Predictors of weight change in overweight patients with myocardial infarction

The obesity paradox in ST-segment elevation myocardial infarction patients: A meta-analysis

OBJECTIVE

The aim of this study was to investigate whether there was a difference in survival after initial percutaneous coronary intervention (PCI) among ST-segment elevation myocardial infarction (STEMI) patients with different body mass index (BMI).

METHODS

Literature retrieval was conducted on PubMed, Web of Science, Embase, CNKI, and Wanfang databases to obtain the published studies on the survival of STEMI patients with different BMI after initial PCI from the establishment of the database to 2022. All statistical analyses were performed using STATA16.0.

RESULTS

Two hundred thirty-nine studies were retrieved, and 12 studies were eventually included. Meta-analysis showed that overweight patients [OR = 0.66, 95% CI (0.58, 0.76), p < .001] and obese patients [OR = 0.60, 95% CI (0.51, 0.72), p < .001] had lower in-hospital mortality than healthy-weight patients. Overweight patients [OR = 0.66, 95% CI (0.58, 0.74), p < .001] and obese patients [OR = 0.62, 95% CI (0.53, 0.72), p < .001] had lower short-term mortality than healthy-weight patients. In addition, overweight patients [OR = 0.63, 95% CI (0.58, 0.69), p < .001] and obese patients [OR = 0.59, 95% CI (0.52, 0.66), p < .001] also had lower long-term mortality than healthy-weight patients. There was no significant difference in in-hospital mortality [OR = 1.06, 95% CI (0.89, 1.27), p > .05], short-term mortality [OR = 1.04, 95% CI (0.89, 1.22), p > .05], and long-term mortality [OR = 1.07, 95% CI (0.95, 1.20), p > .05] between overweight and obese patients.

CONCLUSION

This meta-analysis confirmed an obesity paradox in STEMI patients following PCI. The obesity paradox exists in in-hospital, short-term, and long-term conditions.

Potential for optimizing management of obesity in the secondary prevention of coronary heart disease

AIMS

Prevention guidelines have identified the management of obese patients as an important priority to reduce the burden of incident and recurrent cardiovascular disease. Still, studies have demonstrated that over 80% of patients with coronary heart disease (CHD) fail to achieve their weight target. Here, we describe advice received and actions reported by overweight CHD patients since being discharged from hospital and how weight changes relate to their risk profile.

METHODS AND RESULTS

Based on data from 10 507 CHD patients participating in the EUROASPIRE IV and V studies, we analysed weight changes from hospital admission to the time of a study visit ≥6 and <24 months later. At hospitalization, 34.9% were obese and another 46.0% were overweight. Obesity was more frequent in women and associated with more comorbidities. By the time of the study visit, 19.5% of obese patients had lost ≥5% of weight. However, in 16.4% weight had increased ≥5%. Weight gain in those overweight was associated with physical inactivity, non-adherence to dietary recommendations, smoking cessation, raised blood pressure, dyslipidaemia, dysglycaemia, and lower levels of quality of life. Less than half of obese patients was considering weight loss in the coming month.

CONCLUSIONS

The management of obesity remains a challenge in the secondary prevention of CHD despite a beneficial effect of weight loss on risk factor prevalences and quality of life. Cardiac rehabilitation programmes should include weight loss interventions as a specific component and the incremental value of telehealth intervention as well as recently described pharmacological interventions need full consideration.

Weight management and determinants of weight change in patients with coronary artery disease

OBJECTIVE

To study the effects of a comprehensive secondary prevention programme on weight loss and to identify determinants of weight change in patients with coronary artery disease (CAD).

METHODS

We performed a secondary analysis focusing on the subgroup of overweight CAD patients (BMI ≥27 kg/m²) in the Randomised Evaluation of Secondary Prevention by Outpatient Nurse SpEcialists-2 (RESPONSE-2) multicentre randomised trial. We evaluated weight change from baseline to 12-month follow-up; multivariable logistic regression with backward elimination was used to identify determinants of weight change.

RESULTS

Intervention patients (n=280) lost significantly more weight than control patients (n=257) (-2.4±7.1 kg vs -0.2±4.6 kg; p<0.001). Individual weight change varied widely, with weight gain (≥1.0 kg) occurring in 36% of interventions versus 41% controls (p=0.21). In the intervention group, weight loss of ≥5% was associated with higher age (OR 2.94), lower educational level (OR 1.91), non-smoking status (OR 2.92), motivation to start with weight loss directly after the baseline visit (OR 2.31) and weight loss programme participation (OR 3.33), whereas weight gain (≥1 kg) was associated with smoking cessation ≤6 months before or during hospitalisation (OR 3.21), non-Caucasian ethnicity (OR 2.77), smoking at baseline (OR 2.70), lower age (<65 years) (OR 1.47) and weight loss programme participation (OR 0.59).

