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Yang G, Liu Z, Dong S, Zhao X, Ge Z, Cheng Z, Zhang X, Wang K. Duodenal-jejunal bypass surgery activates eNOS and enhances antioxidant system by activating AMPK pathway to improve heart oxidative stress in diabetic cardiomyopathy rats. J Diabetes 2024; 16:e13516. [PMID: 38087869 PMCID: PMC11212293 DOI: 10.1111/1753-0407.13516] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/19/2023] [Accepted: 11/18/2023] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Diabetic cardiomyopathy is a serious complication of obesity with type 2 diabetes and is a major cause of mortality. Metabolic surgery, such as duodenal-jejunal bypass (DJB), can effectively improve diabetic cardiomyopathy; however, the underlying mechanisms remain elusive. Oxidative stress is one of the pivotal mechanisms of diabetic cardiomyopathy. Our objective was to investigate the effect and potential mechanisms of DJB on oxidative stress in the heart of diabetic cardiomyopathy rats. METHODS High-fat diet combined with intraperitoneal injection of streptozotocin was used to establish diabetic cardiomyopathy rats. DJB was performed on diabetic cardiomyopathy rats, and high glucose and palmitate were used to simulate diabetic cardiomyopathy in H9C2 cells in vitro. Sera from different groups of rats were used for experiments in vivo and in vitro. RESULTS DJB effectively improved oxidative stress and activated the adenosine monophosphate (AMP)-activated protein kinase (AMPK) pathway to increase endothelial nitric oxide synthase (eNOS) phosphorylation level and the expression of antioxidative system-related proteins and genes in the heart of diabetic cardiomyopathy rats. AMPK agonists and serum from DJB rats activated the AMPK pathway to increase eNOS phosphorylation level and the expression of antioxidative system-related proteins and genes and decreased the content of reactive oxygen species in H9C2 cells, but this improvement was almost eliminated by the addition of AMPK inhibitors. CONCLUSIONS DJB activates eNOS and enhances the antioxidant system by activating the AMPK pathway-and not solely by improving blood glucose-to improve oxidative stress in the heart of diabetic cardiomyopathy rats.
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Affiliation(s)
- Guangwei Yang
- Department of General SurgeryQilu Hospital of Shandong UniversityJinanChina
| | - Zitian Liu
- Department of General SurgeryQilu Hospital of Shandong UniversityJinanChina
| | - Shuohui Dong
- Department of General SurgeryQilu Hospital of Shandong UniversityJinanChina
| | - Xiang Zhao
- Department of General SurgeryQilu Hospital of Shandong UniversityJinanChina
| | - Zheng Ge
- Department of General SurgeryQilu Hospital of Shandong UniversityJinanChina
| | - Zhiqiang Cheng
- Department of General SurgeryQilu Hospital of Shandong UniversityJinanChina
| | - Xiang Zhang
- Department of General SurgeryQilu Hospital of Shandong UniversityJinanChina
| | - Kexin Wang
- Department of General SurgeryQilu Hospital of Shandong UniversityJinanChina
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Cui DY, Zhang C, Chen Y, Qian GZ, Zheng WX, Zhang ZH, Zhang Y, Zhu P. Associations between non-insulin-based insulin resistance indices and heart failure prevalence in overweight/obesity adults without diabetes mellitus: evidence from the NHANES 2001-2018. Lipids Health Dis 2024; 23:123. [PMID: 38678275 PMCID: PMC11055335 DOI: 10.1186/s12944-024-02114-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/18/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND The triglyceride glucose (TyG) index and triglyceride-to-high-density lipoprotein cholesterol (TG/HDL-C) ratio are recognized as simple non-insulin-based insulin resistance indices. Our study aimed to explore the relationship between these two indicators and heart failure (HF) in overweight or obesity individuals without diabetes. METHODS This cross-sectional study selected 13,473 participants from the National Health and Nutrition Examination Survey (NHANES) 2001-2018 dataset. Weighted multivariable logistic regression and subgroup analysis were employed to evaluate the relationships between TyG index, TG/HDL-C ratio, and HF prevalence, respectively. Additionally, smooth curve fitting was utilized to analyze the dose-response relationships. RESULTS A total of 13,473 obesity or overweight people without diabetes were included in this study through screening, among whom 291 (2.16%) had comorbid HF. The results of multivariable logistic regression suggested that the highest TyG index (OR = 2.4, 95% CI = 1.4-4.2, p = 0.002) and the highest TG/HDL-C ratio (OR = 1.2, 95% CI = 1.1-1.3, p < 0.001) both increased the prevalence of HF, especially in the non-Hispanic population. Dose-response relationships suggested nonlinear relationships between these two indicators and HF. CONCLUSION Our study demonstrated that elevated TyG index and TG/HDL-C ratio were closely associated with the prevalence of HF, and both exhibited nonlinear relationships with HF prevalence in overweight/obesity adults without diabetes. Based on these findings, additional prospective studies are needed for further validation.
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Affiliation(s)
- Di-Yu Cui
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Chao Zhang
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Yi Chen
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Gang-Zhen Qian
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Wan-Xiang Zheng
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Zhi-Hui Zhang
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
| | - Yu Zhang
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China.
| | - Ping Zhu
- Department of Cardiovascular Medicine, Center for Circadian Metabolism and Cardiovascular Disease, Southwest Hospital, Third Military Medical University (Army Medical University), 30 Gaotanyan Street, Shapingba District, Chongqing, 400038, China.
