The prognostic importance of weight loss in coronary artery disease: a systematic review and meta-analysis

Telemedicine-supported lifestyle intervention for glycemic control in patients with CHD and T2DM: multicenter, randomized controlled trial

Patients with coronary heart disease (CHD) and type 2 diabetes mellitus (T2DM) have a substantially increased risk for major cardiovascular events and mortality. Increasing physical activity and improving a healthy diet may effectively reduce cardiovascular risk factors; however, the effects are often transient. In a multicenter, 1:1 randomized controlled trial including 502 patients with combined CHD and T2DM (68 ± 8 years; 84% men), we assessed the effects of a home-based telemedicine-supported lifestyle intervention (exercise training, nutritional recommendations and health literacy training) with regular individualized feedback versus usual care. The study met its primary endpoint of reduced glycated hemoglobin after 6 months in favor of the lifestyle intervention group (mean between-group difference in the complete-case analysis (n = 197 and n = 193), -0.13% (95% confidence interval, -0.25 to -0.01), P = 0.04). When individualized feedback and health literacy training were discontinued after 6 months (while other telemedicine tools were maintained), no statistically significant between-group differences were observed at 12 months. At 12 months, 31 patients (6.2%) had a major adverse cardiovascular event (lifestyle intervention, n = 20 (8.0%); usual care, n = 11 (4.4%); P = 0.15), with the main reason being hospitalization for angina or revascularization (lifestyle intervention, n = 15; usual care, n = 8). There were five deaths (lifestyle intervention, n = 2; usual care, n = 3), none of which were categorized as related to the intervention. However, three events that resulted in hospitalization were categorized as potentially related to the intervention (decompensation of heart failure, vertebral disc prolapse and inguinal hernia). In conclusion, a home-based lifestyle intervention with telemedicine support showed modest effects in patients with CHD and T2DM. ClinicalTrials.gov registration: NCT03835923 .

Overweight, obesity, and cardiovascular disease in heterozygous familial hypercholesterolaemia: the EAS FH Studies Collaboration registry

BACKGROUND AND AIMS

Overweight and obesity are modifiable risk factors for atherosclerotic cardiovascular disease (ASCVD) in the general population, but their prevalence in individuals with heterozygous familial hypercholesterolaemia (HeFH) and whether they confer additional risk of ASCVD independent of LDL cholesterol (LDL-C) remains unclear.

METHODS

Cross-sectional analysis was conducted in 35 540 patients with HeFH across 50 countries, in the EAS FH Studies Collaboration registry. Prevalence of World Health Organization-defined body mass index categories was investigated in adults (n = 29 265) and children/adolescents (n = 6275); and their association with prevalent ASCVD.

RESULTS

Globally, 52% of adults and 27% of children with HeFH were overweight or obese, with the highest prevalence noted in Northern Africa/Western Asia. A higher overweight/obesity prevalence was found in non-high-income vs. high-income countries. Median age at familial hypercholesterolaemia diagnosis in adults with obesity was 9 years older than in normal weight adults. Obesity was associated with a more atherogenic lipid profile independent of lipid-lowering medication. Prevalence of coronary artery disease increased progressively across body mass index categories in both children and adults. Compared with normal weight, obesity was associated with higher odds of coronary artery disease in children (odds ratio 9.28, 95% confidence interval 1.77-48.77, adjusted for age, sex, lipids, and lipid-lowering medication) and coronary artery disease and stroke in adults (odds ratio 2.35, 95% confidence interval 2.10-2.63 and odds ratio 1.65, 95% confidence interval 1.27-2.14, respectively), but less consistently with peripheral artery disease. Adjusting for diabetes, hypertension and smoking modestly attenuated the associations.

CONCLUSIONS

Overweight and obesity are common in patients with HeFH and contribute to ASCVD risk from childhood, independent of LDL-C and lipid-lowering medication. Sustained body weight management is needed to reduce the risk of ASCVD in HeFH.

Intentional Weight Loss, Waist Circumference Reduction, and Mortality Risk Among Postmenopausal Women

Importance

Research investigating weight loss and mortality risk often fails to differentiate between intentional and unintentional weight loss and typically uses body mass index (BMI) as the measure of excess body weight.

Objective

To evaluate associations between weight loss and waist circumference (WC) reduction and mortality, considering weight loss intentionality.

Design, Setting, and Participants

This cohort study used data from the Women's Health Initiative Observational Study, which had a prospective cohort with mean follow-up of 18.6 years ending in February 2023. The study included women aged 50 to 79 years at 40 clinical centers in the US. Women with missing data, cancer at baseline, or considered underweight at baseline were excluded. Data were collected from September 1993 to February 2023 and were analyzed from June to December 2024.

Exposures

Measured weight loss and WC reduction between baseline and year 3, stratified by women who reported intentional weight loss or not.

Main Outcomes and Measures

Outcomes included adjudicated all-cause, cancer, cardiovascular, and other mortality through the end of follow-up. Cox proportional hazards regression models were used to evaluate the associations (hazard ratios [HRs] and 95% CIs) between weight loss, WC reduction, and mortality over 18.6 years of follow-up.

Results

This study included 58 961 women at baseline (mean [SD] age, 63.3 [7.2] years; mean [SD] BMI, 27.0 [5.6]; mean [SD] WC, 84.1 [13.0] cm). As of February 28, 2023, 29 183 women (49.5%) died from all causes. Intentional weight loss measured by questionnaire was associated with lower subsequent mortality rates for all-cause mortality (HR, 0.88; 95% CI, 0.86-0.90), cancer mortality (HR, 0.87; 95% CI, 0.82-0.92), cardiovascular mortality (HR, 0.87; 95% CI, 0.83-0.91), and other mortality (HR, 0.89; 95% CI, 0.86-0.92), comparing loss of 5 pounds or more to stable weight. Reported intentional weight loss coupled with actual weight reduction of 5% or more was associated only with lower cardiovascular mortality (HR, 0.90; 95% CI, 0.81-0.99). Reported intentional weight loss coupled with measured WC loss was associated with lower rates of all-cause mortality (HR, 0.91; 95% CI, 0.86-0.95), cancer mortality (HR, 0.85; 95% CI, 0.76-0.95), and cardiovascular mortality (HR, 0.79; 95% CI, 0.72-0.87). Unintentional weight loss or unintentional WC loss were each associated with increased mortality risk for all groups, as were weight gain and WC gain.

Conclusions and Relevance

In this cohort study, reported intentional weight loss efforts that were coupled with measured WC reductions were associated with lower risk of all-cause, cancer, and cardiovascular mortality. Attention to diet and exercise that promote reductions in central adiposity should be encouraged.

Obesity as a Disease: A Primer on Clinical and Physiological Insights

Obesity is now recognized as a multifaceted chronic disease that is intricately linked to metabolic, biochemical, and psychosocial dysfunction. In this article, we review the epidemiology of obesity, current understanding of its physiopathology, and the recommended staging system used to approach it as a chronic disease, and we include an overview of its health implications.

Modifiable risk factors and self-reported health after percutaneous coronary intervention: with and without a history of atrial fibrillation

AIMS

Atrial fibrillation (AF) and coronary artery disease have several common risk factors, and 10-15% of patients with AF undergo percutaneous coronary intervention (PCI). Little is known about changes over time in modifiable risk factors and self-reported health in patients with and without a history of AF after PCI. Therefore, the aims were to determine and compare changes in modifiable risk factors and self-reported health in patients with and without a history of AF after PCI.

