Impact of the Obesity Paradox Between Sexes on In-Hospital Mortality in Cardiogenic Shock: A Retrospective Cohort Study

Impact of the obesity paradox on 28-day mortality in elderly patients critically ill with cardiogenic shock: a retrospective cohort study

BACKGROUND

Previous studies have shown that the obesity paradox exists in cardiovascular disease (CVD), giving patients a survival advantage, but controversy remains as to whether it applies to patients with cardiogenic shock (CS), especially in the elderly. We therefore aimed to determine whether obesity affects 28-day prognosis in elderly patients with CS.

METHODS

We used clinical data from the Medical Information Market in Critical Care IV (MIMIC-IV) database. Critical patients with CS were categorized into two groups based on age; age < 65 years and ≥ 65 years were classified as young adult patients and elderly patients, respectively. Patients were then categorized into two subgroups based on their body mass index (BMI), one with a BMI ≥ 30 kg/m2 and the other with a BMI < 30 kg/m2. The primary outcome was a 28-day prognosis. Secondary outcomes were mechanical ventilation status, length of hospitalization, and length of ICU stay.

RESULTS

1827 patients from the MIMIC-IV ICU database were analyzed, of which 571 patients were < 65 years old and 1256 patients were ≥ 65 years old. According to multifactorial logistic analysis, BMI > 30 kg/m2 was not a 28-day risk factor for death in elderly patients critically ill with CS (Overweight OR 1.28, P = 0.221; Obesity OR 1.15, P = 0.709; Severe obesity OR 1.46, P = 0.521; using normal weight as a reference). In contrast, underweight was a risk factor (OR 2.42, P = 0.039). Kaplan-Meier curves showed that in the older age group, 28-day survival was significantly higher in patients with BMI ≥ 30 kg/m2 compared to those with BMI < 30 kg/m2 [261 (66.75%) vs. 522 (60.35%), P = 0.024].

CONCLUSION

Underweight affects the 28-day prognosis of critically ill elderly patients with CS. In contrast, overweight and or obesity do not appear to have a significant impact on the prognosis of these patients.

Cardiogenic shock in general intensive care unit: a nationwide prospective analysis of epidemiology and outcome

AIMS

Cardiogenic shock (CS) is a life-threatening disease burdened by a mortality up to 50%. The epidemiology has changed with non-ischaemic aetiologies being predominant, although data were mainly derived from patients admitted to dedicated acute cardiac care. We report the epidemiology and outcome of patients with CS admitted to general intensive care unit (ICU).

METHODS AND RESULTS

Prospective multicentric epidemiological study including 314 general ICU adhering to the GiViTI nationwide registry from 2011 to 2018, excluding cardiac arrest. The primary endpoint of the study was mortality. The association between clinical factors and mortality was evaluated using a logistic regression model. The odds ratios (ORs) of the covariates quantify their association with mortality during hospitalization. A total of 11 052 patients admitted to general ICU {incidence 2.17%; median age 72 [interquartile range (66-81)], 38.7% were women} with CS were included. Forty-seven per cent of patients had more than three organ insufficiency at the time of admission. The most common CS aetiologies were left heart failure (LHF, 5247-47.5%); acute myocardial infarction (3612-32.6%); right heart failure (RHF, 515-4.6%); and biventricular failure (532-4.8%). A total of 85.5% were mechanically ventilated during the ICU hospitalization. The overall ICU mortality was 44.8%, increasing to 53.4% during the hospitalization in the index hospital and to 54.3% at the latest hospital. Right heart failure-cardiogenic shock patients exhibited the highest mortality risk [OR: 1.19, 95% confidence interval (CI) (0.94-1.50); P < 0.001], followed by biventricular CS [OR 1.04, 95% CI (0.82-1.32)]. Respiratory failure [OR 1.13 (95% CI 1.08-1.19)], coagulation disorder [1.17 (95% CI 1.1-1.24)], renal dysfunction [OR 1.55 (95% CI 1.50-1.61)], and neurological alteration [OR 1.45 (95% CI 1.39-1.50)] were associated with worsen outcome along with severe hypotension [systolic blood pressure < 70 mmHg-OR 2.35, 95% CI (2.06-2.67)], increasing age [OR 2.21 95% CI (2.01-2.42)], and longer ICU stay prior to admission (two-fold increase for each 4.7 days).