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Mentias A, Desai MY, Aminian A, Patel KV, Keshvani N, Verma S, Cho L, Jacob M, Alvarez P, Lincoff AM, Van Spall HGC, Lam CSP, Butler J, Nissen SE, Pandey A. Trends and Outcomes Associated With Bariatric Surgery and Pharmacotherapies With Weight Loss Effects Among Patients With Heart Failure and Obesity. Circ Heart Fail 2024; 17:e010453. [PMID: 38275114 DOI: 10.1161/circheartfailure.122.010453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 09/28/2023] [Indexed: 01/27/2024]
Abstract
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.
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Affiliation(s)
- Amgad Mentias
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, OH (A.M., M.Y.D., L.C., M.J., P.A., A.M.L., S.E.N.)
| | - Milind Y Desai
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, OH (A.M., M.Y.D., L.C., M.J., P.A., A.M.L., S.E.N.)
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, OH (A.A.)
| | - Kershaw V Patel
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, TX (K.V.P.)
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.K., A.P.)
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, ON, Canada (S.V.)
| | - Leslie Cho
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, OH (A.M., M.Y.D., L.C., M.J., P.A., A.M.L., S.E.N.)
| | - Miriam Jacob
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, OH (A.M., M.Y.D., L.C., M.J., P.A., A.M.L., S.E.N.)
| | - Paulino Alvarez
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, OH (A.M., M.Y.D., L.C., M.J., P.A., A.M.L., S.E.N.)
| | - A Michael Lincoff
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, OH (A.M., M.Y.D., L.C., M.J., P.A., A.M.L., S.E.N.)
| | - Harriette G C Van Spall
- Population Health Research Institute, Hamilton, ON, Canada (H.G.C.V.S.)
- McMaster University, Hamilton, ON, Canada (H.G.C.V.S.)
- Baim Institute for Clinical Research, Boston, MA (H.G.C.V.S.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- Department of Medicine, University of Mississippi School of Medicine, Jackson (J.B.)
| | - Steven E Nissen
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, OH (A.M., M.Y.D., L.C., M.J., P.A., A.M.L., S.E.N.)
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas (N.K., A.P.)
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Lee MMY, Lean MEJ, Sattar N, Petrie MC. Appetite and its Regulation: Are there Palatable Interventions for Heart Failure? Curr Heart Fail Rep 2024; 21:1-4. [PMID: 38133864 PMCID: PMC10827951 DOI: 10.1007/s11897-023-00637-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE OF REVIEW Obesity is a major driver of heart failure (HF) incidence, and aggravates its pathophysiology. We summarized key reported and ongoing randomized clinical trials of appetite regulation and/or dietary energy restriction in individuals with HF. RECENT FINDINGS Weight loss can be achieved by structured supervised diet programs with behavioural change, medications, or surgery. The new glucagon-like peptide-1 receptor agonists alone or in combination with other agents (e.g., glucose-dependent insulinotropic polypeptide and glucagon receptor agonists or amylin analogues) potently and sustainably reduce appetite, and, taken together with dietary advice, can produce substantial, life-changing, weight loss approaching that achieved by surgery. To date, data from the STEP-HFpEF trial show meaningful improvements in health status (Kansas City Cardiomyopathy Questionnaire). Effective weight management could relieve several drivers of HF, to complement the existing treatments for HF with both reduced and preserved ejection fraction. Further trials of weight loss interventions will provide more definitive evidence to understand their effects on clinical events in patients with HF.
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Affiliation(s)
- Matthew M Y Lee
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK.
| | - Michael E J Lean
- Human Nutrition, School of Medicine, Dentistry & Nursing, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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Frederiksen TC, Christiansen MK, Benjamin EJ, Overvad K, Olsen A, Dahm CC, Jensen HK. Five-year changes in weight and risk of atrial fibrillation in the Danish Diet, Cancer, and Health Cohort. Eur J Prev Cardiol 2024; 31:244-249. [PMID: 37708406 PMCID: PMC10809168 DOI: 10.1093/eurjpc/zwad300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/09/2023] [Accepted: 09/10/2023] [Indexed: 09/16/2023]
Abstract
AIMS Obesity is a major risk factor for atrial fibrillation (AF). Compared with stable weight, gaining weight was associated with a higher risk of incident AF in observational studies. The results, however, are conflicting regarding weight loss and risk of AF. This study aimed to assess the association between 5-year weight changes and risk of incident AF. METHODS AND RESULTS The study was based on participants from the Danish Diet, Cancer, and Health Cohort. Body mass index (BMI) was assessed at a baseline examination and at a second examination 5 years later. Diagnoses of AF and co-morbidities were retrieved from the Danish National Patient Registry. In total, 43 758 participants without prior AF were included. The median age was 61 years and 54% were female. During a median follow-up of 15.7 years, 5312 individuals had incident AF (incidence rate 8.6/1000 person-years). Compared with stable weight, weight gain between 2.5 and 5 BMI units (kg/m2) was associated with a higher risk of AF [hazard ratio (HR) 1.24, 95% confidence interval (CI) 1.09-1.41]. Weight gain of 5 or more BMI units (kg/m2) was associated with a HR of 1.95 (95% CI 1.48-2.56) of incident AF. However, there was no statistically significant association between weight loss and risk of AF. CONCLUSION Five-year weight gain was associated with greater risk of AF compared with stable weight in the Danish Diet, Cancer, and Health Cohort. There was no statistically significant association between weight loss and risk of AF.