CONCLUSION

The comprehensive secondary prevention programme was, on average, effective in achieving weight loss. However, wide variation was observed. As weight gain was observed in over one in three participants in both groups, prevention of weight gain may be as important as attempts to lose weight.

TRIAL REGISTRATION NUMBER

NTR3937.

Association of predicted lean body mass and fat mass with cardiovascular events in patients with type 2 diabetes mellitus

BACKGROUND

Previous studies have found that predicted fat mass and lean body mass may act differently on adverse events. However, the cardiovascular prognostic value of lean body mass and fat mass in patients with type 2 diabetes mellitus (T2DM) has not yet been investigated. We sought to investigate the relation between predicted lean body mass or fat mass and the risk of cardiovascular disease in patients with T2DM.

METHODS

We conducted a post hoc analysis of data from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study to investigate the relation between the predicted lean body mass or fat mass and major adverse cardiovascular events in patients with T2DM. We used sex-specific quartiles of predicted lean body mass index (BMI; kg/m²) and fat mass index (kg/m²). We defined a major adverse cardiovascular event as a composite of nonfatal myocardial infarction, nonfatal stroke or death from cardiovascular causes.

RESULTS

After a mean follow-up period of 8.8 years, we found that a major cardiovascular event occurred in 1801 of 10 251 patients (17.8%). Predicted lean BMI was not associated with major cardiovascular events (p = 0.34). Compared with patients in the first quartile (incidence rate 16.4%; 17.2%, 17.5% and 19.8% for the second, third and four quartiles, respectively) of predicted fat mass index, those in the fourth quartile had a hazard ratio of 1.53 (95% confidence interval 1.23-1.91).

INTERPRETATION

In patients with T2DM, we found that predicted fat mass had a strong positive association with a higher risk of a major adverse cardiovascular event. Increasing lean body mass did not have a protective role. Trial registration: ClinicalTrials.gov., no. NCT00000620.

Relationship of Obesity to Adverse Events Among Patients With Mean 10-Year History of Type 2 Diabetes Mellitus: Results of the ACCORD Study

Background

Recent evidence from cohort studies and meta‐analyses suggests that the obesity paradox phenomenon may exist in patients with diabetes mellitus. The goal of this study was to assess the association between adverse events and obesity by using 2 different measures of obesity, body mass index (BMI; kg/m²) and waist circumference, in patients with a mean 10‐year history of type 2 diabetes mellitus.

Methods and Results

We used data from the ACCORD (the Action to Control Cardiovascular Risk in Diabetes) study to evaluate the relationship between obesity and adverse events in patients with a mean 10‐year history of type 2 diabetes mellitus. The primary outcome of this study was all‐cause mortality. Secondary outcomes were cardiac death, nonfatal myocardial infarction, and stroke. Patients who were class III obese with BMI ≥40 had the highest risk of all‐cause mortality, followed by patients with class II obesity, whereas overweight patients had the lowest risk. We found significant correlations between BMI and waist circumference (r=0.802). We observed that the relationships between waist circumference and primary and second end points were much like the relationships between BMI and primary and second end points (J‐shaped relationship for all‐cause mortality, V‐shaped relationship for cardiac death, U‐shaped relationship for nonfatal myocardial infarction, and reverse linear relationship for noncardiac death).

Conclusions

No evidence of the obesity paradox was observed in patients with a 10‐year history of diabetes mellitus. Class III obese patients showed the highest risk of adverse events (all‐cause mortality, cardiac death, nonfatal myocardial infarction, and noncardiac death). BMI and waist circumference showed similar relationships with adverse events.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000620.

Relationship of obesity to adverse events in myocardial infarction patients without primary percutaneous coronary intervention: results from the Occluded Artery Trial (OAT)

Objective: Our goal was to investigate the "obesity paradox" in myocardial infarction populations without primary percutaneous coronary intervention (PPCI).Methods: The Occluded Artery Trial (OAT, Clinicaltrials.gov: NCT00004562) is a randomized, multicenter study to investigate the influence of routine percutaneous coronary intervention (PCI) on the clinical outcomes of myocardial infarction patients without PPCI. We stratified these patients into three groups according to body mass index (BMI): normal, 18.5 kg/m² ≤ BMI < 25 kg/m²; overweight, 25 kg/m² ≤ BMI < 30 kg/m²; obese, BMI ≥ 30 kg/m². The purpose of our study was to investigate the effects of BMI on the primary endpoint (all-cause mortality) and the secondary endpoint (cardiac death, non-cardiac death or New York Heart Association [NYHA] class IV heart failure) in the population enrolled in the OAT.Results: A total of 2153 patients (99.4%) constituted the final study population. We found that obese patients were younger and were more likely to have cardiovascular risk factors compared with other BMI groups. A U-shaped relationship was observed between BMI and all-cause mortality. The adjusted hazard ratios (HRs) were 0.892 (95% CI: 0.658-1.210, p = .460) for normal weight patients and 0.671 (95% CI: 0.508-0.888, p = .013) for overweight patients compared with obese patients. The same pattern was also observed for non-cardiac death. The adjusted HRs were 0.919 (95% CI: 0.601-1.40, p = .663) for normal weight patients and 0.524 (95% CI: 0.346-0.792, p = .004) for overweight patients compared with obese patients. We did not find any statistical differences among BMI categories in terms of cardiac death or NYHA class IV heart failure.Conclusions: A U-shaped relationship was observed between BMI and all-cause mortality or non-cardiac death. Overweight patients have the lowest risk of all-cause mortality, which may be attributed to their having the lowest risk of non-cardiac death of the groups studied.