CONCLUSION

In the general ICU, the aetiology of CS, excluding cardiac arrest, remains characterized mostly by LHF with RHF-CS burdened by higher mortality. Multiorgan failure at admission and longer hospital stay before ICU admission predispose to worsen outcome.

Sex difference in outcomes and management of cardiogenic shock: A systematic review and meta-analysis

BACKGROUND

Cardiogenic shock (CS) is associated with significant morbidity and mortality. Sex differences in the outcomes and management of cardiogenic shock are not well established. The primary objective of this study is to investigate the differences inik cardiogenic shock outcomes between males and females.

METHODS

A systematic review and meta-analysis were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Studies were searched via the MEDLINE/PubMed, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception to December 2022.

RESULTS

The analysis included 24 studies comprising 1,567,660 patients. Compared to females, males with CS had a significantly lower risk of in-hospital all-cause mortality (risk ratio [RR] 0.88, 95 % confidence interval [CI] 0.85-0.90, p < 0.001) and 1-year mortality (RR 0.90, 95 % CI 0.89-0.92, p < 0.001). Males were more likely to undergo percutaneous coronary intervention (RR 1.21, 95 % CI 1.13-1.31, p < 0.0001) and intra-aortic balloon pump placement (RR 1.21, 95 % CI 1.11-1.32, p < 0.0001), with no significant sex differences in the use of extracorporeal membrane oxygenation or Impella. During the index hospitalization, males were at higher risk of arrhythmias (RR 1.18, 95 % CI 1.05-1.34, p = 0.003) and less likely to develop acute kidney injury (RR 0.86, 95 % CI 0.79-0.94, p < 0.001).

CONCLUSION

Men have a lower all-cause mortality risk in cardiogenic shock. Addressing disparities in management is crucial for improving CS outcomes, especially for women.

Clinical impact of visceral adiposity on long-term mortality in patients undergoing coronary artery bypass grafting

INTRODUCTION AND OBJECTIVES

Although visceral adiposity increases cardiovascular risk in the general population, the obesity paradox has been reported in critically ill patients. However, evidence for its prognostic role in patients undergoing coronary artery bypass grafting (CABG) is limited. This study evaluated the prognostic implications of visceral adiposity in patients who underwent CABG using computed tomography-based measurement of visceral fat.

METHODS

A total of 2810 patients who underwent CABG from 2007 to 2017 were analyzed. The study population was classified into 3 groups according to visceral fat area index (VFAI) tertiles. VFAI was calculated as visceral fat area (cm2)/height2 (m2) at the L3 level. The primary outcome was all-cause mortality during follow-up.

RESULTS

Patients in the low VFAI group (lowest tertile) were younger and had a lower body mass index and less subcutaneous fat than those in the high VFAI group (highest tertile). During a median 8.7-year follow-up, VFAI was significantly associated with the risk of mortality in restricted cubic spline curve analysis (HR, 0.94 per 10 increases; 95%CI, 0.91-0.97; P<.001). Patients in the low VFAI group had a higher incidence of long-term mortality than those in the intermediate and high VFAI groups (T1 36.1%, T2 27.2%, and T3 29.1%; T1 vs T2; adjusted HR, 1.36; 95%CI, 1.15-1.61; P<.001; T1 vs T3; adjusted HR, 1.37; 95%CI, 1.16-1.62; P<.001). Similar results were obtained after inverse probability treatment-weighting analysis.

CONCLUSIONS

Low visceral adiposity was associated with an increased risk of long-term mortality in patients who underwent CABG.

