Gastric Bypass Surgery Produces a Durable Reduction in Cardiovascular Disease Risk Factors and Reduces the Long-Term Risks of Congestive Heart Failure

Remission of type 2 diabetes: always more questions, but enough answers for action

The concept of type 2 diabetes remission is evolving rapidly, and gaining wide public and professional interest, following demonstration that with substantial intentional weight loss almost nine in ten people with type 2 diabetes can reduce their HbA1c level below the diagnostic criterion (48 mmol/mol [6.5%]) without glucose-lowering medications, and improve all features of the metabolic syndrome. Pursuing nomoglycaemia with older drugs was dangerous because of the risk of side effects and hypoglycaemia, so the conventional treatment target was an HbA1c concentration of 53 mmol/mol (7%), meaning that diabetes was still present and allowing disease progression. Newer agents may achieve a normal HbA1c safely and, by analogy with treatments that send cancers or inflammatory diseases into remission, this might also be considered remission. However, although modern glucagon-like peptide-1 receptor agonists and related medications are highly effective for weight loss and glycaemic improvement, and generally safe, many people do not want to take drugs indefinitely, and their cost means that they are not available across much of the world. Therefore, there are strong reasons to explore and research dietary approaches for the treatment of type 2 diabetes. All interventions that achieve sustained weight loss of >10-15 kg improve HbA1c, potentially resulting in remission if sufficient beta cell capacity can be preserved or restored, which occurs with loss of the ectopic fat in liver and pancreas that is found with type 2 diabetes. Remission is most likely with type 2 diabetes of short duration, lower HbA1c and a low requirement for glucose-lowering medications. Relapse is likely with weight regain and among those with a poor beta cell reserve. On current evidence, effective weight management should be provided to all people with type 2 diabetes as soon as possible after diagnosis (or even earlier, at the stage of prediabetes, defined in Europe, Australasia, Canada [and most of the world] as ≥42 and <48 mmol/mol [≥6.0 and <6.5%], and in the USA as HbA1c ≥39 and <48 mmol/mol [≥5.7 and <6.5%]). Raising awareness among people with type 2 diabetes and their healthcare providers that remission is possible will enable earlier intervention. Weight loss of >10 kg and remission lasting 1-2 years may also delay vascular complications, although more evidence is needed. The greatest challenge for research is to improve long-term weight loss maintenance, defining cost-effective approaches tailored to the preferences and needs of people living with type 2 diabetes.

Bariatric surgery mitigated electrocardiographic abnormalities in patients with morbid obesity

Obesity can lead to cardiovascular dysfunctions and cause electrocardiographic disruptions. Bariatric surgery plays a significant role in weight loss. To assess its benefits, this study investigated electrocardiographic changes before and after bariatric surgery. The present article describes a retrospective cohort study with a 6-month follow-up period. Electrocardiograms were interpreted and compared before and six months after surgery. The relationships between weight loss, type of surgery, and electrocardiographic alterations were analyzed. A total of 200 patients participated in the study, with 34 (17%) men and 166 (83%) women. The mean age of the participants was 44.6 ± 8.6, and their mean body mass index was 43.8 ± 5.5 kg/m2. The mean of QTc decreased after the surgery, while the Sokolow-Lyon scores increased. The statistical analysis showed that QTc dispersion (> 40) (P < 0.001), right ventricular hypertrophy (P < 0.001), abnormal R wave progression (P < 0.001), QTc (P < 0.001) and Sokolow-Lyon criteria (P < 0.001) significantly changed postoperatively. In conclusion, bariatric surgery can reduce QTc, correct poor R wave progression, and resolve right ventricular hypertrophy (RVH) in patients with morbid obesity.

A machine learning framework for optimizing obesity care by simulating clinical trajectories and targeted interventions

OBJECTIVE

This study aimed to determine the important clinical management bottlenecks that contribute to underuse of weight loss surgery (WLS) and assess risk factors for attrition at each of them.

METHODS

A multistate conceptual model of progression from primary care to WLS was developed and used to study all adults who were seen by a primary care provider (PCP) and eligible for WLS from 2016 to 2017 at a large institution. Outcomes were progression from each state to each subsequent state in the model: PCP visit, endocrine weight management referral, endocrine weight management visit, WLS referral, WLS visit, and WLS.

RESULTS

Beginning with an initial PCP visit, the respective 2-year Kaplan-Meier estimate for each outcome was 35% (n = 2063), 15.6% (n = 930), 6.3% (n = 400), 4.7% (n = 298), and 1.0% (n = 69) among 5876 eligible patients. Individual providers and clinics differed significantly in their referral practices. Female patients, younger patients, those with higher BMI, and those seen by trainees were more likely to progress. A simulated intervention to increase referrals among PCPs would generate about 49 additional WLS procedures over 3 years.

CONCLUSIONS

This study discovered novel insights into the specific dynamics underlying low WLS use rates. This methodology permits in silico testing of interventions designed to optimize obesity care prior to implementation.

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.

Prior metabolic surgery reduced COVID-19 severity: Systematic analysis from year one of the COVID-19 pandemic

Background

Obesity is a risk factor for COVID-19 severity. Recent studies suggest that prior metabolic surgery (MS) modifies the risk of COVID-19 severity.

Methods

COVID-19 outcomes were compared between patients with MS (n = 287) and a matched cohort of unoperated patients (n = 861). Multiple logistic regression was used to identify predictors of hospitalization. A systematic literature review and pooled analysis was conducted to provide overall evidence of the influence of prior metabolic surgery on COVID-19 outcomes.

Results

COVID-19 patients with MS had less hospitalization (9.8% versus 14.3%, p = 0.049). Age 70+, higher BMI, and low weight regain after MS were associated with more hospitalization after COVID-19. A systematic review of 7 studies confirmed that MS reduced the risk of post-COVID-19 hospitalization (OR = 0.71, 95%CI = [0.61-0.83], p < 0.0001) and death (OR = 0.44, 95%CI = [0.30-0.65], p < 0.0001).

Conclusion

MS favorably modifies the risks of severe COVID-19 infection. Older age and higher BMI are major risk factors for severity of COVID-19 infection.

Microvascular Function, Inflammatory Status, and Oxidative Stress in Post-Bariatric Patients with Weight Regain

Weight loss after bariatric surgery in obesity improves vascular function and metabolic/inflammatory profiles and reduces cardiovascular mortality but there are limited data on the effects of weight regain on vascular health. We compared the metabolic/inflammatory profiles, oxidative status, and vascular function of post-bariatric patients with a high ratio of weight regain (RWR) vs. non-surgical controls. Thirty-two post-bariatric patients [Roux-en-Y gastric bypass; aged = 44 ± 8 years, BMI = 40.1 ± 7.7 kg/m², and RWR = 58.7 ± 24.3%] and thirty controls that were BMI-, age-, and gender-matched entered the study. We collected clinical data, metabolic/inflammatory/oxidative stress circulating biomarkers, and endothelial/microvascular reactivity through Venous occlusion plethysmography and Laser speckle contrast imaging. The bariatric group exhibited lower neck circumference, fasting glucose, and triglycerides than the non-surgical group, while HDL-cholesterol was higher in the bariatric group (p < 0.001). There was no significant difference between groups for endothelial/microvascular reactivities (p ≥ 0.06). Resistin, leptin, endothelin-1, soluble forms of intercellular cell adhesion molecule-1 and vascular cell adhesion molecule-1, tumor necrosis factor-α, and thiobarbituric acid reactive substances did not differ significantly between groups (p ≥ 0.09) either. The adiponectin level was higher in the bariatric compared to the non-surgical group, while interleukin-6 was lower in the bariatric group (p < 0.001). Despite the fact that endothelial/microvascular functions were not significantly different between groups, post-bariatric patients present partially preserved metabolic/inflammatory benefits even with high RWR.