Weight change is associated with increased all-cause mortality and non-cardiac mortality among patients with type 2 diabetes mellitus

BACKGROUND

It is unclear whether changes in weight affect subsequent adverse events in patients with type 2 diabetes mellitus (T2DM) already at high risk of cardiovascular disease (CVD).

METHODS AND RESULTS

This is a post hoc analysis of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study data to examine the relationship between changes in weight and adverse events. Patients were divided into groups based on changes in body mass index (BMI): stable weight, gain or loss of BMI ≤1.5 kg/m²; moderate weight gain, BMI gain of 1.5-5 kg/m²; pronounced weight gain, BMI gain >5 kg/m²; moderate weight loss, BMI loss of 1.5-5 kg/m²; and pronounced weight loss, BMI loss >5 kg/m². The primary endpoint of the present study was all-cause mortality. Secondary endpoints were cardiac death, non-fatal myocardial infarction (MI), and non-cardiac mortality. A total of 9372 T2DM patients with a mean follow-up of 8.08 ± 3.00 years were included for analysis. The average change in weight across the entire study population was 1.80 ± 9.00%, representing ~0.448 ± 2.98 kg/m². Patients with pronounced weight loss had the highest risk of all-cause mortality (hazard ratio (HR) 2.07, 95% confidence interval (CI): 1.68-2.55), followed by patients with pronounced weight gain (HR 1.23, 95% CI: 1.02-1.56); patients with stable weight had the lowest risk. An asymmetric V-shaped relationship was observed between changes in BMI and all-cause mortality and non-cardiac mortality. Although no statistical significance was observed in terms of cardiac death and non-fatal MI, a flat V-shaped relationship may exist.

CONCLUSIONS

Weight was stable in most T2DM patients with high risk of CVD. Weight loss and gain is associated with increased all-cause mortality and non-cardiac mortality. Pronounced weight loss and weight gain is associated with a slight increase in cardiac death and non-fatal MI incidence, which does not reach statistical significance.

Comparison of long-term mortality according to obesity in patients with successful percutaneous chronic total occlusion interventions using drug-eluting stents

OBJECTIVE

To evaluate the long-term mortality according to obesity in patients with chronic total occlusion (CTO) lesions after successful percutaneous coronary intervention (PCI).

BACKGROUND

Despite the potential impact of coronary revascularization and lesion severity on the obesity paradox, the long-term survival according to obesity in CTO patients after successful PCI has been unknown.

METHODS AND RESULTS

Between January 2003 and September 2014, we examined 1,172 consecutive Korean patients with 1,190 CTO lesions who underwent successful drug-eluting stent (DES) implantation in two tertiary academic medical centers. The primary and secondary endpoints were all-cause and cardiac death, respectively. Obesity was defined as a body mass index ≥25.0 kg/m² , based on the criteria for Asians. The median follow-up time was 4.4 years. The prevalence of obesity was 54.4%. During the follow-up periods, the occurrence of all-cause (6.1 vs. 10.7%) and cardiac death (3.8 vs. 6.7%) was lower in obese patients than in non-obese patients (P <0.05, respectively). Kaplan-Meier analysis showed that obese patients had lower cumulative rates of all-cause and cardiac death than did non-obese patients (log-rank P <0.05, respectively). Univariate Cox regression analysis showed that age ≥65 years (hazard ratio [HR], 3.62), diabetes mellitus (HR, 1.94), renal dysfunction (HR, 7.03), systolic heart failure (HR, 2.61), and obesity (HR, 0.58) were associated with all-cause death (P <0.05). Multivariate Cox regression models showed that high BMI was independently associated with the decreased risk of all-cause death.

CONCLUSIONS

Obese patients appear to have a lower long-term mortality than do non-obese patients in CTO after successful PCI using DES. © 2017 Wiley Periodicals, Inc.

