Bariatric Surgery and Cardiovascular Outcomes in Patients With Obesity and Cardiovascular Disease:: A Population-Based Retrospective Cohort Study

Mechanisms of myocardial reverse remodelling and its clinical significance: A scientific statement of the ESC Working Group on Myocardial Function

Cardiovascular disease (CVD) is the leading cause of morbimortality in Europe and worldwide. CVD imposes a heterogeneous spectrum of cardiac remodelling, depending on the insult nature, that is, pressure or volume overload, ischaemia, arrhythmias, infection, pathogenic gene variant, or cardiotoxicity. Moreover, the progression of CVD-induced remodelling is influenced by sex, age, genetic background and comorbidities, impacting patients' outcomes and prognosis. Cardiac reverse remodelling (RR) is defined as any normative improvement in cardiac geometry and function, driven by therapeutic interventions and rarely occurring spontaneously. While RR is the outcome desired for most CVD treatments, they often only slow/halt its progression or modify risk factors, calling for novel and more timely RR approaches. Interventions triggering RR depend on the myocardial insult and include drugs (renin-angiotensin-aldosterone system inhibitors, beta-blockers, diuretics and sodium-glucose cotransporter 2 inhibitors), devices (cardiac resynchronization therapy, ventricular assist devices), surgeries (valve replacement, coronary artery bypass graft), or physiological responses (deconditioning, postpartum). Subsequently, cardiac RR is inferred from the degree of normalization of left ventricular mass, ejection fraction and end-diastolic/end-systolic volumes, whose extent often correlates with patients' prognosis. However, strategies aimed at achieving sustained cardiac improvement, predictive models assessing the extent of RR, or even clinical endpoints that allow for distinguishing complete from incomplete RR or adverse remodelling objectively, remain limited and controversial. This scientific statement aims to define RR, clarify its underlying (patho)physiologic mechanisms and address (non)pharmacological options and promising strategies to promote RR, focusing on the left heart. We highlight the predictors of the extent of RR and review the prognostic significance/impact of incomplete RR/adverse remodelling. Lastly, we present an overview of RR animal models and potential future strategies under pre-clinical evaluation.

Putting More Weight on Obesity Trials in Heart Failure

PURPOSE OF REVIEW

To review ongoing and planned clinical trials of weight loss among individuals with or at high risk of heart failure.

RECENT FINDINGS

Intentional weight loss via semaglutide among persons with heart failure and preserved ejection fraction and obesity significantly improves weight loss and health status as assessed by the KCCQ-CSS score and is associated with improvements in 6-min walk test. Ongoing and planned trials will explore the role of intentional weight loss with treatments such as semaglutide or tirzepatide for individuals with heart failure across the entire ejection fraction spectrum.

The Impact of Metabolic and Bariatric Surgery on Apo B100 Levels in Individuals with high BMI: A Multi-Centric Prospective Cohort Study

BACKGROUND

Metabolic and Bariatric surgery (MBS) leads to significant weight loss and improvements in obesity-related comorbidities. However, the impact of MBS on Apolipoprotein B100 (Apo-B100) regulation is unclear. Apo-B100 is essential for the assembly and secretion of serum lipoprotein particles. Elevated levels of these factors can accelerate the development of atherosclerotic plaques in blood vessels. This study aimed to evaluate changes in Apo-B100 levels following MBS.

METHODS

121 participants from the Iranian National Obesity and Metabolic Surgery Database (INOSD) underwent Laparoscopic Sleeve Gastrectomy (LSG) (n = 43), One-Anastomosis Gastric Bypass (OAGB) (n = 70) or Roux-en-Y Gastric Bypass (RYGB) (n = 8). Serum Apo-B100, lipid profiles, liver enzymes, and fasting glucose were measured preoperatively and six months postoperatively.

RESULTS

Apo-B100 levels significantly decreased from 94.63 ± 14.35 mg/dL preoperatively to 62.97 ± 19.97 mg/dL after six months (p < 0.01), alongside reductions in total cholesterol, triglycerides, LDL, VLDL, AST, and ALT (p < 0.05). Greater Apo-B100 reductions occurred in non-diabetics versus people with diabetes (p = 0.012) and strongly correlated with baseline Apo-B100 (r = 0.455, p < 0.01) and LDL levels (r = 0.413, p < 0.01). However, surgery type did not impact Apo-B100 changes in multivariate analysis (p > 0.05).

CONCLUSION

Bariatric surgery leads to a significant reduction in Apo-B100 levels and improvements in lipid profiles and liver enzymes, indicating a positive impact on dyslipidemia and cardiovascular risk in individuals with high BMI.

Updates in Bariatric Surgery

Bariatric surgery is currently the most effective long-term treatment for morbid obesity as well as type-2 diabetes mellitus. The field of metabolic and bariatric surgery has seen tremendous growth over the past decade with dramatically reduced risks. This article aims to provide an update on bariatric surgery, highlighting the latest outcomes, improvements, and challenges in the field. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) released a major update to the indications for bariatric surgery at BMI ≥35 kg/m2 regardless of co-morbidities and 30-34.9 kg/m2 with obesity-related comorbidities. Sleeve gastrectomy has emerged as the most popular bariatric procedure in the last 10 years with its remarkable efficacy and safety profile. The implementation of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and Enhanced Recovery After Surgery (ERAS) protocols have significantly improved the quality of care for all bariatric patients. The recent introduction and FDA approval of Glucagon-Like Peptide-1 (GLP-1) agonists for chronic obesity has garnered significant media coverage and popularity, but no guidelines exist regarding its use in relation to bariatric surgery. This update underscores the need for tailored approaches, ongoing research, and the integration of evidence-based medicine and innovations to enhance patient care.

Incidence of ocular pathology following bariatric surgery for with morbid obesity across a large United States National Database

BACKGROUND/OBJECTIVES

Bariatric surgery, as indicated for treatment of morbid obesity, has been studied in association with short term effects on ocular pathology. However, effects of surgery on postoperative disease incidence is largely unknown.

SUBJECTS/METHODS

In this retrospective cohort study, the TriNetX United States Collaborative Network national database, was queried for patients with an ICD-10 code for morbid obesity and a procedural code for bariatric surgery. Patients were propensity score matched across baseline demographics at the time of surgery and compared to those presenting with an ICD10 code for morbid obesity with no records of a procedural code for bariatric surgery, identifying 42,408 patients per cohort. New diagnoses or procedural codes found after the surgical index date for diabetic retinopathy, age-related macular degeneration, glaucoma, low vision, and blindness along with pertinent treatment metrics were monitored.

RESULTS

Bariatric surgery was found to be associated with reduced future risk of diabetic retinopathy (RR: 0.283; 95% CI: 0.252-0.319), macular edema (RR: 0.224; 95% CI: 0.170-0.297), vitreous hemorrhage (RR: 0.459; 95% CI: 0.323-0.653), ocular hypertension (RR: 0.387; 95% CI: 0.387-0.487), glaucoma (RR: 0.360; 95% CI: 0.326-0.399), use of ocular pressure lowering medications (RR: 0.565; 95% CI: 0.496-0.644), age-related macular degeneration (RR: 0.628; 95% CI: 0.447-0.882), cataract surgery (RR: 0.524; 95% CI: 0.448-0.612), and low vision and blindness (RR: 0.328; 95% CI: 0.294-0.365) compared to patients not surgically managed.

CONCLUSIONS

The present analysis comprising a large US cohort of patients suggests that bariatric surgery is associated with a decreased risk of future ocular morbidity and mortality.

Unexplained Residual Risk In Type 2 Diabetes: How Big Is The Problem?

PURPOSE OF REVIEW

What is new? Cardiovascular disease (CVD) is the leading cause of mortality in type 2 diabetes (T2D) individuals. Of the major risk factors for CVD, less than 10% of T2D people meet the American Diabetes Association/American Heart Association recommended goals of therapy. The present review examines how much of the absolute cardiovascular (CV) risk in type 2 diabetes patients can be explained by major CV intervention trials.

