Association of obesity with heart failure outcomes in 11 Asian regions: A cohort study

Heart failure and obesity: Translational approaches and therapeutic perspectives. A scientific statement of the Heart Failure Association of the ESC

Obesity and heart failure (HF) represent two growing pandemics. In the general population, obesity affects one in eight adults and is linked with an increased risk for HF. Obesity is even more common in patients with HF, where it complicates the diagnosis of HF and is linked with worse symptoms and impaired exercise capacity. Over the past few years, new evidence on the mechanisms linking obesity with HF has been reported, particularly in relation to HF with preserved ejection fraction. Novel therapies inducing weight loss appear to have favourable effects on health status and cardiovascular risk. Against the backdrop of this rapidly evolving evidence landscape, HF clinicians are increasingly required to tailor their preventive, diagnostic, and therapeutic approaches to HF in the presence of obesity. This scientific statement by the Heart Failure Association of the European Society of Cardiology provides an up-to-date summary on obesity in HF, covering key areas such as epidemiology, translational aspects, diagnostic challenges, therapeutic approaches, and trial design.

Association of BMI with adherence and outcome in heart failure patients treated with wearable cardioverter defibrillator

BACKGROUND

Obesity is a known risk factor for cardiovascular disease (CVD), yet an 'obesity paradox' has been observed in various CVD contexts. The impact of obesity on heart failure (HF) patients treated with a wearable cardioverter-defibrillator (WCD) remains underexplored.

METHODS

In a multicentre international registry, we retrospectively collected data from a consecutive series of 1003 patients. These patients were divided into three body mass index (BMI) groups: <25 kg/m2 (n = 348), 25-30 kg/m2 (n = 383), and >30 kg/m2 (n = 272), with BMI > 30 kg/m2 defined as the reference category. Demographics, indications, adherence, WCD shocks, arrhythmic events, rehospitalization due to cardiovascular causes, and mortality were analysed.

RESULTS

At 3 month follow-up, patients with a BMI > 30 showed the greatest improvement in left ventricular ejection fraction (LVEF) at 51.4%, significantly higher than the 41.4% in those with a BMI < 25 (P = 0.017) and comparable with the 49.4% in the BMI 25-30 group (P = 0.635). WCD wearing time and adherence were similar across all BMI groups. The incidence of WCD shock was similar across BMI groups. Rates of ventricular tachycardia (VT), ventricular fibrillation and non-sustained VT (ns-VT) were comparable across BMI groups. The rate of implantable cardioverter-defibrillator (ICD) implantation was 40.3% across all patients, with a slightly lower rate in the BMI > 30 group (36.8%) compared with others, although not significantly. Rehospitalization due to cardiovascular causes was significantly lower in the BMI > 30 group (55.4%) compared with the BMI 25-30 group (70.9%; P = 0.048), but similar to the BMI < 25 group (54.9%; P = 0.957). At 2 year follow-up, mortality was lower in the BMI > 30 group (5.9%) compared with the BMI < 25 (7.5%; P = 0.029) and BMI 25-30 groups (7%; P = 0.681). In multivariable analysis, LVEF at long term was significantly associated with a reduction in mortality.

CONCLUSIONS

Obese patients exhibited significantly greater improvement in LVEF, which was associated with reduced mortality. Adherence to WCD therapy was excellent across all BMI groups. ICD implantation occurred in 40.3% of patients, with similar WCD shock rates and arrhythmic events across BMI groups. An obesity paradox was observed, with obese patients demonstrating significantly lower rehospitalization rates due to cardiovascular causes and reduced mortality at follow-up.

Visceral obesity and HFpEF: targets and therapeutic opportunities

The effectiveness of weight-loss drugs in heart failure (HF) with preserved ejection fraction (HFpEF) highlights the link between obesity (adipose tissue) and HF (the heart). Recent guidelines incorporating the waist:height ratio for diagnosing and treating obesity reflect the growing recognition of the significance of visceral adiposity. However, its unique impact on HFpEF and their complex relationship remain underexplored. With limited treatment options for obesity-related HFpEF, novel disease-modifying treatments are urgently needed. Here, we clarify the relationship between visceral obesity and HFpEF, introducing the concept of the visceral adipose tissue-heart axis to explore its mechanisms and therapeutic potential. We also discuss promising strategies targeting visceral obesity in HFpEF and propose directions for future research.

Exploring the nonlinear association between cardiometabolic index and hypertension in U.S. Adults: an NHANES-based study

BACKGROUND

Hypertension is a prevalent chronic disease affecting over 1.2 billion people worldwide, representing a major modifiable risk factor for cardiovascular diseases. The Waist-to-Height Ratio (WHtR) and Triglyceride to High-Density Lipoprotein Cholesterol (TG/HDL-C) ratio are established metabolic indicators linked to the risk of cardiovascular and metabolic diseases. Recently, a Cardiometabolic Index (CMI), combining WHtR and TG/HDL-C ratios, has been proposed to provide a comprehensive assessment of metabolic health. This study investigates the association between CMI and hypertension using data from the National Health and Nutrition Examination Survey (NHANES).

METHODS

The study utilized NHANES data from nine cycles spanning 2001 to 2018, encompassing 20,049 participants aged over 20. Exclusions were made for individuals with incomplete CMI or hypertension data, and pregnant women. CMI was calculated by multiplying the WHtR by the TG/HDL-C ratio. Hypertension was defined according to American Heart Association guidelines. The relationship between CMI and hypertension was evaluated using multivariate logistic regression analyses, with additional subgroup analyses conducted based on demographic factors. Nonlinear relationships were analyzed using smoothing curve fitting techniques.

RESULTS

The study identified a significant positive correlation between CMI and hypertension risk, with an increase of one unit in CMI associated with a 9% heightened risk of hypertension (OR: 1.09, 95% CI: 1.05, 1.13). The association remained significant across various demographic subgroups. A nonlinear relationship was observed, with a critical CMI threshold of 2.64. Below this threshold, higher CMI values were associated with a progressively higher prevalence of hypertension, whereas beyond this threshold, further increases in CMI did not significantly correlate with an elevated risk of hypertension.

CONCLUSION

The study demonstrates that CMI is significantly associated with hypertension risk and may serve as a valuable tool for early screening and risk assessment, particularly in identifying individuals at higher risk before reaching the critical CMI threshold. These results underscore the importance of addressing metabolic health in the prevention and management of hypertension. Future research should focus on longitudinal studies to establish causality, explore the clinical utility of CMI in hypertension screening, and examine its applicability in diverse populations.

Nutrition literacy is associated with general obesity, abdominal obesity, and body fat percentage obesity

Background

Obesity is associated with unhealthy eating behavior among adults. Nutrition literacy (NL) is an important determinant of eating behavior. This study investigated the association of NL with general obesity, abdominal obesity, and body fat percentage (BFP) obesity among adults.

Methods

This study was a cross-sectional survey on the Nutrition Literacy and Obesity, conducted in Bengbu City, China (May to July 2023). The Short-Form Nutrition Literacy scale was used to evaluate the NL of adults. General obesity was defined as a body mass index of ≥28 kg/m2. Abdominal obesity was defined as a waist circumference of ≥90 cm in men and ≥85 cm in women. BFP obesity was defined as a BFP of ≥30% in men and ≥42% in women. Binary logistic regression analysis was performed to identify the correlations of NL with general obesity, abdominal obesity, and BFP obesity in adults. Subgroup analyses and interaction tests were also performed.

Results

Participants with a high level of NL had low odds of general obesity (odds ratio [OR]: 0.66; 95% confidence interval [CI]: 0.43-0.99), abdominal obesity (OR: 0.63; 95% CI: 0.46-0.87), and BFP obesity (OR: 0.55; 95% CI: 0.35-0.87). In subgroup analyses and interaction tests, age significantly influenced the negative correlations of NL with abdominal obesity and BFP obesity (p for interaction <0.05), but not general obesity (p for interaction >0.05). Moreover, sex and smoking status significantly influenced the negative correlations of NL with general obesity and abdominal obesity (p for interaction <0.05), but not BFP obesity (p for interaction >0.05), and drinking status significantly influenced the negative correlations of NL with abdominal obesity (p for interaction <0.05), but not general obesity and BFP obesity (p for interaction >0.05). However, marital status did not significantly influence the correlation of NL with obesity (p for interaction >0.05).

Conclusion

Our findings highlight that adults with high levels of NL have low odds of general obesity, abdominal obesity, and BFP obesity. Age, sex, smoking status, and drinking status influence the correlation between NL and obesity. The results indicate the importance of NL in the prevention and management of obesity in adults. To effectively address the challenges of adult obesity management, public health practitioners should tailor nutrition education and skill training programs to specific demographic profiles.

Tirzepatide for Heart Failure with Preserved Ejection Fraction and Obesity

BACKGROUND

Obesity increases the risk of heart failure with preserved ejection fraction. Tirzepatide, a long-acting agonist of glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptors, causes considerable weight loss, but data are lacking with respect to its effects on cardiovascular outcomes.

METHODS

In this international, double-blind, randomized, placebo-controlled trial, we randomly assigned, in a 1:1 ratio, 731 patients with heart failure, an ejection fraction of at least 50%, and a body-mass index (the weight in kilograms divided by the square of the height in meters) of at least 30 to receive tirzepatide (up to 15 mg subcutaneously once per week) or placebo for at least 52 weeks. The two primary end points were a composite of adjudicated death from cardiovascular causes or a worsening heart-failure event (assessed in a time-to-first-event analysis) and the change from baseline to 52 weeks in the Kansas City Cardiomyopathy Questionnaire clinical summary score (KCCQ-CSS; scores range from 0 to 100, with higher scores indicating better quality of life).