Impact of Body Mass Index on 5-Year Clinical Outcomes in Patients With ST-Segment Elevation Myocardial Infarction After Everolimus-Eluting or Bare-Metal Stent Implantation

Patients with high body mass index (BMI) seem to have better outcomes after percutaneous coronary intervention than normal-weight patients. However, contrasting results have been reported on the "obesity paradox" in patients presenting with ST-elevation myocardial infarction (STEMI). The aim of our study was to investigate the impact of BMI on mortality in the population enrolled in the Evaluation of the Xience-V stent in Acute Myocardial INfArcTION (EXAMINATION) trial. The EXAMINATION trial randomized 1,498 patients with STEMI to a bare-metal stent or an everolimus-eluting stent. In this substudy patients were stratified into 3 groups according to BMI values: normal (BMI < 25 kg/m²), overweight (BMI = 25 to 29.9 kg/m²), and obese (BMI ≥ 30 kg/m²). The coprimary end points were the all-cause and cardiac deaths among the groups at the 5-year follow-up. BMI was available in 1,421 patients, divided in 401 (28.2%) normal, 702 (49.4%) overweight, and 318 (22.4%) obese. Obese patients were younger (p = 0.012) compared with the other groups, but with a worse cardiovascular risk profile. They were more frequently female (p <0.001) and with a higher rate of obesity-related co-morbidity conditions such as diabetes mellitus (p = 0.005), arterial hypertension (p <0.001), and hyperlipidemia (p = 0.001) compared with the other groups. At the 5-year follow-up, all-cause and cardiac deaths were less frequent in obese patients than in the other groups (p = 0.003 and p = 0.030, respectively). After adjustment for confounding variables, BMI was an independent predictor of all-cause death (hazard ratio 0.765, 95% confidence interval 0.599 to 0.979, p = 0.033), but not of cardiac death, without any interaction with the stent type. In conclusion, in patients with STEMI who underwent primary PCI, the long-term all-cause death rate decreased as BMI increased, confirming the obesity paradox, irrespective of the stent type.

Smokers and Postcessation Weight Gain After Acute Coronary Syndrome

Background

Smoking cessation and weight management are recommended after acute coronary syndrome (ACS); however, little is known about the effects of smoking cessation on weight change after ACS. We aimed to assess the effect of smoking cessation after ACS on weight over a 12‐month follow‐up period.

Methods and Results

Data were prospectively collected from the EVITA (Evaluation of Varenicline in Smoking Cessation for Patients Post‐Acute Coronary Syndrome) trial. Weight change was compared among 3 groups of patients: those who were completely abstinent (n=70), those who smoked intermittently (n=68), and those who smoked persistently (n=34). Patients' mean baseline weight was 83.9 kg (SD 17.7) with a mean body mass index of 28.5 (SD 5.4). Patients smoked a mean of 37.7 years (SD 17.7) and a mean of 21.0 cigarettes (SD 9.0) per day prior to their ACS. Weight change varied across groups, with abstainers gaining a mean of 4.8 kg (SD 8.6), intermittent smokers gaining a mean of 2.0 kg (SD 8.9) and persistent smokers losing a mean of 0.7 kg (SD 7.4). At 52 weeks, abstainers were more likely to gain weight than persistent smokers (difference in means 5.5 kg; 95% CI 2.3–8.8). This weight gain was not associated with an increase in the use of antihypertensive or antidiabetic medications.

Conclusions

Following an ACS, significant weight is gained by patients who quit smoking. Weight‐management interventions among smokers who quit after ACS should be a focus of investigation in future research so that the cardiovascular benefits achieved by smoking cessation are not offset by weight gain in this high‐risk population.

Clinical Trial Registration

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00794573.

Underweight, Markers of Cachexia, and Mortality in Acute Myocardial Infarction: A Prospective Cohort Study of Elderly Medicare Beneficiaries

BACKGROUND

Underweight patients are at higher risk of death after acute myocardial infarction (AMI) than normal weight patients; however, it is unclear whether this relationship is explained by confounding due to cachexia or other factors associated with low body mass index (BMI). This study aimed to answer two questions: (1) does comprehensive risk adjustment for comorbid illness and frailty measures explain the higher mortality after AMI in underweight patients, and (2) is the relationship between underweight and mortality also observed in patients with AMI who are otherwise without significant chronic illness and are presumably free of cachexia?