RECENT FINDINGS

Multiple long-term cardiovascular (CV) intervention trials have examined the effect of specific target-directed therapies on the MACE endpoint. Only one prospective study, STENO-2, has employed a multifactorial intervention comparing intensified versus conventional treatment of modifiable risk factors in T2D patients, and demonstrated a 20% absolute CV risk reduction. If the absolute CV risk reduction in these trials is added to that in the only prospective multifactorial intervention trial (STENO-2), the unexplained CV risk is 44.1%. What are the clinical implications? Potential explanations for the unaccounted-for reduction in absolute CV risk in type 2 diabetes (T2D) patients are discussed.

HYPOTHESIS

failure to take into account synergistic interactions between major cardiovascular risk factors is responsible for the unexplained CV risk in T2D patients. Simultaneous treatment of all major CV risk factors to recommended AHA/ADA guideline goals is required to achieve the maximum reduction in CV risk.

Impact of antidepressant use on post-operative weight loss following bariatric surgery

BACKGROUND

Antidepressant medication can be associated with weight gain. Consideration should be given to the specific agent prescribed to optimize bariatric surgery outcomes.

AIM

The aim of this study is to investigate if patients treated with antidepressants stratified by risk of weight gain are associated with less weight loss at 1 year postbariatric surgery.

METHOD

A single centre, retrospective analysis of all patients who underwent bariatric surgery between July 2018 and 2021 within St Vincent's University Hospital group. The exposure was antidepressant use, stratified for risk of weight gain, and the control group was patients who underwent surgery but no antidepressant use. The primary outcome was % TWL (total weight loss) at 6 weeks, 6 months and 12 months post-surgery. Multivariate linear regression analysis was used to estimate the impact of antidepressant treatment on post-surgery weight loss at 12 months using the variables of age, gender and pre-operative BMI.

RESULTS

Of the total cohort (n = 315), 70 patients (22.2%) were taking antidepressants. At 12 months, post-operatively patients taking medium risk for weight gain antidepressants had significantly less mean %TWL compared to those not taking antidepressants (p = 0.015). Overall, taking any antidepressant was not found to be a significant predictor of %TWL at 12 months after surgery (β =  - 2.590, p = 0.0836).

CONCLUSION

Many patients undergoing bariatric surgery have concurrent psychiatric conditions. Given the complex relationship between bariatric surgery and mental health, psychotropic medications may be best managed by a specialist in the field such as a bariatric psychiatrist in order to optimize patient outcomes.

Factors Associated with Statin Discontinuation Following Metabolic and Bariatric Surgery: A Retrospective Analysis of 2012-2021 Electronic Medical Records Network Data

BACKGROUND

Bariatric surgery has been shown to improve hyperlipidemia, decreasing the need for statin medications. Although maintaining statin therapy post-surgery for those with a history of atherosclerotic cardiovascular disease (ASCVD) is advised, it is uncertain if discontinuation risks differ between those with and without ASCVD history.

AIM

The study aims to analyze the rate and reasons for statin cessation post-bariatric surgery in the US using real-world data.

METHODS

Using the TriNetX electronic medical records network from 2012 to 2021, the study involved patients aged 18 or older on statins at the time of bariatric surgery. They were categorized into primary and secondary prevention groups based on prior ASCVD. Statin discontinuation was defined as a 90-day gap post the last statin dosage. The Cox model assessed factors influencing statin cessation.

RESULTS

Seven hundred and thirty-three statin users undergoing bariatric surgery were identified, with 564 (77%) in primary prevention. Six months post-surgery, 48% of primary prevention patients and 34.5% of secondary ones stopped statins. Primary prevention patients had a 30% higher likelihood of cessation compared to secondary prevention (hazard ratio, 1.30; 95% CI, 1.06-1.60) as shown by multivariable analysis.

CONCLUSIONS

Post-bariatric surgery, primary prevention patients are more likely to discontinue statins than secondary prevention patients.

Contemporary pharmacological treatment and management of heart failure

The prevention and treatment strategies for heart failure (HF) have evolved in the past two decades. The stages of HF have been redefined, with recognition of the pre-HF state, which encompasses asymptomatic patients who have developed either structural or functional cardiac abnormalities or have elevated plasma levels of natriuretic peptides or cardiac troponin. The first-line treatment of patients with HF with reduced ejection fraction includes foundational therapies with angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors and diuretics. The first-line treatment of patients with HF with mildly reduced ejection fraction or with HF with preserved ejection fraction includes SGLT2 inhibitors and diuretics. The timely initiation of these disease-modifying therapies and the optimization of treatment are crucial in all patients with HF. Reassessment after initiation of these therapies is recommended to evaluate patient symptoms, health status and left ventricular function, and timely referral to a HF specialist is necessary if a patient has persistent advanced HF symptoms or worsening HF. Lifestyle modification and treatment of comorbidities such as diabetes mellitus, ischaemic heart disease and atrial fibrillation are crucial through each stage of HF. This Review provides an overview of the management strategies for HF according to disease stages that are derived from the recommendations in the latest US and European HF guidelines.

Metabolic surgery in improving arterial health in obese individuals

PURPOSE

Arterial stiffness has gained recognition as a stand-alone risk factor for cardiovascular disease (CVD). Obesity is intricately linked to elevated arterial stiffness, the development of left ventricular (LV) hypertrophy, and the emergence of diastolic dysfunction, all of which collectively contribute substantially to an unfavorable prognosis. Weight loss has become a standard recommendation for all patients with CVD concurrent with morbid obesity; however, randomized evidence to support this recommendation was limited earlier. The latest scientific studies revealed dynamic changes in aortic stiffness after substantial weight loss by bariatric surgery, also known as metabolic surgery, in patients with obesity. There is also a favorable evolution in LV hypertrophy and a significant impact on arterial hypertension and other promising cardiovascular outcomes in obese people after bariatric surgery.

METHODS/RESULTS

We aimed to examine the cardiovascular effects of various metabolic surgeries in morbidly obese individuals, especially their role in improving arterial health, the potential impact on surrogate markers of atherosclerotic vascular disease, and consequently reducing the likelihood of cardiovascular events.

CONCLUSION

In conclusion, metabolic surgery is associated with a significant decrease in the occurrence of major adverse cardiovascular events (MACE) and all-cause mortality among obese individuals, alongside remarkable enhancement of arterial health. These findings underscore the critical importance of implementing strategies to combat obesity and reduce adiposity within the general population.

Evaluating the Impact of Enhanced Recovery After Surgery Protocols on Surgical Outcomes Following Bariatric Surgery-A Systematic Review and Meta-analysis of Randomised Clinical Trials

BACKGROUND

Enhanced recovery after surgery (ERAS) programmes are evidence-based care improvement processes for surgical patients, which are designed to decrease the impact the anticipated negative physiological cascades following surgery.

AIM

To perform a systematic review and meta-analysis of randomised clinical trials (RCTs) to evaluate the impact of ERAS protocols on outcomes following bariatric surgery compared to standard care (SC).

METHODS

A systematic review was performed in accordance with PRISMA guidelines. Meta-analysis was performed using Review Manager version 5.4 RESULTS: Six RCTs including 740 patients were included. The mean age was 40.2 years, and mean body mass index was 44.1 kg/m2. Overall, 54.1% underwent Roux-en-Y gastric bypass surgery (400/740) and 45.9% sleeve gastrectomy (340/700). Overall, patients randomised to ERAS programmes had a significant reduction in nausea and vomiting (odds ratio (OR): 0.42, 95% confidence interval (CI): 0.19-0.95, P = 0.040), intraoperative time (mean difference (MD): 5.40, 95% CI: 3.05-7.77, P < 0.001), time to mobilisation (MD: - 7.78, 95% CI: - 5.46 to - 2.10, P < 0.001), intensive care unit stay (ICUS) (MD: 0.70, 95% CI: 0.13-1.27, P = 0.020), total hospital stay (THS) (MD: - 0.42, 95% CI: - 0.69 to - 0.16, P = 0.002), and functional hospital stay (FHS) (MD: - 0.60, 95% CI: - 0.98 to - 0.22, P = 0.002) compared to those who received SC.