Predicting survival after Impella implantation in patients with cardiogenic shock: The J-PVAD risk score

AIMS

Impella has become a new option for mechanical circulatory support in patients with cardiogenic shock (CS); however, prognostic models for patients after Impella are lacking. We aimed to identify the factors that predict in-hospital mortality in patients with CS requiring Impella and develop a new risk prediction model.

METHODS AND RESULTS

We utilized the J-PVAD registry, which includes all cases where Impella was implanted in Japan. Two-thirds of the patients in the J-PVAD registry were randomly assigned to the derivation cohort (n = 1701), and the other third was assigned to the validation cohort (n = 850). A backward stepwise logistic regression model was developed to identify factors associated with in-hospital mortality. In the derivation cohort, 956 patients were discharged alive, and 745 patients (43.8%) died during hospitalization. Among 29 candidate variables, 12 were independently associated with in-hospital mortality and were applied as components of the risk model, including age, sex, body mass index, fulminant myocarditis aetiology, cardiac arrest in hospital, baseline veno-arterial extracorporeal membrane oxygenation use, mean arterial pressure, lactate, lactate dehydrogenase, total bilirubin, creatinine, and albumin levels. The comparison of predicted and observed in-hospital mortality according to the 7th quantiles using the J-PVAD risk score showed good calibration. The area under the curve for the J-PVAD risk score was 0.76 (95% confidence interval 0.73-0.78). In the validation cohort, the J-PVAD risk score showed good calibration and discrimination ability.

CONCLUSIONS

The J-PVAD risk score can be calculated using variables easily obtained in routine clinical practice. It helps the accurate stratification of mortality risk and facilitates clinical decision-making.

The obesity paradox and 90 day mortality in chronic critically ill patients: a cohort study using a large clinical database

BACKGROUND

This study investigates the obesity paradox, where obesity is linked to lower mortality in certain patient groups, focusing on its impact on long-term mortality in chronic critically ill (CCI) patients.

METHODS

We retrospectively analyzed CCI patients from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database's Intensive Care Unit, categorizing them into six groups based on Body Mass Index (BMI). Using stepwise multivariable Cox regression and restricted cubic spline models, we examined the association between BMI and 90 day mortality, accounting for confounding variables through subgroup analyses.

RESULTS

The study included 1996 CCI patients, revealing a 90 day mortality of 34.12%. Overweight and obese patients exhibited significantly lower mortality compared to normal-weight individuals. Adjusted analysis showed lower mortality risks in overweight and obese groups (HRs 0.60 to 0.72, p < 0.001). The cubic spline model indicated a negative correlation between BMI and 90 day mortality, with subgroup analyses highlighting interactions with age.

CONCLUSION

Our findings confirm the obesity paradox in CCI patients, especially among the elderly (65-85 years) and very elderly (≥ 85 years). The results suggest a beneficial association of higher BMI in older CCI patients, though caution is advised for those under 45.

Modifiable factors associated with Huntington's disease progression in presymptomatic participants

OBJECTIVE

Huntington's disease (HD) is a neurodegenerative disorder characterized by progressive motor, cognitive, and psychiatric symptoms. Our aim here was to identify factors that can be modified to slow disease progression even before the first symptoms appear.

METHODS

We included 2636 presymptomatic individuals (comparison with family controls) drawn from the prospective observational cohort Enroll-HD, with more than 35 CAG repeats and at least two assessments of disease progression measured with the composite Huntington's disease rating Scale (cUHDRS). The association between sociodemographic factors, health behaviors, health history, and cUHDRS trajectory was assessed with a mixed-effects random forest using partial dependence plots and Shapley additive explanation method.

RESULTS

Participants were followed by an average of 3.4 (SD = 1.97) years. We confirmed the negative impact of age and a high number of CAG repeats. We found that a high level of education, a body mass index (BMI) <23 kg/m2 before the age of 40 and >23 kg/m2 thereafter, alcohol consumption of <15 units per week, current coffee consumption and no smoking were linked to slow disease progression, as did no previous exposure to antidepressants or anxiolytic, no psychiatric history or comorbidities, and being female. Other comorbidities or marital status showed no major association with HD evolution.