Anti-Diabetic Therapy and Heart Failure: Recent Advances in Clinical Evidence and Molecular Mechanism

Diabetic patients have a two- to four-fold increase in the risk of heart failure (HF), and the co-existence of diabetes and HF is associated with poor prognosis. In randomized clinical trials (RCTs), compelling evidence has demonstrated the beneficial effects of sodium-glucose co-transporter-2 inhibitors on HF. The mechanism includes increased glucosuria, restored tubular glomerular feedback with attenuated renin-angiotensin II-aldosterone activation, improved energy utilization, decreased sympathetic tone, improved mitochondria calcium homeostasis, enhanced autophagy, and reduced cardiac inflammation, oxidative stress, and fibrosis. The RCTs demonstrated a neutral effect of the glucagon-like peptide receptor agonist on HF despite its weight-reducing effect, probably due to it possibly increasing the heart rate via increasing cyclic adenosine monophosphate (cAMP). Observational studies supported the markedly beneficial effects of bariatric and metabolic surgery on HF despite no current supporting evidence from RCTs. Bromocriptine can be used to treat peripartum cardiomyopathy by reducing the harmful cleaved prolactin fragments during late pregnancy. Preclinical studies suggest the possible beneficial effect of imeglimin on HF through improving mitochondrial function, but further clinical evidence is needed. Although abundant preclinical and observational studies support the beneficial effects of metformin on HF, there is limited evidence from RCTs. Thiazolidinediones increase the risk of hospitalized HF through increasing renal tubular sodium reabsorption mediated via both the genomic and non-genomic action of PPARγ. RCTs suggest that dipeptidyl peptidase-4 inhibitors, including saxagliptin and possibly alogliptin, may increase the risk of hospitalized HF, probably owing to increased circulating vasoactive peptides, which impair endothelial function, activate sympathetic tones, and cause cardiac remodeling. Observational studies and RCTs have demonstrated the neutral effects of insulin, sulfonylureas, an alpha-glucosidase inhibitor, and lifestyle interventions on HF in diabetic patients.

Contemporary medical, device, and surgical therapies for obesity in adults

The goal of obesity management is to improve health. Sustained weight loss of more than 10% overall bodyweight improves many of the complications associated with obesity (eg, prevention and control of type 2 diabetes, hypertension, fatty liver disease, and obstructive sleep apnoea), as well as quality of life. Maintenance of weight loss is the major challenge of obesity management. Like all chronic diseases, managing obesity requires a long-term, multimodal approach, taking into account each individual's treatment goals, and the benefit and risk of different therapies. In conjunction with lifestyle interventions, anti-obesity medications and bariatric surgery improve the maintenance of weight loss and associated health gains. Most available anti-obesity medications act on central appetite pathways to reduce hunger and food reward. In the past 5 years, therapeutic advances have seen the development of targeted treatments for monogenic obesities and a new generation of anti-obesity medications. These highly effective anti-obesity medications are associated with weight losses of more than 10% of overall bodyweight in more than two-thirds of clinical trial participants. Long-term data on safety, efficacy, and cardiovascular outcomes are awaited. Long-term studies have shown that bariatric surgical procedures typically lead to a durable weight loss of 25% and rapid, sustained improvements in complications of obesity, although they have not yet been compared with new-generation highly effective anti-obesity medications. Further work is required to determine optimal patient-specific treatment strategies, including combinations of lifestyle interventions, anti-obesity medications, endoscopic and bariatric surgical procedures, and to ensure equitable access to effective treatments.

Risk of Myocardial Infarction, Ischemic Stroke, and Mortality in Patients Who Undergo Gastric Bypass for Obesity Compared With Nonoperated Obese Patients and Population Controls

OBJECTIVE

The aim of this study was to estimate risks of myocardial infarction, ischemic stroke, and cardiovascular-related and all-cause mortality after Roux-en-Y gastric bypass (RYGB) for obesity compared with nonop-erated obese patients and matched nonobese population controls.

BACKGROUND

Few studies have assessed the influence of RYGB on fatal and non-fatal myocardial infarction and ischemic stroke, and the results vary between studies.

METHOD

All patients aged 20 to 65 years with obesity diagnosis in the nationwide Swedish Patient Registry in 2001 to 2013 were included. These participants were divided into those who underwent RYGB within 2 years of obesity diagnosis (n = 28,204) and nonoperated (n = 40,827), and were matched for age, sex, and region with 2 nonobese population controls. Participants were followed until onset of outcome disease, death, or end of follow-up. Multivariable Cox regression provided hazard ratios (HR) with 95% confidence intervals (95% CI).

RESULTS

Compared with nonoperated patients with obesity, RYGB patients had a reduced risk of myocardial infarction [HR = 0.44 (95% CI 0.28-0.63)], similar risk of ischemic stroke [HR = 0.79 (95% CI 0.54-1.14)], and decreased risks of cardiovascular-related [HR = 0.47 (95% CI 0.35-0.65)] and all-cause mortality [HR = 0.66 (95% CI 0.54-0.81)] within the first 3 years of follow-up, but not later. Compared with nonobese population controls, RYGB patients had excess risks of ischemic stroke [HR = 1.57 (95% CI 1.08-2.29)], cardiovascular-related mortality [HR = 1.82 (95% CI 1.29-2.60)], and all-cause mortality [HR = 1.42 (95% CI 1.16-1.74)], but not of myocardial infarction [HR = 1.02 (95% CI 0.72-1.46)].

CONCLUSION

RYGB for obesity might not decrease the risk of ischemic stroke, but seems to decrease the risk of myocardial infarction back to population levels.

The Effects of Bariatric Surgery on Cardiovascular Outcomes and Cardiovascular Mortality: A Systematic Review and Meta-Analysis

Obesity is a major public health problem that is associated with serious comorbidities and premature mortality. Cardiovascular disease (CVD) is the major cause of morbidity and mortality associated with obesity. Lifestyle modifications, pharmacological therapy, and weight reduction surgery are the major interventions to date available for obesity management. Bariatric surgery has been increasingly utilized as a therapeutic option for obesity. In this meta-analysis, we aim to assess the effects of bariatric surgery on CVD outcomes and cardiovascular mortality. This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. PubMed, Embase, Cochrane Library, Google Scholar, and Web of Science were searched until 03/01/2022. Our search included three types of bariatric surgery: Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy, and gastric banding (GB). All were searched in conjunction with "coronary artery disease," "ischemic heart disease," "myocardial infarction," "cerebrovascular accident," "stroke," "atrial fibrillation," "heart failure," "arrhythmias," and "mortality." We included 49 studies meeting the study criteria. Bariatric surgery showed a beneficial effect on coronary artery disease (CAD) (hazard ratio (HR) of 0.68 {95% confidence interval (CI): 0.52-0.91}, p = 0.008), myocardial infarction (MI) (HR of 0.53 {95% CI: 0.44-0.64}, p < 0.01) heart failure (HF) (HR of 0.45 {95% CI: 0.37-0.55}, p < 0.01), cerebrovascular accident (CVA) (HR of 0.68 {95% CI: 0.59-0.78}, p < 0.01), and cardiovascular mortality (HR of 0.48 {95% CI: 0.40-0.57}, p < 0.01). The effect on atrial fibrillation (AF) did not reach statistical significance: HR of 0.81 (95% CI: 0.65-1.01), p = 0.07. Our study, that is, an updated meta-analysis, including the three types of procedure, confirms beneficial effects on the major CVD outcomes, including coronary artery disease, myocardial infarction, cerebrovascular accident, and heart failure, and on CVD mortality. This study provides updated insights into the long-term CV effects of bariatric surgery, an increasingly common intervention for obesity.

An Assessment of the Effect of Bariatric Surgery on Cardiovascular Disease Risk in the Chinese Population Using Multiple Cardiovascular Risk Models

BACKGROUND

Many studies have reported that bariatric surgery may reduce postoperative cardiovascular risk in patient with obesity, but few have addressed this risk in the Chinese population.

OBJECTIVE

To assess the impact of bariatric surgery on cardiovascular disease (CVD) risk in the Chinese population using the World Health Organization (WHO) risk model, the Global risk model, and the Framingham Risk Score.

METHODS

We retrospectively analyzed data collected on patient with obesity who underwent bariatric surgery at our institution between March 2009 and January 2021. Their demographic characteristics, anthropometric variables, and glucolipid metabolic parameters were assessed preoperatively and at their 1-year postoperative follow-up. Subgroup analysis compared body mass index (BMI) < 35 kg/m² and BMI ≥ 35 kg/m², as well as gender. We used the 3 models to calculate their CVD risk.

RESULTS

We evaluated 61 patients, of whom 26 (42.62%) had undergone sleeve gastrectomy (SG) surgery and 35 (57.38%) Roux-en-Y gastric bypass (RYGB) surgery. Of the patients with BMI ≥ 35 kg/m², 66.67% underwent SG, while 72.97% with BMI < 35 kg/m² underwent RYGB. HDL levels were significantly higher at 12 months postoperatively relative to baseline. When the models were applied to calculate CVD risk in Chinese patients with obesity, the 1-year CVD risk after surgery were reduced lot compared with the preoperative period.

CONCLUSION

Patient with obesity had significantly lower CVD risks after bariatric surgery. This study also demonstrates that the models are reliable clinical tools for assessing the impact of bariatric surgery on CVD risk in the Chinese population.