CONCLUSION

ERAS programmes reduce postoperative nausea and vomiting, intraoperative time, time to mobilisation, ICUS, THS, and FHS compared to those who received SC. Accordingly, ERAS should be implemented, where feasible, for patients indicated to undergo bariatric surgery. Trial registration International Prospective Register of Systematic Reviews (PROSPERO - CRD42023434492.

Trends and Outcomes Associated With Bariatric Surgery and Pharmacotherapies With Weight Loss Effects Among Patients With Heart Failure and Obesity

BACKGROUND

Utilization patterns of bariatric surgery among older patients with heart failure (HF), and the associations with cardiovascular outcomes, are not well known.

METHODS

Medicare beneficiaries with HF and at least class II obesity from 2013 to 2020 were identified with Medicare Provider Analysis and Review 100% inpatient files and Medicare 5% outpatient files. Patients who underwent bariatric surgery were matched to controls in a 1:2 ratio (matched on exact age, sex, race, body mass index, HF encounter year, and HF hospitalization rate pre-surgery/matched period). In an exploratory analysis, patients prescribed pharmacotherapies with weight loss effects (semaglutide, liraglutide, naltrexone-bupropion, or orlistat) were identified and matched to controls with a similar strategy in addition to HF medical therapy data. Cox models evaluated associations between weight loss therapies (as a time-varying covariate) and mortality risk and HF hospitalization rate (calculated as the rate of HF hospitalizations following index HF encounter per 100 person-months) during follow-up.

RESULTS

Of 298 101 patients with HF and body mass index ≥35 kg/m2, 2594 (0.9%) underwent bariatric surgery (45% men; mean age, 56.2 years; mean body mass index, 51.5 kg/m2). In propensity-matched analyses over a median follow-up of 4.7 years, bariatric surgery was associated with lower risk of all-cause mortality (HR, 0.55 [95% CI, 0.49-0.63]; P<0.001), greater reduction in HF hospitalization rate (rate ratio, 0.72 [95% CI, 0.67-0.77]; P<0.001), and lower atrial fibrillation risk (HR, 0.78 [95% CI, 0.65-0.93]; P=0.006). Use of pharmacotherapies with weight loss effects was low (4.8%), with 96.3% prescribed GLP-1 (glucagon-like peptide-1) agonists (semaglutide, 23.6%; liraglutide, 72.7%). In propensity-matched analysis over a median follow-up of 2.8 years, patients receiving pharmacotherapies with weight loss effects (versus matched controls) had a lower risk of all-cause mortality (HR, 0.82 [95% CI, 0.71-0.95]; P=0.007) and HF hospitalization rate (rate ratio, 0.87 [95% CI, 0.77-0.99]; P=0.04).

CONCLUSIONS

Bariatric surgery and pharmacotherapies with weight loss effects are associated with a lower risk of adverse outcomes among older patients with HF and obesity; however, overall utilization remains low.

Primary prevention of cardiovascular disease in women

Ischemic heart disease is the primary cause of cardiovascular disease (CVD) mortality in both men and women. Strategies targeting traditional modifiable risk factors are essential - including hypertension, smoking, dyslipidemia and diabetes mellitus - particularly for atherosclerosis, but additionally for stroke, heart failure and some arrhythmias. However, challenges related to education, screening and equitable access to effective preventative therapies persist, and are particularly problematic for women around the globe and those from lower socioeconomic groups. The association of female-specific risk factors (e.g. premature menopause, gestational hypertension, small for gestational age births) with CVD provides a potential window for targeted prevention strategies. However, further evidence for specific effective screening and interventions is urgently required. In addition to population-level factors involved in increasing the risk of suffering a CVD event, efforts are leveraging the enormous potential of blood-based 'omics', improved imaging biomarkers and increasingly complex bioinformatic analytic approaches to strive toward more personalized early disease detection and personalized preventative therapies. These novel tactics may be particularly relevant for women in whom traditional risk factors perform poorly. Here we discuss established and emerging approaches for improving risk assessment, early disease detection and effective preventative strategies to reduce the mammoth burden of CVD in women.

The relation between excess adiposity and breast cancer in women: Clinical implications and management

BACKGROUND

Breast cancer (BC) is the most common cancer in women. While the combination of improved screening, earlier detection, and advances in therapeutics has resulted in lower BC mortality, BC survivors are now increasingly dying of cardiovascular disease. Cardiovascular disease in the leading cause of non-cancer related mortality among BC survivors. This situation underscores the critical need to research the role of modifiable cardiometabolic risk factors, such as excess adiposity, that will affect BC remission, long-term survivorship, and overall health and quality of life.

PURPOSE

First, this review summarizes the evidence on the connection between adipose tissue and BC. Then we review the data on weight trends after BC diagnosis with a focus on the effect of weight gain on BC recurrence and BC- and non-BC-related death. Finally, we provide a guide for weight management in BC survivors, considering the available data on the effect of weight loss interventions on BC.

Short-term cardiovascular events after bariatric surgery in patients with metabolic syndrome

BACKGROUND

Patients with metabolic syndrome (MetS) are at increased risk of developing cardiovascular disease along with other adverse events after bariatric surgery.

OBJECTIVES

The incidence of short-term major adverse cardiovascular events (MACE) in patients with MetS undergoing bariatric surgery is not well characterized.

SETTING

Accredited bariatric surgery centers in the United States and Canada.

METHODS

A total of 760,076 patients aged ≥18 years with body mass index ≥35 kg/m2 who underwent primary bariatric surgery between 2015 and 2018 were included. Patients with both diabetes and hypertension were described as the MetS cohort. Patient characteristics, operative technique, and 30-day outcomes were compared. The primary outcome was incidence of MACE, a composite of myocardial infarction, stroke, and all-cause mortality. Unadjusted and multivariable logistic regression analyses were performed and included an interaction between MetS and hyperlipidemia (HLD).

RESULTS

Of the 577,882 patients included, 111,128 (19.2%) exhibited MetS. Patients with MetS more frequently experienced MACE compared with patients without MetS (.3% versus .1%; P < .001). The odds of MACE were greater for patients with MetS versus Non-MetS (odds ratio [OR] 2.87; 95% CI, 2.49-3.32) in the unadjusted analysis. MetS without HLD, MetS with HLD, and Non-MetS with HLD are significantly associated with MACE when compared with those with non-MetS without HLD.

CONCLUSIONS

Patients with MetS have an increased frequency of cardiac events following bariatric surgery. Future studies should determine if optimization of 1 or more components of MetS or other related co-morbidities reduces the cardiovascular risk for patients.

Managing Obesity in Heart Failure: A Chance to Tip the Scales?

Obesity is associated with incident heart failure (HF), independent of other cardiovascular risk factors. Despite rising rates of both obesity and incident HF, the associations remain poorly understood between: 1) obesity and HF outcomes; and 2) weight loss and HF outcomes. Evidence shows that patients with HF and obesity have high symptom burdens, lower exercise capacity, and higher rates of hospitalization for HF when compared with patients with HF without obesity. However, the impact of weight loss on these outcomes for patients with HF and obesity remains unclear. Recent advances in medical therapies for weight loss have offered a new opportunity for significant and sustained weight loss. Ongoing and recently concluded cardiovascular outcomes trials will offer new insights into the role of weight loss through these therapies in preventing HF and mitigating HF outcomes and symptom burdens among patients with established HF, particularly HF with preserved ejection fraction.