METHODS AND RESULTS

CONCARDPCI, a prospective multi-centre cohort study including patients after PCI, was conducted at seven high-volume PCI centres in Norway and Denmark (n = 3417). Of these, 408 had a history of AF. Data collection was conducted at the index admission and at 2-, 6-, and 12 months after discharge. Self-reported health was assessed with RAND-12 and the myocardial infarction dimensional assessment scale. Patients with a history of AF reported poorer health at baseline. However, the physical (P = 0.012) and mental (P < 0.001) health improved over time in both groups. The patients with a history of AF reported more emotional reactions (P = 0.029) and insecurities (P = 0.015). The proportion of smokers increased from 2- to 12 months in patients with a history of AF (P = 0.041), however, decreased in patients without AF from baseline to 6 months (P < 0.001).

CONCLUSION

An intensified focus on lifestyle interventions is needed to improve modifiable risk factors and self-reported health in patients with and without a history of AF after PCI.

Association of weight change with cardiovascular events and all-cause mortality in obese participants with cardiovascular disease: a prospective cohort study

BACKGROUND

Studies have examined the association between weight change and risk of cardiovascular (CV) outcomes in the general population. However, very few literature reported the association among obese people with established CV disease (CVD) and the factors associated with weight change are not clear. We sought to investigate this using the UK Biobank data.

METHODS

In this large prospective population-based cohort study, absolute interval change scores in weight were calculated between weight measurements at baseline and the follow-up. The estimated HRs with 95% CIs were obtained from the Cox regression models to assess the association between weight change and the risk of CV death, cerebrovascular and ischaemic heart diseases and all-cause mortality.

RESULTS

Of the 8297 obese participants who had CVD with repeated weight measurements, 43.1% were female. The mean age was 56.6 (SD: 7.2) years. The overall median follow-up of the study was 13.9 (IQR: 13.1-14.6) years. 52.7% of the participants had stable weight change (weight loss or gain<5 kg), 14.2% had large weight loss (≥10 kg) and 5.1% had large weight gain (≥10 kg). Compared with stable weight, only large weight gain was associated with an increased risk of CV death and all-cause mortality (fully adjusted HR (95% CI): 3.05 (1.40 to 6.67) for CV death and 1.93 (1.15 to 3.26) for all-cause mortality).

CONCLUSIONS

Among obese individuals with CVD, large weight gain is associated with a higher risk of CV death and all-cause mortality. Further studies are needed to understand the exact mechanisms underlying the associations between weight loss or weight gain and mortality.

Weight loss as a predictor of reduced survival in patients with lung cancer: a systematic review with meta-analysis

BACKGROUND

The impact of weight loss on survival outcomes remains challenging in patients with lung cancer. The objective of this systematic review with meta-analysis was to assess the association of weight loss with survival outcomes in these patients.

METHODS

Two authors conducted a comprehensive literature search of PubMed, Web of Science, and Embase databases up to January 15, 2024. Observational studies that assessed the weight loss as a prognostic factor of overall survival and progression-free survival in patients with lung cancer were included this analysis. Weight loss defined by at least 5% loss of total body weight over 2 months.

RESULTS

Fifteen studies involving 14,540 patients with lung cancer were included. Pooled adjusted hazard ratios (HR) indicated that weight loss was associated with reduced overall survival (HR 1.65; 95% confidence intervals [CI] 1.43-1.91) and progression-free survival (HR 1.40; 95% CI 1.15-1.71). Subgroup analysis showed that weight loss significantly predicted overall survival, regardless of study design, lung cancer subtypes, clinical stage of cancer, weight loss definition, or length of follow-up.

CONCLUSIONS

Weight loss is a significant predictor of overall survival and progression-free survival in patients with lung cancer. Weight monitoring has potential to improve prognostication of survival outcomes for these patients.

Association of normal body mass index and weight loss with long-term major cardiovascular events after PCI for myocardial infarction

Objectives: To investigate whether normal body mass index (BMI) shortly after percutaneous coronary intervention (PCI) for myocardial infarction is associated with increased risk of long-term major cardiovascular events (MACE), and to explore potential clinical determinants of long-term weight loss (WL) after PCI. Methods: Single-center cohort study with 5-year follow-up of patients treated with PCI for myocardial infarction between 2016 and 2018. Categorical WL was defined as > 0 kg body weight reduction from baseline to end of follow-up. Results: Of 236 patients (24% women), mean age was 64.9 ± 10.2 years and mean BMI within 4 days after PCI was 27.1 ± 4.3 kg/m2. Seventy-five patients (32%) had at least one MACE, equally distributed between those with normal weight (31%), overweight (32%), and obesity (31%). Patients with overweight or obesity had a lower crude mortality rate than their normal weight counterparts (7.4% vs 16.4%, p = 0.049), but the relative hazard of death did not differ from those with normal weight, HR 0.50, 95% CI 0.22-1.15. Patients with either a long-term WL (n = 112) or no WL (n = 95) had a comparable incidence of non-fatal MACE (27% vs 22%, p = 0.518). The proportion of patients reporting unintentional weight loss was significantly higher in the normal weight group (82%) compared with those with overweight (41%) or obesity (28%), p < 0.001. Conclusion: Our results did not confirm any association between normal BMI after PCI and long-term MACE. However, patients with normal BMI at baseline had a higher incidence of unintentional WL than those with elevated BMI. Trial registration: Current research information system in Norway (CRISTIN): ID 542528.

Healthy Lifestyle and Cardiac Rehabilitation for Weight Loss

PURPOSE OF REVIEW

Considerable current interest is directed at pharmacological agents for producing significant weight loss. However, healthy lifestyle choices can also lead to clinically meaningful weight loss and improvements in cardiovascular disease (CVD) risk factors.

RECENT FINDINGS

In this review, we summarize the recent research from our PROmoting Successful Weight Loss in Primary CarE in Louisiana (PROPEL) randomized controlled trial and review previous data on the potential benefits of cardiac rehabilitation and exercise training (CRET) programs to produce weight loss and improvements in CVD risk factors. Although obesity medications are becoming extremely attractive for secondary and even primary CVD prevention, high-intensity non-pharmacological therapies with healthy lifestyle choices reviewed herein can also lead to substantial health improvements in patients with obesity, including improvements in body weight and other body composition parameters as well as overall CVD risk.

Rethinking weight loss treatments as cardiovascular medicine in obesity, a comprehensive review

The global escalation of obesity has made it a worldwide health concern, notably as a leading risk factor for cardiovascular disease (CVD). Extensive evidence corroborates its association with a range of cardiac complications, including coronary artery disease, heart failure, and heightened vulnerability to sudden cardiac events. Additionally, obesity contributes to the emergence of other cardiovascular risk factors including dyslipidaemia, type 2 diabetes, hypertension, and sleep disorders, further amplifying the predisposition to CVD. To adequately address CVD in patients with obesity, it is crucial to first understand the pathophysiology underlying this link. We herein explore these intricate mechanisms, including adipose tissue dysfunction, chronic inflammation, immune system dysregulation, and alterations in the gut microbiome.Recent guidelines from the European Society of Cardiology underscore the pivotal role of diagnosing and treating obesity to prevent CVD. However, the intricate relationship between obesity and CVD poses significant challenges in clinical practice: the presence of obesity can impede accurate CVD diagnosis while optimizing the effectiveness of pharmacological treatments or cardiac procedures requires meticulous adjustment, and it is crucial that cardiologists acknowledge the implications of excessive weight while striving to enhance outcomes for the vulnerable population affected by obesity. We, therefore, sought to overcome controversial aspects in the clinical management of heart disease in patients with overweight/obesity and present evidence on cardiometabolic outcomes associated with currently available weight management interventions, with the objective of equipping clinicians with an evidence-based approach to recognize and address CVD risks associated with obesity.