RESULTS

A total of 364 patients were assigned to the tirzepatide group and 367 to the placebo group; the median duration of follow-up was 104 weeks. Adjudicated death from cardiovascular causes or a worsening heart-failure event occurred in 36 patients (9.9%) in the tirzepatide group and in 56 patients (15.3%) in the placebo group (hazard ratio, 0.62; 95% confidence interval [CI], 0.41 to 0.95; P = 0.026). Worsening heart-failure events occurred in 29 patients (8.0%) in the tirzepatide group and in 52 patients (14.2%) in the placebo group (hazard ratio, 0.54; 95% CI, 0.34 to 0.85), and adjudicated death from cardiovascular causes occurred in 8 patients (2.2%) and 5 patients (1.4%), respectively (hazard ratio, 1.58; 95% CI, 0.52 to 4.83). At 52 weeks, the mean (±SD) change in the KCCQ-CSS was 19.5±1.2 in the tirzepatide group as compared with 12.7±1.3 in the placebo group (between-group difference, 6.9; 95% CI, 3.3 to 10.6; P<0.001). Adverse events (mainly gastrointestinal) leading to discontinuation of the trial drug occurred in 23 patients (6.3%) in the tirzepatide group and in 5 patients (1.4%) in the placebo group.

CONCLUSIONS

Treatment with tirzepatide led to a lower risk of a composite of death from cardiovascular causes or worsening heart failure than placebo and improved health status in patients with heart failure with preserved ejection fraction and obesity. (Funded by Eli Lilly; SUMMIT ClinicalTrials.gov number, NCT04847557.).

Association of anthropometric and obesity indices with abnormal blood lipid levels in young and middle-aged adults

Introduction

Obesity is a known risk factor for dyslipidemia. We aimed to evaluate the association between nine obesity indices and various types of abnormal lipid levels in the young and middle-aged.

Methods

From July to November 2022, we distributed health survey questionnaires to the target population in the hospital and collected their biochemical and anthropometric data. Multivariate regression models and Receiver operating characteristic (ROC) curve analysis were used for data analyzing.

Results

We collected a total of 1174 complete samples. Among the five blood lipid indexes tested in this study, TG (triglyceride) is most closely related to various body measurements (P < 0.05). WC (Waist circumference) has the greatest risk for abnormal TG levels (OR, 2.61; P < 0.001) and high-density lipoprotein cholesterol (HDL-C) levels(OR, 1.96; P < 0.001).WHR has the greatest risk of abnormal low-density lipoprotein cholesterol (LDL-C) levels (OR, 1.35; P < 0.05) and non-high-density lipoprotein cholesterol levels(OR, 1.59; P < 0.001). ROC curve analyses revealed that all the tested variables gave the highest area under the curve (AUC) values for predicting high TG in comparison to other plasma lipid abnormalities. The AUC of WC, AVI and BMI were 0.81, 0.80 and 0.79 respectively.

Conclusion

Specific obesity-related anthropometric measurements, including WC, AVI, and WHR, show improved predictive accuracy in identifying abnormal lipid levels across diverse types. This study supports their effectiveness in early dyslipidemia screening among young and middle-aged individuals.

Association of Body Mass Index and Clinical Outcomes in Patients with Coronary Artery Disease Undergoing Percutaneous Coronary Intervention

Background

The obesity paradox refers to lower mortality rates among overweight or obese individuals within certain populations. However, whether this paradox is applicable to patients undergoing percutaneous coronary intervention (PCI) remains unclear.

Methods

A total of 5,427 patients with coronary artery disease (CAD) who underwent successful PCI between 2005 and 2015 were enrolled. The association between body mass index (BMI) and future adverse cardiovascular events post PCI was analyzed. The study endpoints encompassed total cardiovascular (CV) events, including cardiac death, nonfatal myocardial infarction (MI), ischemic stroke, and hospitalization for congestive heart failure (CHF).

Results

Over an average follow-up period of 65.1 ± 32.1 months, 942 patients (17.4%) had CV events, including 200 CV deaths (3.7%), 294 acute MIs (5.4%), 111 ischemic strokes (2.0%), 469 CHF hospitalizations (8.6%), and 1,098 revascularizations (20.2%). A J-shaped relationship between BMI and future adverse events was observed, in which individuals with a BMI of 25.0-29.9 kg/m2 had significantly lower risks of total CV events [hazard ratio (HR) = 0.84, 95% confidence interval (CI) = 0.72-0.98], major adverse cardiovascular events (HR = 0.76, 95% CI = 0.63-0.93), acute MI (HR = 0.76, 95% CI = 0.58-1.00), and ischemic stroke (HR = 0.61, 95% CI = 0.39-0.95), compared to those with a BMI of 22.0-24.9 kg/m2.

Conclusions

We found a J-shaped relationship between baseline BMI and future adverse events in CAD patients undergoing PCI. Overweight individuals (BMI 25.0-29.9 kg/m2) had the lowest future risk of total CV events compared to those with a normal BMI (22.0-24.9 kg/m2).

The Impact of Idiopathic Intracranial Hypertension on Cardiovascular Disease Risk Among UK Women: An Obesity-Adjusted Analysis

Introduction

Idiopathic intracranial hypertension (IIH) is known to elevate cardiovascular disease (CVD) risk, but the extent to which obesity and IIH-specific factors contribute to this risk is not well understood. WE aim to separate the effects of obesity from IIH-specific factors on the risk of stroke and CVD, building on previous findings that indicate a two-fold increase in cardiovascular events in women with IIH compared to BMI-matched controls.

Methods

An obesity-adjusted risk analysis was conducted using Indirect Standardization based on data from a cohort study by Adderley et al., which included 2,760 women with IIH and 27,125 matched healthy controls from The Health Improvement Network (THIN). Advanced statistical models were employed to adjust for confounding effects of obesity and determine the risk contributions of IIH to ischemic stroke and CVD, independent of obesity. Four distinct models explored the interactions between IIH, obesity, and CVD risk.

Results

The analysis showed that IIH independently contributes to increased cardiovascular risk beyond obesity alone. Risk ratios for cardiovascular outcomes were significantly higher in IIH patients compared to controls within similar obesity categories. Notably, a synergistic effect was observed in obese IIH patients, with a composite CVD risk ratio of 6.19 (95% CI: 4.58-8.36, p<0.001) compared to non-obese controls.

Conclusions

This study underscores a significant, independent cardiovascular risk from IIH beyond obesity. The findings advocate for a shift in managing IIH to include comprehensive cardiovascular risk assessment and mitigation. Further research is required to understand the mechanisms and develop specific interventions for this group.

Novel Adiposity Indices Are Associated With Poor Prognosis in Heart Failure With Preserved Ejection Fraction Without the Obesity Paradox

BACKGROUND

There is limited study that illuminates the relationship between obesity indices and prognosis in patients with heart failure with preserved ejection fraction, nor has it been examined whether the obesity paradox persists when using these metrics.

METHODS AND RESULTS

This study is a post hoc analysis of data from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial. A total of 3114 individuals were included in our final analysis, and a total of 481 (15.4%) all-cause deaths, and 389 (12.5%) heart failure hospitalizations were recorded. In a multivariable Cox regression model, compared with patients with a body mass index (BMI) <24.9 kg/m2, those with a BMI of 25.0-29.9, 30.0-34.9, and 35-39.9 kg/m2 were associated with a decreased risk of all-cause death, with hazard ratio (95% CI) of 0.59 (0.45-0.78), 0.61 (0.46-0.82), and 0.66 (0.47-0.92), respectively. Conversely, patients with a BMI ≥40 kg/m2 showed an increased risk of heart failure hospitalization, compared with BMI <24.9 kg/m2. Furthermore, patients in the highest quintile of obesity indices exhibited a significantly elevated hazard ratio for both all-cause death and heart failure hospitalization, compared with the lowest quintile.

CONCLUSIONS

An elevated BMI over a certain range was associated with a reduced risk of all-cause death in heart failure with preserved ejection fraction, displaying a U-shaped relationship, with no mortality reduction observed in cases of extreme obesity. In contrast, higher values of novel obesity indices were positively correlated with all-cause death and heart failure hospitalization without the obesity paradox.

Disparities in Heart Failure Deaths among Patients with Cirrhosis

Background: Heart failure deaths have increased in recent years in the United States and are projected to continue to increase in the future. Rates of liver disease and cirrhosis have similarly increased in the United States. Patients with cirrhosis are at an elevated risk of heart failure with a worsened prognosis. As such, investigations of the epidemiology of these comorbid conditions are important. Methods: We obtained data on heart failure deaths among people with cirrhosis in the United States from 1999 to 2020 from the Centers for Disease Control Wide-ranging Online Data for Epidemiologic Research multiple cause of death database. Rates were analyzed for the population as a whole and for demographic subgroups. Results: From 1999 to 2020, there were 7424 cirrhosis-related heart failure deaths. Rates were higher among Black (AAMR ratio = 1.288, 95% CI: 1.282-1.295) and Asian people (AAMR ratio = 3.310, 95% CI: 3.297-3.323) compared to White people. Rates were also higher in rural areas than in urban areas (AAMR ratio = 1.266, 95% CI: 1.261-1.271). Rates increased over time across demographic subgroups. Conclusions: People with cirrhosis are at an elevated risk of heart failure death compared to the general population. Rates were particularly elevated in Asian people, Black people, males, and people living in rural areas. These data indicate a significant and previously underappreciated disease burden. Clinicians taking care of cirrhosis patients should be aware of the risk of heart failure and should collaborate with cardiac specialists as needed.