The effect of a randomised controlled lifestyle intervention on weight loss and plasma proneurotensin

AIMS

Proneurotensin (Pro-NT) is a strong predictor of cardiometabolic disease including type 2 diabetes and obesity, however, the effect of lifestyle change on Pro-NT has not been investigated in this context. Middle Eastern (ME) immigrants represent the largest and fastest growing minority population in Europe and are a high-risk population for obesity and type 2 diabetes. In this randomised controlled lifestyle intervention (RCT) addressing ME immigrants to Sweden where weight-loss was previously studied as the main outcome, as a secondary analysis we aimed to study change in Pro-NT during follow-up and if baseline Pro-NT predicted weight loss.

METHODS

Immigrants from the Middle East at high risk for type 2 diabetes were invited to participate in this RCT adapted lifestyle intervention of four months' duration. The intervention group (N = 48) received a culturally adapted lifestyle intervention comprising seven group sessions and a cooking class addressing healthier diet and increased physical activity. The control group (N = 44) received treatment as usual with information to improve lifestyle habits on their own. Data assessed using mixed effects regression.

OUTCOMES

Primary outcome; change in Pro-NT. Secondary outcome; change in BMI in relation to baseline plasma concentration of Pro-NT.

RESULTS

During the four months follow up, weight was significantly reduced in the intervention (-2.5 kg) compared to the control group (0.8 kg) (β -0.12, 95% CI -0.24 to -0.01, P = 0.028). Pro-NT increased to a significantly greater extent in the intervention compared to the control group during follow up (28.2 vs. 3.5 pmol/L) (β 11.4; 4.8 to 18.02, P < 0.001). Change over time in BMI was associated with baseline Pro-NT (β 0.02; 0.01 to 0.04, P = 0.041).

CONCLUSION

In consistence with data from surgical weight loss, this RCT paradoxically shows increased levels of Pro-NT during a multifactorial lifestyle intervention resulting in weight loss. Long term studies of Pro-NT following weight loss are needed.

TRIAL REGISTRATION

This study is a secondary analysis of the RCT trial registered at www.

CLINICALTRIALS

gov .

REGISTRATION NUMBER

NCT01420198. Date of registration 19/08/2011. The performance and results of this trial conform to the CONSORT 2010 guidelines.

Japanese traditional Kampo medicine bofutsushosan improves body mass index in participants with obesity: A systematic review and meta-analysis

Background

The number of people with obesity is rapidly increasing worldwide. Since obesity is a critical risk factor for cardiovascular diseases and mortality, the management of obesity is an urgent issue. However, anti-obesity drugs are insufficient in current clinical settings. Bofutsushosan (BTS, Fang-Feng-Tong-Sheng-San in China) is a traditional Japanese Kampo formula for patients with obesity. Recent basic studies have indicated that BTS potentially improves the pathophysiology of obesity. However, it is still unknown whether BTS clinically reduces body mass index (BMI) in patients with obesity.

Methods

We searched electronic databases, including the Medline, EMBASE, Cochrane Library, and Japanese/Chinese/Korean databases, on June 15, 2021. We conducted a meta-analysis of randomized controlled trials to evaluate the effects of BTS on BMI, waist circumference, glycolipid metabolism, and blood pressure in participants with obesity. The primary outcome was change in BMI.

Results

We included seven studies and 679 participants (351 in the BTS group and 328 in the control group). In participants with obesity, BTS significantly reduced BMI relative to controls (mean difference, MD [95% confidence interval]: −0.52 kg/m2 [−0.86, −0.18], P = 0.003). There was no significant difference in waist circumference, glycolipid parameters, or blood pressure. Sensitivity analyses showed robust outcomes for the primary endpoint, although the heterogeneity was considerable. Moreover, no serious adverse events were observed in the BTS group.

Conclusion

BTS showed a potential benefit in safely and tolerably improving BMI in participants with obesity.

Roux-en-Y Gastric Bypass Modulates AMPK, Autophagy and Inflammatory Response in Leukocytes of Obese Patients

Obesity is characterized by low-grade chronic inflammation, metabolic overload, and impaired endothelial and cardiovascular function. Roux-en-Y gastric bypass (RYGB) results in amelioration of the pro-oxidant status of leukocytes and the metabolic profile. Nevertheless, little is known about the precise mechanism that drives systemic and metabolic improvements following bariatric surgery. In this cohort study, we investigated the effect of RYGB on molecular pathways involving energy homeostasis in leukocytes in 43 obese subjects one year after surgery. In addition to clinical and biochemical parameters, we determined protein expression of systemic proinflammatory cytokines by Luminex®, different markers of inflammation, endoplasmic reticulum (ER) stress, autophagy/mitophagy by western blot, and mitochondrial membrane potential by fluorescence imaging. Bariatric surgery induced an improvement in metabolic outcomes that was accompanied by a systemic drop in hsCRP, IL6, and IL1β levels, and a slowing down of intracellular inflammatory pathways in leukocytes (NF-κB and MCP-1), an increase in AMPK content, a reduction of ER stress (ATF6 and CHOP), augmented autophagy/mitophagy markers (Beclin 1, ATG5, LC3-I, LC3-II, NBR1, and PINK1), and a decrease of mitochondrial membrane potential. These findings shed light on the specific molecular mechanisms by which RYGB facilitates metabolic improvements, highlighting the relevance of pathways involving energy homeostasis as key mediators of these outcomes. In addition, since leukocytes are particularly exposed to physiological changes, they could be used in routine clinical practice as a good sensor of the whole body’s responses.

“Greedy Organs Hypothesis” for sugar and salt in the pathophysiology of non-communicable diseases in relation to sodium-glucose co-transporters in the intestines and the kidney

Deposition of visceral fat and insulin resistance play central role in the development of non-communicable diseases (NCDs) including obesity, hypertension and type 2 diabetes. However, we shed more light upon the intestines and the kidney as a strong driver of NCDs. Based upon unexpected outcomes of clinical trials using sodium-glucose cotransporter (SGLT) 2 inhibitors to demonstrate their actions for not only body weight reduction and blood glucose fall but also remarkable cardiorenal protection, we speculate that hyperfunction of the intestines and the kidney is one of critical contributing factors for initiation of NCDs. By detecting high amount of glucose and sodium chloride around them by sweet/salt taste sensors, the intestines and the kidney are designed to (re)absorb these nutrients by up-regulating SGLT1 or SGLT2. We designate these hyperfunctioning organs for nutrient uptake as “greedy organs”. The greedy organs can induce NCDs (“greedy organ hypothesis”). SGLTs are regulated by glucose and sodium chloride, and SGLTs or other genes can be “greedy genes.” Regulating factors for greedy organs are renin-angiotensin system, renal sympathetic nervous activity, gut inflammation/microbiota or oxidative stress. Mitigation of organ greediness by SGLT2 inhibitors, ketone bodies, bariatric surgery, and regular lifestyle to keep rhythmicity of biological clock are promising.

•

We propose the concept of “Greedy Organs” hypothesis as a possible cause of NCDs.

•

Clinical implication of greedy kidney is supported by the effect of SGLT2 inhibitors.

•

The significance of greedy intestines is suggested by the effect of bariatric surgery.

•

The intestines and kidney become hyperactive through upregulation of SGLT1 or 2.

•

To mitigate “greedy organs” should be a promising strategy against NCDs.

Roux-en-Y Gastric Bypass Is Associated With Increased Hazard for De Novo Alcohol-related Complications and Liver Disease

GOAL

The goal of this study was to determine if bariatric surgeries are associated with de novo alcohol-related complications.

BACKGROUND

Bariatric surgery is associated with an increased risk of alcohol use disorders. The effect of bariatric surgeries on other alcohol-related outcomes, including liver disease, is understudied.

MATERIALS AND METHODS

Using the IMS PharMetrics database, we performed a cohort study of adults undergoing bariatric surgery or cholecystectomy, excluding patients with an alcohol-related diagnosis within 1 year before surgery. The primary outcome was any alcohol-related diagnosis after surgery. We fit a multivariable Cox proportional hazards model to determine independent associations between bariatric surgeries [Roux-en-Y gastric bypass (RYGB); adjustable gastric band; sleeve gastrectomy] versus cholecystectomy and the development of de novo alcohol-related outcomes. We further fit complication-specific models for each alcohol-related diagnosis.