METHODS AND FINDINGS

We analyzed data from the Cooperative Cardiovascular Project, a cohort-based study of Medicare beneficiaries hospitalized for AMI between January 1994 and February 1996 with 17 y of follow-up and detailed clinical information to compare short- and long-term mortality in underweight and normal weight patients (n = 57,574). We used Cox proportional hazards regression to investigate the association of low BMI with 30-d, 1-y, 5-y, and 17-y mortality after AMI while adjusting for patient comorbidities, frailty measures, and laboratory markers of nutritional status. We also repeated the analyses in a subset of patients without significant comorbidity or frailty. Of the 57,574 patients with AMI included in this cohort, 5,678 (9.8%) were underweight and 51,896 (90.2%) were normal weight at baseline. Underweight patients were older, on average, than normal weight patients and had a higher prevalence of most comorbidities and measures of frailty. Crude mortality was significantly higher for underweight patients than normal weight patients at 30 d (25.2% versus 16.4%, p < 0.001), 1 y (51.3% versus 33.8%, p < 0.001), 5 y (79.2% versus 59.4%, p < 0.001), and 17 y (98.3% versus 94.0%, p < 0.001). After adjustment, underweight patients had a 13% higher risk of 30-d death and a 26% higher risk of 17-y death than normal weight patients (30-d hazard ratio [HR] 1.13, 95% CI 1.07-1.20; 17-y HR 1.26, 95% CI 1.23-1.30). Survival curves for underweight and normal weight patients separated early and remained separate over 17 y, suggesting that underweight patients remained at a significant survival disadvantage over time. Similar findings were observed among the subset of patients without comorbidity at baseline. Underweight patients without comorbidity had a 30-d adjusted mortality similar to that of normal weight patients but a 21% higher risk of death over the long term (30-d HR 1.08, 95% CI 0.93-1.26; 17-y HR 1.21, 95% CI 1.14-1.29). The adverse effects of low BMI were greatest in patients with very low BMIs. The major limitation of this study was the use of surrogate markers of frailty and comorbid conditions to identify patients at highest risk for cachexia rather than clear diagnostic criteria for cachexia.

CONCLUSIONS

Underweight BMI is an important risk factor for mortality after AMI, independent of confounding by comorbidities, frailty measures, and laboratory markers of nutritional status. Strategies to promote weight gain in underweight patients after AMI are worthy of testing.

Excess weight and life expectancy after acute myocardial infarction: The obesity paradox reexamined

BACKGROUND

An "obesity paradox" has been described in patients with acute myocardial infarction (AMI), whereby obese and overweight patients have a lower risk of short-term mortality after AMI than normal-weight patients. However, the long-term association of obesity with mortality after AMI remains unknown.

METHODS

We used data from the Cooperative Cardiovascular Project, a prospective medical record study of Medicare beneficiaries hospitalized with AMI with 17 years of follow-up (N = 124,981), to evaluate the association of higher body mass index (BMI) with short- and long-term survival after AMI. Cox proportional hazards models were used to estimate life expectancy after AMI and the years of potential life lost or gained attributable to excess weight.

RESULTS

Approximately 41.5% of patients were classified as normal weight; 38.7%, as overweight; 14.3%, as obese; and 5.5%, as morbidly obese. Normal-weight patients had the highest crude mortality at all follow-up time points, whereas obese patients had the lowest. Adjustment for patient and treatment characteristics reduced this difference, but the survival benefit persisted in overweight and obese patients at all time points. Morbidly obese and normal-weight patients had a comparable risk of death at 17 years. Life expectancy estimates were generally lowest for morbidly obese patients and highest for overweight patients. Differences in life expectancy between BMI groups were most pronounced in younger patients. After adjustment, overweight and obesity were associated with greater life years at all ages; however, morbid obesity was only associated with better survival in patients ≥75 years of age at the time of AMI.

CONCLUSIONS

Overweight and obesity are associated with improved short- and long-term survival after AMI, which results in moderate gains in life expectancy relative to normal-weight patients. These findings suggest that higher BMI confers a protective advantage over the entire remaining lifespan in older patients with AMI.

Review Of Obesity And Atrial Fibrillation: Exploring The Paradox

There is a well established association between obesity and atrial fibrillation (AF). Nevertheless, the effects of obesity in the outcomes of patients with AF has not been investigated since a few years before. In this regard, several studies have demonstrated a better clinical prognosis of AF in overweight and obese populations. In the present manuscrit, we aimed to explore the main articles in which the "obesity paradox in AF" was found.

Predictors of longterm changes in body mass index in rheumatoid arthritis

OBJECTIVE

Low body mass index (BMI) is a risk factor for poor longterm outcomes in rheumatoid arthritis (RA). The purpose of this study was to identify factors associated with longterm changes in BMI.

METHODS

Subjects with RA from the Veterans Affairs (VA) Rheumatoid Arthritis (VARA) Registry (n = 1474) were studied. Information on inflammatory markers, presence of erosions, and smoking status were extracted from the VARA database. BMI was extracted from VA electronic medical records within 14 days of each visit date. VA pharmacy records were queried to identify prescriptions for specific RA therapies within 1 month of the visit date. We used robust generalized estimating equations marginal regression models to calculate independent associations between clinical variables and BMI over time. Similar models determined predictors of change in weight and risk of weight loss over the subsequent study observation period.