Clinical outcomes and adverse events of bariatric surgery in adults with severe obesity in Scotland: the SCOTS observational cohort study

Background

Bariatric surgery is a common procedure worldwide for the treatment of severe obesity and associated comorbid conditions but there is a lack of evidence as to medium-term safety and effectiveness outcomes in a United Kingdom setting.

Objective

To establish the clinical outcomes and adverse events of different bariatric surgical procedures, their impact on quality of life and the effect on comorbidities.

Design

Prospective observational cohort study.

Setting

National Health Service secondary care and private practice in Scotland, United Kingdom.

Participants

Adults (age >16 years) undergoing their first bariatric surgery procedure.

Main outcome measures

Change in weight, hospital length of stay, readmission and reoperation rate, mortality, diabetes outcomes (HbA1c, medications), quality of life, anxiety, depression.

Data sources

Patient-reported outcome measures, hospital records, national electronic health records (Scottish Morbidity Record 01, Scottish Care Information Diabetes, National Records Scotland, Prescription Information System).

Results

Between December 2013 and February 2017, 548 eligible patients were approached and 445 participants were enrolled in the study. Of those, 335 had bariatric surgery and 1 withdrew from the study. Mean age was 46.0 (9.2) years, 74.7% were female and the median body mass index was 46.4 (42.4; 52.0) kg/m2. Weight was available for 128 participants at 3 years: mean change was -19.0% (±14.1) from the operation and -24.2% (±12.8) from the start of the preoperative weight-management programme. One hundred and thirty-nine (41.4%) participants were readmitted to hospital in the same or subsequent 35 months post surgery, 18 (5.4% of the operated cohort) had a reoperation or procedure considered to be related to bariatric surgery gastrointestinal complications or revisions. Fewer than five participants (<2%) died during follow-up. HbA1c was available for 93/182 and diabetes medications for 139/182 participants who had type 2 diabetes prior to surgery; HbA1c mean change was -5.72 (±16.71) (p = 0.001) mmol/mol and 65.5% required no diabetes medications (p < 0.001) at 3 years post surgery. Physical quality of life, available for 101/335 participants, improved in the 3 years post surgery, mean change in Rand 12-item Short Form Survey physical component score 8.32 (±8.95) (p < 0.001); however, there was no change in the prevalence of anxiety or depression.

Limitations

Due to low numbers of bariatric surgery procedures in Scotland, recruitment was stopped before achieving the intended 2000 participants and follow-up was reduced from 10 years to 3 years.

Conclusions

Bariatric surgery is a safe and effective treatment for obesity. Patients in Scotland, UK, appear to be older and have higher body mass than international comparators, which may be due to the small number of procedures performed.

Future work

Intervention studies are required to identify the optimal pre- and post surgery pathway to maximise safety and cost-effectiveness.

Study registration

This study is registered as ISRCTN47072588.

Funding details

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 10/42/02) and is published in full in Health Technology Assessment; Vol. 28, No. 7. See the NIHR Funding and Awards website for further award information.

Lifestyle management of hypertension: International Society of Hypertension position paper endorsed by the World Hypertension League and European Society of Hypertension

Hypertension, defined as persistently elevated systolic blood pressure (SBP) >140 mmHg and/or diastolic blood pressure (DBP) at least 90 mmHg (International Society of Hypertension guidelines), affects over 1.5 billion people worldwide. Hypertension is associated with increased risk of cardiovascular disease (CVD) events (e.g. coronary heart disease, heart failure and stroke) and death. An international panel of experts convened by the International Society of Hypertension College of Experts compiled lifestyle management recommendations as first-line strategy to prevent and control hypertension in adulthood. We also recommend that lifestyle changes be continued even when blood pressure-lowering medications are prescribed. Specific recommendations based on literature evidence are summarized with advice to start these measures early in life, including maintaining a healthy body weight, increased levels of different types of physical activity, healthy eating and drinking, avoidance and cessation of smoking and alcohol use, management of stress and sleep levels. We also discuss the relevance of specific approaches including consumption of sodium, potassium, sugar, fibre, coffee, tea, intermittent fasting as well as integrated strategies to implement these recommendations using, for example, behaviour change-related technologies and digital tools.

Early outcomes of one-anastomosis gastric bypass in the elderly population at high-volume bariatric centers

The increasing rate of obesity and life expectancy will lead to increasing numbers of bariatric procedures in the elderly. We aim to report the early (≤ 30 days) adverse events of One-Anastomosis Gastric Bypass (OAGB) in this patient population. Assuta Bariatric Centers in Israel. Retrospective review of perioperative OAGB outcomes between elderly group (≥ 65 years) and non-elderly group (18-64 years) at high-volume bariatric centers between January 2017-December 2021. Operative time, length of stay (LOS), and overall ≤ 30 days complication rates, as ranked by the Clavien-Dindo Classification (CDC) were compared. There were 6618 patients (non-elderly group) and 104 (elderly group) who underwent OAGB. Gender and preoperative BMI were comparable between the two age groups. The elderly group had significantly higher rate of ischemic heart disease and chronic renal failure. The number of patients with LOS ≥ 3 days was significantly higher in the elderly group [19.4% (n = 20) vs. 6.6% (n = 331), respectively; p < 0.001]. The total early adverse events were higher in the elderly group with no statistical significance [7.7% (n = 8) vs. 3.8% (n = 250), respectively; p = 0.062]. The rate of minor and major adverse events and reoperation rate was comparable between the two groups. The rate of readmissions was significantly higher in the elderly group 5.8% (n = 6) vs. 1.9% (n = 124), respectively p = 0.015. There was 0.06% mortality (n = 2) in the non-elderly group. OAGB is a relatively safe metabolic and bariatric surgery for elderly obese patients with early (≤ 30 days) morbidity rates similar to the non-elderly population.

Long term outcomes of metabolic/bariatric surgery in adults

The prevalence of obesity continues to rise around the world, driving up the need for effective and durable treatments. The field of metabolic/bariatric surgery has grown rapidly in the past 25 years, with observational studies and randomized controlled trials investigating a broad range of long term outcomes. Metabolic/bariatric surgery results in durable and significant weight loss and improvements in comorbid conditions, including type 2 diabetes. Observational studies show that metabolic/bariatric surgery is associated with a lower incidence of cardiovascular events, cancer, and death. Weight regain is a risk in a fraction of patients, and an association exists between metabolic/bariatric surgery and an increased risk of developing substance and alcohol use disorders, suicidal ideation/attempts, and accidental death. Patients need lifelong follow-up to help to reduce the risk of these complications and other nutritional deficiencies. Different surgical procedures have important differences in risks and benefits, and a clear need exists for more long term research about less invasive and emerging procedures. Recent guidelines for the treatment of obesity and metabolic conditions have been updated to reflect this growth in knowledge, with an expansion of eligibility criteria, particularly people with type 2 diabetes and a body mass index between 30.0 and 34.9.

Obesity, thrombosis, venous disease, lymphatic disease, and lipedema: An obesity medicine association (OMA) clinical practice statement (CPS) 2023

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians with an overview on obesity, thrombosis, venous disease, lymphatic disease, and lipedema.

Methods

The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

Topics in this CPS include obesity, thrombosis, venous disease, lymphatic disease, and lipedema. Obesity increases the risk of thrombosis and cardiovascular disease via fat mass and adiposopathic mechanisms. Treatment of thrombosis or thrombotic risk includes healthful nutrition, physical activity, and the requisite knowledge of how body weight affects anti-thrombotic medications. In addition to obesity-related thrombotic considerations of acute coronary syndrome and ischemic non-hemorrhagic stroke, this Clinical Practice Statement briefly reviews the diagnosis and management of clinically relevant presentations of deep vein thromboses, pulmonary embolism, chronic venous stasis, varicose veins, superficial thrombophlebitis, lipodermatosclerosis, corona phlebectatica, chronic thromboembolic pulmonary hypertension, iliofemoral venous obstruction, pelvic venous disorder, post-thrombotic syndrome, as well as lymphedema and lipedema - which should be included in the differential diagnosis of other edematous or enlargement disorders of the lower extremities.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on obesity, thrombosis, and venous/lymphatic disease is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity.