Optimal Medical Therapy for Stable Ischemic Heart Disease in 2024: Focus on Exercise and Cardiac Rehabilitation

Given the prevalence of chronic coronary disease, efforts should be made toward risk factor modification. Cardiac rehabilitation is a secondary prevention program consisting of tailored exercise and lifestyle counseling and has been shown to not only reduce cardiovascular morbidity and mortality but also improve quality of life and exercise capacity. Despite the benefits, it remains underutilized. Efforts should be made to increase referral for patients with chronic coronary disease to aid in symptom management and reduction of cardiovascular risk factors.

Latin-American guidelines of recommendations at discharge from an acute coronary syndrome

The diagnostic criteria, treatments at the time of admission, and drugs used in patients with acute coronary syndrome are well defined in countless guidelines. However, there is uncertainty about the measures to recommend during patient discharge planning. This document brings together the most recent evidence and the standardized and optimal treatment for patients at the time of discharge from hospitalization for an acute coronary syndrome, for comprehensive and safe care in the patient's transition between care from the acute event to the outpatient care, with the aim of optimizing the recovery of viable myocardium, guaranteeing the most appropriate secondary prevention, reducing the risk of a new coronary event and mortality, as well as the adequate reintegration of patients into daily life.

The inverted U-shaped relationship between weight loss percentage and cardiovascular health scores

PURPOSE

Obesity is a significant risk factor for cardiovascular disease; however, the impact of weight loss on cardiovascular health (CVH) in individuals with specific obesity patterns remains incompletely understood. The objective of our study was to investigate the relationship weight loss percentage and CVH scores across individuals with various obesity patterns.

METHODS

Our study utilized data from the National Health and Nutrition Examination Survey conducted between 2007 and 2018, involving a total of 12,835 participants aged 16 years or older, to conduct a cross-sectional analysis. Multiple linear regression and multinomial logistic regression methods were used to assess the correlation between the weight loss percentage and the CVH scores. Additionally, restricted cubic spline analysis was employed to examine the nonlinear relationship between the two variables.

RESULTS

Compared to individuals with a weight loss percentage < 0%, participants with weight loss percentages of 0-5% and 5.1-10% showed improved CVH scores, with β values of 2.85 (95% CI 2.32-3.38) and 2.55 (95% CI 1.69-3.4), respectively. Regarding different obesity patterns, compared to participants with a weight loss percentage < 0%, participants with a weight loss percentage of 0-5% showed an increase in CVH scores in the normal weight and overweight/general obesity (OGO) groups, with β values of 1.45 (95% CI 0.7-2.19) and 1.22 (95% CI 0.46-1.97), respectively. Restricted cubic spline analysis revealed a significant inverted U-shaped relationship between the weight loss percentage and the CVH scores (with optimal CVH scores at 3%).

CONCLUSIONS

There was an inverted U-shaped relationship between weight loss percentage and CVH scores, with moderate weight loss (0-10%, optimal value of 3%) being associated with improved CVH scores, especially among individuals with OGO.

LEVEL V

Opinions of respected authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Association between weight change and the predicted 10-year risk for atherosclerosis cardiovascular disease among U.S. older adults: data from National Health and Nutrition Examination Survey 1999-2018

Background

It remains controversial regarding the association between weight change and cardiovascular disease risk in older adults (aged ≥60 years). This study aimed to evaluate the association between weight change and the predicted 10-year atherosclerotic cardiovascular disease (ASCVD) risks in older adults.

Methods

This study used data from the National Health and Nutrition Examination Survey (NHANES). Older adults aged 60-79 years who were free of self-reported ASCVD at the time of the NHANES interview were included. Data were collected from January 1999 to December 2018 and analyzed in March 2022. We focused on the associations between weight change and the 10-year ASCVD risks with the percentage change in weight during short-term (1 year) and long-term (10 years), which categorized as moderate to high weight loss (≥10%), small weight loss (5.1-9.9%), stable weight (±5%), small weight gain (5.1-9.9%), and moderate to high weight gain (≥10%).

Results

The number of participants was 1,867 (mean age 67.49 years; 42.10% female) for the long-term interval (10 years) in our analysis, and 1894 for the short-term interval (1 years). We only observed an inverse association between long-term weight loss and the 10-year ASCVD risk in fully adjusted model (loss ≥ 10%: β = 2.52, 95%CI = 0.98, 4.05; loss 5.1% ~ 9.9%: β = 2.99, 95% CI = 1.30, 4.68), but all intervals of weight gain ≥5% were not significant associated with higher risk than stable weight. However, in the subgroup analyses, the association between long-term weight loss and the 10-year ASCVD risk was not significant in old-old (aged 75-79), obesity (BMI ≥ 35 kg/m2), intentional weight loss, moderate physical activity and diabetics.

Conclusion

Older adults (aged 60-79 years) with weight loss >5% over the past 10 years have excess predicted 10-year ASCVD risk. Our study supports the benefits of stable weight in promoting cardiovascular health in older adults.

Dissecting the mediating and moderating effects of depression on the associations between traits and coronary artery disease: A two-step Mendelian randomization and phenome-wide interaction study

Background

Depression is often present concurrently with coronary artery disease (CAD), a disease with which it shares many risk factors. However, the manner in which depression mediates and moderates the association between traits (including biomarkers, anthropometric indicators, lifestyle behaviors, etc.) and CAD is largely unknown.

Methods

In our causal mediation analyses using two-step Mendelian randomization (MR), univariable MR was first used to investigate the causal effects of 108 traits on liability to depression and CAD. The traits with significant causal effects on both depression and CAD, but not causally modulated by depression, were selected for the second-step analyses. Multivariable MR was used to estimate the direct effects (independent of liability to depression) of these traits on CAD, and the indirect effects (mediated via liability to depression) were calculated. To investigate the moderating effect of depression on the association between 364 traits and CAD, a cross-sectional phenome-wide interaction study (PheWIS) was conducted in a study population from UK Biobank (UKBB) (N=275,257). Additionally, if the relationship between traits and CAD was moderated by both phenotypic and genetically predicted depression at a suggestive level of significance (Pinteraction≤0.05) in the PheWIS, the results were further verified by a cohort study using Cox proportional hazards regression.

Results

Univariable MR indicated that 10 of 108 traits under investigation were significantly associated with both depression and CAD, which showed a similar direct effect compared to the total effect for most traits. However, the traits "drive faster than speed limit" and "past tobacco smoking" were both exceptions, with the proportions mediated by depression at 24.6% and 7.2%, respectively. In the moderation analyses, suggestive evidence of several traits was found for moderating effects of phenotypic depression or susceptibility to depression, as estimated by polygenic risk score, including chest pain when hurrying, reason of smoking quitting and weight change. Consistent results were observed in survival analyses and Cox regression.

Conclusion

The independent role of traits in CAD pathogenesis regardless of depression was highlighted in our mediation analyses, and the moderating effects of depression observed in our study may be helpful for CAD risk stratification and optimized allocation of scarce medical resources.