RESULTS

RYGB was significantly associated with an increased hazard of any de novo alcohol-related diagnosis [adjusted hazard ratio (AHR)=1.51, 95% confidence interval (CI): 1.40-1.62], while adjustable gastric band (AHR=0.55, 95% CI: 0.48-0.63) and sleeve gastrectomy (AHR=0.77, 95% CI: 0.64-0.91) had decreased hazards. RYGB was associated with a 2- to 3-fold higher hazard for alcoholic hepatitis (AHR=1.98, 95% CI: 1.17-3.33), abuse (AHR=2.05, 95% CI: 1.88-2.24), and poisoning (3.14, 95% CI: 1.80-5.49).

CONCLUSIONS

RYGB was associated with higher hazards of developing de novo alcohol-related hepatitis, abuse, and poisoning compared with a control group. Patients without a history of alcohol use disorder should still be counseled on the increased risk of alcohol use and alcohol-related complications, including alcohol-related liver disease, following RYGB, and should be monitored long term for the development of alcohol-related complications.

Changes in Antihypertensive Medication Following Bariatric Surgery

Obesity is a leading cause of hypertension (i.e., high blood pressure [BP]). While hypertension can be managed with antihypertensive medication, substantial weight loss can also lower BP, reducing the need for antihypertensive medication. Articles in this review (n = 60) presented data on antihypertensive medication use among adults pre- and postoperatively. Roux-en-Y gastric bypass was the most studied surgical approach followed by Laparoscopic Sleeve Gastrectomy. Antihypertensive medication was discontinued in a large proportion of patients after surgery, and the mean number of antihypertensive medications decreased by approximately one. In almost a third of the studies, over 75% of participants experienced hypertension remission. All articles aside from two reported a decrease in systolic BP, with about 40% reporting a decrease of ≥ 10 mm Hg.

Obesity management as a primary treatment goal for type 2 diabetes: time to reframe the conversation

Obesity is now recognised as a disease that is associated with serious morbidity and increased mortality. One of its main metabolic complications is type 2 diabetes, as the two conditions share key pathophysiological mechanisms. Weight loss is known to reverse the underlying metabolic abnormalities of type 2 diabetes and, as such, improve glucose control; loss of 15% or more of bodyweight can have a disease-modifying effect in people with type 2 diabetes, an outcome that is not attainable by any other glucose-lowering intervention. Furthermore, weight loss in this population exerts benefits that extend beyond glycaemic control to improve risk factors for cardiometabolic disease and quality of life. We review the evidence supporting the role of weight loss in the management of type 2 diabetes and propose that many patients with type 2 diabetes would benefit from having a primary weight-centric approach to diabetes treatment. We discuss the logistical challenges to implementing a new weight-centric primary treatment goal in people with type 2 diabetes.

OUP accepted manuscript

Aims

Obesity is a global health problem, associated with significant morbidity and mortality, often due to cardiovascular (CV) diseases. While bariatric surgery is increasingly performed in patients with obesity and reduces CV risk factors, its effect on CV disease is not established. We conducted a systematic review and meta-analysis to evaluate the effect of bariatric surgery on CV outcomes, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

Methods and results

PubMed and Embase were searched for literature until August 2021 which compared bariatric surgery patients to non-surgical controls. Outcomes of interest were all-cause and CV mortality, atrial fibrillation (AF), heart failure (HF), myocardial infarction, and stroke. We included 39 studies, all prospective or retrospective cohort studies, but randomized outcome trials were not available. Bariatric surgery was associated with a beneficial effect on all-cause mortality [pooled hazard ratio (HR) of 0.55; 95% confidence interval (CI) 0.49–0.62, P < 0.001 vs. controls], and CV mortality (HR 0.59, 95% CI 0.47–0.73, P < 0.001). In addition, bariatric surgery was also associated with a reduced incidence of HF (HR 0.50, 95% CI 0.38–0.66, P < 0.001), myocardial infarction (HR 0.58, 95% CI 0.43–0.76, P < 0.001), and stroke (HR 0.64, 95% CI 0.53–0.77, P < 0.001), while its association with AF was not statistically significant (HR 0.82, 95% CI 0.64–1.06, P = 0.12).

Conclusion

The present systematic review and meta-analysis suggests that bariatric surgery is associated with reduced all-cause and CV mortality, and lowered incidence of several CV diseases in patients with obesity. Bariatric surgery should therefore be considered in these patients.

Weight-loss thresholds after bariatric surgery and cardiovascular outcomes: more is better

BACKGROUND/OBJECTIVES

Whether the extent of weight loss (WL) modulates bariatric surgery (BS) cardiovascular benefits has scarcely been assessed. Several WL thresholds have been commonly used to classify BS patients as good or poor responders without a proven clinical relevance. We examined the relationship between the magnitude of WL after BS and post-surgery major adverse cardiovascular-event (MACE) incidence. We also compared the performance of three different insufficient weight-loss (IWL) criteria for their association with MACE.

SUBJECTS AND METHODS

All individuals who underwent a primary Roux-en Y gastric bypass (RYGB) or sleeve gastrectomy (SG) in our institution at least six years before data analysis (12/2020) were included in the study. Data on MACE were available in 1638 of 1700 participants (96.4%). Proportional-hazard Cox analyses were performed to ascertain the association between MACE, WL, and the three IWL criteria. IWL was defined as: <50% excess weight loss (<50% EWL), <20% total body-weight loss (<20% TBWL), and -1 standard deviation of alterable weight-loss percentage (<1 SD% AWL).

RESULTS

During a mean follow-up of 10.2 ± 2.8 years, 86 participants experienced a first post-surgery MACE. Higher WL at one year (HR: 0.77 (95% CI: 0.61-0.98)) and 5 years (HR: 0.63 (95% CI: 0.42-0.92)) was related to a lower incidence of MACE. All short-term criteria for defining IWL were similarly associated with MACE, yet <1 SD% AWL identified more at-risk subjects. Five-year TBWL < 20% and 5-year <1 SD-AWL% were significantly associated with a higher risk for CV events. TBWL < 20% identified more subjects at risk.

CONCLUSIONS

The extent of WL is closely related to long-term MACE incidence. Patients who lost -1SD% AWL at one year or <20% TBWL at five years may be considered poor responders.

Clinical epigenetics and restoring of metabolic health in severely obese patients undergoing batriatric and metabolic surgery

Epigenetic-sensitive mechanisms, mainly DNA methylation, mirror the relationship between environmental and genetic risk factors able to affect the sensitiveness to development of obesity and its comorbidities. Bariatric and metabolic surgery may reduce obesity-related cardiovascular risk through tissue-specific DNA methylation changes. Among the most robust results, differential promoter methylation of ACACA, CETP, CTGF, S100A8, and S100A9 genes correlated significantly with the levels of mRNA before and after gastric bypass surgery (RYGB) in obese women. Additionally, promoter hypermethylation of NFKB1 gene was significantly associated with reduced blood pressure in obese patients after RYGB suggesting useful non-invasive biomarkers. Of note, sperm-related DNA methylation signatures of genes regulating the central control of appetite, such as MC4R, BDNF, NPY, and CR1, and other genes including FTO, CHST8, and SH2B1 were different in obese patients as compared to non-obese subjects and patients who lost weight after RYGB surgery. Importantly, transgenerational studies provided relevant evidence of the potential effect of bariatric and metabolic surgery on DNA methylation. For example, peripheral blood biospecimens isolated from siblings born from obese mothers before bariatric surgery showed different methylation signatures in the insulin receptor and leptin signaling axis as compared to siblings born from post-obese mothers who underwent surgery. This evidence suggests that bariatric and metabolic surgery of mothers may affect the epigenetic profiles of the offspring with potential implication for primary prevention of severe obesity. We update on tissue-specific epigenetic signatures as potential mechanisms underlying the restoration of metabolic health after surgery suggesting useful predictive biomarkers.

Effect of Bariatric Surgery on Survival and Hospitalizations in Patients with Severe Obesity. A Retrospective Cohort Study

Bariatric surgery (BS) confers a survival benefit in specific subsets of patients with severe obesity; otherwise, effects on hospital admissions are still uncertain. We assessed the long-term effect on mortality and on hospitalization of BS in patients with severe obesity. This was a retrospective cohort study, including all patients residing in Piedmont (age 18-60 years, BMI ≥ 40 kg/m²) admitted during 2002-2018 to the Istituto Auxologico Italiano. Adjusted hazard ratios (HR) for BS were estimated for mortality and hospitalization, considering surgery as a time-varying variable. Out of 2285 patients, 331 (14.5%) underwent BS; 64.4% received sleeve gastrectomy (SG), 18.7% Roux-en-Y gastric bypass (RYGB), and 16.9% adjustable gastric banding (AGB). After 10-year follow-up, 10 (3%) and 233 (12%) patients from BS and non-BS groups died, respectively (HR = 0.52; 95% CI 0.27-0.98, by a multivariable Cox proportional-hazards regression model). In patients undergoing SG or RYGB, the hospitalization probability decreased significantly in the after-BS group (HR = 0.77; 0.68-0.88 and HR = 0.78; 0.63-0.98, respectively) compared to non-BS group. When comparing hospitalization risk in the BS group only, a marked reduction after surgery was found for all BS types. In conclusion, BS significantly reduced the risk of all-cause mortality and hospitalization after 10-year follow-up.