INTERPRETATION

Reducing modifiable risk factors for HD is one way to support the presymptomatic population. A high level of education, low-to-moderate alcohol consumption, no smoking, and BMI control are likely to slow disease progression in this population.

Sex differences in treatments and outcomes of patients with cardiogenic shock: a systematic review and epidemiological meta-analysis

BACKGROUND

Women are at higher risk of mortality from many acute cardiovascular conditions, but studies have demonstrated differing findings regarding the mortality of cardiogenic shock in women and men. To examine differences in 30-day mortality and mechanical circulatory support use by sex in patients with cardiogenic shock.

MAIN BODY

Cochrane Central, PubMed, MEDLINE and EMBASE were searched in April 2024. Studies were included if they were randomised controlled trials or observational studies, included adult patients with cardiogenic shock, and reported at least one of the following outcomes by sex: raw mortality, adjusted mortality (odds ratio) or use of mechanical circulatory support. Out of 4448 studies identified, 81 met inclusion criteria, pooling a total of 656,754 women and 1,018,036 men. In the unadjusted analysis for female sex and combined in-hospital and 30-day mortality, women had higher odds of mortality (Odds Ratio (OR) 1.35, 95% confidence interval (CI) 1.26-1.44, p < 0.001). Pooled unadjusted mortality was 35.9% in men and 40.8% in women (p < 0.001). When only studies reporting adjusted ORs were included, combined in-hospital/30-day mortality remained higher in women (OR 1.10, 95% CI 1.06-1.15, p < 0.001). These effects remained consistent across subgroups of acute myocardial infarction- and heart failure- related cardiogenic shock. Overall, women were less likely to receive mechanical support than men (OR = 0.67, 95% CI 0.57-0.79, p < 0.001); specifically, they were less likely to be treated with intra-aortic balloon pump (OR = 0.79, 95% CI 0.71-0.89, p < 0.001) or extracorporeal membrane oxygenation (OR = 0.84, 95% 0.71-0.99, p = 0.045). No significant difference was seen with use of percutaneous ventricular assist devices (OR = 0.82, 95% CI 0.51-1.33, p = 0.42).

CONCLUSION

Even when adjusted for confounders, mortality for cardiogenic shock in women is approximately 10% higher than men. This effect is seen in both acute myocardial infarction and heart failure cardiogenic shock. Women with cardiogenic shock are less likely to be treated with mechanical circulatory support than men. Clinicians should make immediate efforts to ensure the prompt diagnosis and aggressive treatment of cardiogenic shock in women.

Sex-specific impact of mild obesity on the prognosis of ST-segment elevation myocardial infarction

This study aimed to clarify the existence of the mild obesity paradox in patients with ST-segment elevation myocardial infarction (STEMI) and assess the impact of mild obesity on the prognosis of STEMI. A retrospective cohort study was conducted on STEMI patients who underwent percutaneous coronary intervention at Xiangtan Central Hospital from January 1, 2020 to July 31, 2022. After excluding individuals with a body mass index (BMI) of no less than 35 kg/m2, subjects were divided into the mildly obese group (BMI, 30-35 kg/m2) and non-obese group (BMI < 30 kg/m2). The cardiovascular events and death were deemed the composite endpoints and were employed as the outcome event. The study recruited 664 patients with STEMI, including 515 males and 149 females. The mildly obese group of male patients exhibited a lower incidence of composite endpoints than the non-obese group (22.4% vs. 41.3%, P < 0.001). For female patients, no significant difference was observed in the incidence of composite endpoints between the two groups (43.6% vs. 43.8%, P = 0.987). After adjusting for confounding factors, the multivariable Cox regression analysis revealed mild obesity as an independent protective factor for male patients [hazard ratio (HR) 0.47; 95% confidence interval (CI) 0.32-0.69; P < 0.001]. Nevertheless, mild obesity was not associated with the prognosis of female patients (HR 0.96; 95% CI 0.47-1.94; P = 0.9). In male STEMI patients, mild obesity presented a paradoxical effect in improving the prognosis and functioned as an independent protective factor for the prognosis of STEMI. However, no association between mild obesity and prognosis was found in female patients, possibly due to distinct physiological and metabolic characteristics between male and female patients, which deserved further investigation and validation.