Current and Future of Heart Failure Care in Asia

Heart failure (HF) is a significant global health concern, particularly in Asia, where over half of the world's population resides. Despite advances in treatment, the burden of HF is expected to rise in the region due to the aging population and an increase in non-communicable diseases associated with HF risk. This narrative review examines the current state of HF in Asia, highlighting differences in treatment utilization, underrepresentation of Asian individuals in clinical trials, emerging therapies, and implementation strategies, including the potential use of polypills and the need for expanded HF training opportunities for healthcare providers.

The Chinese visceral adiposity index: a novel indicator more closely related to cardiovascular disease than other abdominal obesity indices among postmenopausal women

BACKGROUND

Several abdominal obesity indices including waist circumference (WC), waist-hip ratio (WHR), visceral adiposity index (VAI), lipid accumulation product (LAP), and Chinese visceral adiposity index (CVAI) were considered effective and useful predictive markers for cardiovascular disease (CVD) in general populations or diabetic populations. However, studies investigating the associations between these indices among postmenopausal women are limited. Our study aimed to investigate the associations of the five indices with incident CVD and compare the predictive performance of CVAI with other abdominal obesity indices among postmenopausal women.

METHODS

A total of 1252 postmenopausal women without CVD at baseline were analyzed in our investigation based on a 10-year follow-up prospective cohort study. Link of each abdominal obesity index with CVD were assessed by the Cox regression analysis and the Kaplan-Meier curve. The receiver operating characteristic (ROC) curves were drawn to compare the predictive ability for CVD.

RESULTS

During the median follow-up of 120.53 months, 121 participants newly developed CVD. Compared to quartile 1 of LAP and CVAI, quartile 4 had increased risk to develop CVD after fully adjusted among postmenopausal women. When WC, VAI and CVAI considered as continuous variables, significant increased hazard ratios (HRs) for developing CVD were observed. The areas under the curve (AUC) of CVAI (0.632) was greatly higher than other indices (WC: 0.580, WHR: 0.538, LAP: 0.573, VAI: 0.540 respectively).

CONCLUSIONS

This study suggested that the abdominal obesity indices were associated with the risk of CVD excluded WHR and highlighted that CVAI might be the most valuable abdominal obesity indicator for identifying the high risk of CVD in Chinese postmenopausal women.

J-shaped relationship between serum creatinine and mortality in Korean patients with acute heart failure

BACKGROUND

Cachexia and sarcopenia are common among heart failure (HF) patients and are linked to poor outcomes. As serum creatinine levels are influenced by both renal function and muscle mass, our study aimed to investigate the relationship between serum creatinine levels and mortality in acute HF patients.

METHODS

We enrolled 5198 consecutive acute HF patients from the Korea Acute Heart Failure (KorAHF) registry, excluding those on renal replacement therapy. Patients were categorized into five groups based on their discharge serum creatinine levels: low (< 0.6 mg/dL), reference (0.6-0.89 mg/dL), upper normal (0.9-1.19 mg/dL), high (1.2-1.49 mg/dL), and very high (≥ 1.5 mg/dL). The primary endpoint was post-discharge all-cause mortality.

RESULTS

The mean creatinine level was 1.20 ± 0.88 mg/dL. Notably, 335 (6.4%) patients had serum creatinine levels < 0.6 mg/dL. These patients were younger (mean age, 67 years) and more likely to have a low BMI (< 18.5 kg/m2) compared to the reference group (15.3% vs. 6.4%). Over a median follow-up of 975 days, 1743 (34.8%) patients died. We observed a J-shaped relationship between serum creatinine levels and mortality, with both low and high levels associated with increased mortality. After adjusting for covariates, including age, sex, body mass index, diabetes, hypertension, smoking, malignancy, atrial fibrillation on electrocardiography, levels of C-reactive protein, sodium, hemoglobin, albumin, brain natriuretic peptide, de novo heart failure, use of beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists, patients with serum creatinine levels < 0.6 mg/dL had a 33% higher risk of all-cause mortality (HR, 1.33; 95% CI, 1.06 to 1.66) compared to those with levels of 0.6-0.89 mg/dL. However, BUN, which is not affected by muscle metabolism, exhibited a linear relationship with mortality.

CONCLUSIONS

Among acute HF patients, there exists a J-shaped relationship between discharge serum creatinine levels and mortality, highlighting the increased mortality risk in individuals with very low serum creatinine levels.

Relationship of interleukin-16 with different phenogroups in acute heart failure with preserved ejection fraction

AIMS

Interleukin-16 (IL-16) has been reported to mediate left ventricular myocardial fibrosis and stiffening in patients with heart failure with preserved ejection fraction (HFpEF). We sought to elucidate whether IL-16 has a distinct impact on pathophysiology and prognosis across different subphenotypes of acute HFpEF.

METHODS AND RESULTS

We analysed 211 patients enrolled in a prospective multicentre registry of acute decompensated HFpEF for whom serum IL-16 levels after stabilization were available (53% female, median age 81 [interquartile range 75-85] years). We divided this sub-cohort into four phenogroups using our established clustering algorithm. The study endpoint was all-cause death. Patients were subclassified into phenogroup 1 ('rhythm trouble' [n = 69]), phenogroup 2 ('ventricular-arterial uncoupling' [n = 49]), phenogroup 3 ('low output and systemic congestion' [n = 41]), and phenogroup 4 ('systemic failure' [n = 52]). After a median follow-up of 640 days, 38 patients had died. Among the four phenogroups, phenogroup 2 had the highest IL-16 level. The IL-16 level showed significant associations with indices of cardiac hypertrophy, diastolic dysfunction, and congestion only in phenogroup 2. Furthermore, the IL-16 level had a significant predictive value for all-cause death only in phenogroup 2 (C-statistic 0.750, 95% confidence interval 0.606-0.863, P = 0.017), while there was no association between the IL-16 level and the endpoint in the other phenogroups.

CONCLUSIONS

Our results indicated that the serum IL-16 level had a significant association with indices that reflect the pathophysiology and prognosis of HFpEF in a specific phenogroup in acute HFpEF.

Type 2 diabetes mellitus and cardiometabolic outcomes in metabolic dysfunction-associated steatotic liver disease population

The metabolic syndrome, characterized by type 2 diabetes mellitus (T2DM), hypertension, hyperlipidemia, and obesity, collectively increases the risk of cardiovascular diseases. Nonalcoholic fatty liver disease (NAFLD) is a prominent manifestation, affecting over a third of the global population with a concerning annual increase in prevalence. Nearly 70 % of overweight individuals have NAFLD, and NAFLD-related deaths are predicted to rise, especially among young adults. The association of T2DM and NAFLD has led to the proposal of "metabolic dysfunction-associated steatotic liver disease" (MASLD) terminology, encompassing individuals with T2DM, overweight/obesity, hypertension, hypertriglyceridemia, or low HDL-cholesterol. Patients with MASLD will likely have double the risk of developing T2DM, and the combination of insulin resistance, overweight/obesity, and MASLD significantly elevates the risk of T2DM. Cardiovascular diseases remain the leading cause of mortality in the MASLD and T2DM population, with MASLD directly associated with coronary artery disease, compounded by coexisting insulin resistance and T2DM. Urgency lies in early detection of subclinical cardiovascular diseases among patients with T2DM and MASLD. Novel strategies targeting multiple pathways offer hope for effectively improving cardiometabolic health. Understanding and addressing the intertwined factors contributing to these disorders can pave the way towards better management and prevention of cardiometabolic complications.

Heart failure with mildly reduced and preserved ejection fraction: A review of disease burden and remaining unmet medical needs within a new treatment landscape

This review provides a comprehensive overview of heart failure with mildly reduced and preserved ejection fraction (HFmrEF/HFpEF), including its definition, diagnosis, and epidemiology; clinical, humanistic, and economic burdens; current pharmacologic landscape in key pharmaceutical markets; and unmet needs to identify key knowledge gaps. We conducted a targeted literature review in electronic databases and prioritized articles with valuable insights into HFmrEF/HFpEF. Overall, 27 randomized controlled trials (RCTs), 66 real-world evidence studies, 18 clinical practice guidelines, and 25 additional publications were included. Although recent heart failure (HF) guidelines set left ventricular ejection fraction thresholds to differentiate categories, characterization and diagnosis criteria vary because of the incomplete disease understanding. Recent epidemiological data are limited and diverse. Approximately 50% of symptomatic HF patients have HFpEF, more common than HFmrEF. Prevalence varies with country because of differing definitions and study characteristics, making prevalence interpretation challenging. HFmrEF/HFpEF has considerable mortality risk, and the mortality rate varies with study and patient characteristics and treatments. HFmrEF/HFpEF is associated with considerable morbidity, poor patient outcomes, and common comorbidities. Patients require frequent hospitalizations; therefore, early intervention is crucial to prevent disease burden. Recent RCTs show promising results like risk reduction of composite cardiovascular death or HF hospitalization. Costs data are scarce, but the economic burden is increasing. Despite new drugs, unmet medical needs requiring new treatments remain. Thus, HFmrEF/HFpEF is a growing global healthcare concern. With improving yet incomplete understanding of this disease and its promising treatments, further research is required for better patient outcomes.

