risk in individuals with diabetes (hazard ratio [95% CI] per 1 SD higher BMI=1.29 [1.14-1.47]; WC=1.48 [1.29-1.70]; FM=1.25 [1.09-1.43]) but not those without diabetes, including participants with prediabetes and euglycemia. The population attributable risk percentage of overall obesity, abdominal obesity, and high FM for incident HF was higher among participants with diabetes (12.8%, 29.9%, and 13.7%, respectively) versus those without diabetes (≤1% for each).

CONCLUSIONS

Higher BMI, WC, and FM are strongly associated with greater risk of HF among older adults, particularly among those with prevalent diabetes.

MicroRNAs in Obesity-Associated Disorders: The Role of Exercise Training

Obesity is a worldwide epidemic affecting over 13% of the adult population and is defined by an excess of body fat that predisposes comorbidities. It is considered a multifactorial disease in which environmental and genetic factors interact, and it is a risk marker for cardiovascular disease. Lifestyle modifications remain the mainstay of treatment for obesity based on adequate diet and physical exercise. In addition, obesity is related to cardiovascular and skeletal muscle disorders, such as cardiac hypertrophy, microvascular rarefaction, and skeletal muscle atrophy. The discovery of obesity-involved molecular pathways is an important step to improve both the prevention and management of this disease. MicroRNAs (miRNAs) are a class of gene regulators which bind most commonly, but not exclusively, to the 3'-untranslated regions of messenger RNAs of protein-coding genes and negatively regulate their expression. Considerable effort has been made to identify miRNAs and target genes that predispose to obesity. Besides their intracellular function, recent studies have demonstrated that miRNAs can be exported or released by cells and circulate within the blood in a remarkably stable form. The discovery of circulating miRNAs opens up intriguing possibilities for the use of circulating miRNA patterns as biomarkers for obesity and cardiovascular diseases. The aim of this review is to provide an overview of the recent discoveries of the role played by miRNAs in the obese phenotype and associated comorbidities. Furthermore, we will discuss the role of exercise training on regulating miRNAs, indicating the mechanisms related to these alterations.

Causal effect of central obesity on left ventricular structure and function in preserved EF population: A Mendelian randomization study

Background

Observational studies have shown that central obesity is associated with adverse cardiac structure and function. However, causal association between central obesity and left ventricular (LV) structure and function in preserved ejection fraction (EF) population is still uncertain.

Methods

Genome-wide association studies summary data of waist circumference adjusted for body mass index (WCadjBMI) and waist-to-hip ratio adjusted for body mass index (WHRadjBMI) were selected as instrumental variables from the Genetic Investigation of Anthropometric Traits (GIANT) Consortium (n = 224,459). Outcome datasets for LV parameters including LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), LV ejection fraction (LVEF), LV mass (LVM), and LV mass-to-end-diastolic volume ratio (LVMVR) were obtained from the participants without prevalent myocardial infarction or heart failure (LVEF ≥ 50%) in UK Biobank Cardiovascular Magnetic Resonance sub-study (n = 16,923). Two-sample Mendelian randomization (MR) was performed with the inverse-variance weighted (IVW) method as the primary estimate and with the weighted median and MR-Egger as the supplemental estimates. Sensitivity analysis was used to assess the heterogeneity and pleiotropic bias in the MR results.

Results

In the IVW analysis, every 1-standard deviation (SD) higher WHRadjBMI was significantly associated with higher LVMVR (β = 0.4583; 95% confidence interval [CI]: 0.2921 to 0.6244; P = 6.418 × 10^-8) and lower LVEDV (β = -0.2395; 95% CI: -0.3984 to -0.0807; P = 0.0031) after Bonferroni adjustment. No heterogeneity and horizontal pleiotropy were detected in the analysis. No association of WCadjBMI was found with LVEF, LVEDV, LVESV, LVM, or LVMVR.

Conclusion

Our findings provide evidence of significant causal association between WHRadjBMI and adverse changes in LV structure and function in preserved EF population.

The Association of Body Mass Index with Surgical Time Is Mediated by Comorbidity in Patients Undergoing Total Hip Arthroplasty

Overweight represents a major issue in contemporary orthopaedic practice. A higher body mass index (BMI) is associated with an increase of perioperative complications following several orthopaedic procedures, in particular total hip arthroplasty (THA). However, the influence of overweight on THA surgical time is controversial. In this study, we investigated the association between BMI and surgical time analyzing the role of patients’ comorbidities. We conducted a retrospective study on 748 patients undergoing THA at our institutions between 2017 and 2018. Information regarding medical diseases was investigated and the burden of comorbidity was quantified using the Charlson score (CCI). Surgical time and blood loss were also recorded. Median surgical time was 76.5 min. Patients with surgical time above the median had both a higher BMI (28.3 vs. 27.1 kg/m²; p = 0.002); and CCI (1 vs. 0; p = 0.016). According to linear regression, surgical time was associated with BMI in the unadjusted model (p < 0.0001), after adjusting for age and sex (p < 0.0001), and in the multivariable model (p = 0.005). Furthermore, BMI was associated with increased surgical time only in patients with a Charlson score above the median, but not in others. Obesity is associated with increased surgical time during THA, especially in pluricomorbid patients, with a higher risk of perioperative complications.

Pulmonary Artery Pressure Monitoring Effectively Guides Management to Reduce Heart Failure Hospitalizations in Obesity

OBJECTIVES

This study sought to determine the impact of therapy guided by pulmonary artery (PA) pressure monitoring in patients with heart failure (HF) and obesity.

BACKGROUND

Obesity is prevalent in HF and associated with volume retention, but it complicates clinical assessment of congestion.

METHODS

The CardioMEMS Post Approval Study was a prospective, multicenter, open-label trial in 1,200 patients with New York Heart Association functional class III HF and prior HF hospitalization (HFH) within 12 months. Patients with a body mass index (BMI) >35 kg/m² were required to have a chest circumference <65 inches. Therapy was guided by PA pressure monitoring at sites, and HFHs were adjudicated 1 year before implantation and throughout follow-up. This analysis stratified patients according to ejection fraction (EF) <40% or ≥40% and by BMI <35 kg/m² or ≥35 kg/m².

