High cardiovascular risk patients benefit more from bariatric surgery than low cardiovascular risk patients

Long-Term Safety and Efficacy Profile of Bariatric Surgery in Patients Classified with ASA IV Status

INTRODUCTION

Metabolic and bariatric surgery (MBS) is a safe and effective treatment option to reduce weight and manage obesity-related medical conditions in patients with obesity. However, due to limited data, there is uncertainty regarding the short-, mid-, and long-term safety and efficacy profile of MBS in patients with a preoperative ASA IV status.

METHODS

A single-center retrospective cohort study was performed on patients with ASA IV status who underwent sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or biliopancreatic diversion with duodenal switch (BPD-DS) between 2008 and 2020. Data collected included operative details; postoperative complications at 30 days, 90 days, and beyond 90 days; BMI changes; and resolution of obesity-related comorbidities at 0, 6, 12, 24, 48, and 60 months postoperatively.

RESULTS

Among 131 ASA class IV patients, 43 patients underwent SG (32.8%), 66 patients underwent RYGB (50.4%), and 22 patients underwent BPD-DS (16.8%). The greatest %TWL occurred in the BPD-DS cohort (39.5%) at 24 months post-op followed by the RYGB (32.5%) and SG (20.7%) cohorts (p < 0.001). The overall major 30-day complication rate was 8.4% (n = 11/131), while the overall major 90-day complication rate within the cohort was 6.9% (n = 9/131). The overall major late (> 90 days) complication rate was found to be 14.5% (n = 19/131).

CONCLUSIONS

Our study demonstrated that MBS is relatively safe and effective in ASA IV patients in the short-, mid-, and long-term. Accordingly, careful procedure selection is required in this patient population. Further long-term studies are needed to support our findings.

Cardiometabolic Improvements After Metabolic Surgery and Related Presurgery Factors

Context

Metabolic surgery remains the most effective and durable treatment for severe obesity and related metabolic diseases.

Objective

We examined cardiometabolic improvements after metabolic surgery and associated presurgery demographic and clinical factors in a large multiracial cohort.

Methods

Included were 7804 patients (20-79 years) undergoing first-time metabolic surgery at Vanderbilt University Medical Center from 1999 to 2022. Pre- and 1-year postsurgery cardiometabolic profiles were extracted from medical records, including body mass index (BMI), blood pressure, blood lipids, glucose, and hemoglobin A1c. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk was estimated per American College of Cardiology/American Heart Association equations. Pre- to postsurgery cardiometabolic profiles were compared by paired t-test, and associated factors were identified by multivariable linear and logistic regression.

Results

Among 7804 patients, most were women and White, while 1618 were men and 1271 were Black; median age and BMI were 45 years [interquartile range (IQR): 37-53] and 46.4 kg/m2 (IQR: 42.1-52.4). At 1-year postsurgery, patients showed significant decreases in systolic blood pressure (10.5 [95% confidence interval: 10.1, 10.9] mmHg), total cholesterol (13.5 [10.3, 16.7] mg/dL), glucose (13.6 [12.9, 14.4] mg/dL), hemoglobin A1c (1.13% [1.06, 1.20]), and 10-year ASCVD risk (absolute reduction: 1.58% [1.22, 1.94]; relative reduction: 34.4% [29.4, 39.3]); all P < .0001. Older, male, or Black patients showed less reduction in 10-year ASCVD risk and lower odds of diabetes/hypertension/dyslipidemia remission than younger, female, or White patients. Patients with a history of diabetes, hypertension, dyslipidemia, or cardiovascular disease showed less cardiometabolic improvements than those without. Results were similar with or without further adjusting for weight loss and largely sustained at 2-year postsurgery.

Conclusion

Metabolic surgery results in significant cardiometabolic improvements, particularly among younger, female, or White patients and those without comorbidities.

Reaching LDL-C Targets in Patients with Moderate, High, and Very High Risk for Cardiovascular Disease After Bariatric Surgery According to Different Guidelines

BACKGROUND

Cardiovascular disease (CVD) is highly prevalent in obese patients and is the leading cause of death. High levels of plasma low-density lipoprotein cholesterol (LDL-C) are associated with higher coronary artery disease (CAD) risk. The aim of the study was to assess the impact of the Roux-en-Y gastric bypass on the achievement of the currently proposed cardiovascular prevention goals after 1 year.

PATIENTS AND METHODS

We performed a retrospective analysis from a prospectively built database of patients who underwent a primary Roux-en-Y gastric bypass (RYGB) from 2004 to 2018. Patients with intermediate, high, or very high risk for CVD according to the 2018 AHA/ACC or the 2019 ESC/EAS guidelines were selected. An analysis of clinical and biochemical variables in 1 year was performed. Logistic multivariate regressions were made to assess the impact of preoperative and weight loss parameters in the achievement of LDL-C goals.

RESULTS

From 1039 patients, 70 met the selection criteria and were included in the analysis of the 2018 AHA/ACC guidelines, and 75 in the 2019 ESC/EAS guidelines. Mean decrease in LDL-C levels was 21.1 ± 40.2 mg/dL 1 year after surgery, and 29/34 patients were off medications. The percentage of patients achieving LDL-C goals according to the 2018 AHA/ACC guidelines was 27.1%, whereas according to the 2019 ESC/EAS guidelines, the percentages was 9.3%. The %TWL was associated with achieving LDL-C goals according to the 2018 AHA/ACC at 1 year.