Obesity Management in Cardiometabolic Disease: State of the Art

PURPOSE OF REVIEW

To summarize research from the last 5 years on the effects of weight loss treatments, including lifestyle changes, anti-obesity medications, and bariatric procedures on cardiovascular disease (CVD) risk factors and CVD outcomes in adults.

RECENT FINDINGS

This narrative review includes and summarizes the contemporary evidence of the effects of these different weight loss approaches individually. A literature search was performed using the key words obesity, weight loss, CVD, cardiometabolic, and risk factors and included key clinical trials from the past 5 years. Obesity management through weight loss is associated with improvements in CVD risk factors, such as improved blood pressure, lipid profiles, and glycemic control, with greater weight loss leading to greater improvements in CVD risk factors. Bariatric surgery is associated with greater weight loss than the other procedures and treatments for obesity, and for this, and possibly for other reasons, it is associated with greater reductions in CVD outcomes and mortality. Obesity is an independent risk factor and modulator of other CVD risk factors, and thus, treatment of obesity should be an integral part of management strategies to reduce CVD risk. Future trials and real-world studies of longer duration are needed to inform providers and patients on how to individualize the approach to modifying risks of cardiometabolic disorders through obesity management.

Effects of bariatric surgery on kidney diseases, cardiovascular diseases, mortality and severe hypoglycaemia among patients with Type 2 diabetes mellitus

BACKGROUND

Bariatric surgery has been widely indicated for the management of obesity and related comorbidities. However, there are uncertainties pertaining to the risks of post-bariatric severe hypoglycaemia (SH), cardiovascular diseases (CVDs), end-stage kidney diseases (ESKDs) and all-cause mortality in obese patients with Type 2 diabetes mellitus (T2DM), especially among Asian populations.

METHODS

A retrospective population-based cohort of 1702 obese T2DM patients who were free of CVD and ESKD were assembled based on the 2006-17 Hospital Authority database. One-to-five propensity-score matching was used to balance baseline covariates between patients in bariatric surgery and control groups. Incidence rates (IRs) of SH, CVD, Stage 4/5 chronic kidney diseases (CKD), ESKD and all-cause mortality events for two groups were calculated. Hazard ratios (HR) for SH, CVD and Stage 4/5 CKD events were assessed using Cox-proportional hazard models. Changes in estimated glomerular filtration rate (eGFR) and urine albumin-creatinine ratio (UACR) were measured up to 60 months.

RESULTS

Over a mean follow-up period of 32 months with 5725 person-years, cumulative incidences of mortality, CVD, Stage 4/5 CKD, ESKD and SH were 0, 0.036, 0.050, 0.017 and 0.020, respectively. The surgery group had a significant reduction in risk of CVD events (HR = 0.464, P = 0.015) and no occurrence of mortality events. However, there were no significant differences in risks of SH [HR = 0.469, 95% confidence interval (CI): 0.204-1.081], Stage 4/5 CKD (HR =0.896, 95% CI: 0.519-1.545) and ESKD (HR = 0.666, 95% CI: 0.264-1.683) between two groups, although IRs were lower in the surgery group. Surgical patients had significantly higher eGFR within 12 months and had significantly lower UACR until 48 months.

CONCLUSIONS

Among obese T2DM patients, bariatric surgery lowered the risk of CVD and mortality, and was beneficial towards the kidney outcomes.

Cardiovascular Safety and Superiority of Anti-Obesity Medications

Over the past few decades, several anti-obesity medications have demonstrated an association with adverse cardiovascular outcomes, leading to their market withdrawal. This has caused researchers to investigate the cardiovascular safety of such medications in cardiovascular outcome trials. However, the data from these trials are limited, and their outcomes are not promising. Therefore, the aim of this review is to provide an overview of the current and past Food and Drug Administration-approved medications for weight loss, including novel diabetes medications (glucagon-like peptide 1 receptor agonists and sodium-glucose co-transporter-2 inhibitors) and non-diabetes medications, and to highlight the current designs of cardiovascular outcome trials and their importance in the evaluation of the overall safety concerns associated with these anti-obesity medications. The limitations of the trials and opportunities for improvement were also evaluated. Finally, we also briefly describe cardiovascular safety and risks in this review.

Association of Bariatric Surgery With Vascular Outcomes

IMPORTANCE

Bariatric surgical weight loss is associated with reduced cardiovascular mortality; however, the mechanisms underlying this association are incompletely understood.

OBJECTIVES

To identify variables associated with vascular remodeling after bariatric surgery and to examine how sex, race, and metabolic status are associated with microvascular and macrovascular outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This population-based longitudinal cohort included 307 individuals who underwent bariatric surgery. Participants were enrolled in the bariatric weight loss program at Boston Medical Center, a large, multi-ethnic urban hospital, with presurgical and postsurgical assessments. Data were collected from December 11, 2001 to August 27, 2019. Data were analyzed in September 2019.

EXPOSURE

Bariatric surgery.

MAIN OUTCOMES AND MEASURES

Flow-mediated dilation (FMD) and reactive hyperemia (RH) (as measures of macrovascular and microvascular function, respectively) and clinical variables were measured preoperatively at baseline and at least once postoperatively within 12 months of the bariatric intervention.

RESULTS

A total of 307 participants with obesity (mean [SD] age, 42 [12] years; 246 [80%] women; 199 [65%] White; mean [SD] body mass index, 46 [8]) were enrolled in this study. Bariatric surgery was associated with significant weight loss and improved macrovascular and microvascular function across subgroups of sex, race, and traditional metabolic syndrome (mean [SD] pre- vs postsurgery weight: 126 [25] kg vs 104 [25] kg; P < .001; mean [SD] pre- vs postsurgery FMD: 9.1% [5.3] vs 10.2% [5.1]; P < .001; mean [SD] pre- vs postsurgery RH: 764% [400] vs 923% [412]; P < .001). Factors associated with change in vascular phenotype correlated most strongly with adiposity markers and several metabolic variables depending on vascular territory (eg, association of weight change with change in RH: estimate, -3.2; 95% CI, -4.7 to -1.8; association of hemoglobin A1c with change in FMD: estimate, -0.5; 95% CI, -0.95 to -0.05). While changes in macrovascular function among individuals with metabolically healthy obesity were not observed, the addition of biomarker assessment using high-sensitivity C-reactive protein plasma levels greater than 2 mg/dL identified participants with seemingly metabolically healthy obesity who had low-grade inflammation and achieved microvascular benefit from weight loss surgery.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that bariatric intervention is associated with weight loss and favorable remodeling of the vasculature among a wide range of individuals with cardiovascular risk. Moreover, differences in arterial responses to weight loss surgery by metabolic status were identified, underscoring heterogeneity in physiological responses to adiposity change and potential activation of distinct pathological pathways in clinical subgroups. As such, individuals with metabolically healthy obesity represent a mixed population that may benefit from more refined phenotypic classification.

Early benefits of bariatric surgery on subclinical cardiac function: Contribution of visceral fat mobilization

AIMS

We explored the early effects of bariatric surgery on subclinical myocardial function in individuals with severe obesity and preserved left ventricular (LV) ejection fraction.

METHODS

Thirty-eight patients with severe obesity [body mass index (BMI) ≥35 kg/m²] and preserved LV ejection fraction (≥50%) who underwent bariatric surgery (biliopancreatic diversion with duodenal switch [BPD-DS]) (Surgery group), 19 patients with severe obesity managed with usual care (Medical group), and 18 age and sex-matched non-obese controls (non-obese group) were included. Left ventricular global longitudinal strain (LV GLS) was evaluated with echocardiography speckle tracking imaging. Abnormal myocardial function was defined as LV GLS <18%.