RESULTS

Baseline PA diastolic pressure was higher in patients with BMI ≥35 kg/m² regardless of EF, but all PA pressures were reduced at 12 months in each cohort (P < 0.0001). HFH rate was reduced by >50% in both cohorts for EF <40% (BMI <35 kg/m² [HR: 0.48; 95% CI: 0.41-0.55] and ≥35 kg/m² [HR: 0.40; 95% CI: 0.31-0.53]) and EF ≥40% (BMI <35 kg/m² [HR: 0.42; 95% CI: 0.35-0.52] and ≥35 kg/m² [HR: 0.34; 95% CI: 0.25-0.45]; P < 0.0001). There was a nonsignificant trend toward greater reduction with more obesity. The all-cause hospitalization rate was also significantly reduced during monitoring (P < 0.01).

CONCLUSIONS

Management guided by PA pressure monitoring effectively reduced pressures, HFH, and all-cause hospitalization in patients with obesity regardless of EF. (CardioMEMS HF System Post Approval Study; NCT02279888).

Pericardial Fat and the Risk of Heart Failure

BACKGROUND

Obesity is a well-established risk factor for heart failure (HF). However, implications of pericardial fat on incident HF is unclear.

OBJECTIVES

This study sought to examine the association between pericardial fat volume (PFV) and newly diagnosed HF.

METHODS

This study ascertained PFV using cardiac computed tomography in 6,785 participants (3,584 women and 3,201 men) without pre-existing cardiovascular disease from the MESA (Multi-Ethnic Study of Atherosclerosis). Cox proportional hazards regression was used to evaluate PFV as continuous and dichotomous variable, maximizing the J-statistic: (Sensitivity + Specificity - 1).

RESULTS

In 90,686 person-years (median: 15.7 years; interquartile range: 11.7 to 16.5 years), 385 participants (5.7%; 164 women and 221 men) developed newly diagnosed HF. PFV was lower in women than in men (69 ± 33 cm3 vs. 92 ± 47 cm3; p < 0.001). In multivariable analyses, every 1-SD (42 cm3) increase in PFV was associated with a higher risk of HF in women (hazard ratio [HR]: 1.44; 95% confidence interval [CI]: 1.21 to 1.71; p < 0.001) than in men (HR: 1.13; 95% CI: 1.01 to 1.27; p = 0.03) (interaction p = 0.01). High PFV (≥70 cm3 in women; ≥120 cm3 in men) conferred a 2-fold greater risk of HF in women (HR: 2.06; 95% CI: 1.48 to 2.87; p < 0.001) and a 53% higher risk in men (HR: 1.53; 95% CI: 1.13 to 2.07; p = 0.006). In sex-stratified analyses, greater risk of HF remained robust with additional adjustment for anthropometric indicators of obesity (p ≤ 0.008), abdominal subcutaneous or visceral fat (p ≤ 0.03) or biomarkers of inflammation and hemodynamic stress (p < 0.001) and was similar among Whites, Blacks, Hispanics, and Chinese (interaction p = 0.24). Elevated PFV predominantly augmented the risk of HF with preserved ejection fraction (p < 0.001) rather than reduced ejection fraction (p = 0.31).

CONCLUSIONS

In this large, community-based, ethnically diverse, prospective cohort study, pericardial fat was associated with an increased risk of HF, particularly HF with preserved ejection fraction, in women and men.

Obesity cardiomyopathy: evidence, mechanisms, and therapeutic implications

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

Metabolically Healthy/Unhealthy Overweight/Obesity Associations With Incident Heart Failure in Postmenopausal Women: The Women's Health Initiative

BACKGROUND

Obesity is associated with an increased risk of heart failure (HF); however, how metabolic weight groups relate to HF risk, especially in postmenopausal women, has not been demonstrated.

METHODS

We included 19 412 postmenopausal women ages 50 to 79 without cardiovascular disease from the Women's Health Initiative. Normal weight was defined as a body mass index ≥18.5 and <25 kg/m² and waist circumference <88 cm and overweight/obesity as a body mass index ≥25 kg/m² or waist circumference ≥88 cm. Metabolically healthy was based on <2 and unhealthy ≥2 cardiometabolic traits: triglycerides ≥150 mg/dL, systolic blood pressure ≥130 mm Hg or diastolic blood pressure ≥85 mm Hg or blood pressure medication, fasting glucose ≥100 mg/dL or diabetes medication, and HDL-C (high-density lipoprotein cholesterol) <50 mg/dL. Risk factor-adjusted Cox regression examined the hazard ratios (HRs) for incident hospitalized HF among metabolically healthy normal weight (reference), metabolically unhealthy normal weight, metabolically healthy overweight/obese, and metabolically unhealthy overweight/obese.

RESULTS

Among our sample, 455 (2.34%) participants experienced HF hospitalizations over a mean follow-up time of 11.3±1.1 years. Compared with metabolically healthy normal weight individuals, HF risk was greater in metabolically unhealthy normal weight (HR, 1.66 [95% CI, 1.01-2.72], P=0.045) and metabolically unhealthy overweight/obese individuals (HR, 1.95 [95% CI, 1.35-2.80], P=0.0004), but not metabolically healthy overweight/obese individuals (HR, 1.15 [95% CI, 0.78-1.71], P=0.48). Subdividing the overweight/obese into separate groups showed HRs for metabolically unhealthy obese of 2.62 (95% CI, 1.80-3.83; P<0.0001) and metabolically healthy obese of 1.52 (95% CI, 0.98-2.35; P=0.06).

CONCLUSIONS

Metabolically unhealthy overweight/obese and metabolically unhealthy normal weight are associated with an increased risk of HF in postmenopausal women.