Obesity phenotypes and cardiovascular risk: From pathophysiology to clinical management

Obesity epidemic reached the dimensions of a real global health crisis with more than one billion people worldwide living with obesity. Multiple obesity-related mechanisms cause structural, functional, humoral, and hemodynamic alterations with cardiovascular (CV) deleterious effects. A correct assessment of the cardiovascular risk in people with obesity is critical for reducing mortality and preserving quality of life. The correct identification of the obesity status remains difficult as recent evidence suggest that different phenotypes of obesity exist, each one associated with different degrees of CV risk. Diagnosis of obesity cannot depend only on anthropometric parameters but should include a precise assessment of the metabolic status. Recently, the World Heart Federation and World Obesity Federation provided an action plan for management of obesity-related CV risk and mortality, stressing for the instauration of comprehensive structured programs encompassing multidisciplinary teams. In this review we aim at providing an updated summary regarding the different obesity phenotypes, their specific effects on CV risk and differences in clinical management.

Role of age and sex in the association between BMI and functional limitations in stroke patients: Cross-sectional analysis in three European and US cohorts

BACKGROUND

A U- or J-shaped association between BMI and different post-stroke outcomes is suggested. Thus, the aim is to evaluate the association between BMI with ADL, IADL and mobility limitations in the ageing post-stroke population at different ages, as well as the differences in this association by sex.

METHODS

A total of 5,468 participants with stroke and 21,872 without stroke over 50 years of age were assessed for the number of limitations in basic or instrumental activities of daily living (ADL/IADL) as well as mobility tasks. The association between BMI at the interview (continuous time-dependent variable) and the level of limitations was assessed using a linear mixed model stratified by sex and stroke status.

RESULTS

The association between BMI and ADL/IADL and mobility limitations were found to be significant in both men and women regardless of stroke status (p<0.001 for all). The association differs between those who have suffered a stroke and those who have not (p<0.001 for all). In ADL/IADL limitations, men with stroke showed a transition from an inverted J-shape to a U-shape association with age. In women, the BMI showed a less pronounced association between BMI and ADL/IADL limitations compared to men but with similar trends. A effect of sex was observed in the association between BMI and mobility, with women with and without stroke showing a linear association that differed from the inverted J-shaped or U-shaped association of men.

CONCLUSION

Our results suggest that BMI is associated with limitations in ADL, IADL and mobility in stroke patients. In addition, this association differs between men and women and is also influenced by age.

The Impact of Body Mass Index on In-Hospital Mortality in Post-Cardiac-Arrest Patients-Does Sex Matter?

BACKGROUND

A number of factors influence mortality in post-cardiac-arrest (CA) patients, nutritional status being one of them. The aim of this study was to assess whether there are sex differences in the prognostic impact of BMI, as calculated on admission to an intensive care unit, on in-hospital mortality in sudden cardiac arrest (SCA) survivors.

METHODS

We carried out a retrospective analysis of data of 129 post-cardiac-arrest patients with return of spontaneous circulation (ROSC) admitted to the Intensive Care Unit (ICU) of the University Teaching Hospital in Wrocław between 2017 and 2022.

RESULTS

Female patients were significantly older than male patients (68.62 ± 14.77 vs. 62.7 ± 13.95). The results of univariable logistic regression analysis showed that BMI was not associated with the odds of in-hospital death in either male or female patients. In an age-adjusted model, age was an independent predictor of the odds of in-hospital death only in male patients (OR = 1.034). In our final multiple logistic regression model, adjusted for the remaining variables, none of the traits analysed were a significant independent predictor of the odds of in-hospital death in female patients, whereas an initial rhythm of ventricular fibrillation or pulseless ventricular tachycardia (VF/pVT) was an independent predictor of the odds of in-hospital death in male patients (OR = 0.247).