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Affiliation(s)
- Tanja Charlotte Frederiksen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Morten Krogh Christiansen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Emelia J Benjamin
- Department of Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Kim Overvad
- Research Unit for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Anja Olsen
- Research Unit for Epidemiology, Department of Public Health, Aarhus University, Aarhus, Denmark
- Danish Cancer Society Research Center, København Ø, Denmark
| | | | - Henrik Kjærulf Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Health, Aarhus University, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
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Antia A, Evbayeka E, Okorare O, Ubokudom D, Gbegbaje O, Daniel E. Impact of Bariatric Surgery on the Prevalence and Outcomes of Atrial Fibrillation in Obese Patients. Curr Probl Cardiol 2024; 49:102083. [PMID: 37717860 DOI: 10.1016/j.cpcardiol.2023.102083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/11/2023] [Indexed: 09/19/2023]
Abstract
Obesity has been identified as a significant factor contributing to the development of numerous cardiovascular conditions and as a result, the cardiovascular community has prioritized efforts to address obesity and reduce its associated risks. However, despite these efforts, the prevalence of obesity continues to rise steadily, and is projected to double in the upcoming years. Atrial fibrillation is among the most prevalent and extensively researched cardiovascular comorbidities associated with obesity. Several mechanisms have been postulated, including scar tissue formation and fat deposition, which ultimately leads to atrial remodeling and subsequent arrhythmogenesis. Numerous strategies have been implemented to prevent and manage obesity, encompassing lifestyle adjustments, dietary modifications, pharmacological treatments, and surgical interventions. Bariatric surgery has garnered significant recognition over the years due to its promising outcomes, including a decrease in the overall prevalence of atrial fibrillation and other cardiovascular comorbidities in general in obese patients. This study focuses on the current trends regarding the impact of bariatric surgery on obese patients with atrial fibrillation.
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Affiliation(s)
- Akanimo Antia
- Department of Medicine, Lincoln Medical Center, Bronx, New York, United States of America.
| | - Endurance Evbayeka
- Department of Medicine, St. Luke's Hospital, St. Louis, Missouri, United States of America
| | - Ovie Okorare
- Department of Medicine, Vassar Brothers Medical Center, Nuvance Health, Poughkeepsie, New York, United States of America
| | - Daniel Ubokudom
- Department of Medicine, Thomas Hospital, Fairhope, Alabama, United States of America
| | - Oghenetejiri Gbegbaje
- Department of Medicine, Englewood Hospital and Medical Center, Englewood, New Jersey, United States of America
| | - Emmanuel Daniel
- Department of Medicine, Trinity Health Ann Arbor, Ypsilanti, Michigan, United States of America
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Zhou Y, Chai X, Yang G, Sun X, Xing Z. Changes in body mass index and waist circumference and heart failure in type 2 diabetes mellitus. Front Endocrinol (Lausanne) 2023; 14:1305839. [PMID: 38179309 PMCID: PMC10764620 DOI: 10.3389/fendo.2023.1305839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/05/2023] [Indexed: 01/06/2024] Open
Abstract
Background To determine the association of unintentional changes in body mass index (BMI) and waist circumference (WC) with the risk of heart failure (HF) among adults with type 2 diabetes mellitus (T2DM). Methods This was a randomized controlled trial (the Action to Control Cardiovascular Risk in Diabetes [ACCORD] study), with a double 2×2 factorial design conducted at 77 clinical centers across the United States and Canada. In total, the study comprised 10,251 patients with T2DM and cardiovascular disease (CVD) or at a high risk of CVD. The outcome of interest in the present analysis was incident HF, defined as the first hospitalization event for HF or death due to HF. Hospitalization for HF was based on documented clinical and radiological evidence. Death due to HF was based on clinical, radiological, or postmortem evidence of HF, with an absence of an acute ischemic event according to clinical or postmortem evidence. Results Participants with class III obesity had the smallest BMI and WC changes, followed by those with normal weight, overweight, class I obesity, and class II obesity. Increasing BMI (hazard ratio [HR] per standard deviation increase, 1.24; 95% confidence interval [CI], 1.07-1.45) and WC (1.27; 1.10-1.47) were significantly associated with a higher risk of HF. The relationship between BMI and WC changes and HF formed a J-shaped curve, while stable BMI and WC were associated with lower risks of HF. Compared with participants in the first tertiles of BMI and WC change, those in the third tertiles had HRs of 1.41 (95% CI, 1.07-1.45) and 1.48 (1.12-1.95), respectively. Conclusion In conclusion, our findings suggest a noteworthy association between BMI and WC changes among adults with T2DM in HF. We observed a distinctive J-shaped curve in this relationship, indicating that participants with both low and high BMI and WC changes were more susceptible to developing HF. Trial registration http://www.clinicaltrials.gov. Unique identifier: NCT00000620.
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Affiliation(s)
- Yang Zhou
- Department of Critical Care Medicine, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiangping Chai
- Department of Emergency Department, Second Xiangya Hospital, Central South University, Changsha, China
- Emergency Medicine and Difficult Diseases Institute, Second Xiangya Hospital, Central South University, Changsha, China
| | - Guifang Yang
- Department of Emergency Department, Second Xiangya Hospital, Central South University, Changsha, China
- Emergency Medicine and Difficult Diseases Institute, Second Xiangya Hospital, Central South University, Changsha, China
| | - Xin Sun
- College of nursing, Changsha Medical University, Changsha, Hunan, China
| | - Zhenhua Xing
- Department of Emergency Department, Second Xiangya Hospital, Central South University, Changsha, China
- Emergency Medicine and Difficult Diseases Institute, Second Xiangya Hospital, Central South University, Changsha, China
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Ndumele CE, Rangaswami J, Chow SL, Neeland IJ, Tuttle KR, Khan SS, Coresh J, Mathew RO, Baker-Smith CM, Carnethon MR, Despres JP, Ho JE, Joseph JJ, Kernan WN, Khera A, Kosiborod MN, Lekavich CL, Lewis EF, Lo KB, Ozkan B, Palaniappan LP, Patel SS, Pencina MJ, Powell-Wiley TM, Sperling LS, Virani SS, Wright JT, Rajgopal Singh R, Elkind MSV. Cardiovascular-Kidney-Metabolic Health: A Presidential Advisory From the American Heart Association. Circulation 2023; 148:1606-1635. [PMID: 37807924 DOI: 10.1161/cir.0000000000001184] [Citation(s) in RCA: 78] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
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.