Updates on obesity and the obesity paradox in cardiovascular diseases

The prevalence of obesity has reached pandemic proportions worldwide and certainly in the United States. Obesity is a well-established independent risk factor for development of many cardiovascular diseases (CVD), including heart failure, coronary heart disease, atrial fibrillation, and hypertension. Therefore, it is logical to expect obesity would have a strong correlation with CVD mortality. However, a substantial body of literature demonstrates a paradox with improved prognosis of overweight and obese patients with established CVD compared to lean patients with the identical CVD. Surprisingly, similar data has also shown that cardiovascular fitness, rather than weight loss alone, influences the relationship between obesity and mortality in those with established CVD. The impact of fitness, exercise, physical activity (PA), and weight loss and their relationship to the obesity paradox are all reviewed here.

Metabolic syndrome and risk of incident heart failure in non-diabetic patients with established cardiovascular disease

BACKGROUND

In patients with established cardiovascular disease (CVD), the relation between metabolic syndrome (MetS) and incident heart failure (HF) in the absence of diabetes mellitus (DM) is largely unknown. This study assessed this relation in non-diabetic patients with established CVD.

METHODS

Patients from the prospective UCC-SMART cohort with established CVD, but without DM or HF at baseline were included (n = 4653). MetS was defined according to the Adult Treatment Panel III criteria. Insulin resistance was quantified using the homeostasis model of insulin resistance (HOMA-IR). The outcome was a first hospitalization for HF. Relations were assessed using Cox proportional hazards models adjusted for established risk factors: age, sex, prior myocardial infarction (MI), smoking, cholesterol, and kidney function.

RESULTS

During a median follow-up of 8.0 years, 290 cases of incident HF were observed (0.81/100 person years). MetS was significantly related to an increased risk of incident HF independent of established risk factors (hazard ratio [HR] 1.32; 95% confidence interval [CI] 1.04-1.68, HR per criterion 1.17; 95% CI 1.06-1.29), as was HOMA-IR (HR per standard deviation [SD] 1.15; 95% CI 1.03-1.29). Of the individual MetS components, only higher waist circumference independently increased the risk of HF (HR per SD 1.34; 95% CI 1.17-1.53). Relations were independent of the occurrence of interim DM and MI, and were not significantly different for HF with reduced vs preserved ejection fraction.

CONCLUSION

In CVD patients without a current diagnosis of DM, MetS and insulin resistance increase the risk of incident HF independent of established risk factors.

Challenges in Cardiovascular Evaluation and Management of Obese Patients: JACC State-of-the-Art Review

Many unique clinical challenges accompany the diagnosis and treatment of cardiovascular disease (CVD) in people living with overweight/obesity. Similarly, physicians encounter numerous complicating factors when managing obesity among people with CVD. Diagnostic accuracy in CVD medicine can be hampered by the presence of obesity, and pharmacological treatments or cardiac procedures require careful adjustment to optimize efficacy. The obesity paradox concept remains a source of confusion within the clinical community that may cause important risk factors to go unaddressed, and body mass index is a misleading measure that cannot account for body composition (eg, lean mass). Lifestyle modifications that support weight loss require long-term commitment, but cardiac rehabilitation programs represent a potential opportunity for structured interventions, and bariatric surgery may reduce CVD risk factors in obesity and CVD. This review examines the key issues and considerations for physicians involved in the management of concurrent obesity and CVD.

Association of short-term and long-term weight loss with the risk of major adverse cardiovascular disease: Community-based cohort study

BACKGROUND

This study evaluated temporal association of changes in BMI over time with major adverse cardiovascular event (MACE) in Korean middle-aged adults.

METHODS

Between 2001 and 2002, 6855 individuals from the Korean Genome and Epidemiology Study were included and followed up until 2014. The main predictor was the change in BMI determined using group-based trajectory modelling (decreasing, stable, and increasing) from the baseline to 4-, 6-, and 8-years of follow-up. The primary outcome was the occurrence of MACE.

RESULTS

During the mean 10.2 years follow-up, MACEs occurred in 350 (5.1 %) individuals. The median (interquartile rage) age of study population was 50 (44-59) years. In primary analysis with 4-year trajectory model, decreasing BMI trajectory was associated with a 1.41-fold higher risk of the MACEs (hazard ratio [HR], 1.41; 95 % confidence interval [CI], 1.06-1.91) compared with stable BMI trajectory. In secondary analyses with 6- and 8-year trajectory models, this association disappeared, and the corresponding HRs (95 % CIs) were 1.14 (0.81-1.61) and 0.98 (0.65-1.49), respectively. There were concomitant improvements in cardiometabolic risk factors in decreasing BMI group, but unfavorable risk burden remained up to 4 to 6 years.

CONCLUSIONS

The initial 4-year weight loss was paradoxically associated with a higher risk of MACEs, probably due to residual cardiovascular burden. However, this association became null in participants with sustained weight loss ≥ 6 years, suggesting a possible lag effect of weight loss on MACEs.

Saudi Heart Association Guidelines on Best Practices in the Management of Chronic Coronary Syndromes

Background

The prevalence of both chronic coronary syndrome (CCS) and its risk factors is alarming in Saudi Arabia and only a minority of patients achieve optimal medical management. Context-specific CCS guidelines outlining best clinical practices are therefore needed to address local gaps and challenges.

Consensus panel

A panel of experts representing the Saudi Heart Association (SHA) reviewed existing evidence and formulated guidance relevant to local clinical practice considering the characteristics of the Saudi population, the Saudi healthcare system, its resources and medical expertise. They were reviewed by external experts to ensure scientific and medical accuracy.

Consensus findings

Recommendations are provided on the clinical assessment and management of CCS, along with supporting evidence. Risk reduction through non-pharmacological therapy (lifestyle modifications) remains at the core of CCS management. Great emphasis should be placed on the use of available pharmacological options (anti-anginal therapy and event prevention) only as appropriate and necessary. Lifestyle counseling and pharmacological strategy must be optimized before considering revascularization, unless otherwise indicated. Revascularization strategies should be carefully considered by the Heart Team to ensure the appropriate choice is made in accordance to current guidelines and patient preference.

Conclusion

Conscientious, multidisciplinary, and personalized clinical management is necessary to navigate the complex landscape of CCS in Saudi Arabia considering its population and resource differences. The reconciliation of international evidence and local characteristics is critical for the improvement of healthcare outcomes among CCS patients in Saudi Arabia.

Body-weight variability and risk of cardiovascular outcomes in patients with type 1 diabetes: a retrospective observational analysis of data from the DCCT/EDIC population

BACKGROUND

Cardiovascular risk and body-weight management are both emerging challenges of type 1 diabetes care. We evaluated the association between intraindividual variability of body-weight and risk of cardiovascular events in people with type 1 diabetes.

METHODS

We analyzed 1,398 participants from the DCCT/EDIC studies. Five indices of intraindividual variability of body-weight were calculated for each participant taking into account body-weight measures obtained during the DCCT follow-up (average 6 ± 2 years). The Average Successive Variability (ASV) index, the main variable of interest, was defined as the average absolute difference between successive body-weight measures. The primary outcome was a composite of major adverse cardiovascular events (MACE: nonfatal myocardial infarction or stroke, or cardiovascular death) occurring during the subsequent EDIC follow-up (20 ± 3 years). All-cause death was a secondary outcome. Risk of outcomes were assessed by Cox proportional hazards regression analyses, adjusted for traditional cardiovascular risks factors, including BMI.

RESULTS

The cumulative incidence of MACE and all-cause death during follow-up were 5.6% (n = 79) and 6.8% (n = 95), respectively. The adjusted Hazard Ratio (HR) for MACE by every increase of 1 standard deviation (SD) of ASV was 1.34 (95% CI, 1.06-1.66), p = 0.01. For all-cause death, the adjusted HR for 1 SD increase of ASV was 1.25 (1.03-1.50), p = 0.03. Similar results were observed when considering the other indices of intraindividual variability of body-weight.

