Clinical impact of visceral-to-subcutaneous fat ratio in patients with acute aortic dissection

The association between the visceral to subcutaneous abdominal fat ratio and the risk of cardiovascular diseases: a systematic review

BACKGROUND

Cardiovascular diseases (CVDs) are the primary cause of mortality globally. The prevalence of obesity is rising worldwide; there seems to be a significant positive association between obesity and CVDs. The distribution of fat in the abdominal area in the form of visceral (VAT) or subcutaneous adipose tissue (SAT) affects the risk of CVDs. The aim of the present study was to conduct a systematic review of the available literature regarding the association between the VAT-to-SAT ratio and CVDs.

METHODS

A comprehensive search strategy was used to retrieve all human observational studies indexed in PubMed, Scopus and Google Scholar databases/search engines (from Jan 2000 up to Oct 2023). The VAT-to-SAT or SAT-to-VAT ratio was an independent variable and various cardiovascular diseases, including hypertension, atherosclerosis, coronary heart disease, cerebrovascular disease and heart failure, were considered as outcomes of interest.

RESULTS

Out of 1173 initial studies, 910 papers were screened. Based on the inclusion criteria, 883 papers were excluded. Finally, 27 papers (18 cross-sectional and 9 cohort studies) published between 2010 and 2023 which met the inclusion criteria were reviewed.

CONCLUSIONS

The distribution of abdominal fat seems to be associated with the risk of CVDs; the majority of the evidence suggests that a higher abdominal VAT-to-SAT ratio is associated with the development of CVDs. Therefore, this ratio can be used as a prognostic indicator for CVDs.

TRIAL REGISTRATION

Not applicable.

Potential confounders of the obesity paradox in older patients following transcatheter aortic valve replacement

PURPOSE

A higher body mass index (BMI) is associated with lower mortality in older patients following transcatheter aortic valve replacement (TAVR) for severe aortic valve stenosis. The current study aimed to investigate potential confounders of association between BMI and prognosis.

METHODS

The retrospective single-center study included consecutive patients following TAVR and excluded those in whom subcutaneous fat accumulation (SFA), visceral fat accumulation (VFA), and major psoas muscle (MPM) volume were not assessed by computed tomography. Cachexia was defined as a combination of BMI < 20 kg/m2 and any biochemical abnormalities.

RESULTS

After 2 patients were excluded, 234 (age, 86 ± 5 years; male, 77 [33%]; BMI, 22.4 ± 3.8 kg/m2; SFA, 109 (54-156) cm2; VFA, 71 (35-115) cm2; MPM, 202 (161-267) cm3; cachexia, 49 [21%]) were evaluated. SFA and VFA were strongly correlated with BMI (ρ = 0.734 and ρ = 0.712, respectively), whereas MPM was weakly correlated (ρ = 0.346). Two-year all-cause mortality was observed in 31 patients (13%). Higher BMI was associated with lower mortality (adjusted hazard ratio [aHR], 0.86; 95% confidence interval [CI], 0.77-0.95). A similar result was observed in the multivariate model including SFA (aHR in an increase of 20 cm2, 0.87; 95% CI, 0.77-0.98) instead of BMI, whereas VFA was not significant. Cachexia was a worse predictor (aHR, 2.51; 95% CI 1.11-5.65).

CONCLUSIONS

Association of higher BMI with lower mortality may be confounded by SFA in older patients following TAVR. Cachexia might reflect higher mortality in patients with lower BMI.