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Lu SJ, Zhang TT, Zhang XW, Wang L, Zhao YW, Wang R, Miao XQ, Zhao GH. Evidence of Bariatric Surgery Benefits Cardiac Function in Non-HFpEF Patients with Obesity: a Meta-Analysis. Obes Surg 2023; 33:3353-3361. [PMID: 37752326 DOI: 10.1007/s11695-023-06670-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 05/19/2023] [Accepted: 06/07/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND/OBJECTIVE Nowadays, increasing clinical evidence on metabolic and weight-loss effects of bariatric surgery on improving cardiac structure in obese patients, but its application in improving the cardiac function of HF (heart failure) patients remains controversial. The objective of this meta-analysis was to assess the effects of BS on cardiac function by quantifying the changes of LVEF (left ventricular ejection fraction) and NYHA (New York Heart Association classification) after operations in non-HFpEF (heart failure and preserved ejection fraction) patients. METHODS Articles were searched using PubMed and Embase from inception to December 9, 2022, and the Minors scale was used for quality assessments. The included patients should be non-HFpEF and clinically severely obese, and their pre-operative and post-operative values of LVEF or NYHA should be reported. RESULT Nine studies involving 146 patients were eventually included with a final result showing that the cardiac functional parameters were improved in non-HFpEF patients. After a weighted mean follow-up time of 15.8 months, the mean NYHA decreased by 0.59 (I2 = 0; 95% CI 0.27 ~ 0.92; p = 0.003), and the mean LVEF increased by 7.49% (I2 = 0; 95% CI - 9.99 ~ - 4.99; p < 0.00001). CONCLUSION Bariatric surgery offers beneficial cardiac effects on non-HFpEF patients with obesity but failed to show a significant improvement in the pooled analysis for the changes of cardiac parameters. The improving degree may be related to the baseline BMI, the extent of BMI loss, and the baseline age. Future studies should focus on finding out the influencing factors of effectivenesses and defining the suitable crowd.
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Affiliation(s)
- Shi-Jing Lu
- Department of Gastroenterology Surgery, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, No. 826 Southwest Road Shahekou District, Dalian, 116033, People's Republic of China
- Dalian Medical University, No. 9 West Section Lvshun South Road, Dalian, 116044, People's Republic of China
| | - Tao-Tao Zhang
- Department of Gastroenterology Surgery, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, No. 826 Southwest Road Shahekou District, Dalian, 116033, People's Republic of China
| | - Xiang-Wen Zhang
- Department of Gastroenterology Surgery, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, No. 826 Southwest Road Shahekou District, Dalian, 116033, People's Republic of China.
| | - Li Wang
- Department of Cardiology, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, No. 826 Southwest Road Shahekou District, Dalian, 116033, People's Republic of China
| | - You-Wei Zhao
- Department of Gastroenterology Surgery, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, No. 826 Southwest Road Shahekou District, Dalian, 116033, People's Republic of China
- Dalian Medical University, No. 9 West Section Lvshun South Road, Dalian, 116044, People's Republic of China
| | - Ran Wang
- Department of Gastroenterology Surgery, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, No. 826 Southwest Road Shahekou District, Dalian, 116033, People's Republic of China
- Dalian Medical University, No. 9 West Section Lvshun South Road, Dalian, 116044, People's Republic of China
| | - Xiu-Qin Miao
- Department of Gastroenterology Surgery, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, No. 826 Southwest Road Shahekou District, Dalian, 116033, People's Republic of China
| | - Guo-Hua Zhao
- Department of Gastroenterology Surgery, The Dalian Municipal Central Hospital Affiliated of Dalian Medical University, No. 826 Southwest Road Shahekou District, Dalian, 116033, People's Republic of China
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10
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Barillas-Lara MI, Faaborg-Andersen CC, Quintana RA, Loro-Ferrer JF, Mandras SA, daSilva-deAbreu A. Clinical considerations and pathophysiological associations among obesity, weight loss, heart failure, and hypertension. Curr Opin Cardiol 2023:00001573-990000000-00089. [PMID: 37522803 DOI: 10.1097/hco.0000000000001069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
PURPOSE OF REVIEW To describe the relationship between three pandemics: hypertension, obesity, and heart failure. From pathophysiology to treatment, understanding how these disease entities are linked can lead to breakthroughs in their prevention and treatment. The relevance of this review lies in its discussion of novel pharmacological and surgical treatment strategies for obesity and hypertension, and their role in the prevention and treatment of heart failure. RECENT FINDINGS Novel medications such as GLP-1 agonists have demonstrated sustained weight loss in patients with obesity, and concurrent improvements in their cardiometabolic profile, and possibly also reductions in hypertension-related comorbidities including heart failure. Surgical therapies including laparoscopic bariatric surgery represent an important treatment strategy in obese patients, and recent studies describe their use even in patients with advanced heart failure, including those with ventricular assist devices. SUMMARY These developments have deep implications on our efforts to understand, mitigate, and ultimately prevent the three pandemics, and offer promising improvements to quality of life, survival, and the cost burden of these diseases.