CONCLUSIONS

High body-weight variability (body-weight cycling) is associated with increased risk of MACE and all-cause death in people with type 1 diabetes, independently of the BMI and traditional cardiovascular risk factors.

Weight loss and all-cause mortality: A propensity score matching cohort study

BACKGROUND

Weight loss was supposed to help with decreasing risk of premature mortality. However, results on this topic remain debatable and limited by study design.

OBJECTIVE

The present study aimed to investigate the association between weight loss and all-cause mortality among US adults with overweight or obesity in a national cohort study by using propensity score matching (PSM) analysis.

METHODS

A total of 5486 pairs of participants were matched in the National Health and Nutrition Examination Survey (NHANES, 2003-2015) after PSM. Hazard ratios (95% confidence intervals) (HRs (95% CIs)) were employed to evaluate the association between weight loss indicated by long-term weight loss (LTWL) and all-cause mortality by using Cox proportional hazards regression models.

RESULTS

During a median follow-up of 6.8 years, 674 participants died from all-cause mortality. In each PSM match, compared with participants with LTWL < 5%, the HRs (95% CIs) for participants with LTWL of 5-9.9% (2877 pairs), 10-14.9% (1315 pairs), and ≥ 15% (1294 pairs) were 1.18 (0.83-1.68) (P = 0.366), 1.65 (1.17-2.34) (P = 0.005), and 1.91 (1.21-3.00) (P = 0.006), respectively. The significant increased risk of all-cause mortality for LTWL ≥ 15% remained among male, female, participants aged ≥ 65 years, without weight loss intention, with non-communicable diseases, and without exceeding estimated energy requirement.

CONCLUSION

Weight loss especially for being ≥ 15% should be cautious for US adults with overweight or obesity.

Combined Dietary Education and High-Intensity Interval Resistance Training Improve Health Outcomes in Patients with Coronary Artery Disease

BACKGROUND

Reducing cardiovascular risk through lifestyle changes that include a heart-healthy diet and regular exercise is recommended in the rehabilitation of patients with coronary artery disease (CAD). We pilot-tested the effectiveness of a dietary-education and high-intensity interval resistance training (DE-HIIRT) program on healthy food choices and associated anthropometric variables in patients with established CAD.

METHODS

A total of 22 participants, aged 60.0 ± 7.2 years, were enrolled in the study. Over 3 months, under the guidance and supervision of a physiotherapist, participants performed the resistance exercises 2×/week in a group setting (cohort of 11). Participants additionally attended three sessions of dietary education led by a dietician. Participants demonstrated their knowledge and understanding of dietary education by picking heart-healthy foods by reading food labels. Outcomes included change in diet (measured using the tricipital skinfold thickness Mediterranean Diet Adherence questionnaire (MEDAS-14) and the Food Consumption Frequency Questionnaire (FCFQ)) and anthropometric measurements (body composition, body circumference, and tricipital skinfold thickness). A paired t-test was performed to analyze the differences between the baseline and post-intervention results.

RESULTS

Participants significantly increased their consumption of vegetables (p = 0.04) and lowered their consumption of sweet snacks (p = 0.007), pastries (p = 0.02), and processed food (p = 0.05). Significant improvements in body mass index (p = 0.001), waist circumference (p = 0.0001), hip circumference (p = 0.04), and body fat (p = 0.0001) were also achieved.

CONCLUSION

Making lifestyle changes that include both diet and exercise is essential in the management of CAD. The HIIRT program combined with dietary changes shows promise in achieving weight-loss goals in this population and needs to be further investigated with appropriate study designs.

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.

Clinical interventions to break the obesity and cancer link: a narrative review

Excess body weight is a significant risk factor for the development and recurrence of many types of cancer. Patients with a history or current diagnosis of cancer who are overweight or have obesity have an increased risk of cancer treatment-related morbidity, recurrence, and decreased quality of life. Weight loss and maintenance of a healthy body weight may reduce cancer morbidity and recurrence in cancer survivors. While guidelines for cancer survivorship elaborate sufficiently on lifestyle interventions, little guidance is provided when considering additional therapies like anti-obesity pharmacotherapy or bariatric surgery for weight loss. This review will highlight and address current recommendations and feasible interventions that clinicians may consider to further reduce the incidence and recurrence of cancer in patients with obesity.

Recommendations for nutritional assessment across clinical practice guidelines: A scoping review

BACKGROUND & AIMS

CPGs propose several methods and criteria to perform nutritional assessment, a key process to determine the type and severity of malnutrition, which generates variability in clinical practice and outcomes. The aim of the study was to describe the criteria considered by clinical practice guidelines (CPGs) for nutritional assessment.

METHODS

We performed a scoping review systematically searching in PubMed, Trip Database, Google Scholar, and Google, until November 5, 2021. We included all CPGs mentioning tools or criteria for nutritional assessment in adults from the general population or with any specific pathology or condition. Two authors independently reviewed and decided on study selection and data extraction.

RESULTS

We included 18 CPGs (12 elaborated in Europe). The CPGs recommended heterogeneous criteria for nutritional assessment: 16/18 CPGs included at least one body composition parameter (e.g., loss of muscle mass, loss of subcutaneous fat), 15/18 included history related to dietary intake, 15/18 included clinical history (e.g., weight loss), 10/18 included anthropometric measurement (e.g., low body mass index [BMI]), 11/18 included biochemical criteria (e.g., albumin, C-reactive protein), 8/18 included physical examination (e.g., fluid retention, sarcopenia, loss of subcutaneous fat), 8/18 included functional test (e.g., decreased handgrip strength), and 1/18 included catabolic state. Also, 9/18 CPGs mentioned a tool for nutritional assessment, the Subjective Global Assessment (SGA) the most common (8/18). None of the CPGs justified the inclusion of any of the tools or criteria they mentioned.

CONCLUSIONS

The CPGs mentioned heterogeneous criteria for nutritional assessment. The most commonly mentioned criteria were decreased food intake, loss of muscle mass, weight loss, and low BMI. The most mentioned tool was the SGA. None of the CPGs provided a clear rationale for using certain criteria or tools for nutritional assessment.

ASSOCIATION BETWEEN UNDERWEIGHT AND EXCESS BODY WEIGHT BEFORE SARS-COV-2 INFECTION AND CLINICAL OUTCOMES OF COVID-19: MULTICENTER STUDY

Objectives

The present study aimed to identify associations between extremes in body weight status (underweight and excess body weight) before a COVID-19 diagnosis and clinical outcomes in patients infected with SARS coronavirus type 2.

Methods

A multicenter cohort study was conducted in eight different states in northeastern Brazil. Demographic, clinical (previous diagnosis of comorbidities), and anthropometric (self-reported weight and height) data about individuals who tested positive for COVID-19 were collected. Outcomes included hospitalization, mechanical ventilation, and death. Multivariable logistic regression models, adjusted based on age, sex and previous comorbidities, were used to assess the effects of extremes in body weight status on clinical outcomes.

