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Obesity and cardiovascular disease Risk factor,paradox and impact of weight loss

Obesity and cardiovascular disease Risk factor,paradox and impact of weight loss.

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Obesity and cardiovascular disease Risk factor,paradox and impact of weight loss

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  1. Obesity and cardiovascular disease Risk factor,paradox and impact of weight loss

  2. Obesity has reached global epidemic proportions in both adults and children and is associated with numerous comorbidities, including hypertension (HTN), type II diabetes mellitus, dyslipidemia, obstructive sleep apneaand sleep-disordered breathing, certain cancers, and major cardiovascular (CV) diseases.

  3. Because of its maladaptive effects on various CV risk factors and its adverse effects on CV structure and function, obesity has a major impact on CV diseases, such as heart failure (HF) , coronary heart disease (CHD) , sudden cardiac death, and atrial fibrillation, and is associated with reduced overall survival.

  4. Recent evidence indicates that obesity is associated with more morbidity than smoking, alcoholism, and poverty, and if current trends continue, obesity may soon overtake cigarette abuse as the leading cause of preventable death in the world.

  5. Adverse Effects of Obesity A. Increases in insulin resistance 1) Glucose intolerance 2) Metabolic syndrome 3) Type 2 diabetes mellitus B. Hypertension C. Dyslipidemia 1) Elevated total cholesterol 2) Elevated triglycerides 3) Elevated LDL cholesterol 4) Elevated non-HDL cholesterol 5) Elevated apolipoprotein-B 6) Elevated small, dense LDL particles 7) Decreased HDL cholesterol 8) Decreased apolipoprotein-A1 D. Abnormal left ventricular geometry 1) Concentric remodeling 2) Left ventricular hypertrophy E. Endothelial dysfunction F. Increased systemic inflammation and prothrombotic state G. Systolic and diastolic dysfunction H. Heart failure I. Coronary heart disease J. Atrial fibrillation K. Obstructive sleep apnea/sleep-disordered breathing L. Albuminuria M. Osteoarthritis N. Cancers

  6. Despite this adverse association, numerous studies have documented an obesity paradox in which overweight and obese people with established CV disease, including HTN, HF, CHD, and peripheral arterial disease, have a better prognosis compared with nonoverweight/ nonobesepatients.

  7. Obesity, HTN, and the obesity paradox

  8. METHODS: A total of 22,576 hypertensive patients with coronary artery disease (follow up 61,835 patient years, mean age 66±9.8 years) were randomized to blood pressure control according to the Sixth JNC targets. Patients were classified into 5 groups according to baseline BMI: less than 20 kg/m2 (thin), 20 to 25 kg/m2 (normal weight), 25 to 30 kg/m2(overweight), 30 to 35 kg/m2 (class I obesity), and 35 kg/m2 or more (class II-III obesity). The primary outcome was first occurrence of death, nonfatal myocardial infarction, or nonfatal stroke.

  9. RESULTS: With patients of normal weight (BMI 20 to 25 kg/m2) as the reference group, the risk of primary outcome was lower in the overweight patients (adjusted hazard ratio [HR] 0.77, 95% confidence interval [CI], 0.70-0.86, P<.001), class I obese patients (adjusted HR 0.68, 95% CI, 0.59-0.78, P<.001), and class II to III obese patients (adjusted HR 0.76, 95% CI, 0.65-0.88, P <.001). Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months (17.5±21.9 mm Hg/9.8±12.4 mm Hg vs 20.7±23.1 mm Hg / 10.6±12.5 mm Hg, P<.001).

  10. CONCLUSION: In a population with hypertension and coronary artery disease, overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight, which was driven primarily by a decreased risk of all-cause mortality.

  11. Body mass index and prognosis in elderly hypertensive patients: a report from the European Working Party on High Blood Pressure in the Elderly JaakkoTuomilehto, M.D., European Working Party on High Blood Pressure ∗ Department of Epidemiology, National Public Health Institute, Helsinki, Finland

  12. In the current study of 800 elderly hypertensive patients randomly assigned to active treatment, the initial mean body mass index (BMI) was 26.7 kg/m2 in 560 women and 25.7 kg/m2 in 240 men.

  13. During the trial, total mortality and cardiovascular and noncardiovascular terminating events were highest in the patients at the leanest BMI quintile. The association between BMI and cardiovascular end points was U-shaped, whereas noncardiovascular mortality decreased with increasing BMI. The results in the women were similar to those in the total group. The U-shaped relation was confirmed with Cox's proportional hazards model, controlling for age, gender, systolic blood pressure, hemoglobin, serum cholesterol, blood glucose, and cardiovascular complications at entry.

  14. The BMI level with the lowest risk was 28 to 29 kg/m2 for total mortality and cardiovascular terminating events, 26 to 27 kg/m2 for cardiovascular mortality, and 31 to 32 kg/m2 for noncardiovascular mortality. BMI did not modify the favorable effects of drug treatment.