CONCLUSIONS

BMI on admission to ICU is not a predictor of the odds of in-hospital death in either male or female SCA survivors.

Correlation between severity of obesity and mortality in cardiogenic shock

INTRODUCTION

Cardiogenic shock (CS) is associated with high mortality despite the development of risk stratification tools and new treatment strategies. Obesity, although a risk factor for cardiovascular disease, is not included in current risk stratification tools for CS. A relationship between mortality and obesity has only been shown in subsets populations of CS; there is not yet a clear relationship between severity of obesity and all-cause CS.

OBJECTIVES

In this study we evaluate the relationship between rising body mass index (BMI) and mortality in all-cause CS.

METHODS

All patients with BMI measurements and hospitalizations complicated by CS from 2014 to 2019 at a single quaternary care institution were identified. Patients were grouped by obesity classification. Multivariate logistic regression was performed to determine a relationship between higher obesity classifications with 30-day mortality in patients with CS.

RESULTS

Seventy-two patients were available for analysis. Mean BMI for those who survived compared to those who did not was 29.7 ± 8 kg/m2 vs 33.7 ± 7.6 kg/m2 (p = 0.04). The odds ratio for mortality with incremental increase in obesity classification was 1.6 (95% CI 1.1 - 2.6, p = 0.03) after adjusting for etiology of CS and other common associations with CS mortality.

CONCLUSION

This study suggests that the higher mortality risk with incremental increases in BMI should be taken into account when risk stratifying these patients.

Impact of obesity on all-cause and cause-specific mortality among critically ill men and women: a cohort study on the eICU database

Background

The effect of obesity on intensive care unit outcomes among critically ill patients and whether there are sex differences have not been well investigated. We sought to determine the association between obesity and 30-day all-cause and cause-specific mortality among critically ill men and women.

Methods

Adult participants who had body mass index (BMI) measurements were included from the eICU database. Participants were divided into six groups according to BMI (kg/m²) categories (underweight, <18.5; normal weight, 18.5-24.9; overweight, 25-29.9; class I obesity, 30-34.9; class II obesity, 35-39.9; class III obesity, ≥40). A multivariable adjusted logistic model was conducted with odds ratios (ORs) and 95% confidence intervals (CIs). A cubic spline curve based on the generalized additive model was used to represent the nonlinear association. Stratified analysis and sensitivity analysis were also performed.

Results

A total of 160,940 individuals were included in the analysis. Compared with the class I obesity category, the underweight and normal weight categories had higher all-cause mortality, and the multivariable adjusted ORs were 1.62 (95% CI: 1.48-1.77) and 1.20 (95% CI: 1.13-1.27) for the general population, 1.76 (95% CI: 1.54-2.01) and 1.22 (95% CI: 1.13-1.32) for men, and 1.51 (95% CI: 1.33-1.71) and 1.16 (95% CI: 1.06-1.27) for women, respectively. Accordingly, multivariable adjusted ORs for the class III obesity category were 1.14 (95% CI: 1.05-1.24) for the general population, 1.18 (95% CI: 1.05-1.33) for men, and 1.10 (95% CI: 0.98-1.23) for women. With cubic spline curves, the association between BMI and all-cause mortality was U-shaped or reverse J-shaped. Similar findings were observed for cause-specific mortality, with the underweight category associated with a higher risk of mortality. Class III obesity increased the risk of cardiovascular death among men (OR 1.51; 95% CI: 1.23-1.84) and increased the risk of other-cause death among women (OR 1.33; 95% CI: 1.10-1.61).

Conclusion

The obesity paradox appears to be suitable for all-cause and cause-specific mortality among critically ill men and women. However, the protective effect of obesity cannot be extended to severely obese individuals. The association between BMI and cardiovascular mortality was sex-specific and was more pronounced among men than among women. Graphical abstract.