Longitudinal Associations of Fitness and Obesity in Young Adulthood With Right Ventricular Function and Pulmonary Artery Systolic Pressure in Middle Age: The CARDIA Study

Background Low cardiorespiratory fitness (CRF) and obesity are risk factors for heart failure but their associations with right ventricular (RV) systolic function and pulmonary artery systolic pressure (PASP) are not well understood. Methods and Results Participants in the CARDIA (Coronary Artery Risk Development in Young Adults) study who underwent maximal treadmill testing at baseline and had a follow-up echocardiographic examination at year 25 were included. A subset of participants had repeat CRF and body mass index (BMI) assessment at year 20. The associations of baseline and changes in CRF and BMI on follow-up (baseline to year 20) with RV systolic function parameters (tricuspid annular plane systolic excursion, RV Doppler systolic velocity of the lateral tricuspid annulus), and PASP were assessed using multivariable-adjusted linear regression models. The study included 3433 participants. In adjusted analysis, higher baseline BMI but not CRF was significantly associated with higher PASP. Among RV systolic function parameters, higher baseline CRF and BMI were significantly associated with higher tricuspid annular plane systolic excursion and RV systolic velocity of the lateral tricuspid annulus. In the subgroup of participants with follow-up assessment of CRF or BMI at year 20, less decline in CRF was associated with higher RV systolic velocity of the lateral tricuspid annulus and lower PASP, while greater increase in BMI was significantly associated with higher PASP in middle age. Conclusions Higher CRF in young adulthood and less decline in CRF over time are each significantly associated with better RV systolic function. Higher baseline BMI and greater age-related increases in BMI are each significantly associated with higher PASP in middle age. These findings provide insights into possible mechanisms through which low fitness and obesity may contribute toward risk of heart failure.

Serum Individual Nonesterified Fatty Acids and Risk of Heart Failure in Older Adults

BACKGROUND

Heart failure (HF) is highly prevalent among older adults and is associated with high costs. Although serum total nonesterified fatty acids (NEFAs) have been positively associated with HF risk, the contribution of each individual NEFA to HF risk has not been examined.

OBJECTIVE

The aim of this study was to examine the association of individual fasting NEFAs with HF risk in older adults.

METHODS

In this prospective cohort study of older adults, we measured 35 individual NEFAs in 2,140 participants of the Cardiovascular Health Study using gas chromatography. HF was ascertained using review of medical records by an endpoint committee.

RESULTS

The mean age was 77.7 ± 4.4 years, and 38.8% were male. During a median follow-up of 9.7 (maximum 19.0) years, 655 new cases of HF occurred. In a multivariable Cox regression model controlling for demographic and anthropometric variables, field center, education, serum albumin, glomerular filtration rate, physical activity, alcohol consumption, smoking, hormone replacement therapy, unintentional weight loss, and all other measured NEFAs, we observed inverse associations (HR [95% CI] per standard deviation) of nonesterified pentadecanoic (15:0) (0.73 [0.57-0.94]), γ-linolenic acid (GLA) (0.87 [0.75-1.00]), and docosahexaenoic acid (DHA) (0.73 [0.61-0.88]) acids with HF, and positive associations of nonesterified stearic (18:0) (1.30 [1.04-1.63]) and nervonic (24:1n-9) (1.17 [1.06-1.29]) acids with HF.

CONCLUSION

Our data are consistent with a higher risk of HF with nonesterified stearic and nervonic acids and a lower risk with nonesterified 15:0, GLA, and DHA in older adults. If confirmed in other studies, specific NEFAs may provide new targets for HF prevention.

Differential Effect of Metabolic Health and Obesity on Incident Heart Failure: A Nationwide Population-Based Cohort Study

BACKGROUND

Metabolically healthy obese (MHO) individuals and their association with cardiometabolic diseases have remained controversial. We aimed to explore the risk of incident heart failure (HF) based on the baseline metabolic health and obesity status as well as their transition over 2 years.

METHODS

The Korean National Health Insurance Service-National Health Screening Cohort data of 514,886 participants were analyzed. Obesity was defined as BMI ≥25 kg/m² according to the Korean Centers for Disease Control and Prevention. The metabolic health and obesity status were evaluated at baseline and after two years. Study participants were followed to either the date of newly diagnosed HF or the last follow-up visit, whichever occurred first.

RESULTS

The MHO group comprised 9.1% of the entire population and presented a better baseline metabolic profile than the metabolically unhealthy non-obese (MUNO) and metabolicavlly unhealthy obese (MUO) groups. During the median 71.3 months of follow-up, HF developed in 5,406 (1.5%) participants. The adjusted hazard ratios [HRs (95% CI)] of HF at baseline compared with the metabolically healthy non-obese (MHNO) group were 1.29 [1.20-1.39], 1.37 [1.22-1.53], and 1.63 [1.50-1.76] for MUNO, MHO, and MUO groups, respectively. With the stable MHNO group as reference, transition into metabolically unhealthy status (MUNO and MUO) increased the risk of HF, regardless of the baseline status. Subjects who were obese at both baseline and follow-up showed an increased risk of HF, regardless of their metabolic health status.

CONCLUSIONS

Metabolic health and obesity status and their transition can predict the risk of incident HF. Losing metabolic health in baseline non-obese and obese individuals and remaining obese in baseline obese individuals showed a significantly increased risk of incident HF. Maintaining good metabolic health and a lean body may prevent the development of HF.

Risk Prediction of the Diabetes Missing Million: Identifying Individuals at High Risk of Diabetes and Related Complications

Early diagnosis and effective management of type 2 diabetes (T2D) are crucial in reducing the risk of developing life-changing complications such as heart failure, stroke, kidney disease, blindness and amputation, which are also associated with significant costs for healthcare providers. However, as T2D symptoms often develop slowly it is not uncommon for people to live with T2D for years without being aware of their condition-commonly known as the undiagnosed missing million. By the time a diagnosis is received, many individuals will have already developed serious complications. While the existence of undiagnosed diabetes has long been recognised, wide-reaching awareness among the general public, clinicians and policymakers is lacking, and there is uncertainty in how best to identify high-risk individuals. In this article we have used consensus expert opinion alongside the available evidence, to provide support for the diabetes healthcare community regarding risk prediction of the missing million. Its purpose is to provide awareness of the risk factors for identifying individuals at high, moderate and low risk of T2D and T2D-related complications. The awareness of risk predictors, particularly in primary care, is important, so that appropriate steps can be taken to reduce the clinical and economic burden of T2D and its complications.