Results

A total of 1308 individuals were assessed (33.6% were elderly individuals). The univariable analyses showed that only hospitalization was more often observed among underweight (3.2% versus 1.2%) and overweight (68.1% versus 63.3%) individuals. In turn, cardiovascular diseases were more often observed in all clinical outcomes (hospitalization: 19.7% versus 4.8%; mechanical ventilation: 19.9% versus 13.5%; death: 21.8% versus 14.1%). Based on the multivariable analysis, body weight status was not associated with risk of hospitalization (underweight: odds ratio [OR]: 1.10; 95% confidence interval [CI] 95%, 0.50–2.41 and excess body weight: OR: 0.81; 95 CI, 0.57–1.14), mechanical ventilation (underweight: OR: 0.92; 95% CI, 0.52–1.62 and excess weight: OR: 0.90; 95% CI, 0.67–1.19), and death (underweight: OR: 0.61; 95% CI, 0.31–1.20 and excess body weight: OR 0.88; 95% CI, 0.63–1.23).

Conclusions

Being underweight and excess body weight were not independently associated with clinical outcomes in patients with COVID-19 in the herein analyzed cohort. This finding indicates that the association between these variables may be confounded by both age and comorbidities.

The importance of weight stabilization amongst those with overweight or obesity: Results from a large health care system

Data on patterns of weight change among adults with overweight or obesity are minimal. We aimed to examine patterns of weight change and associated hospitalizations in a large health system, and to develop a model to predict 2-year significant weight gain. Data from the Duke University Health System was abstracted from 1/1/13 to 12/31/16 on patients with BMI ≥ 25 kg/m2 in 2014. A regression model was developed to predict patients that would increase their weight by 10% within 2 years. We estimated the association between weight change category and all-cause hospitalization using Cox proportional hazards models. Of the 37,253 patients in our cohort, 59% had stable weight over 2 years, while 24% gained ≥ 5% weight and 17% lost ≥ 5% weight. Our predictive model had reasonable discriminatory capacity to predict which individuals would gain ≥ 10% weight over 2 years (AUC 0.73). Compared with stable weight, the risk of hospitalization was increased by 37% for individuals with > 10% weight loss [adj. HR (95% CI): 1.37 (1.25,1.5)], by 30% for those with > 10% weight gain [adj. HR (95% CI): 1.3 (1.19,1.42)], by 18% for those with 5-10% weight loss [adj. HR (95% CI): 1.18 (1.09,1.28)], and by 10% for those with 5-10% weight gain [adj. HR (95% CI): 1.1 (1.02,1.19)]. In this examination of a large health system, significant weight gain or loss of > 10% was associated with increased all-cause hospitalization over 2 years compared with stable weight. This analysis adds to the increasing observational evidence that weight stability may be a key health driver.

Obesity treatment: Weight loss versus increasing fitness and physical activity for reducing health risks

We propose a weight-neutral strategy for obesity treatment on the following grounds: (1) the mortality risk associated with obesity is largely attenuated or eliminated by moderate-to-high levels of cardiorespiratory fitness (CRF) or physical activity (PA), (2) most cardiometabolic risk markers associated with obesity can be improved with exercise training independent of weight loss and by a magnitude similar to that observed with weight-loss programs, (3) weight loss, even if intentional, is not consistently associated with lower mortality risk, (4) increases in CRF or PA are consistently associated with greater reductions in mortality risk than is intentional weight loss, and (5) weight cycling is associated with numerous adverse health outcomes including increased mortality. Adherence to PA may improve if health care professionals consider PA and CRF as essential vital signs and consistently emphasize to their patients the myriad benefits of PA and CRF in the absence of weight loss.

Body Mass Index and Mortality Among Adults With Incident Myocardial Infarction

The relationship between body mass index (BMI; weight (kg)/height (m)2) and mortality among survivors of myocardial infarction (MI) remains controversial. We examined the relationships of BMI before and after MI and change in weight with all-cause mortality among participants in the Nurses' Health Study (1980-2016) and Health Professionals Follow-up Study (1988-2016) cohorts. During a follow-up period of up to 36 years, we documented 4,856 participants with incident nonfatal MI, among whom 2,407 died during follow-up. For pre-MI and post-MI BMI, overweight was not associated with lower mortality. Obesity (BMI ≥30) was associated with higher risk of mortality. Compared with participants with post-MI BMI of 22.5-24.9, hazard ratios were 1.16 (95% confidence interval (CI): 1.01, 1.34) for BMI 30.0-34.9 and 1.52 (95% CI: 1.27, 1.83) for BMI ≥35.0 (P for trend < 0.001). Compared with stable weight from before MI to after MI, a reduction of more than 4 BMI units was associated with increased mortality (hazard ratio = 1.53, 95%: CI: 1.28, 1.83). This increase was seen only among participants who lost weight without improving their physical activity or diet. Our findings showed no survival benefit of excess adiposity in relation to risk of mortality. Weight loss from before to after MI without lifestyle improvement may reflect reverse causation and disease severity.

The Treatment of Obesity in Cardiac Rehabilitation: A REVIEW AND PRACTICAL RECOMMENDATIONS

BACKGROUND

Cardiac rehabilitation (CR) programs have evolved from exercise-only programs designed to improve cardiorespiratory fitness to secondary prevention programs with a broader mandate to alter lifestyle-related behaviors that control cardiac risk factors and, thereby, reduce overall cardiovascular risk. As the obesity epidemic has evolved in the late 20th and early 21st centuries, the prevalence of type 2 diabetes mellitus and the metabolic syndrome have soared and blunted the otherwise expected downturn in deaths from coronary heart disease related to better control of risk factors. In that the causes of obesity are behavioral in origin, the most effective treatment strategy requires a comprehensive, behavioral-based approach.

PURPOSE

In this review, we outline optimal lifestyle approaches that can be delivered in the CR setting to assist cardiac patients with their long-term goals of reducing weight and improving cardiac risk factors while concurrently improving cardiorespiratory fitness. We also performed a survey of CR program throughout the United States and found that only 8% currently deliver a behavioral weight programs.

CONCLUSIONS

Cardiac rehabilitation programs need to take on an important challenge of secondary prevention, which is to develop behavioral weight loss programs to assist cardiac patients to lose weight and, thereby, improve multiple risk factors and long-term prognosis.

Long-Term Body Mass Index Variability, Weight Change Slope, and Risk of Cardiovascular Outcomes: 7-Year Prospective Study in Chinese Hypertensive Subjects

BACKGROUND

The relationship between long-term body mass index (BMI) variability, weight change slope, and risk of cardiovascular outcomes in Chinese hypertensive patients has not been fully elucidated.

METHODS

A total of 20,737 patients with hypertension and three BMI measurements between 2006 and 2011 were included. Average real variability (ARV) was used to evaluate variability, and the subjects were divided into three groups: tertile 1 with BMI_ARV ≤0.86; tertile 2 with 0.86 < BMI_ARV ≤ 1.60; and tertile 3 with BMI_ARV >1.60. Cox proportional-hazards models were used to analyze the risk of cardiovascular and cerebrovascular diseases (CVD) in each group.

RESULTS

There were 1,352 cases of CVD during an average follow-up of 6.62 years. The 7-year cumulative incidence rates of CVD, stroke, and myocardial infarction (MI) in tertile 3 were 7.53, 6.13, and 1.56%, respectively. After adjustment for average BMI, weight change slope, and other traditional risk factors, the hazard ratio (HR) values for CVD, stroke, and MI in the highest tertile were 1.21 (95% CI 1.05-1.39), 1.21 (95% CI 1.04-1.38), and 1.20 (95% CI 0.88-1.62), respectively. Subgroup analysis showed that the HR values for CVD in tertile 3 were 1.71 (95% CI 1.06-2.75) and 0.98 (95% CI 0.61-1.58) in the positive and the negative weight change subjects, respectively.

CONCLUSIONS

Higher BMI variability was associated with increased risk of CVD in hypertensive subjects with weight gain but not in those with weight loss, independent of traditional cardiovascular risk factors.