  15. Obesity, HF, and the obesity paradox.

  16. Body mass index and mortality in heart failure: A meta-analysis Antigone Oreopoulos, MSca, Raj Padwal, MD, MScb, , , KamyarKalantar-Zadeh, MD, MPH, PhDc, Gregg C. Fonarow, MD, FACCd, Colleen M. Norris, PhDe, Finlay A. McAlister, MD, MScb American Heart Journal Volume 156, Issue 1, July 2008, Pages 13–22

  17. Background: In patients with chronic heart failure (CHF), previous studies have reported reduced mortality rates in patients with increased body mass index (BMI). The potentially protective effect of increased BMI in CHF has been termed the obesity paradox or reverse epidemiology. This meta-analysis was conducted to examine the relationship between increased BMI and mortality in patients with CHF.

  18. Methods: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Scopus, and Web of Science to identify studies with contemporaneous control groups (cohort, case-control, or randomized controlled trials) that examined the effect of obesity on all-cause and cardiovascular mortality. Two reviewers independently assessed studies for inclusion and performed data extraction.

  19. Results: Nine observational studies met final inclusion criteria (total n = 28,209). Mean length of follow-up was 2.7 years. Compared to individuals without elevated BMI levels, both overweight (BMI ∼25.0-29.9 kg/m2, RR 0.84, 95% CI 0.79-0.90) and obesity (BMI ∼≥30 kg/m2, RR 0.67, 95% CI 0.62-0.73) were associated with lower all-cause mortality. Overweight (RR 0.81, 95% CI 0.72-0.92) and obesity (RR 0.60, 95% CI 0.53-0.69) were also associated with lower cardiovascular mortality. In a risk-adjusted sensitivity analysis, both obesity (adjusted HR 0.88, 95% CI 0.83-0.93) and overweight (adjusted HR 0.93, 95% CI 0.89-0.97) remained protective against mortality.

  20. Conclusions: Overweight and obesity were associated with lower all-cause and cardiovascular mortality rates in patients with CHF and were not associated with increased mortality in any study.

  21. An obesity paradox in acute heart failure: Analysis of body mass index and inhospital mortality for 108 927 patients in the Acute Decompensated Heart Failure National Registry Gregg C. Fonarow, MDa, , , PreethiSrikanthan, MDa, Maria Rosa Costanzo, MDb, Guillermo B. Cintron, MDc, Margarita Lopatin, MSd, for the ADHERE Scientific Advisory Committee and Investigators American Heart Journal Volume 153, Issue 1, January 2007, Pages 74–8

  22. Methods: The Acute Decompensated Heart Failure National Registry was analyzed for acute HF hospitalizations in 263 hospitals in the United States from October 2001 through December 2004. Patients with documented height and weight were divided into BMI (measured in kilograms per square meter) quartiles. In hospital mortality by BMI quartile for all the patients and for those with reduced (n = 43 255) and preserved (n = 37 901) systolic function was assessed.

  23. Results: Body mass index quartiles in the 108 927 hospitalizations were QI (16.0-23.6 kg/m2), QII (23.7-27.7 kg/m2), QIII (27.8-33.3 kg/m2), and QIV (33.4-60.0 kg/m2). Patients in the higher BMI quartiles were younger, had more diabetes, and had a higher left ventricular ejection fraction. In hospital mortality rates decreased in a near-linear fashion across successively higher BMI quartiles. After adjustments for age, sex, blood urea nitrogen, blood pressure, creatinine, sodium, heart rate, and dyspnea at rest, BMI quartile still predicted mortality risk. For every 5-U increase in BMI, the odds of risk-adjusted mortality was 10% lower (95% CI 0.88-0.93, P < .0001).

  24. Obesity, CHD, and the obesity paradox

  25. Obesity plays a major role in adversely affecting major CHD risk factors, including HTN, dyslipidemia, and diabetes mellitus (DM), is the major component of metabolic syndrome, and is probably an independent risk factor for atherosclerosis and CHD events.

  26. Nevertheless, as with HTN and HF, many studies have also reported an obesity paradox in CHD, including in patients treated with revascularization.

  27. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies Abel Romero-Corral, MD, Victor M Montori, MD, Prof Virend K Somers, MD, Josef Korinek, MD, Randal J Thomas, MD, Thomas G Allison, PhD, Farouk Mookadam, MD, Francisco Lopez-Jimenez, MD. The LANCET Volume 368, Issue 9536, 19–25 August 2006, Pages 666–678

  28. Methods: We selected cohort studies that provided risk estimates for total mortality, with or without cardiovascular events, on the basis of bodyweight or obesity measures in patients with CAD, and with at least 6 months' follow-up. CAD was defined as history of percutaneous coronary intervention, coronary artery bypass graft, or myocardial infarction. We obtained risk estimates for five predetermined bodyweight groups: low, normal weight (reference), overweight, obese, and severely obese.