Physical activity and the risk of heart failure: a systematic review and dose-response meta-analysis of prospective studies

Although physical activity is an established protective factor for cardiovascular diseases such as ischemic heart disease and stroke, less is known with regard to the association between specific domains of physical activity and heart failure, as well as the association between cardiorespiratory fitness and heart failure. We conducted a systematic review and meta-analysis of prospective observational studies to clarify the relations of total physical activity, domains of physical activity and cardiorespiratory fitness to risk of heart failure. PubMed and Embase databases were searched up to January 14th, 2020. Summary relative risks (RRs) were calculated using random effects models. Twenty-nine prospective studies (36 publications) were included in the review. The summary RRs for high versus low levels were 0.77 (95% CI 0.70–0.85, I² = 49%, n = 7) for total physical activity, 0.74 (95% CI 0.68–0.81, I² = 88.1%, n = 16) for leisure-time activity, 0.66 (95% CI 0.59–0.74, I² = 0%, n = 2) for vigorous activity, 0.81 (95% CI 0.69–0.94, I² = 86%, n = 3) for walking and bicycling combined, 0.90 (95% CI 0.86–0.95, I² = 0%, n = 3) for occupational activity, and 0.31 (95% CI 0.19–0.49, I² = 96%, n = 6) for cardiorespiratory fitness. In dose–response analyses, the summary RRs were 0.89 (95% CI 0.83–0.95, I² = 67%, n = 4) per 20 MET-hours per day of total activity and 0.71 (95% CI 0.65–0.78, I² = 85%, n = 11) per 20 MET-hours per week of leisure-time activity. Nonlinear associations were observed in both analyses with a flattening of the dose–response curve at 15–20 MET-hours/week for leisure-time activity. These findings suggest that high levels of total physical activity, leisure-time activity, vigorous activity, occupational activity, walking and bicycling combined and cardiorespiratory fitness are associated with reduced risk of developing heart failure.

Does Weight Loss Improve Clinical Outcomes in Overweight and Obese Patients with Heart Failure?

PURPOSE OF REVIEW

Obesity increases the risk of new onset heart failure (HF), and particularly HF with preserved ejection fraction (HFpEF). Despite the observations of favorable clinical outcomes in HF patients with obesity in general, sometimes referred to as the "obesity paradox," it is important to recognize that severe obesity is associated with worse clinical outcomes. This review summarizes the effects of obesity treatment on cardiovascular health and HF clinical outcomes.

RECENT FINDINGS

Treatment for obesity utilizes a variety of modalities to achieve purposeful weight loss including lifestyle intervention, medications, and bariatric surgery. There are a cluster of benefits of obesity treatment in terms of clinical outcomes in HF. The mechanisms of these benefits include both weight loss-dependent and weight loss-independent mechanisms. Obesity treatment is safe and associated with favorable clinical outcomes across the spectrum of the HF population. The potential benefits are facilitated through multiple mechanisms.

Correlates of Physical Activity of Children and Adolescents with Visual Impairments: A Systematic Review

Background and Objective:

The benefits of physical activity (PA) for children and adolescents with disabilities are well documented, and children and adolescents with visual impairments (VI) engage in less PA than their sighted peers. Two reviews have summarized studies on PA of children and adolescents with VI, but no systematic review with semi-quantitative assessment has been conducted to specifically identify the correlates of their PA. This review aims to systematically summarize the existing literature, which investigated the correlates of PA of children and adolescents with VI until 2019 and identify variables that contribute to their PA participation.

Methods:

A systematic search using Academic Search Premier (ASP), Education Resources Information Center (ERIC), Education Source (ES), PsycINFO, Psychology and Behavioral Sciences Collection (PBSC), MEDLINE, Scopus, and Web of Science (WOS) was conducted in September 2019 to identify studies examining the correlates of PA in children and adolescents with VI aged 5 to 17 years. Two researchers independently screened studies, assessed their methodological quality and extracted relevant data. The correlates of PA among children and adolescents with VI were synthesized and further assessed semi-quantitatively.

Results:

A total of 17 articles identified correlates of PA in children and adolescents with VI. Out of 21 variables identified from the reviewed studies, 3 were consistently associated with PA of children and adolescents with VI. Body mass index (BMI)/obesity, percent of body fat, and visual impairment level were consistently and negatively associated with PA of children and adolescents with VI. Gender and age were identified as having inconsistent relationships with PA in children and adolescents with VI. The level of parental education was identified to have “no association” with children and adolescents with VI.

Conclusions:

This review can aid in developing effective interventions to improve the PA of children and adolescents with VI and propose directions for future research.

Bariatric Surgery as a Bridge to Heart Transplantation in Morbidly Obese Patients: a Systematic Review and Meta-Analysis

Class 2 obesity or greater (body mass index [BMI] >35 kg/m) is a relative contraindication for heart transplant due to its associated perioperative risks and mortality. Whether bariatric surgery can act as a potential bridging procedure to heart transplantation is unknown. The aim of this systematic review and meta-analysis is to investigate the role of bariatric surgery on improving transplant candidacy in patients with end-stage heart failure (ESHF). MEDLINE, EMBASE, CENTRAL, and PubMed databases were searched up to September 2019 for studies that performed bariatric surgery on patients with severe obesity and ESHF. Outcomes of interest included incidence of patients listed for heart transplantation after bariatric surgery, proportion of patients that successfully received transplant, the change in BMI after bariatric surgery, and 30-day complications. Pooled estimates were calculated using a random effects meta-analysis of proportions. Eleven studies with 98 patients were included. Mean preoperative BMI was 44.9 (2.1) kg/m and BMI after surgery was 33.2 (2.3) kg/m with an absolute BMI reduction of 26.1%. After bariatric surgery, 71% (95% confidence interval [CI], 55%-86%) of patients with ESHF were listed for transplantation. The mean time from bariatric surgery to receiving a heart transplant was 14.9 (4.0) months. Of the listed patients, 57% (95% CI, 39-74%) successfully received heart transplant. The rate of 30-day mortality after bariatric surgery was 0%, and the 30-day major and minor complications after bariatric surgery was 28% (95% CI, 10%-49%). Bariatric surgery can facilitate sustained weight loss in obese patients with ESHF, improving heart transplant candidacy and the incidence of transplantation.