RESULTS

Age of the participants was 42 ± 11 years with a BMI of 48 ± 8 kg/m² (mean ± standard deviation); 82% were female. The percentage of total weight loss at 6 months after bariatric surgery was 26.3 ± 5.2%. Proportions of hypertension (61 vs. 30%, P = 0.0005), dyslipidemia (42 vs. 5%, P = 0.0001) and type 2 diabetes (40 vs. 13%, P = 0.002) were reduced postoperatively. Before surgery, patients with obesity displayed abnormal subclinical myocardial function vs. non-obese controls (LV GLS, 16.3 ± 2.5 vs. 19.6 ± 1.7%, P < 0.001). Six months after bariatric surgery, the subclinical myocardial function was comparable to non-obese (LV GLS, 18.2 ± 1.9 vs. 19.6 ± 1.7%, surgery vs. non-obese, P = NS). On the contrary, half of individuals with obesity managed medically worsened their myocardial function during the follow-up (P = 0.002). Improvement in subclinical myocardial function following bariatric surgery was associated with changes in abdominal visceral fat (r = 0.43, P < 0.05) and inflammatory markers (r = 0.45, P < 0.01), whereas no significant association was found with weight loss or change in insulin sensitivity (HOMA-IR) (P > 0.05). In a multivariate model, losing visceral fat mass was independently associated with improved subclinical myocardial function.

CONCLUSIONS

Bariatric surgery was associated with significant improvement in the metabolic profile and in subclinical myocardial function. Early improvement in subclinical myocardial function following bariatric surgery was related to a greater mobilization of visceral fat depot, linked to global fat dysfunction and cardiometabolic morbidity.

Update on Metabolic Bariatric Surgery for Morbidly Obese Adolescents

Despite worldwide public attention and intense medical efforts, the prevalence of severe morbid obesity in children and adolescents is still rising. Similar to adults, excess adipose tissue triggers multiple immunological and metabolic pathways leading to serious co-morbidities such as impaired glucose tolerance or even type 2 diabetes (T2D), dyslipidemia, arterial hypertension, non-alcoholic fatty liver disease, and hyperuricemia. The management of severe childhood obesity requires a life-long multidisciplinary approach with a combination of lifestyle changes, nutrition, and medications. Standardized life-style intervention programs remain the first-line treatment for morbid obese children and adolescents, but unfortunately reveal limited long-term success. In such cases, metabolic bariatric surgery (MBS) has evolved from being a controversial issue to being included in distinct recommendations. According to the American Society for Metabolic and Bariatric Surgery (ASMBS) Pediatric Committee, indications for bariatric surgery in adolescence must follow very strict criteria. Adolescents with class II obesity (BMI > 120% of the 95th percentile) and a diagnosed co-morbidity or with class III obesity (BMI ≥ 140% of the 95th percentile) should be considered for MBS. These interventions represent high-risk operations, and adolescents should be treated in specialized, multidisciplinary high-volume obesity centers with long-term follow-up programs. The Roux-en-Y gastric bypass (RYGB) remains the gold standard of all malabsorptive procedures. Laparoscopic sleeve gastrectomy (LSG), which the authors pioneered as a stand-alone procedure in morbidly obese adolescents in 2008, has become the most commonly performed operation in morbidly obese adolescents at present. Recent literature proves that MBS is safe and effective in morbidly obese adolescents. Mid-term data have revealed significant improvement or even resolution of major co-morbidities. Thus, MBS for the treatment of morbidly obese adolescents has evolved from being a controversial issue to being included in distinct recommendations by several medical societies as a therapeutic strategy to reduce severe co-morbidities potentially causing end-organ damage in adulthood.

Relation of Bariatric Surgery to Inpatient Cardiovascular Outcomes (from the National Inpatient Sample)

Approximately one in 3 patients in the United States are obese. There is a strong association between obesity and an increased rate of cardiovascular disease (CVD)-related mortality. Bariatric surgery (BS) has emerged as an effective strategy to achieve reduction of excess weight. Our study aims to explore the relationship between BS and major adverse cardiovascular events (MACE) among obese hospitalized patients in the United States. This is a retrospective study of all obese adult patients with BMI ≥35 kg/m² (n= 1,700,943) in the National Inpatient Sample between 2012 and 2016. Differences in the clinical characteristics of obese patients with a history of BS versus obese patients without a history of BS were analyzed as well as the association between BS and MACE after adjusting for CVD risk factors. Among 50,296 obese patients with a history of BS (2.96%), the mean age was 53 ± 12 years with the majority being female (75.32%) and Caucasian (71.85%). Multivariate analysis revealed that obese patients with a history of BS had a1.6-fold decrease odds of MACE compared with patients without BS (OR 0.62; 95% CI, 0.60 to 0.65; p <0.001). In conclusion, this study illustrates that among obese patients with BMI ≥35 kg/m², history of BS was associated with a significantly lower odds of inpatient MACE, after adjusting for CVD risk factors.

Left ventricular mass index and ventricular contractility improvement in patients with severe obesity following rapid weight loss after bariatric surgery

BACKGROUND

Obesity is a well-known risk factor for heart disease, resulting in a broad spectrum of cardiovascular changes. Left ventricular mass (LVM) and contractility are recognized markers of cardiac function.

OBJECTIVES

To determine the changes of LVM and contractility after bariatric surgery (BaS).

SETTING

University hospital, United States METHODS: To determine the cardiac changes in ventricular mass, ventricular contractility, and left ventricular shortening fraction (LVSF), we retrospectively reviewed the 2-dimensional echocardiographic parameters of patients with obesity who underwent BaS at our institution. We compared these results before and after BaS.

RESULTS

A total of 40 patients met the inclusion criteria. The majority were females (57.5%; n = 23), with an average age of 63.5 ± 12.1. The excess body mass index (BMI) lost at 12 months was 48.9 ± 28.9%. The percent total weight loss after BaS was 16.46 ± 9.9%. The left ventricular mass was 234.9 ± 88.1 grams before and 181.5 ± 52.7 grams after BaS (P = .002). The LVM index was 101.3 ± 38.3 g/m² before versus 86.7 ± 26.6 g/m² after BaS (P = .005). The LVSF was 31% ± 8.8% before and 36.3% ± 8.2% after BaS (P = .007). We found a good correlation between the decrease in LVM index and the BMI after BaS (P = .03).

CONCLUSION

Rapid weight loss results in a decrease of the LVM index, as well as improvement in the left ventricular muscle contractility. Our results suggest that there is left ventricular remodeling and an improvement of heart dynamics following bariatric surgery. Further studies are needed to better assess these findings.

Safety of Bariatric Surgery in Patients With Congestive Heart Failure: Results of an 11-Year Retrospective Study

INTRODUCTION

Congestive heart failure (CHF) is a known risk factor for increased postoperative morbidity. However, the safety in patients with CHF has not been well established. The objective of this study was to assess the safety of surgery in patients with a history of CHF undergoing bariatric surgical procedures.

METHODS

Retrospective review of a prospectively maintained Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Center of Excellence database. Patients with known CHF undergoing bariatric procedures over an 11-year period were reviewed.

RESULTS

Over the 11-year period, 4470 total bariatric surgeries were performed, of which 41 (.92%) patients had known CHF. Twenty-one patients were men (51.2%) with a mean age of 55.8 years and mean body mass index (BMI) of 51.9. Comorbidities included hypertension (87.8%), obstructive sleep apnea (80.5%), osteoarthritis (63.4%), gastroesophageal reflux disease (56%), and diabetes (53.7%). Surgical procedures included 16 sleeve gastrectomies (SGs) (39%), 11 Roux-en-Y gastric bypasses (RYGBs) (26.8%), 10 laparoscopic adjustable gastric bands (LAGBs) (24.4%), 1 removal of a gastric band and conversion to SG (2.4%), 1 removal of a gastric band to RYGB (2.4%), 1 gastric band over RYGB pouch (2.4%), and 1 gastric band replacement (2.4%). All cases were performed minimally invasively (73.2% laparoscopic and 26.8% robotic). Mean LOS was 2.53 days. Thirty-day complications included 2 readmissions (4.9% [1 small bowel obstruction and 1 pulmonary edema]), 1 reoperation (2.4% [small bowel obstruction]), and 1 mortality (2.4%) on postoperative day 30 unrelated to the surgery.

CONCLUSIONS

Bariatric surgery can be performed safely in patients with CHF.

Long-term incidence and outcomes of obesity-related peripheral vascular disease after bariatric surgery

Background and aims

Patients with obesity are at high risk of suffering from arterial and venous peripheral vascular disease (PVD). Bariatric surgery is an effective strategy to achieve weight reduction for patients with obesity. The long-term impact of bariatric surgery on obesity-related morbidity is subject to increasing research interest. This study aimed to ascertain the impact of bariatric surgery on the long-term occurrence of PVD in patients with obesity.