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Affiliation(s)
| | | | - Raymundo A Quintana
- Cardiovascular Imaging Section, Division of Cardiology, University of Colorado, Aurora, Colorado, USA
| | | | - Stacy A Mandras
- Transplant Institute, Orlando AdventHealth, Orlando, Florida
| | - Adrian daSilva-deAbreu
- Doctoral School, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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11
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Yang W, Zhan M, Li Z, Sun X, Zhang K. Major Adverse Cardiovascular Events Among Obese Patients with Diabetes After Metabolic and Bariatric Surgery: a Meta-analysis of Matched Cohort and Prospective Controlled Studies with 122,361 Participates. Obes Surg 2023; 33:2098-2107. [PMID: 37184826 DOI: 10.1007/s11695-023-06634-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE Metabolic and bariatric surgery (MBS) can exert effective function on glycemic control. The present study aimed to estimate the risk of MACE among obese patients with diabetes after MBS. MATERIALS AND METHODS Systematic search of PubMed, Embase, Medline, and Web of Science was performed for studies published before 20th February 2023. The odds ratio (OR) corresponding to the 95% confidence interval (95% CI) was used to assess the outcome. The statistical heterogeneity among studies was assessed with the Q-test and I2 statistics. RESULTS Fifteen cohort studies with 122,361 obese patients with diabetes were available for analysis. Our meta-analysis found significantly decreased morbidity and mortality of MACE (OR = 0.65, 95% CI = 0.59-0.72, I2 = 62.8% for morbidity, OR = 0.49, 95% CI = 0.36-0.67, I2 = 68.7% for mortality). Subgroup analysis revealed MBS decreased cerebrovascular disease, coronary artery disease, atrial fibrillation, heart failure, myocardial infarction, and stroke risk. CONCLUSION Our meta-analysis indicated that MBS for obese patients with diabetes is beneficial to decreasing MACE risk. Moreover, further studies estimating the functional effect may eventually provide a better and comprehensive understanding of the effect on different populations.
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Affiliation(s)
- Wenxing Yang
- Department of Physiology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Mengjun Zhan
- Department of Forensic Pathology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Zhuo Li
- Department of Forensic Pathology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Xuehong Sun
- Department of Forensic Pathology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Kui Zhang
- Department of Forensic Pathology, West China School of Basic Medical Sciences & Forensic Medicine, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China.
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12
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Hsu CN, Hsuan CF, Liao D, Chang JKJ, Chang AJW, Hee SW, Lee HL, Teng SIF. Anti-Diabetic Therapy and Heart Failure: Recent Advances in Clinical Evidence and Molecular Mechanism. Life (Basel) 2023; 13:1024. [PMID: 37109553 PMCID: PMC10144651 DOI: 10.3390/life13041024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/19/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
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.
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Affiliation(s)
- Chih-Neng Hsu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin 640, Taiwan
| | - Chin-Feng Hsuan
- Division of Cardiology, Department of Internal Medicine, E-Da Hospital, I-Shou University, Kaohsiung 824, Taiwan
- Division of Cardiology, Department of Internal Medicine, E-Da Dachang Hospital, I-Shou University, Kaohsiung 824, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung 840, Taiwan
| | - Daniel Liao
- Graduate Institute of Medical Genomics and Proteomics, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Jack Keng-Jui Chang
- Biological Programs for Younger Scholar, Academia Sinica, Taipei 115, Taiwan
| | - Allen Jiun-Wei Chang
- Graduate Institute of Medical Genomics and Proteomics, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Siow-Wey Hee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Hsiao-Lin Lee
- Graduate Institute of Medical Genomics and Proteomics, College of Medicine, National Taiwan University, Taipei 100, Taiwan
| | - Sean I. F. Teng
- Department of Cardiology, Ming-Sheng General Hospital, Taoyuan 330, Taiwan
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13
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Tsao CW, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Beaton AZ, Boehme AK, Buxton AE, Commodore-Mensah Y, Elkind MSV, Evenson KR, Eze-Nliam C, Fugar S, Generoso G, Heard DG, Hiremath S, Ho JE, Kalani R, Kazi DS, Ko D, Levine DA, Liu J, Ma J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Virani SS, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Martin SS. Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association. Circulation 2023; 147:e93-e621. [PMID: 36695182 DOI: 10.1161/cir.0000000000001123] [Citation(s) in RCA: 1209] [Impact Index Per Article: 1209.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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Pontiroli AE, Centofanti L, Le Roux CW, Magnani S, Tagliabue E, Folli F. Effect of Prolonged and Substantial Weight Loss on Incident Atrial Fibrillation: A Systematic Review and Meta-Analysis. Nutrients 2023; 15:nu15040940. [PMID: 36839298 PMCID: PMC9964297 DOI: 10.3390/nu15040940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/11/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023] Open
Abstract
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.
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Affiliation(s)
- Antonio E. Pontiroli
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20133 Milan, Italy
- Correspondence:
| | - Lucia Centofanti
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20133 Milan, Italy
| | - Carel W. Le Roux
- Diabetes Complications Research Centre, University College Dublin, D04 V1W8 Dublin, Ireland
| | | | - Elena Tagliabue
- IRCCS MultiMedica, Value-Based Healthcare Unit, 20099 Milan, Italy
| | - Franco Folli
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20133 Milan, Italy
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15
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Chandrakumar H, Khatun N, Gupta T, Graham-Hill S, Zhyvotovska A, McFarlane SI. The Effects of Bariatric Surgery on Cardiovascular Outcomes and Cardiovascular Mortality: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e34723. [PMID: 36909063 PMCID: PMC9998117 DOI: 10.7759/cureus.34723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 02/10/2023] Open
Abstract
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.