Prognostic Effect of a Novel Simply Calculated Nutritional Index in Acute Decompensated Heart Failure

The TCB index (triglycerides × total cholesterol × body weight), a novel simply calculated nutritional index based on serum triglycerides (TGs), serum total cholesterol (TC), and body weight (BW), was recently reported to be a useful prognostic indicator in patients with coronary artery disease. Thus, this study aimed to investigate the relationship between TCBI and long-term mortality in acute decompensated heart failure (ADHF) patients. Patients with a diagnosis of ADHF who were consecutively admitted to the cardiac intensive care unit in our institution from 2007 to 2011 were targeted. TCBI was calculated using the formula TG (mg/dL) × TC (mg/dL) × BW (kg)/1000. Patients were divided into two groups according to the median TCBI value. An association between admission TCBI and mortality was assessed using univariable and multivariable Cox proportional hazard analyses. Overall, 417 eligible patients were enrolled, and 94 (22.5%) patients died during a median follow-up period of 2.2 years. The cumulative survival rate with respect to all-cause, cardiovascular, and cancer-related mortalities was worse in patients with low TCBI than in those with high TCBI. In the multivariable analysis, although TCBI was not associated with cardiovascular and cancer mortalities, the association between TCBI and reduced all-cause mortality (hazard ratio: 0.64, 95% confidence interval: 0.44-0.94, p = 0.024) was observed. We computed net reclassification improvement (NRI) when TCBI or Geriatric Nutritional Risk Index (GNRI) was added on established predictors such as hemoglobin, serum sodium level, and both. TCBI improved discrimination for all-cause mortality (NRI: 0.42, p < 0.001; when added on hemoglobin and serum sodium level). GNRI can improve discrimination for cancer mortality (NRI: 0.96, p = 0.002; when added on hemoglobin and serum sodium level). TCBI, a novel and simply calculated nutritional index, can be useful to stratify patients with ADHF who were at risk for worse long-term overall mortality.

Predictive Accuracy of Heart Failure-Specific Risk Equations in an Electronic Health Record-Based Cohort

BACKGROUND

Guidelines recommend identification of individuals at risk for heart failure (HF). However, implementation of risk-based prevention strategies requires validation of HF-specific risk scores in diverse, real-world cohorts. Therefore, our objective was to assess the predictive accuracy of the Pooled Cohort Equations to Prevent HF within a primary prevention cohort derived from the electronic health record.

METHODS

We retrospectively identified patients between the ages of 30 to 79 years in a multi-center integrated healthcare system, free of cardiovascular disease, with available data on HF risk factors, and at least 5 years of follow-up. We applied the Pooled Cohort Equations to Prevent HF tool to calculate sex and race-specific 5-year HF risk estimates. Incident HF was defined by the International Classification of Diseases codes. We assessed model discrimination and calibration, comparing predicted and observed rates for incident HF.

RESULTS

Among 31 256 eligible adults, mean age was 51.4 years, 57% were women and 11% Black. Incident HF occurred in 568 patients (1.8%) over 5-year follow-up. The modified Pooled Cohort Equations to Prevent HF model for 5-year risk prediction of HF had excellent discrimination in White men (C-statistic 0.82 [95% CI, 0.79-0.86]) and women (0.82 [0.78-0.87]) and adequate discrimination in Black men (0.69 [0.60-0.78]) and women (0.69 [0.52-0.76]). Calibration was fair in all race-sex subgroups (χ²<20).

CONCLUSIONS

A novel sex- and race-specific risk score predicts incident HF in a real-world, electronic health record-based cohort. Integration of HF risk into the electronic health record may allow for risk-based discussion, enhanced surveillance, and targeted preventive interventions to reduce the public health burden of HF.

What are the Physiological Benefits of Increased Daily Number of Steps in Middle-Aged Women?

BACKGROUND

Physical activity plays an important role in the prevention of cardio-metabolic diseases. The present study evaluated the effect of habitual physical activity on body composition, peak oxygen consumption, cardiac and metabolic function.

METHODS

This was a retrospective study. Data was collected between February 2014 and November 2015. Thirty-six healthy women (age 50±16 years) were stratified according to daily number of steps into low- (<7500 steps/day, n=17) or high-active group (>12500 steps/day, n=19). All participants underwent body composition assessment, oral glucose tolerance test and non-invasive gas-exchange and haemodynamic (bioreactance) measurements at rest and in response to maximal graded cardiopulmonary exercise test.

RESULTS

The high active group averaged 16280±3205 steps/day and the low active group averaged 6285±943 steps/day (difference p=0.00). High-active women (vs. low active) demonstrated significantly lower body weight (62.1±12.3 vs. 71.2±9.1 kg, p=0.02), body fat (27.2±9.1 vs 37.7±6.4 %, p=0.00), but increased lean body mass (72.8±9.1 vs. 62.3±6.4 %, p=0.00). Peak oxygen consumption was significantly higher in high- versus low active women (2.0±0.5 vs. 1.5±0.2 l/min, p=0.00). There were no significant differences between the groups in fasting- and 2-hour glucose levels (4.9±0.6 vs. 4.8±0.5, p=0.45 and 4.8±1.3 vs. 5.5±1.4 mmol/L, p=0.16) haemodynamic measures of cardiac function including cardiac power output, cardiac output, stroke volume and arterial blood pressure at rest and in response to exercise stress test (p>0.05).

CONCLUSIONS

Increased levels of habitual physical activity improve body composition and peak oxygen consumption but appears to have limited effect cardio-metabolic function in middle-aged women.