Methods

The study population was extracted from the Clinical Practice Research Datalink, a nation-wide database containing primary and secondary care records of consenting patients. The intervention cohort was 2959 patients who had undergone bariatric surgery during follow-up; their controls were 2959 propensity-score-matched counterparts. The primary endpoint was development of any PVD: arterial or venous. Secondary endpoints were incident peripheral arterial disease alone, incident peripheral venous disease alone.

Results

Three hundred forty-six patients suffered a primary endpoint during follow-up. Bariatric surgery did not improve peripheral vascular disease rates as a whole, but it was associated with significantly lower event rates of arterial disease (HR = 0.560, 95%CI 0.327–0.959, p = 0.035) but higher event rates of venous disease (HR = 1.685, 95%CI 1.256–2.262, p < 0.001).

Conclusions

Bariatric surgery was associated with significantly reduced long-term occurrence of arterial disease but increased occurrence of venous disease in patients with obesity.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-020-02066-9.

Effect of one-anastomosis gastric bypass on cardiovascular risk factors in patients with vitamin D deficiency and morbid obesity: A secondary analysis

BACKGROUND AND AIMS

Bariatric patients often suffer from vitamin D (VD) deficiency, and both, morbid obesity and VD deficiency, are related to an adverse effect on cardiovascular disease (CVD) risk. Therefore, we assessed the change of known CVD risk factors and its associations during the first 12 months following one-anastomosis gastric bypass (OAGB).

METHODS AND RESULTS

In this secondary analysis, CVD risk factors, medical history and anthropometric data were assessed in fifty VD deficient (25-hydroxy-vitamin D (25(OH)D) <75 nmol/l) patients, recruited for a randomized controlled trial of VD supplementation. Based on previous results regarding bone-mass loss and the association between VD and CVD risk, the study population was divided into patients with 25(OH)D ≥50 nmol/l (adequate VD group; AVD) and into those <50 nmol/l (inadequate VD group; IVD) at 6 and 12 months (T6/12) postoperatively. In the whole cohort, substantial remission rates for hypertension (38%), diabetes (30%), and dyslipidaemia (41%) and a significant reduction in CVD risk factors were observed at T12. Changes of insulin resistance markers were associated with changes of total body fat mass (TBF%), 25(OH)D, and ferritin. Moreover, significant differences in insulin resistance markers between AVD and IVD became evident at T12.

CONCLUSION

These findings show that OAGB leads to a significant reduction in CVD risk factors and amelioration of insulin resistance markers, which might be connected to reduced TBF%, change in 25(OH)D and ferritin levels, as an indicator for subclinical inflammation, and an adequate VD status. REGISTERED AT CLINICALTRIALS.GOV: (Identifier: NCT02092376) and EudraCT (Identifier: 2013-003546-16).

Association of Metabolic Surgery With Major Adverse Cardiovascular Outcomes in Patients With Previous Myocardial Infarction and Severe Obesity: A Nationwide Cohort Study

BACKGROUND

The number of patients with myocardial infarction and severe obesity is increasing and there is a lack of evidence how these patients should be treated. The aim of this study was to investigate the association between metabolic surgery (Roux-en-Y gastric bypass and sleeve gastrectomy) and major adverse cardiovascular events in patients with previous myocardial infarction (MI) and severe obesity.

METHODS

Of 566 patients with previous MI registered in the SWEDEHEART registry (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) undergoing metabolic surgery and registered in the nationwide Scandinavian Obesity Surgery Registry, 509 patients (Roux-en-Y gastric bypass n=465; sleeve gastrectomy n=44) could be matched 1:1 to a control with MI from SWEDEHEART, but no subsequent metabolic surgery regarding sex, age (±3 years), year of MI (±3 years), and body mass index (±3). The 2 groups were well matched, except for a lower proportion of reduced ejection fraction after MI (7% versus 12%), previous heart failure (10% versus 19%), atrial fibrillation (6% versus 10%), and chronic obstructive pulmonary disease (4% versus 7%) in patients undergoing metabolic surgery.

RESULTS

The median (interquartile range) follow-up time was 4.6 (2.7-7.1) years. The 8-year cumulative probability of major adverse cardiovascular events was lower in patients undergoing metabolic surgery (18.7% [95% CI, 15.9-21.5%] versus 36.2% [33.2-39.3%], adjusted hazard ratio, 0.44 [95% CI, 0.32-0.61]). Patients undergoing metabolic surgery had also a lower risk of death (adjusted HR, 0.45 [95% CI, 0.29-0.70]; MI, 0.24 [0.14-0.41]) and new onset heart failure, but there were no significant differences regarding stroke (0.91 [0.38-2.20]) and new onset atrial fibrillation (0.56 [0.31-1.01]).

CONCLUSIONS

In severely obese patients with previous MI, metabolic surgery is associated with a low risk for serious complications, lower risk of major adverse cardiovascular events, death, new MI, and new onset heart failure. These findings need to be confirmed in a randomized, controlled trial.

Gastrointestinal manifestations after Roux-en-Y gastric bypass surgery in individuals with and without type 2 diabetes

BACKGROUND

Roux-en-Y gastric bypass (RYGB) surgery is an effective treatment for obesity, which improves cardiovascular health and reduces the risk of premature mortality. However, some reports have suggested that RYGB may predispose patients to adverse health outcomes, such as inflammatory bowel disease (IBD) and colorectal cancer.

OBJECTIVES

The present prospective study aimed to evaluate the impact of RYGB surgery on cardiovascular risk factors and gastrointestinal inflammation in individuals with and without type 2 diabetes (T2D).

SETTING

University hospital setting in Finland.

METHODS

Blood and fecal samples were collected at baseline and 6 months after surgery from 30 individuals, of which 16 had T2D and 14 were nondiabetics. There were also single study visits for 6 healthy reference patients. Changes in cardiovascular risk factors, serum cholesterol, and triglycerides were investigated before and after surgery. Fecal samples were analyzed for calprotectin, anti-Saccharomyces cerevisiae immunoglobulin A antibodies (ASCA), active lipopolysaccharide (LPS) concentration, short-chain fatty acids (SCFAs), intestinal alkaline phosphatase activity, and methylglyoxal-hydro-imidazolone (MG-H1) protein adducts formation.

RESULTS

After RYGB, weight decreased on average -21.6% (-27.2 ± 7.8 kg), excess weight loss averaged 51%, and there were improvements in cardiovascular risk factors. Fecal calprotectin levels (P < .001), active LPS concentration (P < .002), ASCA (P < .02), and MG-H1 (P < .02) values increased significantly, whereas fecal SCFAs, especially acetate (P < .002) and butyrate (P < .03) levels, were significantly lowered.

CONCLUSION

The intestinal homeostasis is altered after RYGB, with several fecal markers suggesting increased inflammation; however, clinical significance of the detected changes is currently uncertain. As chronic inflammation may predispose patients to adverse health effects, our findings may have relevance for the suggested association between RYGB and increased risks of incident IBD and colorectal cancer.

Erythrocyte deformability and aggregation in morbidly obese women undergoing laparoscopic gastric bypass surgery and effects of oral omega-3 fatty acid supplementation

BACKGROUND: An adequate erythrocyte function is vital for tissue oxygenation and wound healing. The erythrocyte membrane phospholipid composition plays an important role in erythrocyte function and administration of omega-3 fatty acids may provide a means to improve it. OBJECTIVE: To investigate peri-operative erythrocyte function and effects of oral omega-3 fatty acids in morbidly obese women undergoing gastric bypass surgery METHODS: Fifty-six morbidly obese women undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery were randomized between a low calorie diet (LCD) during 2 weeks or oral omega-3 poly-unsaturated fatty acids (n-3 PUFAs) and a normal diet during 4 weeks. Peri-operative blood samples were analyzed with the Lorrca MaxSIS Ektacytometer for erythrocyte deformability and aggregability. RESULTS: There were no significant differences in erythrocyte function between the groups at any time point. Only erythrocyte aggregability parameters were affected by surgery. At six month follow-up, aggregation index (AI) and cholesterol, glucose and insulin were significantly improved. CONCLUSIONS: In this study, oral Omega-3 supplementation did not affect erythrocyte function compared to a LCD. Six months after surgery a significant improvement in AI and metabolic parameters was observed in both groups, contributing to a reduction in the risk at thromboembolic and cardiovascular complications.