Association between Periodontal Condition and Fat Distribution in Japanese Adults: A Cross-Sectional Study Using Check-Up Data

Some studies have reported a significant association between periodontal condition and obesity status. We hypothesized that visceral fat area (VFA) and subcutaneous fat area (SFA) volumes might be correlated with periodontal condition. The purpose of the present cross-sectional study was to investigate the association between periodontal condition and fat distribution in Japanese adults. A total of 158 participants, aged 35-74 years, underwent a health check-up including fat distribution and oral examinations. All of the participants underwent magnetic resonance imaging to quantify VFA and SFA. Periodontal condition was evaluated using the periodontal pocket depth (PPD) and clinical attachment level. The VFA volumes differed among the PPD score and clinical attachment level (CAL) code groups. On the other hand, no significant differences in SFA volume were observed among different periodontal conditions. Multiple regression analysis showed that VFA was positively correlated with a greater CAL (standardized coefficient β = 0.123, p = 0.009), but not with a greater PPD score. A larger VFA was positively associated with a greater CAL in Japanese adults, whereas no association was found between SFA and periodontal condition.

Sex-specific impact of anthropometric parameters on outcomes after transcatheter edge-to-edge repair for secondary mitral regurgitation

BACKGROUND

Body surface area (BSA) has been reported to be the stronger predictor for prognosis than body mass index in heart failure (HF) patients. The sex-specific association of BSA with mortality has been unclear.

METHODS

EuroSMR, a European multicenter registry, included patients who underwent edge-to-edge repair (TEER) for secondary mitral regurgitation (SMR). The outcome was two-year all-cause mortality.

RESULTS

The present cohort included 1594 HF patients (age, 74 ± 10 years; male, 66%). Association of calculated BSA with two-year all-cause mortality was evaluated. Patients were classified into three BSA groups: the lowest 10% (S), the highest 10% (L), and intermediate between S and L (M). Mean BSA was 1.87 ± 0.21 m² (male, 1.94 ± 0.18 m²; female, 1.73 ± 0.18 m²). The association of BSA with the endpoint in females showed a U-shaped curve, indicating worse prognosis for both S and L. The association in males followed a linear regression, demonstrating better prognosis for L. Hazard ratio (HR) of L to S in males was 0.43 (95% confidence interval [CI], 0.25-0.74; p = 0.002), whereas HR of L to M in females was 1.76 (95% CI, 1.11-2.78; p = 0.016) (p for interaction = 0.003).

CONCLUSIONS

Sex-specific association patterns demonstrate the complex influence of anthropomorphic factors in HF patients scheduled for TEER. Further investigation beyond simple evaluation of weight and height is needed for better comprehension of the obesity paradox and better prediction of the results of transcatheter therapy in HF patients.

Impact of sarcopenic obesity on long-term clinical outcomes after ST-segment elevation myocardial infarction

BACKGROUND AND AIMS

Both low appendicular skeletal muscle index (ASMI) and specific abdominal fat composition [i.e., increased visceral to subcutaneous (V/S) fat ratio] have been associated with cardiovascular events. However, the combined impact of these 2 components on long-term outcomes remains unclear, especially in patients with ST-segment elevation myocardial infarction (STEMI).

METHODS

In 303 patients with STEMI, ASMI and V/S fat ratio were assessed using dual-energy X-ray absorptiometry and abdominal computed tomography. Based on the criteria of the Asian Working Group for Sarcopenia and median of V/S fat ratio, sarcopenic obesity (SO) pattern was defined as low ASMI with high V/S fat ratio. The primary endpoint was composite outcomes of all-cause death, myocardial infarction, ischemic stroke, hospitalization for heart failure and unplanned revascularization.

RESULTS

During a median follow-up of 3.9 years, primary endpoint occurred in 67 patients. Patients with an SO pattern showed significantly lower event-free survival rate compared with those without (p=0.006 by log-rank). Notably, when stratified by median age (67 years), this trend was particularly prominent in the younger-age group (p <0.001), but not significant in the older-age group (p=0.38). In the younger-age group, the multivariate analysis revealed that patients with SO pattern had a 2.97 (1.10-7.53) fold higher risk for primary endpoints compared with those without.