Heart failure among people with Type 2 diabetes mellitus: real-world data of 289 954 people from a diabetes database

AIM

Comparing people with Type 2 diabetes mellitus with and without heart failure in terms of metabolic control, therapeutic regimen and comorbidities.

METHODS

The Prospective Diabetes Registry (DPV) is a longitudinal documentation system for demographics, medical care and outcome in people with diabetes mellitus. It consists of follow-up data from people with diabetes mellitus who have agreed to be recorded in the registry. Clinical data are submitted by general practitioners, specialists and clinics throughout Germany and Austria. Some 289 954 people with Type 2 diabetes mellitus (years 2000 to 2015) were analysed using demographic statistics and adjustment for confounders based on linear and logistic regression analysis.

RESULTS

People with Type 2 diabetes mellitus (ICD code: E11) and heart failure (ICD code: I50) (N = 14 723) were older, more often women and presented with longer diabetes duration compared with those without heart failure. After adjustment for age, gender and diabetes duration, people with heart failure showed lower HbA_1c , higher BMI and more intense insulin therapy. Analysis revealed that people with heart failure were more often treated with insulin, and more frequently received anti-hypertensives and lipid-lowering medication. They presented with lower systolic and diastolic BP. People with heart failure more frequently showed a history of comorbidities.

CONCLUSION

Heart failure is common in diabetes mellitus, but the prevalence in the DPV is lower frequent than expected. The reason for improved metabolic control in heart failure may be intensified therapy with insulin, lipid-lowering medication and anti-hypertensives in this cohort.

Diabetes mellitus and risk of new-onset and recurrent heart failure: a systematic review and meta-analysis

Despite mounting evidence of the positive relationship between diabetes mellitus (DM) and heart failure (HF), the entire context of the magnitude of risk for HF in relation to DM remains insufficiently understood. The principal reason is because new‐onset HF (HF occurring in participants without a history of HF) and recurrent HF (HF re‐occurring in patients with a history of HF) are not discriminated. This meta‐analysis aims to comprehensively and separately assess the risk of new‐onset and recurrent HF depending on the presence or absence of DM. We systematically searched cohort studies that examined the relationship between DM and new‐onset or recurrent HF using EMBASE and MEDLINE (from 1 Jan 1950 to 28 Jul 2019). The risk ratio (RR) for HF in individuals with DM compared with those without DM was pooled with a random‐effects model. Seventy‐four and 38 eligible studies presented data on RRs for new‐onset and recurrent HF, respectively. For new‐onset HF, the pooled RR [95% confidence interval (CI)] of 69 studies that examined HF as a whole [i.e. combining HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF)] was 2.14 (1.96–2.34). The large between‐study heterogeneity (I² = 99.7%, P < 0.001) was significantly explained by mean age [pooled RR (95% CI) 2.60 (2.38–2.84) for mean age < 60 years vs. pooled RR (95% CI) 1.95 (1.79–2.13) for mean age ≥ 60 years] (P < 0.001). Pooled RRs (95% CI) of seven and eight studies, respectively, that separately examined HFpEF and HFrEF risk were 2.22 (2.02–2.43) for HFpEF and 2.73 (2.71–2.75) for HFrEF. The risk magnitudes between HFpEF and HFrEF were not significantly different in studies that examined both HFpEF and HFrEF risks (P = 0.86). For recurrent HF, pooled RR (95% CI) of the 38 studies was 1.39 (1.33–1.45). The large between‐study heterogeneity (I² = 80.1%, P < 0.001) was significantly explained by the proportion of men [pooled RR (95% CI) 1.53 (1.40–1.68) for < 65% men vs. 1.32 (1.25–1.39) for ≥65% men (P = 0.01)] or the large pooled RR for studies of only participants with HFpEF [pooled RR (95% CI), 1.73 (1.32–2.26) (P = 0.002)]. Results indicate that DM is a significant risk factor for both new‐onset and recurrent HF. It is suggested that the risk magnitude is large for new‐onset HF especially in young populations and for recurrent HF especially in women or individuals with HFpEF. DM is associated with future HFpEF and HFrEF to the same extent.

Physical activity and the risk of sudden cardiac death: a systematic review and meta-analysis of prospective studies

Background

Physical activity has been associated with a significant reduction in risk of sudden cardiac death in epidemiological studies, however, the strength of the association needs clarification. We conducted a systematic review and meta-analysis to summarize the available data from population-based prospective studies.

Methods

PubMed and Embase databases were searched for studies of physical activity and sudden cardiac death from inception to March 26th 2019. Prospective studies reporting adjusted relative risk (RR) estimates and 95% confidence intervals (CIs) of sudden cardiac death associated with physical activity were included. A random effects model was used to estimate summary RRs (95% CIs).

Results

Thirteen prospective studies were included in the systematic review. Eight prospective studies with 1193 sudden cardiac deaths among 136,298 participants were included in the meta-analysis of physical activity and sudden cardiac death and the summary RR for highest vs. lowest level of physical activity was 0.52 (95% CI: 0.45–0.60, I² = 0%, p_{heterogeneity} = 0.72). The association was similar in men and women and among American and European studies. In the dose-response analysis the summary RR was 0.68 (95% CI: 0.55–0.86, I² = 44%, n = 3) per 20 MET-hours/week. Although the test for nonlinearity was not significant, p_nonlinearity = 0.18, there was no further reduction in risk beyond 20–25 MET-hours/week. The summary RR was 0.58 (95% CI: 0.41–0.81, I² = 0%, p_{heterogeneity} = 0.65, n = 2) for the highest vs. the lowest level of cardiorespiratory fitness.

Conclusion

This meta-analysis suggest that a high compared to a low level of physical activity may reduce the risk of sudden cardiac death in the general population. Further studies are needed to clarify the dose-response relationship between specific subtypes and intensities of physical activity in relation to sudden cardiac death.

Longitudinal Changes in Cardiac Structure and Function in Severe Obesity: 11-Year Follow-Up in the Utah Obesity Study

Background

Progressive cardiac remodeling and worsening myocardial function over time have been proposed as potential mediators of heart failure in obesity.