Association of anthropometric measures with all-cause and cause-specific mortality in US adults: revisiting the obesity paradox

OBJECTIVE

Previous studies have shown that the obesity paradox exists in a variety of clinical settings, whereby obese individuals have lower mortality than their normal-weight counterparts. It remains unclear whether the association between obesity and mortality risk varies by anthropometric measures. The purpose of this study is to examine the association between various anthropometric measures and all-cause and cause-specific mortality in US adults.

METHODS

This cohort study included data from the National Health and Nutrition Examination Survey between 2009 and 2018, with a sample size of 28,353 individuals weighted to represent 231 million US adults. Anthropometric measurements were obtained by trained technicians using standardized methods. Mortality data were collected from the date of enrollment through December 31, 2019. Weighted Cox proportional hazards models, restricted cubic spline curves, and cumulative incidence analyses were performed.

RESULTS

A total of 2091 all-cause deaths, 606 cardiovascular deaths, 519 cancer deaths, and 966 other-cause deaths occurred during a median follow-up of 5.9 years. The association between body mass index (BMI) and mortality risk was inversely J-shaped, whereas the association between waist-to-height ratio (WHtR) and mortality risk was positively J-shaped. There was a progressive increase in the association between the WHtR category and mortality risk. Compared with the reference category of WHtR < 0.5, the estimated hazard ratio (HR) for all-cause mortality was 1.004 (95% confidence interval [CI] 1.001-1.006) for WHtR 0.50-0.59, 1.123 (95% CI 1.120-1.127) for WHtR 0.60-0.69, 1.591 (95% CI 1.584-1.598) for WHtR 0.70-0.79, and 2.214 (95% CI 2.200-2.228) for WHtR ≥ 0.8, respectively. Other anthropometric indices reflecting central obesity also showed that greater adiposity was associated with higher mortality.

CONCLUSIONS

Anthropometric measures reflecting central obesity were independently and positively associated with mortality risk, eliminating the possibility of an obesity paradox.

Association between obesity and new-onset heart failure among patients with hypertension in Thailand

BACKGROUND

In Thailand, the epidemiological data on the relationship between obesity and heart failure (HF) among high-risk populations was limited. We assessed the association between body mass index (BMI) and the new-onset HF among people with hypertension (HTN), and also assessed the effect modifier of uncontrolled HTN on this association.

METHODS

We analyzed the data obtained from the 2018 Thailand DM/HT study database. Thai people with HTN aged 20 years and older receiving continuous care at outpatient clinics in hospitals nationwide were included. The new-onset HF was defined regarding the ICD-10 as I50 in the medical records within 12 months. Obesity was defined as BMI ≥ 25 kg/m2. Multivariable log-binomial regression analysis was used to determine the association between BMI and new-onset HF and presented as the adjusted risk ratio (aRR) and 95% confidence interval (CI).

RESULTS

A total of 35,756 participants were included in the analysis. In all, 50.0% of the participants had BP control for the last two consecutive visits. The mean BMI was 25.1 ± 4.7 kg/m2. New-onset HF occurred in 75 participants (0.21%; 95% CI 0.17-0.26). After adjusting for potential confounders, an elevated BMI was associated with new-onset HF (p value for quadratic trend < 0.001). In comparison with participants with normal BMI (18.5-22.9 kg/m2), the aRR for new-onset HF was 1.57 (95% CI 0.80-3.07) and 3.97 (95% CI 1.95-8.10) in those with BMI 25.0-29.9, and ≥ 30.0 kg/m2. For participants with obesity, aRR for new-onset HF was 2.05 (95% CI 1.24-3.39) compared to non-obese participants. The study found that among patients with control BP, obesity was associated with a higher risk of new-onset HF with an adjusted RR of 2.33 (95% CI 1.12-4.83). For those with uncontrolled BP, the adjusted RR was 1.83 (95% CI 0.93-3.58), but there was no heterogeneity with p value = 0.642.

CONCLUSION

An increased BMI had a higher risk for new-onset HF among Thai people with HTN. Obesity was independently associated with new-onset HF among people with HTN, regardless of uncontrolled HTN. Our findings highlight that weight reduction is crucial for mitigating the risk of HF development in HTN patients, regardless of their BP control status.

Influence of Body Mass Index on the Prognostic Value of N-Terminal Pro-B-Type Natriuretic Peptide Level in Chinese Patients with Heart Failure

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is an essential biomarker for the prediction of heart failure (HF), but its prognostic ability across body mass index (BMI) categories needs to be clarified. Our study aimed to explore the association between BMI and NT-proBNP and assess the effect of BMI on the prognostic ability of NT-proBNP in Chinese patients with HF. We retrospectively analyzed clinical data from the FuWai Hospital HF Center in Beijing, China. According to the Chinese adult BMI standard, 1,508 patients with HF were classified into four groups: underweight (BMI < 18.5 kg/m2), normal weight (BMI 18.5-23.9 kg/m2, as a reference category), overweight (BMI 24-27.9 kg/m2), and obesity (BMI ≥ 28 kg/m2). NT-proBNP was examined for its prognostic role in adverse events as an endpoint. BMI was independently and negatively associated with NT-proBNP (β = -0.074; P < 0.001), and NT-proBNP levels tended to decrease as BMI increased across the different BMI categories. The results of our study differ from those of other studies of European-American populations. In this study, NT-proBNP was a weak predictor of a 4-year adverse prognosis in underweight patients (BMI < 18.5 kg/m2). In other BMI categories, NT-proBNP was an independent predictor of adverse events in HF. BMI and sex significantly affected the optimal threshold for NT-proBNP to predict the risk of adverse events. There is a negative correlation between BMI and NT-proBNP, and NT-proBNP independently predicts adverse HF events in patients with a BMI of ≥ 18.5 kg/m2. The optimal risk prediction cutoffs are lower in patients who are overweight and obese.

Waist to height ratio as a simple tool for predicting mortality: a systematic review and meta-analysis

BACKGROUND

The association of central obesity with higher rates of mortality is not well studied. This study evaluates the association between waist-to-height ratio (WHtR), as a measure of central obesity, with mortality.

METHODS

Documents were retrieved from PubMed, Web of Science, Scopus, and Google Scholar databases until May 2022. Data were extracted from cohort studies reporting effect size (hazard ratio (HR)) regarding the association between WHtR as a continuous (per 1 SD increment) or categorical (highest/lowest) measure and all-cause and cause-specific mortality. Screening of included studies was performed independently by two authors. Moreover, the quality assessment of included studies was performed based on the Newcastle-Ottawa assessment scale. Finally, random effect meta-analysis was performed to pool the data, and the outcomes' certainty level was assess based on the GRADE criteria.

RESULTS

Of the 815 initial studies, 20 were included in the meta-analysis. Random effect meta-analysis showed that in the general population, the all-cause mortality HRs for categorical and continuous measurements of WHtR increased significantly by 23% (HR:1.23; 95% CI: 1.04-1.41) and 16% (HR:1.16; 95% CI: 1.07-1.25), respectively. Moreover, the hazard of cardiovascular (CVD) mortality increased significantly for categorical and continuous measurements of WHtR by 39% (HR:1.39; 95% CI: 1.18-1.59) and 19% (HR:1.19; 95% CI: 1.07-1.31). The quality assessment score of all included studies was high.

CONCLUSIONS

Higher levels of WHtR, indicating central obesity, were associated with an increased hazard of CVD and all-cause mortality. This measure can be used in the clinical setting as a simple tool for predicting mortality.

Effects of weight loss in heart failure patients with overweight and obesity: a systematic review and meta-analysis

AIMS

To perform a systematic review and meta-analysis to evaluate the impact of weight loss (WL) on the prognosis of overweight and obese patients with heart failure (HF).

METHODS AND RESULTS

We reviewed the literature up to 1 February 2023 from PubMed, Web of Science, Embase, Cochrane Library, and Chinese databases for cohort studies, and randomized controlled trials (RCTs). Data from eligible studies were extracted, and statistical analyses were performed using Review Manager 5.3. A total of 19 studies (involving 449 882 patients) were included in the systematic review and meta-analyses. The results showed that WL did not reduce the mortality and rehospitalization rates in overweight and obese HF patients, but could improve the quality of life (P = 0.002), cardiac function (P = 0.0001), and exercise capacity (P = 0.03). The subgroup analysis showed that WL from bariatric surgery (BS) reduced the risk of death (P < 0.00001), WL from medication or exercise was not significantly associated with the risk of death (P = 0.18), and WL was associated with a higher mortality in the subgroup with unspecified WL modality or unintentional WL (P < 0.00001). In addition, it did not reduce the risk of short-term rehospitalization (P = 0.11), but reduced the rehospitalization rates over the long-term (P = 0.03).

CONCLUSION

WL improves the long-term rehospitalization (>3 months), quality of life, cardiac function, and exercise capacity in overweight and obese HF patients. Although overall WL is not proven effective, subgroup analysis shows that BS can reduce mortality.

