“Obesity paradox” in coronary artery disease

Obesity Management for Patients with Coronary Artery Disease and Heart Failure

Obesity is causally linked to heart disease directly by triggering various adverse pathophysiological changes and indirectly through convergent risk factors such as type 2 diabetes, hypertension, dyslipidemia, and sleep disorder. Weight reduction is an important intervention for obesity-related cardiomyopathy, and antiobesity medications that target both obesity and heart failure (HF), particularly sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists, have a role in treatment. Bariatric surgery offers a viable treatment option for patients with severe obesity associated with coronary artery disease and HF but requires careful patient selection, preoperative optimization, choice of procedure, and postoperative management to minimize risks.

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.

Correlation between severity of obesity and mortality in cardiogenic shock

INTRODUCTION

Cardiogenic shock (CS) is associated with high mortality despite the development of risk stratification tools and new treatment strategies. Obesity, although a risk factor for cardiovascular disease, is not included in current risk stratification tools for CS. A relationship between mortality and obesity has only been shown in subsets populations of CS; there is not yet a clear relationship between severity of obesity and all-cause CS.

OBJECTIVES

In this study we evaluate the relationship between rising body mass index (BMI) and mortality in all-cause CS.

METHODS

All patients with BMI measurements and hospitalizations complicated by CS from 2014 to 2019 at a single quaternary care institution were identified. Patients were grouped by obesity classification. Multivariate logistic regression was performed to determine a relationship between higher obesity classifications with 30-day mortality in patients with CS.

RESULTS

Seventy-two patients were available for analysis. Mean BMI for those who survived compared to those who did not was 29.7 ± 8 kg/m2 vs 33.7 ± 7.6 kg/m2 (p = 0.04). The odds ratio for mortality with incremental increase in obesity classification was 1.6 (95% CI 1.1 - 2.6, p = 0.03) after adjusting for etiology of CS and other common associations with CS mortality.

CONCLUSION

This study suggests that the higher mortality risk with incremental increases in BMI should be taken into account when risk stratifying these patients.

Stroke Severity in Ischemic Stroke Patients with a History of Diastolic Blood Pressure Treated in a Telestroke Network

Background: The relationship between diastolic blood pressure (DBP), risk factors, and stroke severity in acute ischemic stroke (AIS) patients treated in a telestroke network is not fully understood. The present study aims to determine the effect of risk factors on stroke severity in AIS patients with a history of elevated DBP. Material and Methods: We retrospectively analyzed data on stroke severity for AIS patients treated between January 2014 and June 2016 treated in the PRISMA Health telestroke network. Data on the severity of stroke on admission were evaluated using NIHSS scores ≤7 for reduced, and >7 for increased, stroke severity. DBP was stratified as ≤80 mmHg for reduced DBP and >80 mmHg for elevated DBP. The study’s primary outcomes were risk factors associated with improving neurologic functions or reduced stroke severity and deteriorating neurologic functions or increased stroke severity. The associations between risk factors and stroke severity for AIS with elevated DBP were determined using multi-level logistic and regression models. Results: In the adjusted analysis, AIS patients with a DBP ≤ 80 mmHg, obesity (OR = 0.388, 95% Cl, 0.182−0.828, p = 0.014) was associated with reduced stroke severity, while an increased heart rate (OR = 1.025, 95% Cl, 1.001−1.050, p = 0.042) was associated with higher stroke severity. For AIS patients with a DBP > 80 mmHg, hypertension (OR = 3.453, 95% Cl, 1.137−10.491, p = 0.029), history of smoking (OR = 2.55, 95% Cl, 1.06−6.132, p = 0.037), and heart rate (OR = 1.036, 95% Cl, 1.009−1.064, p = 0.009) were associated with higher stroke severity. Caucasians (OR = 0.294, 95% Cl, 0.090−0.964, p = 0.002) and obesity (OR = 0.455, 95% Cl, 0.207−1.002, p = 0.05) were more likely to be associated with reduced stroke severity. Conclusions: Our findings reveal specific risk factors that can be managed to improve the care of AIS patients with elevated DBP treated in the telestroke network.

Identification of Key Genes as Early Warning Signals of Acute Myocardial Infarction Based on Weighted Gene Correlation Network Analysis and Dynamic Network Biomarker Algorithm

Purpose

The specific mechanisms and biomarkersunderlying the progression of stable coronary artery disease (CAD) to acute myocardial infarction (AMI) remain unclear. The current study aims to explore novel gene biomarkers associated with CAD progression by analyzing the transcriptomic sequencing data of peripheral blood monocytes in different stages of CAD.