Methods and Results

We serially assessed cardiac structure and function in 254 subjects participating in a longitudinal study of obesity. Demographic, clinical, laboratory, and echocardiographic features were determined at baseline and 2‐, 6‐, and 11‐year follow‐up. We measured body mass index (BMI) exposure as the area under the curve of the BMI at each of the 4 visits. At enrollment, mean age of the subjects was 47 years, 79% were women, mean BMI was 44 kg/m², 26% had diabetes mellitus, 48% had hypertension, and 53% had hyperlipidemia. Between baseline and 11 years, BMI increased by 1.1 and 0.3 kg/m² in men and women, respectively. There were modest increases in left ventricular (LV) end‐diastolic volume, LV mass, and left atrial volume, and significant decreases in early/late mitral diastolic flow velocity ratio and E wave deceleration time. However, there were no significant changes in LV ejection fraction or ratio of early mitral diastolic flow velocity/early mitral annular velocity, whereas right ventricular fractional area change increased. Significant predictors of the change in LV mass were male sex, baseline BMI, BMI area under the curve, and change in LV stroke volume, but not smoking, hypertension, or diabetes mellitus.

Conclusions

In long‐standing, persistent severe obesity, there was evidence of cardiac remodeling over a period of 11 years, but no clear worsening of systolic or diastolic function. Measures of remodeling were most strongly related to BMI. The observed changes might predispose to heart failure with preserved ejection fraction, but are not classic for an evolving dilated cardiomyopathy.

Age-related longitudinal change in cardiac structure and function in adults at increased cardiovascular risk

AIM

Heart failure (HF) incidence increases markedly with age. We examined age-associated longitudinal change in cardiac structure and function, and their prediction by age and cardiovascular disease (CVD) risk factors, in a community-based cohort aged ≥60 years at increased CVD risk but without HF.

METHODS AND RESULTS

CVD risk factors were recorded in 3065 participants who underwent a baseline echocardiographic examination, of whom 2358 attended a follow-up examination 3.8 [median, inter-quartile range (IQR) 3.5, 4.2] years later. Median age was 71 (IQR 67, 76) years and 55% of participants were male. Age was associated with longitudinal increase in left ventricular (LV) mass index (LVMI); decrease in LV volumes; increase in LV ejection fraction; decrease in mitral annular systolic velocity; decrease in diastolic function (decreased mitral early diastolic annular velocity (e'); and increase in left atrial volume index, mitral peak early diastolic flow velocity (E)/e' ratio, and tricuspid regurgitant velocity (TR_Vmax ) in men and women, except for TR_Vmax in men). In multivariable analysis, longitudinal increase in LVMI was explained by CVD risk factors alone, whereas age, together with CVD risk factors, independently predicted longitudinal change in all other echocardiographic parameters. CVD risk factors were differentially associated with longitudinal change in different echocardiographic parameters.

CONCLUSIONS

Whereas the increase in LVMI with age was explained by CVD risk factors alone, age, together with risk factors, independently predicted longitudinal change in all other echocardiographic parameters, providing evidence for age-specific mechanisms of change in cardiac structure and function as people age. Age-associated change in LVMI, LV volumes, and diastolic function resembled what might be expected for the evolution of HF with preserved ejection fraction. Given the differential association of different CVD risk factors with longitudinal change in different echocardiographic parameters, therapies aimed at attenuation of age-associated change in cardiac structure and function, and HF evolution, will likely need to address multiple CVD risk factors.

Association of body mass index and cardiotoxicity related to anthracyclines and trastuzumab in early breast cancer: French CANTO cohort study

BACKGROUND

In patients treated with cardiotoxic chemotherapies, the presence of cardiovascular risk factors and previous cardiac disease have been strongly correlated to the onset of cardiotoxicity. The influence of overweight and obesity as risk factors in the development of treatment-related cardiotoxicity in breast cancer (BC) was recently suggested. However, due to meta-analysis design, it was not possible to take into account associated cardiac risk factors or other classic risk factors for anthracycline (antineoplastic antibiotic) and trastuzumab (monoclonal antibody) cardiotoxicity.

METHODS AND FINDINGS

Using prospective data collected from 2012-2014 in the French national multicenter prospective CANTO (CANcer TOxicities) study of 26 French cancer centers, we aimed to examine the association of body mass index (BMI) and cardiotoxicity (defined as a reduction in left ventricular ejection fraction [LVEF] > 10 percentage points from baseline to LVEF < 50%). In total, 929 patients with stage I-III BC (mean age 52 ± 11 years, mean BMI 25.6 ± 5.1 kg/m2, 42% with 1 or more cardiovascular risk factors) treated with anthracycline (86% epirubicin, 7% doxorubicin) and/or trastuzumab (36%), with LVEF measurement at baseline and at least 1 assessment post-chemotherapy were eligible in this interim analysis. We analyzed associations between BMI and cardiotoxicity using multivariate logistic regression. At baseline, nearly 50% of the study population was overweight or obese. During a mean follow-up of 22 ± 2 months following treatment completion, cardiotoxicity occurred in 29 patients (3.2%). The obese group was more prone to cardiotoxicity than the normal-weight group (9/171 versus 8/466; p = 0.01). In multivariate analysis, obesity (odds ratio [OR] 3.02; 95% CI 1.10-8.25; p = 0.03) and administration of trastuzumab (OR 12.12; 95% CI 3.6-40.4; p < 0.001) were independently associated with cardiotoxicity. Selection bias and relatively short follow-up are potential limitations of this national multicenter observational cohort.

CONCLUSIONS

In BC patients, obesity appears to be associated with an important increase in risk-related cardiotoxicity (CANTO, ClinicalTrials.gov registry ID: NCT01993498).

TRIAL REGISTRATION

ClinicalTrials.gov NCT01993498.

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

OBJECTIVE

The aim of the meta-analysis was to determine the association of obesity and heart failure (HF) and the cardiac impact of intentional weight loss following bariatric surgery on cardiac structure and myocardial function in obese subjects.