Diagnosis and Management of Stable Angina: A Review

IMPORTANCE

Nearly 10 million US adults experience stable angina, which occurs when myocardial oxygen supply does not meet demand, resulting in myocardial ischemia. Stable angina is associated with an average annual risk of 3% to 4% for myocardial infarction or death. Diagnostic tests and medical therapies for stable angina have evolved over the last decade with a better understanding of the optimal use of coronary revascularization.

OBSERVATIONS

Coronary computed tomographic angiography is a first-line diagnostic test in the evaluation of patients with stable angina due to higher sensitivity and comparable specificity compared with imaging-based stress testing. Moreover, coronary computed tomographic angiography allows detection of nonobstructive atherosclerosis that would not be identified with other noninvasive imaging modalities, improving risk assessment and potentially triggering more appropriate allocation of preventive therapies. Novel therapies treating lipids (proprotein convertase subtilisin/kexin type 9 inhibitors, ezetimibe, and icosapent ethyl) and type 2 diabetes (sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists) have improved cardiovascular outcomes in patients with stable ischemic heart disease when added to usual care. Randomized clinical trials showed no improvement in the rates of mortality or myocardial infarction with revascularization (largely by percutaneous coronary intervention) compared with optimal medical therapy alone, even in the setting of moderate to severe ischemia. In contrast, revascularization provides a meaningful benefit on angina and quality of life compared with antianginal therapies. Measures of the effect of angina on a patient's quality of life should be integrated into the clinic encounter to assist with the decision to proceed with revascularization.

CONCLUSIONS AND RELEVANCE

For patients with stable angina, emphasis should be placed on optimizing lifestyle factors and preventive medications such as lipid-lowering and antiplatelet agents to reduce the risk for cardiovascular events and death. Antianginal medications, such as β-blockers, nitrates, or calcium channel blockers, should be initiated to improve angina symptoms. Revascularization with percutaneous coronary intervention should be reserved for patients in whom angina symptoms negatively influence quality of life, generally after a trial of antianginal medical therapy. Shared decision-making with an informed patient is important for effective treatment of stable angina.

Risk Factor Burden and Long-Term Prognosis of Patients With Premature Coronary Artery Disease

Background Coronary artery disease (CAD) is increasing among young adults. We aimed to describe the cardiovascular risk factors and long-term prognosis of premature CAD. Methods and Results Using the Duke Databank for Cardiovascular Disease, we evaluated 3655 patients admitted between 1995 and 2013 with a first diagnosis of obstructive CAD before the age of 50 years. Major adverse cardiovascular events (MACEs), defined as the composite of death, myocardial infarction, stroke, or revascularization, were ascertained for up to 10 years. Cox proportional hazard regression models were used to assess associations with the rate of first recurrent event, and negative binomial log-linear regression was used for rate of multiple event recurrences. Past or current smoking was the most frequent cardiovascular factor (60.8%), followed by hypertension (52.8%) and family history of CAD (39.8%). Within a 10-year follow-up, 52.9% of patients had at least 1 MACE, 18.6% had at least 2 recurrent MACEs, and 7.9% had at least 3 recurrent MACEs, with death occurring in 20.9% of patients. Across follow-up, 31.7% to 37.2% of patients continued smoking, 81.7% to 89.3% had low-density lipoprotein cholesterol levels beyond the goal of 70 mg/dL, and 16% had new-onset diabetes mellitus. Female sex, diabetes mellitus, chronic kidney disease, multivessel disease, and chronic inflammatory disease were factors associated with recurrent MACEs. Conclusions Premature CAD is an aggressive disease with frequent ischemic recurrences and premature death. Individuals with premature CAD have a high proportion of modifiable cardiovascular risk factors, but failure to control them is frequently observed.

Association of general and abdominal obesity and their changes with stroke in Chinese adults: Results from an 11.8-year follow-up study

BACKGROUND AND AIMS

Obesity-related diseases play a significant role in the epidemiology of stroke; however, the exact effects of obesity and transitions in obesity status on stroke risk are still unclear. This study was performed to investigate the association of general and abdominal obesity and their changes with stroke in Chinese adults.

METHODS AND RESULTS

A total of 26,815 subjects (13,684 men and 13,131 women) aged ≥35 years participated in the study. The association of general and abdominal obesity and their changes with stroke was estimated by Cox proportional hazards models. During a median follow-up period of 11.8 years, 1507 people developed an incident stroke event. The multivariable-adjusted hazard ratios (HRs) (95% CIs) for stroke comparing the highest vs. lowest quartiles of these measurements were 1.276 (1.068-1.524) for BMI, 1.245 (1.035-1.499) for WC, 0.940 (0.786-1.125) for WHR, and 1.221 (1.019-1.464) for WHtR in men. For women, the corresponding values were 1.368 (1.089-1.718), 1.424 (1.119-1.813), 0.971 (0.765-1.232), and 1.341 (1.059-1.699), respectively. C- statistics showed no difference in the predictive value for stroke among various measures of adiposity. Compared with participants who maintained a normal BMI, the HRs for reversed general obesity was 1.272 (95% CI: 1.044-1.550) among men and 1.240 (95% CI: 0.948-1.623) among women.

CONCLUSION

Increasing levels of general or abdominal adiposity consistently predict increased risk of stroke, and maintenance of a normal BMI or WC may aid in stroke prevention.

COVID-19 is associated with clinically significant weight loss and risk of malnutrition, independent of hospitalisation: A post-hoc analysis of a prospective cohort study

BACKGROUND & AIMS

Coronavirus disease 2019 (COVID-19) may associate with clinical manifestations, ranging from alterations in smell and taste to severe respiratory distress requiring intensive care, that might associate with weight loss and malnutrition. We aimed to assess the incidence of unintentional weight loss and malnutrition in COVID-19 survivors.

METHODS

In this post-hoc analysis of a prospective observational cohort study, we enrolled all adult (age ≥18 years) patients with a confirmed diagnosis of COVID-19 who had been discharged home from either a medical ward or the Emergency Department of San Raffaele University Hospital, and were re-evaluated after remission at the Outpatient COVID-19 Follow-Up Clinic of the same Institution from April 7, 2020, to May 11, 2020. Demographic, anthropometric, clinical and biochemical parameters upon admission were prospectively collected. At follow-up, anthropometrics, the mini nutritional assessment screening and a visual analogue scale for appetite were assessed.

RESULTS

A total of 213 patients were included in the analysis (33% females, median age 59.0 [49.5-67.9] years, 70% overweight/obese upon initial assessment, 73% hospitalised). Sixty-one patients (29% of the total, and 31% of hospitalised patients vs. 21% of patients managed at home, p = 0.14) had lost >5% of initial body weight (median weight loss 6.5 [5.0-9.0] kg, or 8.1 [6.1-10.9]%). Patients who lost weight had greater systemic inflammation (C-reactive protein 62.9 [29.0-129.5] vs.48.7 [16.1-96.3] mg/dL; p = 0.02), impaired renal function (23.7% vs. 8.7% of patients; p = 0.003) and longer disease duration (32 [27-41] vs. 24 [21-30] days; p = 0.047) as compared with those who did not lose weight. At multivariate logistic regression analysis, only disease duration independently predicted weight loss (OR 1.05 [1.01-1.10] p = 0.022).

CONCLUSIONS

COVID-19 might negatively impact body weight and nutritional status. In COVID-19 patients, nutritional evaluation, counselling and treatment should be implemented at initial assessment, throughout the course of disease, and after clinical remission. CLINICALTRIALS.