A Stepwise Approach to the Management of Heart Failure and its Comorbidities

Modern medical and technological advances provide highly effective management for the treatment of patients with heart failure with reduced ejection fraction (HFrEF). In this review, the authors propose a 2-step approach to treatment that is straightforward, practical, and thorough. For the patient whose life now includes HFrEF, the physician's first step is to ensure that the patient is taking the 3 key medications ([1] renin-angiotensin inhibitors (angiotensin receptor/neprilysin inhibitors, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers), [2] β-blockers, and [3] mineralocorticoid receptor antagonists) recommended in guideline-directed doses to attain comprehensive receptor blockade. Significant coexisting medical issues are also characteristic in patients with HFrEF. Therefore, the physician's second step is to address the comorbidities of heart failure to fulfill comprehensive patient care. This review presents evidence to implement the management of HFrEF and heart failure comorbidities that will reduce cardiac mortality and hospitalization and to avoid treatments that are of no benefit or may cause harm.

Effect of Bariatric Surgery on Cardiovascular Function and Heart Failure Outcomes

In this article, we explore the influence of obesity on cardiovascular health and the role of bariatric surgery in reducing cardiovascular comorbidities, preventing the onset of heart failure and improving mortality and quality of life in those with cardiac dysfunction. We highlight the mechanisms by which obesity leads to cardiovascular remodeling, diastolic dysfunction, and eventual heart failure. These mechanisms include systemic inflammation, local lipotoxicity by way of ectopic fat deposition, and hemodynamic alterations that have significant effects on cardiac structure and function. Bariatric surgery has been shown to reverse these mechanisms, thereby leading to the reversal of adverse cardiac remodeling, improved diastolic function, and in some cases, improved systolic function in patients with systolic heart failure. Most importantly, bariatric surgery leads to significant improvements in cardiovascular outcomes, including the risks of myocardial infarction and stroke, heart failure incidence, and mortality. In patients with heart failure, bariatric surgery has been shown to decrease heart failure exacerbations and admissions and improve quality of life. Furthermore, in advanced heart failure patients, including those requiring mechanical circulatory support, bariatric surgery has been successfully and safely used for weight loss, as a bridge to cardiac transplantation. Therefore, bariatric surgery should be considered as a treatment for conditions ranging from subclinical cardiac dysfunction to symptomatic, advanced heart failure.

Impact of Metabolic Surgery on Type 2 Diabetes Mellitus, Cardiovascular Risk Factors, and Mortality: A Review

BACKGROUND

The association between obesity and a reduction in life expectancy is well established, and cardiovascular disease is a leading cause of mortality. Bariatric surgery has long been established as the most effective and durable intervention for obesity, and is the only intervention for obesity that consistently improves multiple comorbidities, reduces cardiovascular disease and long-term mortality. The purpose of this review is to describe the impact of metabolic/bariatric surgery on type 2 diabetes mellitus and cardiometabolic parameters, including cardiovascular mortality.

METHODS

A systematic literature search of Pubmed, MEDLINE, and Cochrane Central Register was performed. We included randomized controlled trials, meta-analysis, case-control trials, and cohort studies that contain data on reductions in cardiovascular risk factors and cardiovascular mortality in subjects who underwent metabolic/bariatric surgery from January 1, 2005 to June 1, 2020.

CONCLUSION

There is sufficient evidence from randomized controlled trials that metabolic/bariatric surgery is associated with a significant improvement of all cardiovascular risk factors. Although studies are showing a reduction of macrovascular events and cardiovascular mortality, these findings come from observational studies and should be confirmed in randomized clinical trials.

Change in predicted 10-year and lifetime cardiovascular disease risk after Roux-en-Y gastric bypass

BACKGROUND

Long-term changes in cardiovascular disease (CVD) risk after bariatric surgery are not well characterized.

OBJECTIVE

To report sex-specific changes in CVD risk after Roux-en-Y gastric bypass surgery (RYGB).

SETTING

Observational cohort study at ten hospitals throughout the United States.

METHODS

Between 2006 and 2009, 1770 adults enrolled in a prospective cohort study underwent RYGB at 1 of 10 U.S. hospitals. Research assessments were conducted presurgery and annually postsurgery over 7 years. Sex specific-predicted 10-year and lifetime CVD risk were calculated using the Framingham10-year and lifetime risk scores, Framingham-body mass index, and atherosclerotic CVD scoring algorithms among participants with no history of CVD. Of 1566 eligible participants, 1234 (75.9%) with CVD risk determination pre- and postsurgery were included (1013 females, 221 males).

RESULTS

Based on the Framingham10-year and lifetime risk scores, the percentage of females with predicted high (>20%) 10-year CVD risk declined from presurgery (6.5% [95% confidence interval: 6.7-7.5]) to 1 year postsurgery (1.0% [95% confidence interval: .8-1.2]; P < .001), then increased 1 to 7 years postsurgery (to 2.8% [95% confidence interval: 1.6-3.3]; P = .003), but was lower 7 years postsurgery versus presurgery (P < .001). Time trends for percentage of high-risk participants and mean CVD risk scores were similar for both sexes and other evaluated CVD risk scores. For example, among males mean lifetime atherosclerotic CVD score declined from presurgery to 1 year postsurgery, then increased 1 to 7 years postsurgery. However, there was a net decline from presurgery (P < .001).

CONCLUSION

Among both females and males, predicted 10-year and lifetime CVD risk was substantially lower 7 years post RYGB than presurgery, suggesting RYGB surgery can lead to sustained improvements in short- and long-term CVD risk.

Obesity, Hypertension, and Bariatric Surgery

PURPOSE OF REVIEW

Obesity increases the risk of hypertension. However, blood pressure decreases before any significant loss of body weight after bariatric surgery. We review the mechanisms of the temporal dissociation between blood pressure and body weight after bariatric surgery.

RECENT FINDINGS

Restrictive and bypass bariatric surgery lower blood pressure and plasma leptin levels within days of the procedure in both hypertensive and normotensive morbidly obese patients. Rapidly decreasing plasma leptin levels and minimal loss of body weight point to reduced sympathetic nervous system activity as the underlying mechanism of rapid blood pressure decline after bariatric surgery. After the early rapid decline, blood pressure does not decrease further in patients who, while still obese, experience a steady loss of body weight for the subsequent 12 months. The divergent effects of bariatric surgery on blood pressure and body weight query the role of excess body weight in the pathobiology of the obesity phenotype of hypertension. The decrease in blood pressure after bariatric surgery is moderate and independent of body weight. The lack of temporal relationship between blood pressure reduction and loss of body weight for 12 months after sleeve gastrectomy questions the nature of the mechanisms underlying obesity-associated hypertension.

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.

Treatment of Obesity in Mitigating Metabolic Risk

Through diverse mechanisms, obesity contributes to worsened cardiometabolic health and increases rates of cardiovascular events. Effective treatment of obesity is necessary to reduce the associated burdens of diabetes mellitus, cardiovascular disease, and death. Despite increasing cardiovascular outcome data on obesity interventions, only a small fraction of the population with obesity are optimally treated. This is a primary impetus for this article in which we describe the typical weight loss, as well as the associated impact on both traditional and novel cardiovascular disease risk factors, provided by the 4 primary modalities for obtaining weight loss in obesity-dietary modification, increasing physical activity, pharmacotherapy, and surgery. We also attempt to highlight instances where changes in metabolic risk are relatively specific to particular interventions and appear at least somewhat independent of weight loss. Finally, we suggest important areas for further research to reduce and prevent adverse cardiovascular consequences due to obesity.

A case report of recurrent transient ischaemic attacks on dabigatran for atrial fibrillation: real-world insight into treatment failure

Background 

Non-valvular atrial fibrillation (AF) is an important risk factor for acute ischaemic stroke. There has been an increase in the use of direct-acting oral anticoagulants (DOAC therapy) in stroke prophylaxis due to their convenience and rapid action of onset. However, there is a lack of information in the literature regarding management options and possible mechanisms with the apparent failure of DOAC therapy.

Case summary 

We present a clinical case of a 51-year-old man presenting with transient ischaemic attacks on a background of AF on therapeutic doses of dabigatran. His medication box suggested 100% compliance and his admission coagulation studies showed a marginally prolonged activated partial thromboplastin time and thrombin time (TT). While in hospital, our patient had supervised doses of dabigatran (150 mg b.i.d.). Despite this, his peak dabigatran level was undetectable (<40 ng/mL). With the apparent failure of therapy, he was switched to apixaban 5 mg b.i.d., which showed subsequent peak levels in the target range.

Discussion 

There are a number of isolated case reports of DOAC failure in stroke prophylaxis and management has simply involved switching to another DOAC or warfarin. This case is unique as we have discovered undetectable levels of dabigatran providing a mechanism for failure.