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Affiliation(s)
- Harshith Chandrakumar
- Internal Medicine, State University of New York (SUNY) Downstate Health Sciences University Hospital, Brooklyn, USA
| | - Nazima Khatun
- Internal Medicine, State University of New York (SUNY) Downstate Health Sciences University Hospital, Brooklyn, USA
| | - Tanuj Gupta
- Internal Medicine, State University of New York (SUNY) Downstate Health Sciences University Hospital, Brooklyn, USA
| | | | | | - Samy I McFarlane
- Internal Medicine, State University of New York (SUNY) Downstate Health Sciences University Hospital, Brooklyn, USA
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16
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Wang M, Yu G, Wang X, Xu B. Evaluation of changes in atrial fibrillation predictors(P wave parameters and left atrial diameter) in morbidly obese patients undergoing bariatric surgery. J Electrocardiol 2023; 78:12-16. [PMID: 36696818 DOI: 10.1016/j.jelectrocard.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/20/2022] [Accepted: 01/01/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND Bariatric surgery has been associated with reduced cardiovascular event in obese patients.In this study, we aimed to investigate the changes between pre-operation and post-operation atrial fibrillation predictors(p-wave parameters and left atrial diameter)in morbidly obese patients who underwent bariatric surgery. METHODS 176 obese patients undergoing bariatric surgery were enrolled. Heart rate, PR, P-wave max, P-wave min,P-wave dispersion (PWdis), average P-axis, P-wave peak time (PWPT) of lead II and lead V1, terminal force of lead V1 (PWTF V1), partial interatrial block (p-IAB), advanced interatrial block(a-IAB), and left atrial diamete were measured both before operation and 8 months post-operation. RESULTS Heart rate, PR, PW max, PW min, PWdis, mean P-axis, PWPT II, PWPT V1, and PWTF V1 were near their upper limits before operation. Left atrial diameter was larger than the upper limit before operation. All parameters showed statistically significant decrease at 8 months post-operation. The most significant changes were observed in PWPT II (55.69 ± 6.87 ms vs 50.43 ± 7.48 ms, p < 0.001), PWPT V1(54.21 ± 7.01 ms vs 48.02 ± 7.13 ms, p < 0.001), PWTF V1(74 [42.0%] vs 41 [23.3%], p < 0.001),p-IAB(41[23.2%]vs11[6.2%],p < 0.001),a-IAB(6[3.4%]vs2[1.1%], p < 0.001), and left atrial diameter(43.25 ± 9.23 mm vs 34.27 ± 6.21 mm,p < 0.001). CONCLUSIONS The results of our study showed that bariatric surgery had a positive effect on the regression of P wave parameters and left atrial diameter which are predictors of atrial fibrillation.
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Affiliation(s)
- Meng Wang
- Department of Cardiology, the Second Affiliated Hospital of Anhui Medical University, Hefei, China.
| | - Gang Yu
- Department of Gastroenterology, the Second Affiliated Hospital of Anhui Medical University, China
| | - Xiaochen Wang
- Department of Cardiology, the Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Banglong Xu
- Department of Cardiology, the Second Affiliated Hospital of Anhui Medical University, Hefei, China
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17
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Abstract
The global prevalence of atrial fibrillation (AF) has increased substantially over the past three decades and is currently approximately 60 million cases. Incident AF and its clinical consequences are largely the result of risk factors that can be modified by lifestyle changes. In this Review, we provide evidence that the lifetime risk of AF is modified not only by sex and race but also through the clinical risk factor and comorbidity burden of individual patients. We begin by summarizing the epidemiology of AF, focusing on non-modifiable and modifiable risk factors, as well as targets and strategies for the primary prevention of AF. Furthermore, we evaluate the role of modifiable risk factors in the secondary prevention of AF as well as the potential effects of risk factor interventions on the frequency and severity of subsequent AF episodes. We end the Review by proposing strategies that require evaluation as well as global policy changes that are needed for the prevention of incident AF and the management of recurrent episodes in patients already affected by AF.
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18
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King S, Calisi O, Caldwell C, Berger D, Rich AM, Dan Y, Qureshi U, Ramedani S, Peterson BR. Frequency and Predictors of Preoperative Cardiac Testing Overuse in Low-Risk Patients Before Laparoscopic Bariatric Surgery. Am J Cardiol 2023; 186:181-185. [PMID: 36270826 DOI: 10.1016/j.amjcard.2022.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 09/17/2022] [Accepted: 09/26/2022] [Indexed: 11/26/2022]
Abstract
Adverse cardiac events after laparoscopic bariatric surgery are rare, yet preoperative cardiology evaluation and testing remain common, resulting in the overuse of cardiac testing in low-risk patients. Our objective was to assess the frequency of, and factors associated with, overuse of preoperative cardiac testing in patients at low cardiac risk before laparoscopic bariatric surgery. We retrospectively reviewed data from 1,094 adult patients who underwent laparoscopic bariatric surgery at our institution from January 1, 2015, through December 31, 2019. The cardiac risk was determined using the Revised Cardiac Risk Index (RCRI) and the National Surgical Quality Improvement Program Myocardial Infarction and Cardiac Arrest (NSQIP MICA) risk model. Multivariate logistic regression was used to evaluate risk factors associated with the overuse of cardiac testing in low-risk patients. Overall, 1,059 patients (96.8%) were estimated to be at low cardiac risk by the RCRI, and 1,094 (100%) were at low cardiac risk by NSQIP MICA. A total of 587 patients (51.8%) were referred to cardiology for preoperative evaluation, and 643 patients (56.7%) underwent one or more preoperative cardiac tests. Factors associated with overuse of preoperative cardiac testing in low-risk patients included preoperative cardiology referral (adjusted odds ratio 37.2, 95% confidence interval 25.3 to 54.7) and patient age (adjusted odds ratio 1.05, 95% confidence interval 1.03 to 1.07). Overuse of preoperative cardiac testing was common in patients at low cardiac risk before laparoscopic bariatric surgery. Preoperative referral to cardiology was the most significant risk factor associated with the overuse of preoperative cardiac testing. Application of risk models such as the RCRI or NSQIP MICA at the time of bariatric program enrollment may reduce unnecessary preoperative cardiac testing in low-risk patients.