Material and Methods

A total of 24 age- and sex- matched patients at different CAD stages who received coronary angiography were enrolled, which included 8 patients with normal coronary angiography, 8 patients with angiographic intermediate lesion, and 8 patients with AMI. The RNA from peripheral blood monocytes was extracted and transcriptome sequenced to analyze the gene expression and the differentially expressed genes (DEG). A Gene Oncology (GO) enrichment analysis was performed to analyze the biological function of genes. Weighted gene correlation network analysis (WGCNA) was performed to classify genes into several gene modules with similar expression profiles, and correlation analysis was carried out to explore the association of each gene module with a clinical trait. The dynamic network biomarker (DNB) algorithm was used to calculate the key genes that promote disease progression. Finally, the overlapping genes between different analytic methods were explored.

Results

WGCNA analysis identified a total of nine gene modules, of which two modules have the highest positive association with CAD stages. GO enrichment analysis indicated that the biological function of genes in these two gene modules was closely related to inflammatory response, which included T-cell activation, cell response to inflammatory stimuli, lymphocyte activation, cytokine production, and the apoptotic signaling pathway. DNB analysis identified a total of 103 genes that may play key roles in the progression of atherosclerosis plaque. The overlapping genes between DEG/WGCAN and DNB analysis identified the following 13 genes that may play key roles in the progression of atherosclerosis disease: SGPP2, DAZAP2, INSIG1, CD82, OLR1, ARL6IP1, LIMS1, CCL5, CDK7, HBP1, PLAU, SELENOS, and DNAJB6.

Conclusions

The current study identified a total of 13 genes that may play key roles in the progression of atherosclerotic plaque and provides new insights for early warning biomarkers and underlying mechanisms underlying the progression of CAD.

Height is Inversely Associated with Biomarkers of Intracranial Atherosclerotic Disease in Older Adults of Amerindian Ancestry: Exploring the Obesity Paradox

BACKGROUND

Various anthropometric measurements have been inversely associated with atherosclerosis, giving rise to the concept of an "obesity paradox" However, inconsistent study results make it difficult to determine the best anthropometric measurement with which to assess such inverse relationship. Height has been inversely associated with atherosclerosis and it is unlikely to be associated with unexpected biases. In this study, we aimed to assess the association between height and other anthropometric measurements and intracranial atherosclerotic disease (ICAD).

METHODS

Community-dwelling older adults enrolled in the Three Villages Study received anthropometric measurements, high-resolution head CT (to evaluate calcium content in carotid siphons) and time-of-flight MRA (to assess stenosis of large intracranial arteries). Logistic regression models were fitted to assess the independent association between each anthropometric measurements and the presence of ICAD, after adjusting for relevant confounders. Estimated adjusted proportions were used to show how increases of different anthropometric measurements impacted ICAD log odds and corresponding odds ratios.

RESULTS

A total of 581 individuals were enrolled. Height was the single variable inversely associated with ICAD at the mean of other anthropometric measurements (OR: 0.954; 95% C.I.: 0.918 - 0.991; p=0.016). Every additional cm of height reduced by 4.6% the probability of having ICAD. The significance of other anthropometric measurements vanished in multivariate models with height as an independent variable.

CONCLUSIONS

This study demonstrates a robust inverse association between height and ICAD in Amerindians and opens new avenues of research for a better understanding of the obesity paradox in diverse ethnic groups.

Challenging the obesity paradox: extreme obesity and COPD mortality in the SUMMIT trial

Populations with COPD demonstrate higher survival in overweight and obese compared with normal weight; the “obesity paradox”. Relationships in less-severe COPD are unclear, as is the impact of cardiovascular risk, and few studies include individuals at extremes of obesity.

 We examined the relationship between body mass index (BMI; defined as underweight: <20 kg·m⁻², normal: 20–25 kg·m⁻², overweight: 25– <30 kg·m⁻², obese class I: 30– <35 kg·m⁻², class II: 35– <40 kg·m⁻² and class III: ≥40 kg·m⁻²), morbidity, and mortality in the SUMMIT trial population (n=16 485), characterised by moderate COPD and heightened cardiovascular risk with a substantial proportion with class III obesity. The association between BMI category and time to event was modelled via proportional hazards (reference normal weight) adjusted for demographics and cardiorespiratory disease.

 Consistent with the paradox, underweight individuals demonstrated higher mortality (hazard ratio (HR) 1.31 (95% CI 1.04–1.64)), with lower mortality among overweight (HR 0.62 (95% CI 0.52–0.73)) and obese class I (HR 0.75 (95% CI 0.62–0.90)). However, mortality increased in obese class III (HR 1.36 (95% CI 1.00–1.86)). Death was primarily attributable to cardiovascular causes.

 Within a large, multinational cohort with moderate COPD and increased cardiovascular risk, the phenomenon of reduced mortality with obesity did not persist at BMI >40 kg·m⁻², suggesting that obesity may not remain protective at the extremes in this population.