The Global Burden of premature cardiovascular disease, 1990-2019

Aims

Premature cardiovascular disease (pCVD) definition varies in literature, with age cut-offs ranging from 50-65 years. While there is some literature available on pCVD in North America, comprehensive data on its global burden is still lacking which hinders the development of efficient strategies for early detection and prevention. In this study we aimed to investigate the global trends in pCVD related morbidity and mortality from 1990 to 2019.

Methods

The 1990-2019 Global Burden of Disease (GBD) database was utilized to examine global trends in cardiovascular disease-related total mortality, mortality rates, and Disability-Adjusted Life Years (DALYs) within individuals aged 15-49 years. The findings were further analyzed based on factors such as age, sex, and Socio-Demographic Index (SDI).

Results

From 1990 to 2019, the number of global annual pCVD deaths increased by 25%, from 992,067 (95% UI 1,042,261 - 946,383) to 1,241,484 (95% UI 1,339,193 -1,146,252). The rate of associated mortality decreased by 13%. Metabolic conditions were the most significant risk factors for pCVD mortality. Ischemic heart disease and stroke are the leading causes of death across all age groups. pCVD mortality presented progressive widening between high and low SDI regions. Additionally, sex-specific disparities in CVD mortality were significantly greater in the premature age group as compared to all-age groups.

Conclusion

pCVD is an increasingly significant global cause of morbidity and mortality that disproportionately affects males and individuals living in less privileged regions. Furthermore, ischemic heart disease and stroke were identified as the main drivers of pCVD global burden.

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.

Natriuretic peptide testing strategies in heart failure: A 2023 update

Natriuretic peptides (NPs), including B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP), have been recommended as standard biomarkers for diagnosing heart failure (HF), and one of the strongest risk predictors for mortality and HF hospitalization regardless of ejection fraction (EF) and etiology of HF. BNP is an active neurohormone opposing renin-angiotensin-aldosterone and sympathetic nervous system overactivated in HF, whereas NT-proBNP is an inactive prohormone released from cardiomyocytes in response to wall stress. Despite substantial advances in the development of guideline-directed medical therapy (GDMT) for HF with reduced EF, studies demonstrating direct benefits of NP-guided chronic HF therapy on mortality, HF hospitalization, and GDMT optimization have yielded conflicting results. However, accumulating evidence shows that achieving prespecified BNP or NT-proBNP target over time is significantly associated with favorable outcomes, suggesting that benefits of serially measured NPs may be limited to particular groups of HF patients, such as those with extreme levels of baseline BNP or NT-proBNP, which could represent severe phenotypes of HF associated with natriuretic peptide resistance or cardiorenal syndrome. Over the past decade, clinical utilization of BNP and NT-proBNP has been expanded, especially using serial NP measurements for guiding HF therapy, optimizing GDMT and identifying at-risk patients with HF phenotypes who may be minimally symptomatic or asymptomatic.

A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association

A growing appreciation of the pathophysiological interrelatedness of metabolic risk factors such as obesity and diabetes, chronic kidney disease, and cardiovascular disease has led to the conceptualization of cardiovascular-kidney-metabolic syndrome. The confluence of metabolic risk factors and chronic kidney disease within cardiovascular-kidney-metabolic syndrome is strongly linked to risk for adverse cardiovascular and kidney outcomes. In addition, there are unique management considerations for individuals with established cardiovascular disease and coexisting metabolic risk factors, chronic kidney disease, or both. An extensive body of literature supports our scientific understanding of, and approach to, prevention and management for individuals with cardiovascular-kidney-metabolic syndrome. However, there are critical gaps in knowledge related to cardiovascular-kidney-metabolic syndrome in terms of mechanisms of disease development, heterogeneity within clinical phenotypes, interplay between social determinants of health and biological risk factors, and accurate assessments of disease incidence in the context of competing risks. There are also key limitations in the data supporting the clinical care for cardiovascular-kidney-metabolic syndrome, particularly in terms of early-life prevention, screening for risk factors, interdisciplinary care models, optimal strategies for supporting lifestyle modification and weight loss, targeting of emerging cardioprotective and kidney-protective therapies, management of patients with both cardiovascular disease and chronic kidney disease, and the impact of systematically assessing and addressing social determinants of health. This scientific statement uses a crosswalk of major guidelines, in addition to a review of the scientific literature, to summarize the evidence and fundamental gaps related to the science, screening, prevention, and management of cardiovascular-kidney-metabolic syndrome.

Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association

Cardiovascular-kidney-metabolic health reflects the interplay among metabolic risk factors, chronic kidney disease, and the cardiovascular system and has profound impacts on morbidity and mortality. There are multisystem consequences of poor cardiovascular-kidney-metabolic health, with the most significant clinical impact being the high associated incidence of cardiovascular disease events and cardiovascular mortality. There is a high prevalence of poor cardiovascular-kidney-metabolic health in the population, with a disproportionate burden seen among those with adverse social determinants of health. However, there is also a growing number of therapeutic options that favorably affect metabolic risk factors, kidney function, or both that also have cardioprotective effects. To improve cardiovascular-kidney-metabolic health and related outcomes in the population, there is a critical need for (1) more clarity on the definition of cardiovascular-kidney-metabolic syndrome; (2) an approach to cardiovascular-kidney-metabolic staging that promotes prevention across the life course; (3) prediction algorithms that include the exposures and outcomes most relevant to cardiovascular-kidney-metabolic health; and (4) strategies for the prevention and management of cardiovascular disease in relation to cardiovascular-kidney-metabolic health that reflect harmonization across major subspecialty guidelines and emerging scientific evidence. It is also critical to incorporate considerations of social determinants of health into care models for cardiovascular-kidney-metabolic syndrome and to reduce care fragmentation by facilitating approaches for patient-centered interdisciplinary care. This presidential advisory provides guidance on the definition, staging, prediction paradigms, and holistic approaches to care for patients with cardiovascular-kidney-metabolic syndrome and details a multicomponent vision for effectively and equitably enhancing cardiovascular-kidney-metabolic health in the population.

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.

Impact of Bariatric Surgery on Mortality of Mitral Valve Surgery: A National Analysis

OBJECTIVE

Obesity is a common comorbidity of cardiac surgery patients. The goal of this study is to determine if a lower weight achieved through bariatric surgery has any association with mitral valve (MV) replacement or repair surgery mortality.

METHODS

This study used a retrospective analysis of the National Inpatient Sample dataset from 2012 to 2020. Adult patients who underwent MV surgery with normal weight following bariatric surgery (n = 1,125) and patients with obesity (n = 48,555) were compared. The primary outcome was in-hospital mortality.

RESULTS

This study included 49,680 patients. The median age was 64 (55 to 71) years, and the majority were female (55%). Bariatric surgery was found to significantly decrease the odds of mortality, even after adjusting for important covariates, indicating a reduction of mortality risk by 54% (adjusted odds ratio = 0.46, p = 0.024). Other significant protective factors include isolated and elective surgery. Significant risk factors were older age, female sex, and diabetes mellitus. Patients who were obese demonstrated longer lengths of stay (LOS), greater transfers to other facilities, and higher hospital costs.

CONCLUSIONS

In patients receiving MV surgery, bariatric surgery demonstrated significant survival benefits during hospitalization, in addition to reducing LOS and cost. Our data support prior evidence of bariatric surgery improving cardiovascular outcomes. Therefore, bariatric surgery may be a meaningful method of weight loss to improve surgical patient outcomes in patients with obesity. However, longer-term data are needed.