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Affiliation(s)
- Steven King
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Olivia Calisi
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Catherine Caldwell
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Daniel Berger
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Alyson M Rich
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Yongwook Dan
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Umer Qureshi
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Shayann Ramedani
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - Brandon R Peterson
- Penn State Heart and Vascular Institute, Penn State College of Medicine, Hershey, Pennsylvania.
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Lopez-Jimenez F, Almahmeed W, Bays H, Cuevas A, Di Angelantonio E, le Roux CW, Sattar N, Sun MC, Wittert G, Pinto FJ, Wilding JPH. Obesity and cardiovascular disease: mechanistic insights and management strategies. A joint position paper by the World Heart Federation and World Obesity Federation. Eur J Prev Cardiol 2022; 29:2218-2237. [PMID: 36007112 DOI: 10.1093/eurjpc/zwac187] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/19/2022] [Accepted: 08/23/2022] [Indexed: 01/11/2023]
Abstract
The ongoing obesity epidemic represents a global public health crisis that contributes to poor health outcomes, reduced quality of life, and >2.8 million deaths each year. Obesity is relapsing, progressive, and heterogeneous. It is considered a chronic disease by the World Obesity Federation (WOF) and a chronic condition by the World Heart Federation (WHF). People living with overweight/obesity are at greater risk for cardiovascular (CV) morbidity and mortality. Increased adiposity (body fat), particularly visceral/abdominal fat, is linked to CV risk and CV disease (CVD) via multiple direct and indirect pathophysiological mechanisms. The development of CVD is driven, in part, by obesity-related metabolic, endocrinologic, immunologic, structural, humoral, haemodynamic, and functional alterations. The complex multifaceted nature of these mechanisms can be challenging to understand and address in clinical practice. People living with obesity and CVD often have concurrent chronic physical or psychological disorders (multimorbidity) requiring multidisciplinary care pathways and polypharmacy. Evidence indicates that intentional weight loss (particularly when substantial) lowers CVD risk among people with overweight/obesity. Long-term weight loss and maintenance require ongoing commitment from both the individual and those responsible for their care. This position paper, developed by the WOF and the WHF, aims to improve understanding of the direct and indirect links between overweight/obesity and CVD, the key controversies in this area and evidence relating to cardiometabolic outcomes with available weight management options. Finally, an action plan for clinicians provides recommendations to help in identifying and addressing the risks of obesity-related CVD (recognizing resource and support variances between countries).
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Affiliation(s)
| | - Wael Almahmeed
- Department of Cardiology, Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Harold Bays
- Louisville Metabolic and Atherosclerosis Research Center, Louisville, KY, USA
| | - Ada Cuevas
- Center for Advanced Metabolic Medicine and Nutrition (CAMMYN), School of Medicine University Finis Terrae, Santiago, Chile
| | - Emanuele Di Angelantonio
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Health Data Science Centre, Human Technopole, Milan, Italy
| | - Carel W le Roux
- Diabetes Complications Research Centre, University College Dublin, Dublin, Ireland
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Marie Chan Sun
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Mauritius, Mauritius
| | - Gary Wittert
- Freemasons Centre for Male Health and Wellbeing, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Office of the President, World Heart Federation, Geneva, Switzerland
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Clinical Sciences Centre, Aintree University Hospital, Liverpool, UK
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20
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Conte M, Petraglia L, Cabaro S, Valerio V, Poggio P, Pilato E, Attena E, Russo V, Ferro A, Formisano P, Leosco D, Parisi V. Epicardial Adipose Tissue and Cardiac Arrhythmias: Focus on Atrial Fibrillation. Front Cardiovasc Med 2022; 9:932262. [PMID: 35845044 PMCID: PMC9280076 DOI: 10.3389/fcvm.2022.932262] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/13/2022] [Indexed: 01/02/2023] Open
Abstract
Atrial Fibrillation (AF) is the most frequent cardiac arrhythmia and its prevalence increases with age. AF is strongly associated with an increased risk of stroke, heart failure and cardiovascular mortality. Among the risk factors associated with AF onset and severity, obesity and inflammation play a prominent role. Numerous recent evidence suggested a role of epicardial adipose tissue (EAT), the visceral fat depot of the heart, in the development of AF. Several potential arrhythmogenic mechanisms have been attributed to EAT, including myocardial inflammation, fibrosis, oxidative stress, and fat infiltration. EAT is a local source of inflammatory mediators which potentially contribute to atrial collagen deposition and fibrosis, the anatomical substrate for AF. Moreover, the close proximity between EAT and myocardium allows the EAT to penetrate and generate atrial myocardium fat infiltrates that can alter atrial electrophysiological properties. These observations support the hypothesis of a strong implication of EAT in structural and electrical atrial remodeling, which underlies AF onset and burden. The measure of EAT, through different imaging methods, such as echocardiography, computed tomography and cardiac magnetic resonance, has been proposed as a useful prognostic tool to predict the presence, severity and recurrence of AF. Furthermore, EAT is increasingly emerging as a promising potential therapeutic target. This review aims to summarize the recent evidence exploring the potential role of EAT in the pathogenesis of AF, the main mechanisms by which EAT can promote structural and electrical atrial remodeling and the potential therapeutic strategies targeting the cardiac visceral fat.