Trends and predictions of metabolic risk factors for acute myocardial infarction: findings from a multiethnic nationwide cohort

Background

Understanding the trajectories of metabolic risk factors for acute myocardial infarction (AMI) is necessary for healthcare policymaking. We estimated future projections of the incidence of metabolic diseases in a multi-ethnic population with AMI.

Methods

The incidence and mortality contributed by metabolic risk factors in the population with AMI (diabetes mellitus [T2DM], hypertension, hyperlipidemia, overweight/obesity, active/previous smokers) were projected up to year 2050, using linear and Poisson regression models based on the Singapore Myocardial Infarction Registry from 2007 to 2018. Forecast analysis was stratified based on age, sex and ethnicity.

Findings

From 2025 to 2050, the incidence of AMI is predicted to rise by 194.4% from 482 to 1418 per 100,000 population. The largest percentage increase in metabolic risk factors within the population with AMI is projected to be overweight/obesity (880.0% increase), followed by hypertension (248.7% increase), T2DM (215.7% increase), hyperlipidemia (205.0% increase), and active/previous smoking (164.8% increase). The number of AMI-related deaths is expected to increase by 294.7% in individuals with overweight/obesity, while mortality is predicted to decrease by 11.7% in hyperlipidemia, 29.9% in hypertension, 32.7% in T2DM and 49.6% in active/previous smokers, from 2025 to 2050. Compared with Chinese individuals, Indian and Malay individuals bear a disproportionate burden of overweight/obesity incidence and AMI-related mortality.

Interpretation

The incidence of AMI is projected to continue rising in the coming decades. Overweight/obesity will emerge as fastest-growing metabolic risk factor and the leading risk factor for AMI-related mortality.

Funding

This research was supported by the NUHS Seed Fund (NUHSRO/2022/058/RO5+6/Seed-Mar/03) and National Medical Research Council Research Training Fellowship (MOH-001131). The SMIR is a national, ministry-funded registry run by the National Registry of Diseases Office and funded by the Ministry of Health, Singapore.

Pathophysiologic Contributions of Visceral Adiposity to Left Ventricular Diastolic Dysfunction

BACKGROUND

Visceral fat produces inflammatory cytokines and may play a major role in heart failure with preserved ejection fraction (HFpEF). However, little data exist regarding how qualitative and quantitative abnormalities of visceral fat would contribute to left ventricular diastolic dysfunction (LVDD).

METHODS

We studied 77 participants who underwent open abdominal surgery for intra-abdominal tumors (LVDD, n = 44; controls without LVDD, n = 33). Visceral fat samples were obtained during the surgery, and mRNA levels of inflammatory cytokines were measured. Visceral and subcutaneous fat areas were measured using abdominal computed tomography.

RESULTS

Patients with significant LVDD had greater LV remodeling and worse LVDD than controls. While body weight, body mass index, and subcutaneous fat area were similar in patients with LVDD and controls, the visceral fat area was larger in patients with LVDD than in controls. The visceral fat area was correlated with BNP levels, LV mass index, mitral e' velocity, and E/e' ratio. There were no significant differences in the mRNA expressions of visceral adipose tissue cytokines (IL-2, -6, -8, and -1β, TNFα, CRP, TGFβ, IFNγ, leptin, and adiponectin) between the groups.

CONCLUSIONS

Our data may suggest the pathophysiological contribution of visceral adiposity to LVDD.

Fat Mass is Associated with Subclinical Left Ventricular Systolic Dysfunction in Patients with Type 2 Diabetes Mellitus Without Established Cardiovascular Diseases

INTRODUCTION

Left ventricular global longitudinal strain (GLS) is considered to be the first marker of diabetes mellitus-related subclinical cardiac dysfunction, but whether it is attributable to fat mass and distribution remains uncertain. In this study, we explored whether fat mass, especially fat mass in the android area, is associated with subclinical systolic dysfunction before the onset of cardiac disease.

METHODS

We conducted a single-center prospective cross-sectional study between November 2021 and August 2022 on inpatients of the Department of Endocrinology, Nanjing Drum Tower Hospital. We included 150 patients aged 18-70 years with no signs, symptoms, or history of clinical cardiac disease. Patients were evaluated with speckle tracking echocardiography and dual energy X-ray absorptiometry. The cutoff values for subclinical systolic dysfunction were set at a global longitudinal strain (GLS) < 18%.

RESULTS

After adjusting for sex and age, patients with GLS < 18% had a higher mean (± standard deviation) fat mass index (8.06 ± 2.39 vs. 7.10 ± 2.09 kg/m², p = 0.02), higher mean trunk fat mass (14.9 ± 4.9 vs. 12.8 ± 4.3 kg, p = 0.01), and higher android fat mass (2.57 ± 1.02 vs. 2.18 ± 0.86 kg, p = 0.02) than those in the GLS ≥ 18%. Partial correlation analysis showed that the fat mass index, truck fat mass, and android fat mass were negatively correlated with GLS after adjusting for sex and age (all p < 0.05). Adjusted for traditional cardiovascular metabolic factors, fat mass index (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.05-1.55, p = 0.02), trunk fat mass (OR 1.13, 95% CI 1.03-1.24, p = 0.01), and android fat mass (OR 1.77, 95% CI 1.16-2.82, p = 0.01) were independent risk factors for GLS < 18%.

CONCLUSION

Among patients with type 2 diabetes mellitus without established clinical cardiac disease, fat mass, especially android fat mass, was associated with subclinical systolic dysfunction independently of age and sex.

Obesity paradox and stroke outcomes according to stroke subtype: a propensity score-matched analysis

OBJECTIVE

Obesity has traditionally been considered a risk factor for ischemic stroke. However, some clinical observations have reported a complex relationship between patients who are overweight or obese with paradoxically better stroke outcomes. Stroke subtypes have differing distributions of risk factors, so this study aimed to explain the relationship between body mass index (BMI) and functional prognosis according to stroke subtype.

METHODS

A prospective institutional database on stroke was accessed between March 2014 and December 2021, and consecutive patients with ischemic stroke were retrospectively selected. BMI was categorized into five groups (underweight, normal weight, overweight, obese, and morbid obesity). The outcome of interest in this study was the modified Rankin Scale (mRS) at 90 d, which was divided into favorable (mRS = 0-2) and unfavorable (mRS ≥ 3) groups. The relationship between functional outcome and BMI was analyzed according to stroke subtype.

RESULTS

Among 2779 patients with stroke, 913 (32.9%) had unfavorable outcomes. After a propensity score-matched analysis, obesity was inversely associated with unfavorable outcomes (adjusted odds ratio [aOR] = 0.61, 95% confidence interval [95% CI]: 0.46-0.80) in all patients with stroke. Among the stroke subtypes, overweight (aOR = 0.38, 95% CI: 0.20-0.74) and obese (aOR = 0.40, 95% CI: 0.21-0.76) groups were inversely associated with unfavorable outcomes in the cardioembolism subtype. Obesity (aOR = 0.55, 95% CI: 0.32-0.95) was inversely associated with unfavorable outcomes in the small vessel disease subtype. There was no significant relationship between stroke outcome and BMI classification in the large artery disease subtype.

CONCLUSIONS

These findings suggest that the obesity paradox in ischemic stroke outcomes might differ according to the stroke subtype.

Association of body mass index and waist-to-height ratio with outcomes in ischemic stroke: results from the Third China National Stroke Registry

BACKGROUND AND PURPOSE

Conflicting reports of obesity paradox have led to confusion about weight management strategies for post-stroke patients. The main purpose of this study is to determine whether the obesity paradox measured by body mass index (BMI) or by waist-to-height ratio (WHtR) is real.

METHODS

We evaluated the association of general obesity measured by BMI, and abdominal obesity measured by WHtR with 1-year all-cause mortality, recurrence of stroke and combined vascular events of acute ischemic stroke (AIS) patients in a cohort -- the Third China National Stroke Registry (CNSR-III). Cox proportional hazards models and restricted cubic splines were performed to investigate the association between obesity and clinical outcomes.

RESULTS

A total of 14,146 patients with ischemic stroke were included. When BMI was used as a measure of obesity, compared to the normal weight patients, mortality decreased in overweight patients (hazard ratio [HR] 0.74 [95% confidence interval (CI) 0.61-0.91], P = 0.0035) and obese patients (HR 0.54 [0.40-0.73], P < 0.0001); and increased in underweight patients (HR 2.55 [1.75-3.73], P < 0.0001). After adjustment for confounding factors, the protective effect of obesity and overweight disappeared. BMI had no association with recurrence of stroke or combined vascular events. When WHtR was used as a measure of obesity, obese patients had lower 1-year all-cause mortality (HR 0.64 [0.43-0.97], P = 0.0357). After adjustment for confounding factors, this difference disappeared; overweight patients still had lower all-cause mortality (adjusted hazard ratio [aHR] 0.42 [0.26-0.67], P = 0.0003), recurrence of stroke (aHR 0.77 [0.60-0.99], P = 0.0440) and combined vascular events (aHR 0.75 [0.58-0.95], P = 0.0198).

CONCLUSIONS

Among Chinese patients with AIS, our study does not support the BMI paradox; overweight patients measured by WHtR had a more favorable prognosis. TOAST subtypes did not modify the association.

Anthropometric measures and adverse outcomes in heart failure with reduced ejection fraction: revisiting the obesity paradox

AIMS

Although body mass index (BMI) is the most commonly used anthropometric measure, newer indices such as the waist-to-height ratio, better reflect the location and amount of ectopic fat, as well as the weight of the skeleton, and may be more useful.