The impact of obesity and LVAD-bridging on heart transplant candidate outcomes: a linked STS INTERMACS - OPTN/UNOS data analysis

BACKGROUND

Limited data integrating waitlist and postheart transplant (HT) mortality have evaluated outcomes of left ventricular assist device (LVAD)-bridged strategy vs no LVAD according to patient characteristics. We evaluated waitlist and post-HT mortality in LVAD-bridged vs nonbridged patients based on body mass index (BMI).

METHODS

We included linked adults listed for HT in Organ Procurement and Transplant Network/United Network for Organ Sharing and patients receiving durable LVAD as bridge to HT or candidacy in Society of Thoracic Surgeons/Interagency Mechanical Circulatory Support databases (2010-2019). Using BMI at listing or LVAD implant, we categorized patients as underweight (<18.5 kg/m2), normal weight (18.5-24.99 kg/m2), overweight (25-29.99 kg/m2), and obese (≥30 kg/m2). Kaplan-Meier analysis and multivariable Cox proportional hazards models informed the effect of LVAD-bridged and nonbridged strategy by BMI on waitlist, post-HT, and overall mortality (including waitlist and post-HT mortality).

RESULTS

Among 11,216 LVAD-bridged and 17,122 nonbridged candidates, bridged candidates were more frequently obese (37.3% vs 28.6%) (p < 0.001). Multivariable analysis indicated increased waitlist mortality in LVAD-bridged vs nonbridged with overweight (Hazard ratio (HR) 1.18, 95% confidence interval (CI) 1.02-1.36) or obesity (HR 1.35, 95%CI 1.17-1.56) in comparison to normal weight candidates (HR 1.02, 95%CI 0.88-1.19) (p-interaction < 0.001). Post-transplant mortality was not statistically different in LVAD-bridged vs nonbridged patients across BMI categories (p-interaction = 0.26). There was a nonsignificant graded increase in overall mortality in LVAD-bridged with overweight (HR 1.53, 95%CI 1.39-1.68) or obesity (HR 1.61, 95%CI 1.46-1.78) compared to nonbridged patients (p-interaction = 0.13).

CONCLUSIONS

LVAD-bridged candidates with obesity had higher waitlist mortality compared to nonbridged candidates with obesity. Post-transplant mortality was similar in LVAD-bridged and nonbridged patients, but obesity remained associated with increased mortality in both groups. This study may aid clinicians and advanced heart failure patients with obesity in decision-making.

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.

Clinical Pathway for Coronary Atherosclerosis in Patients Without Conventional Modifiable Risk Factors: JACC State-of-the-Art Review

Reducing the incidence and prevalence of standard modifiable cardiovascular risk factors (SMuRFs) is critical to tackling the global burden of coronary artery disease (CAD). However, a substantial number of individuals develop coronary atherosclerosis despite no SMuRFs. SMuRFless patients presenting with myocardial infarction have been observed to have an unexpected higher early mortality compared to their counterparts with at least 1 SMuRF. Evidence for optimal management of these patients is lacking. We assembled an international, multidisciplinary team to develop an evidence-based clinical pathway for SMuRFless CAD patients. A modified Delphi method was applied. The resulting pathway confirms underlying atherosclerosis and true SMuRFless status, ensures evidence-based secondary prevention, and considers additional tests and interventions for less typical contributors. This dedicated pathway for a previously overlooked CAD population, with an accompanying registry, aims to improve outcomes through enhanced adherence to evidence-based secondary prevention and additional diagnosis of modifiable risk factors observed.

Weight loss and metabolic benefits of bariatric surgery in China: A multicenter study

BACKGROUND

This retrospective multicenter study evaluated the efficacy and safety of bariatric surgery in Chinese patients with obesity.

METHODS

Patients with obesity who underwent laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass and completed a 12-month follow-up between February 2011 and November 2019 were enrolled. Weight loss, glycemic and metabolic control, insulin resistance, cardiovascular risk, and surgery-related complications at 12 months were analyzed.

RESULTS

We enrolled 356 patients aged 34.3 ± 0.6 years with a mean body mass index of 39.4 ± 0.4 kg/m2 . Successful weight loss occurred in 54.6%, 86.8%, and 92.7% of patients at 3, 6, and 12 months, respectively, with no difference in percent excess weight loss between the laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass surgery groups. The average percentage of total weight loss was 29.5% ± 0.6% at 12 months; 99.4%, 86.8%, and 43.5% of patients achieved at least 10%, 20%, and 30% weight loss, respectively, at 12 months. Significant improvements in metabolic indices, insulin resistance, and inflammation biomarkers were observed at 12 months.

CONCLUSIONS

Bariatric surgery resulted in successful weight loss and improved metabolic control, insulin resistance, and cardiovascular risk in Chinese patients with obesity. Both laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass are suitable approaches for such patients.

A review of the evidence on cardiovascular outcomes from obesity treatment

Background

Obesity is a chronic disease with a myriad of complications including cardiovascular disease. There is a growing interest to examine if obesity treatment is associated with cardiovascular outcomes.

Methods

In this narrative review, we focused on randomized controlled trials (RCT) with cardiovascular outcomes (CVO) from lifestyle intervention, bariatric surgery, glucagon-like peptide-1 analogues (GLP-1a) and other pharmacotherapy. Additionally, we provide a comprehensive look into the RCT of sodium glucose cotransporter 2 inhibitors (SGLT2i) and CVO in obesity, while also summarizing several ongoing randomized cardiovascular outcome controlled trials for the pharmacological treatment of obesity.

Results

To date, the results from the randomized controlled trials supported the association between obesity treatment and cardiovascular outcomes. Studies have large sample sizes, conducted over long duration, with the majority demonstrating superiority in primary cardiovascular outcome end points compared to placebo.

Conclusion

Future data from several ongoing anti-obesity medications cardiovascular outcome trials such as SELECT, SURPASS, SUMMIT and SURMOUNT-MMO hold promises. Further studies are warranted to investigate the long term cardiovascular outcomes following lifestyle intervention and bariatric surgery.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Continuous glucose monitoring in patients with post-bariatric hypoglycaemia reduces hypoglycaemia and glycaemic variability

AIM

To determine whether continuous glucose monitoring (CGM) can reduce hypoglycaemia in patients with post-bariatric hypoglycaemia (PBH).

MATERIALS AND METHODS

In an open-label, nonrandomized, pre-post design with sequential assignment, CGM data were collected in 22 individuals with PBH in two sequential phases: (i) masked (no access to sensor glucose or alarms); and (ii) unmasked (access to sensor glucose and alarms for low or rapidly declining sensor glucose). Twelve participants wore the Dexcom G4 device for a total of 28 days, while 10 wore the Dexcom G6 device for a total of 20 days.

RESULTS

Participants with PBH spent a lower percentage of time in hypoglycaemia over 24 hours with unmasked versus masked CGM (<3.3 mM/L, or <60 mg/dL: median [median absolute deviation {MAD}] 0.7 [0.8]% vs. 1.4 [1.7]%, P = 0.03; <3.9 mM/L, or <70 mg/dL: median [MAD] 2.9 [2.5]% vs. 4.7 [4.8]%; P = 0.04), with similar trends overnight. Sensor glucose data from the unmasked phase showed a greater percentage of time spent between 3.9 and 10 mM/L (70-180 mg/dL) (median [MAD] 94.8 [3.9]% vs. 90.8 [5.2]%; P = 0.004) and lower glycaemic variability over 24 hours (median [MAD] mean amplitude of glycaemic excursion 4.1 [0.98] vs. 4.4 [0.99] mM/L; P = 0.04). During the day, participants also spent a greater percentage of time in normoglycaemia with unmasked CGM (median [MAD] 94.2 [4.8]% vs. 90.9 [6.2]%; P = 0.005), largely due to a reduction in hyperglycaemia (>10 mM/L, or 180 mg/dL: median [MAD] 1.9 [2.2]% vs. 3.9 [3.6]%; P = 0.02).