CONCLUSIONS

Low ASMI with high V/S fat ratio, or so-called sarcopenic obesity, was associated with poor prognosis after STEMI, particularly in younger-age patients. The combined assessment of skeletal muscle with abdominal fat distribution may help stratify the risk among patients with STEMI, rather than each component alone.

Incidence and recurrence of new-onset atrial fibrillation detected during hospitalization for non-cardiac surgery: a systematic review and meta-analysis

PURPOSE

This systematic review aimed to summarize reports of the incidence and long-term recurrence of new-onset atrial fibrillation (AF) associated with non-cardiac surgery.

SOURCES

We searched CENTRAL, MEDLINE and EMBASE from inception to November 2019. We included studies that reported on the incidence of new-onset perioperative AF during hospitalization for non-cardiac surgery and/or AF recurrence in such patients following discharge. Reviewers screened articles and abstracted data independently and in duplicate. We assessed study quality by appraising methodology for collecting AF history, incident AF during hospitalization, and AF recurrence after discharge.

PRINCIPAL FINDINGS

From 39,233 citations screened, 346 studies that enrolled a total of 5,829,758 patients met eligibility criteria. Only 27 studies used prospective, continuous inpatient electrocardiographic (ECG) monitoring to detect incident AF. Overall, the incidence of postoperative AF during hospitalization ranged from 0.004 to 50.3%, with a median [interquartile range] of 8.7 [3.8-15.0]%. Atrial fibrillation incidence varied with type of surgery. Prospective studies using continuous ECG monitoring reported significantly higher incidences of AF than those that did not (13.9% vs 1.9%, respectively; P < 0.001). A total of 13 studies (25,726 patients) with follow-up up to 5.4 years reported on AF recurrence following hospital discharge; only one study used a prospective systematic monitoring protocol. Recurrence rates ranged from 0 to 37.3%.

CONCLUSIONS

Rates of AF incidence first detected following non-cardiac surgery and long-term AF recurrence vary markedly. Differences in the intensity of ECG monitoring and type of surgery may account for this variation.

TRIAL REGISTRATION

PROSPERO (CRD42017068055); registered 1 September 2017.

Visceral to subcutaneous fat ratio as an indicator of a ≥30% eGFR decline in chronic kidney disease

Whether the visceral-to-subcutaneous fat ratio (V/S ratio) is associated with renal prognosis in patients with chronic kidney disease (CKD) remains unclear. Furthermore, little is known about the effect of sex and the absolute amount of visceral fat accumulation such as visceral fat area (VFA) ≥100 cm² on the V/S ratio in relation to renal prognosis. In this study, 200 patients with CKD were evaluated for renal prognosis. Survival analyses and logistic regression analyses were conducted, generating time-series pseudo-R² values. The mean and percent change of the pseudo-R² values from the 6^th year to the 10^th year (6Y–10Y Mean and 6Y–10Y Change, respectively) were calculated for determining the cut-off points for the medium-term renal prognosis. Multivariate Cox regression analysis revealed that the V/S ratio was significantly associated with renal outcomes and that the VFA category (VFA ≥ 100 cm²) had significant interactions with the V/S ratio regarding renal prognosis. The hazard ratio (HR) of the V/S ratio was higher in the sub-cohort of VFA < 100 cm² than in the sub-cohort of VFA ≥ 100 cm² (HR: 6.42 vs. 1.00). Regarding sex differences, a strong association was noted between the V/S ratio and renal prognosis in women but not in men (HR: 2.40 vs. 1.10). On the other hand, 6Y–10Y Mean of the pseudo-R² values indicated differences in the cut-off points of the V/S ratio between men and women (V/S ratio: 0.75 vs. 0.5). Our findings indicate that it may be clinically meaningful to consider the differences in sex and the amount of VFA ≥100 cm² for the V/S ratio in relation to renal outcomes in patients with CKD. The 6Y–10Y Mean of the pseudo-R² values contributed to determining the cut-off points of the V/S ratio according to the sex difference.