RESULTS

Increasing age, active smoking, and the presence of erosions at baseline were associated with lower BMI. Weight decreased over time among older adults. Factors associated with greater reductions in BMI over time and a greater risk of weight loss were higher inflammatory markers, smoking, older age, higher BMI, and less subsequent improvement in inflammation. Methotrexate use was associated with a lower risk of weight loss. The use of prednisone or anti-tumor necrosis factor therapies was not associated with change in BMI or the risk of weight loss independent of other factors.

CONCLUSION

Greater age, greater inflammatory activity, and active smoking are associated with greater weight loss in RA over time.

Weight change in patients attempting to quit smoking post-myocardial infarction

BACKGROUND

Current guidelines recommend smoking cessation and weight management for secondary prevention in patients post-myocardial infarction. However, little is known about the effects of smoking cessation on weight change post-myocardial infarction.

METHODS

We examined patterns of weight change and its effects on blood pressure and glycemic control using data from a randomized trial investigating the effect of bupropion on smoking cessation in patients post-myocardial infarction. Weight change was compared among 3 groups of patients: those who were completely abstinent (n = 92), those who smoked intermittently (n = 49), and those who smoked persistently (n = 38) during the 12-month follow-up. Analyses were restricted to patients who attended all follow-up visits.

RESULTS

The median weight at baseline was 77.1 kg (interquartile range [IQR], 66.0, 87.5), and 64.3% of patients were overweight/obese (body mass index ≥25.0 kg/m(2)). The median weight gain at 12 months was 4.0 kg (IQR, 0-7.0), with more than one third gaining >5 kg. The proportion of patients who were overweight/obese increased by approximately 10%, and 23.2% of patients moved up a body mass index category. Abstainers gained a median of 4.8 kg (IQR, 1.0, 8.6), intermittent smokers gained a median of 2.0 kg (IQR, -2.0, 5.0), and persistent smokers gained a median of 3.0 kg (IQR, -0.8, 6.0). Weight gain was associated with an increase in blood pressure and requirements for hypoglycemic medications at 12 months.

CONCLUSIONS

The majority of patients attempting to quit smoking gain weight 12 months post-myocardial infarction, with abstainers gaining more weight than those who return to smoking. Weight gain was associated with an increased prevalence of hypertension and diabetes.

Exploring The Obesity Paradox In Atrial Fibrillation. AFBAR (Atrial Fibrillation Barbanza Area) Registry Results

INTRODUCTION AND OBJECTIVES

Previous studies have described an inverse relationship between obesity and adverse events in a variety of conditions. Our aim was to investigate the relationship between obesity and prognosis in patients with atrial fibrillation.

METHODS

We studied 746 patients who were prospectively included, between January and April 2008, in the AFBAR (Atrial Fibrillation in BARbanza area) registry. Patients were categorized into 3 body mass index groups using baseline measurements: normal (< 25 kg/m2), overweight (25-30 kg/m2), and obese (≥30 kg/m2). Survival free from the composite endpoint hospitalization for cardiovascular causes or all-cause mortality was compared across the 3 body mass index groups. A multivariable Cox proportional hazard regression was also performed to determine the independent effect of obesity as well as overweight, with respect to normal body mass index as a reference category, regarding the study endpoint. Median follow-up time was 36 (28-36) months.

RESULTS

49.3% were obese and 38.2% had overweight. The composite endpoint rate was 70.9%, 67.5%, and 57.6% for obese, overweight, and normal weight patients, respectively (log rank test; p=0.02). An inverse association of obesity with a favorable prognosis persisted even after multivariable adjustment: hazard ratio 0.668; 95% confidence interval 0.449-0.995; p=0.047. Hazard ratio of overweight, however, was 0.741; 95% confidence interval: 0.500-1.098; p=0.096.

CONCLUSIONS

Obesity, defined as a body mass index ≥ 30 kg/m2, is associated with better prognosis in a community-based cohort of patients with atrial fibrillation.

Clinically significant weight gain 1 year after occupational back injury

OBJECTIVE

To examine the incidence of clinically significant weight gain 1 year after occupational back injury, and risk factors for that gain.

METHODS

A cohort of Washington State workers with wage-replacement benefits for back injuries completed baseline and 1-year follow-up telephone interviews. We obtained additional measures from claims and medical records.

RESULTS

Among 1263 workers, 174 (13.8%) reported clinically significant weight gain (≥7%) 1 year after occupational back injury. Women and workers who had more than 180 days on wage replacement at 1 year were twice as likely (adjusted odds ratio = 2.17, 95% confidence interval = 1.54 to 3.07; adjusted odds ratio = 2.40, 95% confidence interval = 1.63 to 3.53, respectively; both P < 0.001) to have clinically significant weight gain.