METHODS AND RESULTS

The prognostic value of several newer anthropometric indices was compared with that of BMI in patients with heart failure (HF) and reduced ejection fraction (HFrEF) enrolled in prospective comparison of ARNI with ACEI to determine impact on global mortality and morbidity in heart failure. The primary outcome was HF hospitalization or cardiovascular death. The association between anthropometric indices and outcomes were comprehensively adjusted for other prognostic variables, including natriuretic peptides. An 'obesity-survival paradox' related to lower mortality risk in those with BMI ≥25 kg/m2 (compared with normal weight) was identified but this was eliminated by adjustment for other prognostic variables. This paradox was less evident for waist-to-height ratio (as an exemplar of indices not incorporating weight) and eliminated by adjustment: the adjusted hazard ratio (aHR) for all-cause mortality, for quintile 5 vs. quintile 1, was 1.10 [95% confidence interval (CI) 0.87-1.39]. However, both BMI and waist-to-height ratio showed that greater adiposity was associated with a higher risk of the primary outcome and HF hospitalization; this was more evident for waist-to-height ratio and persisted after adjustment e.g. the aHR for HF hospitalization for quintile 5 vs. quintile 1 of waist-to-height ratio was 1.39 (95% CI 1.06-1.81).

CONCLUSION

In patients with HFrEF, alternative anthropometric measurements showed no evidence for an 'obesity-survival paradox'. Newer indices that do not incorporate weight showed that greater adiposity was clearly associated with a higher risk of HF hospitalization.

Epidemiology, Pathophysiology, Diagnosis, and Therapy of Heart Failure With Preserved Ejection Fraction in Japan

Heart failure (HF) with preserved ejection fraction (HFpEF) is a global health care problem, with diagnostic difficulty, limited treatment options and high morbidity and mortality rates. The prevalence of HFpEF is increasing because of the aging population and the increasing burden of cardiac and metabolic comorbidities, such as systemic hypertension, diabetes, chronic kidney disease, and obesity. The knowledge base is derived primarily from the United States and Europe, and data from Asian countries, including Japan, remain limited. Given that phenotypic differences may exist between Japanese and Western patients with HFpEF, careful characterization may hold promise to deliver new therapy specific to the Japanese population. In this review, we summarize the current knowledge regarding the epidemiology, pathophysiology and diagnosis of and the potential therapies for HFpEF in Japan.

Obesity and heart failure with preserved ejection fraction: new insights and pathophysiological targets

Obesity and heart failure with preserved ejection fraction (HFpEF) represent two intermingling epidemics driving perhaps the greatest unmet health problem in cardiovascular medicine in the 21st century. Many patients with HFpEF are either overweight or obese, and recent data have shown that increased body fat and its attendant metabolic sequelae have widespread, protean effects systemically and on the cardiovascular system leading to symptomatic HFpEF. The paucity of effective therapies in HFpEF underscores the importance of understanding the distinct pathophysiological mechanisms of obese HFpEF to develop novel therapies. In this review, we summarize the current understanding of the cardiovascular and non-cardiovascular features of the obese phenotype of HFpEF, how increased adiposity might pathophysiologically contribute to the phenotype, and how these processes might be targeted therapeutically.

Phenomapping in heart failure with preserved ejection fraction: insights, limitations, and future directions

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous entity with complex pathophysiology and manifestations. Phenomapping is the process of applying statistical learning techniques to patient data to identify distinct subgroups based on patterns in the data. Phenomapping has emerged as a technique with potential to improve the understanding of different HFpEF phenotypes. Phenomapping efforts have been increasing in HFpEF over the past several years using a variety of data sources, clinical variables, and statistical techniques. This review summarizes methodologies and key takeaways from these studies, including consistent discriminating factors and conserved HFpEF phenotypes. We argue that phenomapping results to date have had limited implications for clinical care and clinical trials, given that the phenotypes, as currently described, are not reliably identified in each study population and may have significant overlap. We review the inherent limitations of aggregating and utilizing phenomapping results. Lastly, we discuss potential future directions, including using phenomapping to optimize the likelihood of clinical trial success or to drive discovery in mechanisms of the disease process of HFpEF.

Heart Failure and Multimorbidity in Asia

PURPOSE OF THE REVIEW

Multimorbidity, the presence of two or more comorbidities, is common in patients with heart failure (HF) and worsens clinical outcomes. In Asia, multimorbidity has become the norm rather than the exception. Therefore, we evaluated the burden and unique patterns of comorbidities in Asian patients with HF.

RECENT FINDINGS

Asian patients with HF are almost a decade younger than Western Europe and North American patients. However, over two in three patients have multimorbidity. Comorbidities usually cluster due to the close and complex links between chronic medical conditions. Elucidating these links may guide public health policies to address risk factors. In Asia, barriers in treating comorbidities at the patient, healthcare system and national level hamper preventative efforts. Asian patients with HF are younger yet have a higher burden of comorbidities than Western patients. A better understanding of the unique co-occurrence of medical conditions in Asia can improve the prevention and treatment of HF.

Association Between Visceral Fat, Blood Pressure and Arterial Stiffness in Patients with HFpEF: A Mediation Analysis

PURPOSE

To investigate the association of visceral fat with arterial stiffness of heart failure patients with preserved ejection fraction (HFpEF) and to evaluate the extent to which this association is mediated by blood pressure (BP).

PATIENTS AND METHODS

This cross-sectional descriptive study (clinicaltrials.gov identifier: NCT04535726) recruited 94 patients with HFpEF totally from October to December 2020. The obesity-related measurements included visceral fat area (VFA), body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-hip ratio (WC/HC), abdominal circumference (AC), body fat mass and fat percentage. Brachial-ankle pulse wave velocity (baPWV) was used to estimate the degree of arterial stiffness. Mediation analysis was performed to reveal whether the effect of visceral fat area on arterial stiffness can be mediated by BP in patients with HFpEF and the extent to which this association was mediated by BP.

RESULTS

About 93.6% of HFpEF patients were accompanied with abdominal obesity. Patients in baPWV ≥1800cm/s group were older, with a higher incidence of type 2 diabetes mellitus (T2DM), hypertension and abdominal obesity. VFA, systolic BP (SBP), diastolic BP (DBP) and pulse pressure (PP) were correlated with baPWV in total group. Adjusted for age ≥75 years old, gender, smoking, T2DM, calcium channel blocker and statins, the mediation effect of systolic SBP and PP on the VFA-baPWV association were 53.3% (indirect effect was 2.28, 95% CI 0.62-4.73) and 48.4% (indirect effect was 2.07, 95% CI 0.51-4.38), respectively. DBP failed to mediate the association between VFA and baPWV (indirect effect was 0.50, 95% CI -0.41-2.14).

CONCLUSION

The association of visceral fat with baPWV in HFpEF patients may be partly accounted for SBP or PP. Elevated SBP and PP might be important potential targets for preventing arterial stiffness in HFpEF patients.

Association of circulating omentin level and metabolic-associated fatty liver disease: a systematic review and meta-analysis

Background

Metabolic-associated fatty liver disease (MAFLD) is closely associated with omentin, a novel adipokine that plays a vital role in metabolic balance. The literature about the relationship between circulating omentin and MAFLD is conflicting. Therefore, this meta-analysis evaluated circulating omentin levels in patients with MAFLD compared with healthy controls to explore the role of omentin in MAFLD.

Methods

The literature search was performed up to April 8, 2022, using PubMed, Cochrane Library, EMBASE, CNKI, Wanfang, CBM, Clinical Trials Database and Grey Literature Database. This meta-analysis pooled the statistics in Stata and presented the overall results using the standardized mean difference (SMD) and 95% confidence interval (CI).

Results

Twelve studies with 1624 individuals (927 cases and 697 controls) were included, and all of them were case-control studies. In addition, ten of twelve included studies were conducted on Asian participants. Patients with MAFLD had significantly lower circulating omentin levels than healthy controls (SMD=-0.950 [-1.724, -0.177], P=0.016). Subgroup analysis and meta-regression demonstrated that fasting blood glucose (FBG) might be the source of heterogeneity and was inversely associated with omentin levels (coefficient=-0.538, P=0.009). No significant publication bias existed (P>0.05), and outcomes were robust in the sensitivity analysis.

Conclusion

Lower circulating omentin levels were associated with MAFLD, and FBG might be the source of heterogeneity. Since Asian studies accounted for a significant portion of the meta-analysis, the conclusion might be more applicable to the Asian population. By investigating the relationship between omentin and MAFLD, this meta-analysis laid the foundation for the development of diagnostic biomarkers and treatment targets.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022316369.

Association of body roundness index and its trajectories with all-cause and cardiovascular mortality among a Chinese middle-aged and older population: A retrospective cohort study

Objectives

The body roundness index (BRI) is a novel anthropometric index that is a better indicator for predicting fat distribution than the body mass index (BMI). The longitudinal study can repeatedly collect measured results for the variables to be studied and then consider the potential effects of intraindividual changes in measurement. However, few population-based, longitudinal studies of BRI have been conducted, especially among the Chinese population. The study aimed to investigate the association of BRI and its longitudinal trajectories with all-cause and cardiovascular mortality.