METHODS

MEDLINE, Embase and Web of Science were searched up to 3 April 2018. Studies reporting association and prognostic impact of obesity in HF and the impact of intentional weight loss following bariatric surgery on cardiac structure and myocardial function in obesity were included in the meta-analysis.

RESULTS

4959 citations were reviewed. After exclusions, 29 studies were analysed. A 'J curve' relationship was observed between body mass index (BMI) and risk of HF with maximum risk in the morbidly obese (1.73 (95% CI 1.30 to 2.31), p<0.001, n=11). Although 'obesity paradox' was observed for all-cause mortality, the overweight group was associated with lower cardiovascular (CV) mortality (OR=0.86 (95% CI 0.79 to 0.94), n=11) with no significant differences across other BMI groups. Intentional weight loss induced by bariatric surgery in obese patients (n=9) without established HF, atrial fibrillation or known coronary artery disease, was associated with a reduction in left ventricular mass index (p<0.0001), improvement in left ventricular diastolic function (p≤0.0001) and a reduction in left atrial size (p=0.02).

CONCLUSIONS

Despite the increased risk of HF with obesity, an 'obesity paradox' is observed for all-cause mortality. However, the nadir for CV mortality is observed in the overweight group. Importantly, intentional weight loss was associated with improvement in indices of cardiac structure and myocardial function in obese patients.

TRIAL REGISTRATION NUMBER

APP 74412.

The association between physical fitness and physical activity among Chinese college students

Objective: The constant deterioration of the physical fitness of college students has been a popular topic in China, thus this research analyzes the potential health risk of inadequate physical activity among college students. Participants/methods: During the national student fitness test (NSFT) in 2012, 1500 students from Tsinghua University were recruited and asked to complete the international physical activity questionnaire. Finally, 1414 (94.3%) students completed the study. Results/conclusions: Compared with those students who actively participate in exercise, the risk of obesity in college students lacking exercise was 1.25 times higher. Likewise, the probability of failure in the grip strength test and the standing long jump was also higher, with increases of 2.39 fold and 1.39 fold, respectively. Moreover, the total score of physical fitness test was the same. Consequently, this study suggests that college students should exercise regularly to increase their physical fitness.

Weight loss enhances cardiac energy metabolism and function in heart failure associated with obesity

AIMS

Obesity is associated with high rates of cardiac fatty acid oxidation, low rates of glucose oxidation, cardiac hypertrophy and heart failure. Whether weight loss can lessen the severity of heart failure associated with obesity is not known. We therefore determined the effect of weight loss on cardiac energy metabolism and the severity of heart failure in obese mice with heart failure.

MATERIALS AND METHODS

Obesity and heart failure were induced by feeding mice a high-fat (HF) diet and subjecting them to transverse aortic constriction (TAC). Obese mice with heart failure were then switched for 8 weeks to either a low-fat (LF) diet (HF TAC LF) or caloric restriction (CR) (40% caloric intake reduction, HF TAC CR) to induce weight loss.

RESULTS

Weight loss improved cardiac function (%EF was 38 ± 6% and 36 ± 6% in HF TAC LF and HF TAC CR mice vs 25 ± 3% in HF TAC mice, P < 0.05) and it decreased cardiac hypertrophy post TAC (left ventricle mass was 168 ± 7 and 171 ± 10 mg in HF TAC LF and HF TAC CR mice, respectively, vs 210 ± 8 mg in HF TAC mice, P < 0.05). Weight loss enhanced cardiac insulin signalling, insulin-stimulated glucose oxidation rates (1.5 ± 0.1 and 1.5 ± 0.1 μmol/g dry wt/min in HF TAC LF and HF TAC CR mice, respectively, vs 0.2 ± 0.1 μmol/g dry wt/min in HF TAC mice, P < 0.05) and it decreased pyruvate dehydrogenase phosphorylation. Cardiac fatty acid oxidation rates, AMPK^Tyr172 /ACC^Ser79 signalling and the acetylation of ß-oxidation enzymes, were attenuated following weight loss.

CONCLUSIONS

Weight loss is an effective intervention to improve cardiac function and energy metabolism in heart failure associated with obesity.

Body mass index and outcomes of cardiac resynchronization with implantable cardioverter-defibrillator therapy in older patients with heart failure

AIMS

To assess the association of body mass index (BMI) with heart failure (HF) outcomes after cardiac resynchronization therapy with defibrillator (CRT-D) implantation.

METHODS AND RESULTS

Medicare beneficiaries with HF aged ≥ 65 years (n = 18 922) undergoing first-time CRT-D from the National Cardiovascular Data Registry (NCDR) Implantable Cardioverter-Defibrillator Registry between 2010 and 2013, were followed for 3 years post-implantation. Survival curves and covariate adjusted hazard ratio (aHR) or odds ratio were used to assess the risks for death, readmission, and device-related complications by BMI status. Of 18 922 HF patients receiving CRT-D, 5265 (27.8%) were normal weight, 6896 (37%) were overweight, 6318 (33.4%) were obese, and 353 (1.8%) were underweight. Compared to those of normal weight (BMI 18.5-24.9 kg/m² ), underweight patients had a higher 3-year post-device implantation risk of death [aHR: 1.34 (95% confidence interval 1.09-1.65); P < 0.001] and of readmission [sub-aHR: 1.25 (1.09-1.42); P < 0.001]. The corresponding 3-year aHRs for death were 0.83 (0.77-0.89) for overweight, 0.74 (0.67-0.82) for obesity class I (BMI 30-34.9 kg/m² ), 0.78 (0.68-0.90) for obesity class II (BMI 35-39.9 kg/m² ), and 0.75 (0.60-0.93) for obesity class III (BMI ≥ 40 kg/m² , P for all categories < 0.001). Individuals with class III obesity had a higher risk of readmission [sub-aHR: 1.17 (1.06-1.30)]. There were no differences in rates of device-related complications within 90 days across BMI categories.

CONCLUSION

Most elderly patients with HF receiving CRT-D were overweight or obese. While being underweight was associated with greater risks of death and hospitalization, overweight and obese patients were at lower risk of death after CRT-D.