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Affiliation(s)
- Maddalena Conte
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.,Casa di Cura San Michele, Maddaloni, Italy
| | - Laura Petraglia
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Serena Cabaro
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | | | | | - Emanuele Pilato
- Department of Advanced Biomedical Science, University of Naples Federico II, Naples, Italy
| | - Emilio Attena
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Vincenzo Russo
- Chair of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" - Monaldi and Cotugno Hospital, Naples, Italy
| | - Adele Ferro
- Institute of Biostructure and Bioimaging, Consiglio Nazionale delle Ricerche, Naples, Italy
| | - Pietro Formisano
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Dario Leosco
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Valentina Parisi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
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21
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van Veldhuisen SL, Gorter TM, van Woerden G, de Boer RA, Rienstra M, Hazebroek EJ, van Veldhuisen DJ. OUP accepted manuscript. Eur Heart J 2022; 43:1955-1969. [PMID: 35243488 PMCID: PMC9123239 DOI: 10.1093/eurheartj/ehac071] [Citation(s) in RCA: 96] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Sophie L van Veldhuisen
- Department of Surgery/Vitalys Clinic, Rijnstate Hospital Arnhem, Arnhem, The Netherlands
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Thomas M Gorter
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Gijs van Woerden
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands
| | - Eric J Hazebroek
- Department of Surgery/Vitalys Clinic, Rijnstate Hospital Arnhem, Arnhem, The Netherlands
- Division of Human Nutrition and Health, Wageningen University & Research, Wageningen, The Netherlands
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22
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Al-Kaisey AM, Kalman JM. Obesity and Atrial Fibrillation: Epidemiology, Pathogenesis and Effect of Weight Loss. Arrhythm Electrophysiol Rev 2021; 10:159-164. [PMID: 34777820 PMCID: PMC8576485 DOI: 10.15420/aer.2021.36] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/09/2021] [Indexed: 12/13/2022] Open
Abstract
The obesity epidemic continues its relentless advance and is paralleled by an increase in the incidence of AF. Several epidemiological studies have highlighted obesity as an independent risk factor for the development of AF. This relationship is likely multifactorial through a number of interacting mechanisms. Weight loss through lifestyle changes or surgery has been associated with reverse remodelling of the atrial substrate and subsequent reduction in AF, making it an essential pillar in the management of AF in obese patients. In this review, the epidemiological data that support the obesity–AF relationship, the current insights into the underlying pathophysiological mechanism, the impact of weight loss on reverse remodelling and AF reduction, and the strategies to achieve weight loss in patients with AF are discussed.
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Affiliation(s)
- Ahmed M Al-Kaisey
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
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23
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Effect of Bariatric Surgery on Survival and Hospitalizations in Patients with Severe Obesity. A Retrospective Cohort Study. Nutrients 2021; 13:nu13093150. [PMID: 34579025 PMCID: PMC8464847 DOI: 10.3390/nu13093150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/02/2021] [Accepted: 09/06/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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24
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Höskuldsdóttir G, Sattar N, Miftaraj M, Näslund I, Ottosson J, Franzén S, Svensson AM, Eliasson B. Potential Effects of Bariatric Surgery on the Incidence of Heart Failure and Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus and Obesity and on Mortality in Patients With Preexisting Heart Failure: A Nationwide, Matched, Observational Cohort Study. J Am Heart Assoc 2021; 10:e019323. [PMID: 33754795 PMCID: PMC8174344 DOI: 10.1161/jaha.120.019323] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Obesity and diabetes mellitus are strongly associated with heart failure (HF) and atrial fibrillation (AF). The benefits of bariatric surgery on cardiovascular outcomes are known in people with or without diabetes mellitus. Surgical treatment of obesity might also reduce the incidence of HF and AF in individuals with obesity and type 2 diabetes mellitus (T2DM). Methods and Results In this register‐based nationwide cohort study we compared individuals with T2DM and obesity who underwent Roux‐en‐Y gastric bypass surgery with matched individuals not treated with surgery. The main outcome measures were hospitalization for HF and/or AF and mortality in patients with preexisting HF. We identified 5321 individuals with T2DM and obesity who had undergone Roux‐en‐Y gastric bypass surgery between January 2007 and December 2013 and 5321 matched controls. The individuals included were 18 to 65 years old and had a body mass index >27.5 kg/m2. The follow‐up time for hospitalization was until the end of 2015 (mean 4.5 years) and the end of 2016 for death. Our results show a 73% lower risk for HF (hazard ratio [HR], 0.27; CI, 0.19–0.38), 41% for AF (HR, 0.59; CI, 0.44–0.78), and 77% for concomitant AF and HF (HR, 0.23; CI, 0.12–0.46) in the surgically treated group. In patients with preexisting HF we observed significantly lower mortality in the group who underwent surgery (HR, 0.23; 95% CI, 0.12–0.43). Conclusions Bariatric surgery may reduce risk for HF and AF in patients with T2DM and obesity, speculatively via positive cardiovascular and renal effects. Obesity treatment with surgery may also be a valuable alternative in selected patients with T2DM and HF.
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Affiliation(s)
- Gudrún Höskuldsdóttir
- Department of Molecular and Clinical Medicine University of Gothenburg Sweden.,Department of Medicine Sahlgrenska University Hospital Gothenburg Sweden
| | - Naveed Sattar
- The Institute of Cardiovascular and Medical Sciences University of Glasgow United Kingdom
| | - Mervete Miftaraj
- Centre of Registers National Diabetes Register Gothenburg Sweden
| | - Ingmar Näslund
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Johan Ottosson
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Stefan Franzén
- Centre of Registers National Diabetes Register Gothenburg Sweden.,Health Metrics Unit Sahlgrenska AcademyUniversity of Gothenburg Sweden
| | - Ann-Marie Svensson
- Department of Molecular and Clinical Medicine University of Gothenburg Sweden.,Centre of Registers National Diabetes Register Gothenburg Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine University of Gothenburg Sweden.,Department of Medicine Sahlgrenska University Hospital Gothenburg Sweden
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