Methods

A total of 71,166 participants with four times BRI measurements between January 2010 and December 2019 were included in this longitudinal study, with a median follow-up was 7.93 years, and 11,538 deaths were recorded, of which 5,892 deaths were due to cardiovascular disease (CVD). A latent class growth mixture modeling (LCGMM) was used to identify BRI trajectories. Cox proportional hazard models were used to estimate associations between BRI trajectories and the risk of all-cause and cardiovascular mortality.

Results

In the restricted cubic spline regression models, a U-shaped relationship between BRI and all-cause and cardiovascular mortality was observed. Three BRI longitudinal trajectories of low-stable (mean BRI = 2.59), moderate-stable (mean BRI = 3.30), and high-stable (mean BRI = 3.65) were identified by LCGMM. After being adjusted for potential confounders, the HRs for all-cause mortality were 1.18 (1.13-1.24) for the moderate-stable group and 1.74 (1.66-1.82) for the high-stable group compared to the low-stable group. The HRs for cardiovascular mortality were 1.12 (1.05-1.18) for the moderate-stable group and 1.64 (1.53-1.75) for the high-stable group compared to the low-stable group.

Conclusion

A nonlinear association of BRI with all-cause and cardiovascular mortality was observed, and participants in the higher BRI longitudinal trajectory group were significantly associated with an increased risk of all-cause and cardiovascular mortality.

Adiposity and clinical outcomes in East Asian patients with heart failure and preserved ejection fraction

Background

Despite the obesity paradox, visceral adiposity is associated with poor clinical outcomes in patients with heart failure with preserved ejection fraction (HFpEF). However, it remains unclear whether a relationship between visceral fat and clinical outcomes exists in Asian patients with HFpEF, in whom obesity is rare.

Methods

Visceral and subcutaneous adipose tissue (VAT and SAT) volume and area were measured using computed tomography (CT) in 196 HFpEF patients. The primary endpoint was a composite of all-cause mortality or HF hospitalization.

Results

Participants had a normal body mass index (BMI) (22.5 ± 4.4 kg/m²), and obesity (BMI > 30 kg/m²) was rare (4.6 %). The primary outcome was observed in 64 patients during a median follow-up of 11.6 months. Lower VAT and SAT volumes were associated with underweight and malnutrition. Composite outcomes increased as body weight, BMI, and height-indexed SAT volume and area decreased. Lower height-indexed VAT volume and area were also associated with the outcomes. The height-indexed SAT area provided independent and incremental prognostic value over age, BMI, blood pressure, and creatinine and albumin levels.

Conclusions

In lean East Asian patients with HFpEF, a lower VAT volume was associated with poorer clinical outcomes. CT-based assessments of adiposity may provide incremental prognostic value over simple anthropometric indices in lean HFpEF patients.

Machine learning models in heart failure with mildly reduced ejection fraction patients

Objective

Heart failure with mildly reduced ejection fraction (HFmrEF) has been recently recognized as a unique phenotype of heart failure (HF) in current practical guideline. However, risk stratification models for mortality and HF re-hospitalization are still lacking. This study aimed to develop and validate a novel machine learning (ML)-derived model to predict the risk of mortality and re-hospitalization for HFmrEF patients.

Methods

We assessed the risks of mortality and HF re-hospitalization in HFmrEF (45–49%) patients enrolled in the TOPCAT trial. Eight ML-based models were constructed, including 72 candidate variables. The Harrell concordance index (C-index) and DeLong test were used to assess discrimination and the improvement in discrimination between models, respectively. Calibration of the HF risk prediction model was plotted to obtain bias-corrected estimates of predicted versus observed values.

Results

Least absolute shrinkage and selection operator (LASSO) Cox regression was the best-performing model for 1- and 6-year mortality, with a highest C-indices at 0.83 (95% CI: 0.68–0.94) over a maximum of 6 years of follow-up and 0.77 (95% CI: 0.64–0.89) for the 1-year follow-up. The random forest (RF) showed the best discrimination for HF re-hospitalization, scoring 0.80 (95% CI: 0.66–0.94) and 0.85 (95% CI: 0.71–0.99) at the 6- and 1-year follow-ups, respectively. For risk assessment analysis, Kansas City Cardiomyopathy Questionnaire (KCCQ) subscale scores were the most important predictor of readmission outcome in the HFmrEF patients.

Conclusion

ML-based models outperformed traditional models at predicting mortality and re-hospitalization in patients with HFmrEF. The results of the risk assessment showed that KCCQ score should be paid increasing attention to in the management of HFmrEF patients.

Sodium-Glucose Cotransporter 2 Inhibitors and the Risk of Pneumonia and Septic Shock

CONTEXT

Individuals with type 2 diabetes mellitus (DM) have an increased risk of pneumonia and septic shock. Traditional glucose-lowering drugs have recently been found to be associated with a higher risk of infections. It remains unclear whether sodium-glucose cotransporter 2 inhibitors (SGLT2is), which have pleiotropic/anti-inflammatory effects, may reduce the risk of pneumonia and septic shock in DM.

METHODS

MEDLINE, Embase, and ClinicalTrials.gov were searched from inception up to May 19, 2022, for randomized, placebo-controlled trials of SGLT2i that included patients with DM and reported outcomes of interest (pneumonia and/or septic shock). Study selection, data extraction, and quality assessment (using the Cochrane Risk of Bias Assessment Tool) were conducted by independent authors. A fixed-effects model was used to pool the relative risk (RRs) and 95% CI across trials.

RESULTS

Out of 4568 citations, 26 trials with a total of 59 264 patients (1.9% developed pneumonia and 0.2% developed septic shock) were included. Compared with placebo, SGLT2is significantly reduced the risk of pneumonia (pooled RR 0.87, 95% CI 0.78-0.98) and septic shock (pooled RR 0.65, 95% CI 0.44-0.95). There was no significant heterogeneity of effect size among trials. Subgroup analyses according to the type of SGLT2i used, baseline comorbidities, glycemic control, duration of DM, and trial follow-up showed consistent results without evidence of significant treatment-by-subgroup heterogeneity (all Pheterogeneity > .10).

CONCLUSION

Among DM patients, SGLT2is reduced the risk of pneumonia and septic shock compared with placebo. Our findings should be viewed as hypothesis generating, with concepts requiring validation in future studies.

Distinct implications of body mass index in different subgroups of nonobese patients with heart failure with preserved ejection fraction: a latent class analysis of data from the TOPCAT trial

BACKGROUND

Obesity is a well-defined risk factor for heart failure with preserved ejection fraction (HFpEF), but it is associated with a better prognosis in patients with diagnosed HFpEF. The paradoxically poor prognosis in nonobese patients with HFpEF may be driven by a subset of high-risk patients, which suggests that the nonobese HFpEF subpopulation is heterogeneous.

METHODS

Latent class analysis (LCA) was adopted to identify the potential subgroups of 623 nonobese patients enrolled in the TOPCAT trial. The baseline characteristics of the identified nonobese subgroups were compared with each other and with the obese patients. The risks of all-cause, cardiovascular, and noncardiovascular mortality, and an HF composite outcome were also compared.

RESULTS

Two subgroups of nonobese patients with HFpEF (the physiological non-obesity and the pathological non-obesity) were identified. The obese patients were younger than both nonobese subgroups. The clinical profile of patients with pathological non-obesity was poorer than that of patients with physiological non-obesity. They had more comorbidities, more severe HF, poorer quality of life, and lower levels of physical activity. Patients with pathological non-obesity showed low serum hemoglobin and albumin levels. After 2 years of follow-up, more patients in the pathological group lost ≥ 10% of body weight compared with those in the physiological group (11.34% vs. 4.19%, P = 0.009). The prognostic implications of the two subgroups were opposite. Compared to patients with obesity, patients with physiological non-obesity had a 47% decrease in the risk of HF composite outcome (hazard ratio [HR] 0.53, 95% confidence interval [CI] 0.40-0.70, P<0.001) and a trend of decreased all-cause mortality risk (HR 0.75, 95% CI 0.55-1.01, P=0.06), while patients with pathological non-obesity had a 59% increase (HR 1.59, 95% CI 1.24-2.02, P<0.001) in all-cause mortality risk.

CONCLUSIONS

Two subgroups of nonobese patients with HFpEF with distinct clinical profiles and prognostic implications were identified. The low BMI was likely physiological in one group but pathological in the other group. Using a data-driven approach, our study provided an alternative explanation for the "obesity paradox" that the poor prognosis of nonobese patients with HFpEF was driven by a pathological subgroup.

Association between abdominal obesity indices and risk of cardiovascular events in Chinese populations with type 2 diabetes: a prospective cohort study

BACKGROUND

Waist circumference (WC), visceral adiposity index (VAI), lipid accumulation product (LAP), and Chinese visceral adiposity index (CVAI) are considered surrogate indicators of abdominal fat deposition, but the longitudinal association of these indices with cardiovascular (CV) events in adults with type 2 diabetes (T2D) remains unclear. Our study aimed to examine the associations between abdominal obesity indices and incident CV events among people with T2D and to compare their predictive performance in risk assessment.

METHODS

The present study included 2328 individuals with T2D from the Xinjiang Multi-Ethnic Cohort. Multivariable Cox regression analyses were applied to assess the associations between abdominal obesity indices and CV events. Harrell's concordance statistic (C-statistic), net reclassification improvement (NRI) index, and integrated discrimination improvement (IDI) index were utilized to evaluate the predictive performance of each abdominal obesity index.