GOV REGISTRATION

NCT04318366.

Body Weight Variability and the Risk of Cardiovascular Outcomes and Mortality in Patients With Type 2 Diabetes: A Nationwide Cohort Study

OBJECTIVE

Obesity and type 2 diabetes are risk factors for cardiovascular diseases and mortality, and they commonly result in weight variabilities. We aimed to investigate the association between body weight variability and risk of major cardiovascular outcomes and mortality in individuals with type 2 diabetes using large-scale, nationwide cohort data on the Korean population.

RESEARCH DESIGN AND METHODS

We enrolled 624,237 individuals with type 2 diabetes who underwent health examinations provided by the Korean National Health Insurance System between 2009 and 2010, with three or more body weight measurements within 5 years since enrollment and followed up until the end of 2017. We assessed body weight variability using four indices, including variability independent of the mean (VIM). A multivariate-adjusted Cox proportional hazards regression analysis was performed.

RESULTS

During the follow-up, 15,832, 25,038, and 44,716 cases of myocardial infarction (MI), stroke, and all-cause mortality, respectively, were recorded. Body weight variability was associated with increased risks of major cardiovascular outcomes after adjusting for confounding variables. Compared with the hazard ratios (HRs) of the lowest quartile group, the HRs (95% CIs) of the highest quartile group of VIM for body weight were 1.15 (1.10-1.20), 1.22 (1.18-1.26), and 1.58 (1.53-1.62) for MI, stroke, and all-cause mortality, respectively.

CONCLUSIONS

Body weight variability was associated with increased risks of MI, stroke, and all-cause mortality in patients with type 2 diabetes and may be a predictor of cardiovascular outcomes in such patients. Appropriate interventions to maintain stable weight could positively influence health outcomes in patients with type 2 diabetes.

Caloric restriction in heart failure: A systematic review

BACKGROUND AND AIMS

Nutrition exerts a determinant role in maintaining cardiac function, regulating insulin and mitochondrial efficiency, that are essential to support energy production for contractility. In patients with heart failure (HF), myocardial tissue efficiency is reduced because of decreased mitochondrial oxidative capacity. In HF conditions, cardiomyocytes shift toward glucose and a reduction in fatty acid utilization. Calorie restriction induces weight loss in obese patients and can be beneficial in some HF patients, although this has generated some controversy. This study aims to evaluate the impact of the CR diet on myocardial efficiency in HF patients.

METHODS

On Pubmed and Embase, articles related to the keywords: "chronic heart failure" with "diet," "nutrition," "insulin resistance," and "caloric restriction" have been searched, Studies, including exercise or food supplementation, were excluded.

RESULTS

The retrieved articles showed that weight loss, through the activation of insulin and various kinase pathways, regulates the efficiency of myocardial tissue. In contrast, insulin resistance represents a strong cardiovascular risk factor that reduces myocardial function.

CONCLUSION

CR diet represents the first therapy in overweight HF patients, both with preserved ejection fraction (HFpEF) and with reduced ejection fraction (HFrHF) because reducing body fat, the myocardial function increased. Insulin activity is the critical hormone that regulates mitochondrial function and cardiac efficiency. However, a severely restricted diet may represent a severe risk factor correlated with all-cause mortality, particularly in underweight HF patients. Long-term studies conducted on large populations are necessary to evaluate the effects of CR on myocardial function in HF patients.

Obesity and Coronary Heart Disease: Epidemiology, Pathology, and Coronary Artery Imaging

Overweight and obesity contribute to the development of cardiovascular disease (CVD) in general and coronary heart disease (CHD) in particular in part by their association with traditional and nontraditional CVD risk factors. Obesity is also considered to be an independent risk factor for CVD. The metabolic syndrome, of which central obesity is an important component, is strongly associated with CVD including CHD. There is abundant epidemiologic evidence of an association between both overweight and obesity and CHD. Evidence from postmortem studies and studies involving coronary artery imaging is less persuasive. Recent studies suggest the presence of an obesity paradox with respect to mortality in persons with established CHD. Physical activity and preserved cardiorespiratory fitness attenuate the adverse effects of obesity on CVD events. Information concerning the effect of intentional weight loss on CVD outcomes in overweight and obese persons is limited.

Impact of changes in body mass index after percutaneous coronary intervention on long-term outcomes in patients with coronary artery disease

Little is known about the impact of changes in body mass index (BMI) after the percutaneous coronary intervention (PCI) on long-term outcomes in patients with coronary artery disease (CAD). Therefore, this study aimed to clarify this issue. We investigated data on CAD obtained from the SHINANO Registry, a prospective, observational, multicenter cohort study, from 2012 to 2013 in Nagano, Japan. One year after PCI, the enrolled patients were divided into the following three groups based on changes in BMI by tertiles: reduced, maintained, and elevated BMI. The associations among the groups and the 4-year outcomes [major adverse cardiac events (MACEs), all-cause death, Q-wave myocardial infarction, and stroke] were examined. Five hundred seventy-two patients were divided into the reduced, maintained, and elevated BMI groups. Over the 4-year follow-up period, the cumulative incidence of MACEs was 10.5% (60 cases). In the Kaplan-Meier analysis, the incidence rates of MACE were significantly higher in the reduced BMI group than in the maintained and elevated BMI groups [17.7% versus (vs.) 7.3% vs. 9.0%, p = 0.004]. Multivariable cox regression analysis showed that the reduced group showed increased risks of MACEs (hazard ratio 2.15; 95% confidence interval 1.29-3.57; p = 0.003). The long-term clinical outcomes of patients with CAD who underwent PCI were affected by the reduction in BMI after PCI. Furthermore, the elevation of BMI after PCI was not a poor prognostic factor.

Relation of Change of Body Mass Index to Long-Term Mortality After Cardiac Catheterization

Body-mass index (BMI) is a risk marker and therapeutic target in cardiovascular prevention. The effect of changes in BMI on mortality in patients with cardiovascular diseases has not been completely delineated. We aimed to assess the association between percent change in BMI, as measured 3-years after cardiac catheterization, and long-term mortality. Patients who underwent cardiac catheterization (n = 11,220; mean age 63 ± 10 years) were categorized according to BMI groups (normal-weight, 18.50 to 24.99 kg/m²; overweight, 25.00 to 29.99 kg/m²; obesity, ≥30 kg/m²). Follow-up BMI was considered the level measured closest to the timepoint of 3 years post catheterization. Percent change in BMI was calculated and its association with long-term all-cause mortality was investigated. Change in BMI of ±5% was observed in 46% of the patients, a decrease >5% in 15.5%, and an increase of >5% of BMI in 38.5%. Compared with those with the lowest change in BMI (±5%), the adjusted hazard ratios for mortality were 1.45 (95% confidence interval [CI], 1.27 to 1.65), and 1.69 (1.46 to 1.95) in patients with 5% to 10% and >10% decrease in BMI, respectively, and 1.05 (0.94 to 1.17), 1.15 (1.03 to 1.28), and 1.40 (1.19 to 1.64) in patients with 5% to 10%, 10% to 20% and >20% increase in BMI, respectively. The pattern was similar in normal-weight, overweight, and obese subgroups at baseline. However, the magnitude of the association with decrease BMI was more pronounced in normal-weight patients (P-for-interaction 0.031). In conclusion, the association of percent changes in BMI after cardiac catheterization and all-cause mortality had a reversed J-shaped pattern, with both weight loss and weight gain being associated with increased risk. A decrease in BMI was related to higher mortality rates than was an increase in BMI for a comparable degree of percent change.