CONCLUSIONS

Real-time CGM data and alarms are associated with reductions in low sensor glucose, elevated sensor glucose, and glycaemic variability. This suggests CGM allows patients to detect hyperglycaemic peaks and imminent hypoglycaemia, allowing dietary modification and self-treatment to reduce hypoglycaemia. The use of CGM devices may improve safety in PBH, particularly for patients with hypoglycaemia unawareness.

The Impact of Bariatric Surgery on the Incidence of Colorectal Cancer in Patients with Obesity-a Systematic Review and Meta-analysis of Registry Data

PURPOSE

Cancer and obesity represent two of the most significant global health concerns. The risk of malignancy, including colorectal cancer (CRC), increases with obesity. The aim of this study was to perform a systematic review and meta-analysis to determine the value of bariatric surgery in reducing CRC risk in patients with obesity using registry data.

MATERIALS AND METHODS

A systematic review and meta-analysis were performed as per PRISMA guidelines. The risk of CRC was expressed as a dichotomous variable and reported as odds ratios (OR) with 95% confidence intervals (CIs) using the Mantel-Haenszel method. A multi-treatment comparison was performed, examining the risk reduction associated with existing bariatric surgery techniques. Analysis was performed using RevMan, R packages, and Shiny.

RESULTS

Data from 11 registries including 6,214,682 patients with obesity were analyzed. Of these, 14.0% underwent bariatric surgery (872,499/6,214,682), and 86.0% did not undergo surgery (5,432,183/6,214,682). The mean age was 49.8 years, and mean follow-up was 5.1 years. In total, 0.6% of patients who underwent bariatric surgery developed CRC (4,843/872,499), as did 1.0% of unoperated patients with obesity (54,721/5,432,183). Patients with obesity who underwent bariatric surgery were less likely to develop CRC (OR: 0.53, 95% CI: 0.36-0.77, P < 0.001, I2 = 99%). Patients with obesity undergoing gastric bypass surgery (GB) (OR: 0.513, 95% CI: 0.336-0.818) and sleeve gastrectomy (SG) (OR: 0.484, 95% CI: 0.307-0.763) were less likely to develop CRC than unoperated patients.

CONCLUSION

At a population level, bariatric surgery is associated with reduced CRC risk in patients with obesity. GB and SG are associated with the most significant reduction in CRC risk.

PROSPERO REGISTRATION

CRD42022313280.

Therapies for patients with coexisting heart failure with reduced ejection fraction and non-alcoholic fatty liver disease

Heart failure with reduced ejection fraction (HFrEF) and nonalcoholic fatty liver disease (NAFLD) are two common comorbidities that share similar pathophysiological mechanisms. There is a growing interest in the potential of targeted therapies to improve outcomes in patients with coexisting HFrEF and NAFLD. This manuscript reviews current and potential therapies for patients with coexisting HFrEF and NAFLD. Pharmacological therapies, including angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, mineralocorticoids receptor antagonist, and sodium-glucose cotransporter-2 inhibitors, have been shown to reduce fibrosis and fat deposits in the liver. However, there are currently no data showing the beneficial effects of sacubitril/valsartan, ivabradine, hydralazine, isosorbide nitrates, digoxin, or beta blockers on NAFLD in patients with HFrEF. This study highlights the importance of considering HFrEF and NAFLD when developing treatment plans for patients with these comorbidities. Further research is needed in patients with coexisting HFrEF and NAFLD, with an emphasis on novel therapies and the importance of a multidisciplinary approach for managing these complex comorbidities.

Cardiovascular Effects of Weight Loss in Obese Patients with Diabetes: Is Bariatric Surgery the Additional Arrow in the Quiver?

Obesity is an increasingly widespread disease worldwide because of lifestyle changes. It is associated with an increased risk of cardiovascular disease, primarily type 2 diabetes mellitus, with an increase in major cardiovascular adverse events. Bariatric surgery has been shown to be able to reduce the incidence of obesity-related cardiovascular disease and thus overall mortality. This result has been shown to be the result of hormonal and metabolic effects induced by post-surgical anatomical changes, with important effects on multiple hormonal and molecular axes that make this treatment more effective than conservative therapy in determining a marked improvement in the patient's cardiovascular risk profile. This review, therefore, aimed to examine the surgical techniques currently available and how these might be responsible not only for weight loss but also for metabolic improvement and cardiovascular benefits in patients undergoing such procedures.

The Effect of Laparoscopic Sleeve Gastrectomy on the Course of Non-Alcoholic Fatty Liver Disease in Morbidly Obese Patients during One Year of Follow Up

BACKGROUND

Morbid obesity co-exists with non-alcoholic fatty liver disease in up to 90% of cases. Laparoscopic sleeve gastrectomy leads to a reduction in body mass and thus may improve the course of non-alcoholic fatty liver disease. The aim of this study was to evaluate the effect of laparoscopic sleeve gastrectomy on the resolution of non-alcoholic fatty liver disease.

METHODS

The study included 55 patients with non-alcoholic fatty liver disease who underwent laparoscopic sleeve gastrectomy at a tertiary institution. The analysis consisted of preoperative liver biopsy, abdominal ultrasound, weight loss parameters, Non-Alcoholic Fatty Liver Fibrosis Score and selected laboratory parameters.

RESULTS

Before the surgery, 6 patients were diagnosed with grade 1 liver steatosis, 33 patients with grade 2 and 16 patients with grade 3. One year after the surgery, only 21 patients had features of liver steatosis at ultrasound. All weight loss parameters showed statistically significant changes during the observation; the median percentage of total weight loss was 31.0% (IQR: 27.5; 34.5) with p = 0.0003, the median percentage of excess weight loss was 61.8% (IQR: 52.4; 72.3) with p = 0.0013 and the median percentage of excess body mass index loss was 71.0% (IQR: 61.3; 86.9) with p = 0.0036 12 months after laparoscopic sleeve gastrectomy. The median Non-Alcoholic Fatty Liver Fibrosis Score at baseline was 0.2 (IQR: -0.8; 1.0) and decreased to -1.6 (IQR: -2.4; -0.4) (p < 0.0001). Moderate negative correlations between Non-Alcoholic Fatty Liver Fibrosis Score and percentage of total weight loss (r = -0.434, p < 0.0001), percentage of excess weight loss (r = -0.456, p < 0.0001) and percentage of excess body mass index loss (r = -0.512, p < 0.0001) were found.

CONCLUSIONS

The study supports the thesis that laparoscopic sleeve gastrectomy is an effective method for treatment of non-alcoholic fatty liver disease in patients with morbid obesity.

Residual Risk of Breast Cancer After Bariatric Surgery

Importance

Excess adiposity confers higher risk of breast cancer for women. For women who have lost substantial weight, it is unclear whether previous obesity confers residual increased baseline risk of breast cancer compared with peers without obesity.

Objectives

To determine whether there is a residual risk of breast cancer due to prior obesity among patients who undergo bariatric surgery.

Design, Setting, and Participants

Retrospective matched cohort study of 69 260 women with index date between January 1, 2010, and December 31, 2016. Patients were followed up for 5 years after bariatric surgery or index date. Population-based clinical and administrative data from multiple databases in Ontario, Canada, were used to match a cohort of women who underwent bariatric surgery for obesity (baseline body mass index [BMI] ≥35 with comorbid conditions or BMI ≥40) to women without a history of bariatric surgery according to age and breast cancer screening history. Nonsurgical controls were divided into 4 BMI categories (<25, 25-29, 30-34, and ≥35). Data were analyzed on October 21, 2021.