CONCLUSIONS

Women and workers on wage replacement for more than 180 days may be susceptible to clinically significant weight gain after occupational back injury.

Health-care access and weight change among young adults: the Coronary Artery Risk Development in Young Adults (CARDIA) Study

OBJECTIVE

Health-care access is associated with improved control of multiple chronic diseases, but the association between health-care access and weight change is unclear. The present study aims to test the association between health-care access and weight change.

DESIGN

The Coronary Artery Risk Development in Young Adults (CARDIA) Study is a multicentre population-based prospective study. Weight change was calculated at 3 and 13 years after CARDIA year 7 (1992-1993). Health-care access was defined as no barriers or one or more barriers to access (health insurance gap, no usual source of care, not seeking care due to expense). Intermediary variables evaluated included history of dieting and use of diet pills, meal replacements or weight-control programmes.

SETTING

Four cities in the USA.

SUBJECTS

Participants were aged 18-30 years at baseline (1985-1986). Analyses include 3922 black and white men and women with relevant data from CARDIA years 7, 10 and 20 (1992-1993, 1995-1996 and 2005-2006, respectively).

RESULTS

Mean weight change was +2.22 kg (+4.9 lb) by 3 years and +8.48 kg (+18.7 lb) by 13 years, with no differences by health-care access. Being on a weight-reducing diet was not consistently associated with health-care access across examinations. Use of diet pills, meal replacements or organized weight-control programmes was low, and did not vary by health-care access.

CONCLUSIONS

Weight gain was high irrespective of health-care access. Public health and clinical approaches are needed to address weight gain.

Body mass index and mortality in acute myocardial infarction patients

BACKGROUND

Previous studies have described an "obesity paradox" with heart failure, whereby higher body mass index (BMI) is associated with lower mortality. However, little is known about the impact of obesity on survival after acute myocardial infarction.

METHODS

Data from 2 registries of patients hospitalized in the US with acute myocardial infarction between 2003-2004 (PREMIER) and 2005-2008 (TRIUMPH) were used to examine the association of BMI with mortality. Patients (n=6359) were categorized into BMI groups (kg/m(2)) using baseline measurements. Two sets of analyses were performed using Cox proportional hazards regression with fractional polynomials to model BMI as categorical and continuous variables. To assess the independent association of BMI with mortality, analyses were repeated, adjusting for 7 domains of patient and clinical characteristics.

RESULTS

Median BMI was 28.6. BMI was inversely associated with crude 1-year mortality (normal, 9.2%; overweight, 6.1%; obese, 4.7%; morbidly obese; 4.6%; P <.001), which persisted after multivariable adjustment. When BMI was examined as a continuous variable, the hazards curve declined with increasing BMI and then increased above a BMI of 40. Compared with patients with a BMI of 18.5, patients with higher BMIs had a 20% to 68% lower mortality at 1 year. No interactions between age (P=.37), sex (P=.87), or diabetes mellitus (P=.55) were observed.

CONCLUSIONS

There appears to be an "obesity paradox" among patients after acute myocardial infarction such that higher BMI is associated with lower mortality, an effect that was not modified by patient characteristics and was comparable across age, sex, and diabetes subgroups.

Effects of weight change on clinical outcomes in overweight and obese patients with acute myocardial infarction who underwent successful percutaneous coronary intervention

Obesity is a well-established risk factor for many chronic disorders. However, the effect of weight change after acute myocardial infarction (AMI) is not well known. Among consecutive patients who underwent percutaneous coronary intervention between November 2005 and November 2007 due to AMI, patients who were overweight (23.0≤body mass index [BMI]<27.5 kg/m(2), n=341) and obese (BMI≥27.5 kg/m(2), n=80) were selected for analysis. According to weight change, the patients were divided into 4 groups: Group I (weight loss>5%, n=61), Group II (0%<weight loss≤5%, n=133), Group III (0%≤weight gain<5%, n=181), and Group IV (weight gain≥5%, n=46). We assessed the association between weight change and major adverse cardiac events (MACE). Greater weight loss was more frequent among older individuals (Group I: 64.1±12.4 years, II: 60.6±12.1 years, III: 59.0±11.9 years, IV: 61.4±10.6 years; p=0.028) and patients with diabetes (Group I: 34.4%, II: 27.1%, III: 21.2%, IV: 15.2%; p=0.009). However, there were no significant differences in baseline characteristics or in angiographic or procedural factors except for the proportions of patients with three-vessel disease, which were higher in patients with weight loss (Group I: 20.8%, II: 23.0%, III: 12.5%, IV: 11.6%; p=0.005). The group with greater weight loss had the highest MACE rate at the 12-month clinical follow-up (Group I: 36.9%, II: 25.0%, III: 25.9%, IV: 17.3%; p=0.020). Although weight loss after AMI appears to be associated with worse outcomes, it remains unclear whether the effect is of cardiac origin.