CONCLUSIONS

RYGB induces a significant weight loss and an improvement in LDL-C levels 1 year after surgery. The number of patients that reached the goals varies according to the guidelines used and ranged from 9.3 to 27.1%.

Cardiovascular outcome trials in obesity: A review

Obesity is a global epidemic associated with over 200 health complications and a significant risk of developing cardiovascular disease (CVD), partly by increasing classical risk factors such as lipid and glucose levels and blood pressure. Weight loss through lifestyle interventions, pharmacotherapy and/or bariatric surgery improves CV risk factors. Cardiovascular outcome trials (CVOTs) of anti-obesity medications aim to evaluate the CV safety and benefits of pharmacotherapy. Many CVOTs in obesity have either failed to demonstrate a CV benefit or have been terminated prematurely because of safety issues, prompting regulatory agencies to define new requirements (based on those for CVOTs in type 2 diabetes [T2D]). CVOTs of glucagon-like peptide-1 receptor agonists (GLP-1RAs) in T2D have demonstrated that some GLP-1RAs reduce CV risk and may help inform future CVOTs in obesity, given the approval of liraglutide 3.0 mg for obesity. In this review, the evidence for the link between obesity and CVD is considered in the context of studies showing that weight loss improves markers of CV risk and risk of adverse CV events. The review also examines the CVOTs in obesity that have been conducted to date and those under way, such as the SELECT trial with subcutaneous semaglutide of 2.4 mg.

Bariatric surgery and cardiovascular outcome

BACKGROUND

Obesity is recognized as a classic risk factor for atherosclerosis and subsequent cardiovascular disease (CVD). Weight loss after bariatric surgery has been associated with reduced CV mortality and total mortality in obese patients. Our aim was to study the impact of bariatric surgery on CV risk profile, cardiac structure, and function postoperatively.

RESULTS

This prospective longitudinal study included 100 morbidly obese patients at final analysis. All patients were subjected to full clinical, laboratory, and echocardiographic examination at baseline and 6 months after bariatric surgery. The mean age of study population was 37.2 ± 10.49 with BMI of 47 ± 6.82. Females represented 84%. Sleeve gastrectomy and Roux-en-Y gastric bypass were performed in 79% and 21%, respectively. Surgery-related mortality and morbidity were 0.94% and 4.7%, respectively. After 6 months, there were significant decreases in BMI, heart rate, SBP, DBP, and Framingham risk score (P < 0.0001). The prevalence of risk factors decreased as follows: hypertension 24% vs. 12%, P = 0.0005; DM 21% vs. 11%, P = 0.002; dyslipidemia 32% vs. 7%, P < 0.0001; and metabolic syndrome 54% vs. 26%, P < 0.0001. Highly significant (P < 0.0001) decrease in fasting PG and 2 h PP-PG, HbA1c, ASL, ALT, fasting total cholesterol, LDL, TG, and increase in HDL were observed after bariatric surgery. There were significant shortening in QTc interval (P = 0.009), decrease in LV dimensions and LV mass index (P < 0.0001), and increase in LV EF% (P = 0.0003). BMI at follow-up showed significant positive correlation with age, Framingham risk score, and preoperative BMI (r = 0.289, P = 0.0036; r = 0.37, P = 0.0054; and r = 0.31, P = 0.0081, respectively).

CONCLUSION

In addition to enabling patients to achieve a substantial weight loss, bariatric surgery provides a myriad of health benefits. Weight reduction was associated with a favorable improvement in cardiovascular risk profile, cardiac structure, and function.

Impact of bariatric surgery on heart failure mortality

BACKGROUND

The impact of bariatric surgery on discrete cardiovascular events has not been well characterized.

OBJECTIVES

To assess the impact of prior bariatric surgery on mortality associated with heart failure (HF) admission.

SETTING

A retrospective analysis of 2007-2014 Healthcare Cost and Utilization Project-Nationwide Inpatient Sample.

METHODS

Participants including 2810 patients with a principal discharge diagnosis of HF who also had a history of prior bariatric surgery were identified. These patients were matched 1:5 with patients who had similar principal diagnoses but no history of bariatric surgery (controls). Propensity scores, balanced on baseline characteristics, were used to assemble 2 control groups. Control group-1 included patients with obesity (body mass index [BMI] ≥35 kg/m²) only. In control group-2, the BMI was considered as one of the matching criteria in propensity matching. Multivariate regression models were utilized to calculate the odds ratio (OR) and 95% confidence interval (CI) of mortality and length of stay (LOS).

RESULTS

With well-balanced matching, 33,720 (weighted) patients were included in the analysis. In-hospital mortality rates after HF admission were significantly lower in patients with a history of bariatric surgery compared with control group-1 (0.96% versus 1.86%, OR .52, 95% CI .35-0.77, P = .0013) and control group-2 (0.96% versus 1.86%, OR .52, 95% CI .35-0.77, P = .0011). Furthermore, LOS was shorter in the bariatric surgery group compared with control group-1 (4.8 ± 4.4 versus 5.7 ± 5.7 d, P < .001) and control group-2 (4.8 ± 4.4 versus 5.4 ± 6.3 d, P < .001).

CONCLUSIONS

Our data suggest that prior bariatric surgery is associated with almost 50% reduction in in-hospital mortality and shorter LOS in patients with HF admission.