Exposures

Weight loss via bariatric surgery.

Main Outcomes and Measures

Residual hazard of breast cancer after washout periods of 1, 2, and 5 years. Comparisons were made between the surgical and nonsurgical cohorts overall and within each of the BMI subgroups.

Results

In total, 69 260 women were included in the analysis, with 13 852 women in each of the 5 study cohorts. The mean (SD) age was 45.1 (10.9) years. In the postsurgical cohort vs the overall nonsurgical cohort (n = 55 408), there was an increased hazard for incident breast cancer in the nonsurgical group after washout periods of 1 year (hazard ratio [HR], 1.40 [95% CI, 1.18-1.67]), 2 years (HR, 1.31 [95% CI, 1.12-1.53]), and 5 years (HR, 1.38 [95% CI, 1.21-1.58]). When the postsurgical cohort was compared with the nonsurgical cohort with BMI less than 25, the hazard of incident breast cancer was not significantly different regardless of the washout period, whereas there was a reduced hazard for incident breast cancer among postsurgical patients compared with nonsurgical patients in all high BMI categories (BMI ≥25).

Conclusions and Relevance

Findings suggest that bariatric surgery was associated with a reduced risk of developing breast cancer for women with prior obesity equivalent to that of a woman with a BMI less than 25 and a lower risk when compared with all groups with BMI greater than or equal to 25.

Global Impact of Obesity

The prevalence of preobesity and obesity is rising globally, multiple epidemiologic studies have identified preobesity and obesity as predisposing factors to a number of noncommunicable diseases including type 2 diabetes (T2DM), cardiovascular disease (CVD), and cancer. In this review, we discuss the epidemiology of obesity in both children and adults in different regions of the world. We also explore the impact of obesity as a disease not only on physical and mental health but also its economic impact.

Obesity, Preserved Ejection Fraction Heart Failure, and Left Ventricular Remodeling

Owing to the overwhelming obesity epidemic, preserved ejection fraction heart failure commonly ensues in patients with severe obesity and the obese phenotype of preserved ejection fraction heart failure is now commonplace in clinical practice. Severe obesity and preserved ejection fraction heart failure share congruent cardiovascular, immune, and renal derangements that make it difficult to ascertain whether the obese phenotype of preserved ejection fraction heart failure is the convergence of two highly prevalent conditions or severe obesity enables the development and progression of the syndrome of preserved ejection fraction heart failure. Nevertheless, the obese phenotype of preserved ejection fraction heart failure provides a unique opportunity to assess whether sustained and sizeable loss of excess body weight via metabolic bariatric surgery reverses the concentric left ventricular remodeling that patients with preserved ejection fraction heart failure commonly display.

Epicardial Fat in Heart Failure with Preserved Ejection Fraction: Bad Actor or Just Lying Around?

Heart failure with preserved ejection fraction (HFpEF) is increasingly recognised to be strongly associated with obesity and abnormalities in fat distribution. Epicardial fat has been associated with abnormal haemodynamics in HFpEF, with potential for direct mechanical effects on the heart causing constriction-like physiology and local myocardial remodelling effects from secretion of inflammatory and profibrotic mediators. However, patients with epicardial fat generally have more systemic and visceral adipose tissue making determination of causality between epicardial fat and HFpEF complex. In this review, we will summarise the evidence for epicardial fat being either directly causal in HFpEF pathogenesis or merely being a correlate of worse systemic inflammatory and generalised adiposity. We will also discuss therapies that directly target epicardial fat and may have potential for treating HFpEF and elucidating the independent role of epicardial fat in its pathogenesis.

Does ASA classification effectively risk stratify patients undergoing bariatric surgery: a MBSAQIP retrospective cohort of 138,612 of patients

INTRODUCTION

It is important to appropriately risk stratify bariatric surgery patients, as these patients often have obesity-related comorbidities which can increase postoperative complication risk but also benefit the most from bariatric surgery. We aimed to evaluate the utility of risk stratification using ASA class for bariatric surgery patients and assessed predictive factors of postoperative complications.

METHODS

The 2020 MBSAQIP database was analyzed, and an ASA-deemed high-risk cohort (class IV) and normal-risk (ASA class II and III) cohort were compared. Univariate analysis was performed to characterize differences between cohorts and to compare complication rates. Multivariate logistic regression analysis was performed to determine factors associated with increased odds of postoperative complications.

RESULTS

We evaluated 138 612 patients with 5380 (3.9%) considered high-risk and 133 232 (96.1%) normal-risk. High-risk patients were more likely to be older (46.2 ± 12.0vs.43.4 ± 11.9, p < 0.001), male (30.9%vs.18.4%, p < 0.001), have higher BMI (51.4 ± 10.2vs.44.9 ± 7.4, p < 0.001), and have more comorbidities. High-risk patients were more likely to have increased 30-day serious complications (4.5%vs.2.8%, p < 0.001) and death (0.2%vs.0.1%, p = 0.001) but not anastomotic leak (0.2%vs.0.2%, p = 0.983). Multivariate models showed ASA class IV patients were at higher odds for any serious complication by 30 days (aOR 1.36, 95%CI 1.18-1.56, p < 0.001) but not for death (aOR 1.04, 95%CI 0.49-2.21, p = 0.921). The factor independently associated with the highest odds of complication in both models was functional status preoperatively (partially dependent aOR 2.06, 95%CI 1.56-2.72, p < 0.001; fully dependent aOR 3.19, 95%CI 1.10-9.28, p = 0.033 for any serious complication; partially dependent aOR 5.08, 95%CI 2.16-12.00, p < 0.001 for death).

CONCLUSIONS

While elevated ASA class correlates with increased serious complications, pre-operative functional status appears to have a much greater contribution to odds of serious complications and mortality. These findings question the utility of using ASA to risk stratify patients peri-operatively and provides evidence for using a simpler and more practical functional status approach.

Effect of Prolonged and Substantial Weight Loss on Incident Atrial Fibrillation: A Systematic Review and Meta-Analysis

Background. Overweight and obesity are associated with atrial fibrillation (AF), and bariatric surgery (BS), able to induce sustained and prolonged weight loss, might represent the ideal treatment in the prevention of AF. Previous studies could not definitely establish a role for weight loss and BS in preventing incident AF so far. During the last few years, several studies on the effect of bariatric surgery on cardiovascular diseases have been published, and we performed a systematic review and meta-analysis to evaluate the role of weight loss through BS in the prevention of incident AF in obesity. Methods. This meta-analysis followed the PRISMA guideline. Eligible studies were controlled trials evaluating the appearance of atrial fibrillation in patients undergoing weight loss through BS as compared with patients receiving medical treatment. Quality of studies was assessed according to the Newcastle-Ottawa Quality Assessment Scale, and risk-of-bias was evaluated employing the Egger's test. All analyses were run by a random-effects model according to Hartung and Knapp and sensitivity analyses were performed. Heterogeneity was assessed through Q and I² statistics for each comparison, and potential publication bias was formally investigated. Results. Ten studies were included in the meta-analysis, and the overall result was statistically significant [OR = 0.665 (0.475-0.929), p = 0.017], with significant heterogeneity (Q = 48.98, p < 0.001; I² = 81.6%), but with no publication bias. In sensitivity analyses, the amount of weight loss, percentage of patients with diabetes and value of the Newcastle-Ottawa Quality Assessment Scale, were all associated with significance of effect. Since age was different in one study, a sensitivity analysis was performed by excluding this study; OR was similar [OR = 0.608 (0.454-0.814), p < 0.001]; heterogeneity was reduced but still significant (Q = 35.74, p < 0.001, I² = 77.6%) and again no publication bias was detected. Conclusions. Bariatric surgery as compared to medical treatment is associated with reduced appearance of incident AF.