Depression and failure of cholesterol lowering after acute myocardial infarction

OBJECTIVE

Depression after acute myocardial infarction (MI) is independently associated with cardiac mortality, but the mechanism explaining this association remains unclear. To our knowledge, there has been no prior study exploring the impact of post-MI depression on lipid lowering, a key secondary prevention measure in post-MI patients. In this prospective observational cohort pilot study, we hypothesized that patients with early post-MI depression would have inferior cholesterol reduction 6 months post-MI compared to nondepressed patients.

METHOD

Patients admitted to a cardiac intensive care unit or a cardiac step-down unit between October 2003 and July 2005 were enrolled in the study within 72 hours of MI. Two weeks post-MI, subjects were assessed for depression using the module for current major depressive disorder (MDD) from the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) and the Beck Depression Inventory-II (BDI-II). Information regarding cholesterol levels was collected 6 months after MI.

RESULTS

Initial and 6-month cholesterol levels were available for 70 subjects who had 2-week post-MI depression assessments. Post-MI depression, measured both using an interview for MDD and the BDI-II, was associated with inferior cholesterol reduction, with depressed subjects improving their cholesterol levels by approximately 8 mg/dL compared to a cholesterol reduction of 37 mg/dL in nondepressed subjects. Furthermore, depression diagnosed by formal MDD interview (beta=-.301; P<.001) and the BDI-II (beta=-.269; P=.001) continued to be associated with significantly smaller reductions in cholesterol levels on linear regression analyses that accounted for demographic and medical variables.

CONCLUSIONS

In this exploratory pilot study, early post-MI depression was independently associated with impaired lipid lowering 6 months after MI.

Management of overweight and obese patients with coronary heart disease across Europe

AIMS

Several studies have reported increasing obesity rates in the general population. Using data from the EUROASPIRE III survey, we investigated as to what extent the obesity epidemic affects the high priority group of coronary heart disease patients.

METHODS AND RESULTS

Data from 8924 patients, who had experienced a recent coronary acute event, from 22 countries in Europe participating in the EUROASPIRE III study were gathered in 2006-2007. Eight centres had also participated in the earlier two EUROASPIRE surveys carried out in 1994-1995 and 1999-2000. In these eight centres, obesity prevalence in coronary patients had increased from 25 to 38% during the past decade. The most recent survey shows that obesity is more prevalent in women (45 vs. 32% in men) and is a major health problem across all the 22 countries. Only 18% of all the patients were found to reach a body mass index below 25 kg/m whereas 53% were diagnosed with central obesity. Since their hospital discharge, only half of the obese patients reported to have followed the dietary recommendations and 48% reported engagement in more physical activity. Only 13% of the patients who were overweight at the time of the coronary event reached the target of >or=5% weight loss whereas 21% of them presented with a weight gain of 5% or more.

CONCLUSION

The prevalence of obesity is still increasing and reaching epidemic proportions in the high priority group of coronary patients all over Europe. Patients' awareness and current management of obesity seems inadequate. More intensive programs focusing on diet and especially physical activity are urgently required.

Physician diagnosis of overweight status predicts attempted and successful weight loss in patients with cardiovascular disease and central obesity

INTRODUCTION

Despite the association of central obesity with adverse outcomes, most patients with cardiovascular disease (CVD) are unable to successfully lose weight. We undertook this analysis to evaluate the effect of motivational factors, and clinical factors, including physician diagnosis of overweight, on weight loss in patients with CVD and central obesity in the United States.

METHODS AND RESULTS

We used data from the National Health and Nutrition Examination Survey 1999 to 2004. Waist circumference ≥ 102 cm in men and ≥ 88 cm in women were used to classify central obesity. We examined demographic, motivational and clinical determinants of attempted and successful weight loss using multivariable logistic regression. Successful weight loss was defined as ≥ 5% weight loss in the preceding year. There were 907 respondents with CVD and central obesity of which 78% were aware of their overweight status and 80% were desirous to weigh less. Despite this awareness and desire, only 49% of centrally obese adults had attempted weight loss in the last year. Only 62% (n = 584) reported that they had been informed that they were overweight by a physician. On multivariable analysis, physician diagnosis of overweight was a significant predictor of weight loss attempts (OR 2.42, 95% CI 1.44-4.09, P = .006) and successful weight loss (OR 2.70, 95% CI 1.40-5.19, P = .001).

CONCLUSION

In a nationally representative sample of adults with CVD and central obesity, physician diagnosis of overweight status emerged as a significant predictor of attempted and successful weight loss.