  29. Findings: There were 40 studies with 250,152 patients that had a mean follow-up of 3·8 years. Patients with a low body-mass index (BMI) (ie, <20) had an increased relative risk (RR) for total mortality (RR=1·37 [95% CI 1·32–1·43), and cardiovascular mortality (1·45 [1·16–1·81]), overweight (BMI 25–29.9) had the lowest risk for total mortality (0·87 [0·81–0·94]) and cardiovascular mortality (0·88 [0·75–1·02]) compared with those for people with a normal BMI. Obese patients (BMI 30–35) had no increased risk for total mortality (0·93 [0·85–1·03]) or cardiovascular mortality (0·97 [0·82–1·15]). Patients with severe obesity (≥35) did not have increased total mortality (1·10 [0·87–1·41]) but they had the highest risk for cardiovascular mortality (1·88 [1·05–3·34]).

  30. Objectives: This study goal was to determine the impact of lean mass index (LMI) and body fat (BF) on survival in patients with coronary heart disease (CHD).

  31. Methods : We studied 570 consecutive patients with CHD who were referred to cardiac rehabilitation, stratified as Low (25% in men and 35% in women) and High (25% in men and 35% in women) BF and as Low (18.9 kg/m2 in men and 15.4 kg/m2 in women) and High LMI, and followed for 3 years for survival.

  32. Results: Mortality is inversely related to LMI (p ‹ 0.0001). Mortality was highest in the Low BF/Low LMI group (15%), which was significantly higher than in the other 3 groups, and lowest in the High BF/High LMI group (2.2%), which was significantly lower than in the other 3 groups. In Cox regression analysis as categoric variables, low LMI (hazard ratio [HR]: 3.1; 95% confidence interval [CI]: 1.3 to 7.1) and low BF (HR: 2.6; 95% CI: 1.1 to 6.4) predicted higher mortality, and as continuous variables, high BF (HR: 0.91; 95% CI: 0.85 to 0.97) and high LMI (HR: 0.81; 95% CI: 0.65 to 1.00) predicted lower mortality.

  33. Conclusions: In patients with stable CHD, both LMI and BF predict mortality, with mortality particularly high in those with Low LMI/Low BF and lowest in those with High LMI/High BF. Determination of optimal body composition in primary and secondary CHD prevention is needed.

  34. The aim of this study was to investigate the impact of morbid obesity (body mass index ≥40 kg/m2) on in-hospital mortality and coronary revascularization outcomes in patients presenting with acute myocardial infarctions (AMI).

  35. 413,673 patients hospitalized with AMIs in 2009 were reviewed. Morbidly obese patients constituted 3.7% of all patients with AMIs. Analysis of the unadjusted data revealed that morbidly obese patients compared with those not morbidly obese were more likely to undergo any invasive cardiac procedures when presenting with either ST-segment elevation myocardial infarction (97.4% vs 93.8%, p <0.0001) or noneST-segment elevation myocardial infarction (85.5% vs 80.6%, p <0.0001). The unadjusted mortality rate for morbidly obese patients with AMIs was 3.5%, compared with 5.5% of those not obese (p <0.0001). After adjustment, lower odds of mortality in those morbidly obese compared to those not morbidly remained.

  36. In conclusion, patients with morbid obesity had lower odds of in-hospital mortality, compared to those not morbidly obese, consistent with the phenomenon of the “obesity paradox.”

  37. BACKGROUND: An “obesity paradox,” in which overweight and obese individuals with established cardiovascular disease have a better prognosis than normal weight subjects, has been reported in a number of clinical cohorts, but little is known about the effects of weight loss on the obesity paradox and its association with health outcomes.

  38. METHODS: Weight was determined in 3834 men at the time of a clinically referred exercise test and again during a clinical evaluation a mean of 7 years later. The associations among weight changes, baseline fitness, and other risk markers with cardiovascular and all cause mortality were determined by Cox proportional hazards analysis.

  39. RESULTS: During the follow-up period, 314 subjects died (72 of cardiovascular causes). In a multivariate analysis (including baseline weight, weight change, exercise capacity, and cardiovascular disease), weight gain was associated with lower mortality and weight loss was associated with higher mortality (4% higher per pound lost per year, P.001) compared with stable weight. For all-cause mortality, the relative risks for the no change, weight gain, and weight loss groups were 1.0 (referent), 0.64 (95% confidence interval, 0.50-0.83), and 1.49 (95% confidence interval, 1.17-1.89), respectively (P.001). Those who died and exhibited weight loss had a significantly higher prevalence of deaths due to cancer and cardiovascular causes.

  40. CONCLUSION: Weight loss was related to higher mortality and weight gain was related to lower mortality when compared with stable weight.

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