RESULTS

At a median follow-up period of 59 months, 289 participants experienced CV events. After multivariable adjustment, each 1-SD increase in WC, VAI, LAP, and CVAI was associated with a higher risk of CV events in people with T2D, with adjusted hazard ratios (HRs) being 1.57 [95% CI (confidence interval): 1.39-1.78], 1.11 (95% CI 1.06-1.16), 1.46 (95% CI 1.36-1.57), and 1.78 (95% CI 1.57-2.01), respectively. In subgroup analyses, these positive associations appeared to be stronger among participants with body mass index (BMI) < 25 kg/m2 compared to overweight/obese participants. As for the predictive performance, CVAI had the largest C-statistic (0.700, 95% CI 0.672-0.728) compared to VAI, LAP, WC, and BMI (C-statistic: 0.535 to 0.670, all P for comparison < 0.05). When the abdominal obesity index was added to the basic risk model, the CVAI index also showed the greatest incremental risk stratification (C-statistic: 0.751 vs. 0.701, P < 0.001; IDI: 4.3%, P < 0.001; NRI: 26.6%, P < 0.001).

CONCLUSIONS

This study provided additional evidence that all abdominal obesity indices were associated with the risk of CV events and highlighted that CVAI might be a valuable abdominal obesity indicator for identifying the high risk of CV events in Chinese populations with T2D. These results suggest that proactive assessment of abdominal obesity could be helpful for the effective clinical management of the diabetic population.

[Heart failure and obesity]

Obesity is an independent predictor of cardiovascular diseases (CVD), including heart failure (HF). Nevertheless, numerous studies have shown that patients with CVD who are overweight and slightly obese have a better short-term and moderate prognosis than thinner patients with CVD. This phenomenon has been called the obesity paradox. Understanding the obesity paradox is important in patients with HF, given the high prevalence of obesity in patients with HF. The article presents an overview of clinical studies devoted to the study of obesity as a risk factor for HF, the pathogenesis of HF in obesity, and highlights the issues of the obesity paradox and the treatment of obesity in this category of patients.

Defining the Phenotypes for Heart Failure With Preserved Ejection Fraction

PURPOSE OF REVIEW

Heart failure with preserved ejection fraction (HFpEF) imposes a significant burden on society and healthcare. The lack in efficacious therapies is likely due to the significant heterogeneity of HFpEF. In this review, we define various phenotypes based on underlying comorbidities or etiologies, discuss phenotypes arrived at by novel methods, and explore therapeutic targets.

RECENT FINDINGS

A few studies have used machine learning methods to uncover sub-phenotypes within HFpEF in an unbiased manner based on clinical features, echocardiographic findings, and biomarker levels. We synthesized the literature and propose three broad phenotypes: (1) young, with few comorbidities, usually obese and with low natriuretic peptide levels, (2) obese with substantive cardiometabolic burden and comorbidities and impaired ventricular relaxation, (3) old, multimorbid, with high rates of atrial fibrillation, renal and coronary artery disease, chronic obstructive pulmonary disease, and left ventricular hypertrophy. We also propose potential therapeutic strategies for these phenotypes.

Epidemiology and Clinical Features of Heart Failure with Preserved Ejection Fraction

Heart failure (HF) with preserved ejection (HFpEF) constitutes a large and growing proportion of patients with HF around the world, and is now responsible for more than half of all HF cases in ageing societies. While classically described as a condition of elderly, hypertensive women, recent studies suggest heterogeneity in clinical phenotypes involving differential characteristics and pathophysiological mechanisms. Despite a paucity of disease-modifying therapy for HFpEF, an understanding of phenotypic similarities and differences among patients with HFpEF around the world provides the foundation to recognise the clinical condition for early treatment, as well as to identify modifiable risk factors for preventive intervention. This review summarises the epidemiology of HFpEF, its common clinical features and risk factors, as well as differences by age, comorbidities, race/ethnicity and geography.

Relationship Between Prognostic Nutrition Index and New York Heart Association Classification in Patients with Coronary Heart Disease: A RCSCD-TCM Study

Aim

This study aimed to elucidate the relationship between the prognostic nutrition index (PNI) of patients with coronary heart disease (CHD) and the New York Heart Association (NYHA) classification and the complex relationship between PNI combined body mass index (BMI) and NYHA classification.

Methods

The PNI was applied to 17,413 consecutive patients with CHD. Patients were divided into three groups according to PNI: normal nutrition (PNI ≥ 38), moderate malnutrition (35 < PNI < 38), and severe malnutrition (PNI ≤ 35). A total of 2,052 CHD patients with BMI were selected and stratified by combined subgroups of nutritional status and BMI. Logistic regression analysis was used to evaluate the relationship between the PNI and NYHA classification and to adjust for confounding factors.

Results

The prevalence of malnutrition among the 17,413participants with CHD was 4.2%. Moderate and severe malnutrition were significantly related to NYHA class III and V, and the strongest relationship was observed in NYHA class V (odd ratio [OR]: 6.564; 95% confidence interval [CI]: 4.043–10.658). Malnourished-underweight patients and malnourished-overweight patients were significantly associated with higher NYHA classification, and malnourished-underweight patients (OR: 8.038; 95% CI: 2.091–30.892) were significantly more than malnourished-overweight patients (OR: 3.580; 95% CI: 1.286–9.966).

Conclusion

There were differences in the NYHA classification of CHD patients with different nutritional statuses. The lower the PNI, the worse the NYHA classification of CHD patients. Malnourished-underweight patients had a worse NYHA classification than malnourished-overweight patients.

Clinical implications of the universal definition for the prevention and treatment of heart failure

The diagnosis of heart failure (HF) primarily relies on signs and symptoms that are neither sensitive nor specific. This impedes timely diagnosis and delays effective therapies or interventions, despite the availability of several evidence-based treatments for HF. Through monumental collaborative efforts from representatives of HF societies worldwide, the universal definition of HF was published in 2021, to provide the necessary standardized framework required for clinical management, clinical trials, and research. This review elaborates the key concepts of the new universal definition of HF, highlighting the key merits and potential avenues, which can be nuanced further in future iterations. We also discuss the key implications of the universal definition document from the perspectives of various stakeholders within the healthcare framework, including patients, care providers, system/payers and policymakers.

Association between Three Waist Circumference-Related Obesity Metrics and Estimated Glomerular Filtration Rates

Studies that have assessed the associations between obesity and the estimated glomerular filtration rate (eGFR) have reported inconsistent results. This cross-sectional study was performed to investigate the associations between three waist circumference (WC)-related obesity metrics (waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), and waist-to-height^0.5 ratio (WHt.5R)) and eGFRs. This study included 2133 men and 3443 women who were older than 40 years with eGFRs ≥ 60 mL/min/1.73 m² from the Korean Multi-Rural Communities Cohort. We calculated the residual body mass index (BMI) to reduce multicollinearity among the obesity metrics and performed multiple linear regression. For both sexes, among the adjusted models, most of the general obesity metrics were significantly associated with eGFRs. Particularly for women, the WC-related and general obesity metrics had a stronger effect on eGFRs in the quartile models that included the BMI and the residual BMI, respectively. When WC-related obesity metrics had a stronger effect than the general obesity metric, for both sexes, WHtR showed a significant impact than WHt.5R and WHR on eGFRs. Reducing multicollinearity had an important role in assessing the obesity metrics’ association with eGFRs. Overall, applying the residual method in further studies might help with evaluating the obesity paradox on renal function.

Mortality risk in patients with underweight or obesity with peripheral artery disease: a meta-analysis including 5,735,578 individuals

OBJECTIVES

The "obesity paradox" - in which patients with obesity exhibit superior survival than normal-weight counterparts - has been reported for several diseases. However, obesity is a well-known risk factor for cardiovascular disease, and whether the obesity paradox is present in peripheral artery disease (PAD) is unknown.

METHODS

A comprehensive search for studies that reported mortality in patients with PAD grouped by BMI identified 12 studies. We compared the survival of underweight patients with those who were not underweight, and patients with obesity against those without. Underweight was defined by a BMI value of <18.5 kg/m² in most studies and obesity by BMI ≥ 30 kg/m². Subgroup analyses were performed according to length of follow-up, presentation of PAD, and mode of revascularization. Meta-regression analyses were conducted, with covariates including age, sex, presence of coronary artery disease (CAD) and diabetes mellitus (DM).

RESULTS

The mortality risk of underweight patients with PAD was significantly higher compared to those who are not underweight (HR 1.72, 95% CI 1.38-2.14; I² = 84.2%). In contrast, the mortality risk of patients with obesity with PAD was significantly lower than those without (HR 0.78, 95% CI 0.62-0.97; I² = 89.8%). These findings remained consistent regardless of the presentation of PAD, revascularization, age, sex, or presence of CAD. The risk of death in the short-term of underweight patients (HR 1.50, 95% CI 0.47-4.72) and patients with obesity (HR 0.86, 95% CI 0.66-1.13) were not significantly different from their counterparts. The meta-regression showed that of the association between obesity and better survival was more pronounced in studies with a greater proportion of patients with concomitant CAD (regression coefficient -0.029, 95% CI -0.054 to -0.004).

CONCLUSIONS

In patients with PAD, mortality is higher among underweight patients and lower among patients with obesity. The mechanisms underlying the obesity paradox in patients with PAD remain to be elucidated, and further evidence is required to guide optimal weight control strategies in these patients.