In a population with moderate COPD, at heightened cardiovascular risk and containing a substantial proportion of individuals with BMI ≥40 kg/m², BMI and mortality demonstrate a U-shaped (rather than J-shaped) relationshiphttps://bit.ly/3hDztI6

Adipose Tissue-Endothelial Cell Interactions in Obesity-Induced Endothelial Dysfunction

Obesity has a strong impact on the pathogenesis of cardiovascular disease, which raises enthusiasm to understand how excess adiposity causes vascular injury. Adipose tissue is an essential regulator of cardiovascular system through its endocrine and paracrine bioactive products. Obesity induces endothelial dysfunction, which often precedes and leads to the development of cardiovascular diseases. Connecting adipose tissue-endothelial cell interplay to endothelial dysfunction may help us to better understand obesity-induced cardiovascular disease. This Mini Review discussed (1) the general interactions and obesity-induced endothelial dysfunction, (2) potential targets, and (3) the outstanding questions for future research.

Extended intensive care correlates with worsening of surgical outcome after elective abdominal aortic reconstruction

BACKGROUND

The aim of this study was to evaluate the impact of extended postoperative intensive care on short- and long-term patient outcome after elective abdominal aortic surgery and to assess the risk factors for patient survival after extended intensive care unit (ICU) treatment.

METHODS

The data of 231 patients that underwent open or endovascular abdominal aortic surgery were retrospectively analysed with regard to extended postoperative intensive care, defined as ICU treatment for more than 24 consecutive hours. Pre- and intraoperative factors were evaluated. The endpoints of the study were postoperative complications, mortality, and long-term follow-up. Univariate and multivariate Cox proportional regression analyses were performed to identify risk factors of worse overall survival.

RESULTS

Extended postoperative intensive care was needed in 84 patients (63 after open and 21 after endovascular surgery). The period of ICU treatment was similar in both groups. Only the wound complications (31.8% vs. 9.5%, p=.0498; OR 4.42 (0.94-20.84)) and the rate of acute kidney injury (82.5% vs. 57.1%, p=.0352; OR 3.55 (1.20-0.46)) were more frequent after open surgery, whereas brief reactive psychosis (38.1% vs. 14.3%, p=.0281; OR 0.27 (0.09- 0.84)) was more frequent after endovascular surgery. ICU stay of ≥8 days correlated with significantly lower survival rates compared to a shorter ICU stay (p=.0034), independent of open or endovascular techniques. Other multivariate risk factors for worse survival were the absence of preoperative aspirin medication, a body mass index (BMI) of <25, chronic renal insufficiency (CRI), and coronary artery disease (CAD). Endovascular therapy was a positive predictive factor of short ICU stay of ≤3 days.

CONCLUSIONS

The outcome after extended intensive care following elective aortic surgery is strongly dependent on the length of ICU stay.

Discordance between Body-Mass Index and Body Adiposity Index in the Classification of Weight Status of Elderly Patients with Stable Coronary Artery Disease

Background and Aims: Body-mass index (BMI) is a popular method implemented to define weight status. However, describing obesity by BMI may result in inaccurate assessment of adiposity. The Body Adiposity Index (BAI) is intended to be a directly validated method of estimating body fat percentage. We set out to compare body weight status assessment by BMI and BAI in a cohort of elderly patients with stable coronary artery disease (CAD). Methods: A total of 169 patients with stable CAD were enrolled in an out-patient cardiology clinic. The National Research Council (US) Committee on Diet and Health classification was used for individuals older than 65 years as underweight BMI < 24 kg/m², normal weight BMI 24–29 kg/m², overweight BMI 29–35 kg/m², and obesity BMI > 35 kg/m². In case of BAI, we used sex- and age-specific classification of weight status. In addition, body fat was estimated by bioelectrical impedance analysis (BImpA). Results: Only 72 out of 169 patients (42.6%) had concordant classification of weight status by both BMI and BAI. The majority of the patients had their weight status either underestimated or overestimated. There were strong positive correlations between BMI and BImpA (FAT%) (R = 0.78 p < 0.001); BAI and BImpA (FAT%) (R = 0.79 p < 0.001); and BMI and BAI (R = 0.67 p < 0.001). BMI tended to overestimate the rate of underweight, normal weight or overweight, meanwhile underestimating the rate of obesity. Third, BMI exhibited an average positive bias of 14.4% compared to the reference method (BImpA), whereas BAI exhibited an average negative bias of −8.3% compared to the reference method (BImpA). Multivariate logistic regression identified independent predictors of discordance in assessing weight status by BMI and BAI: BImpA (FAT%) odds ratio (OR) 1.29, total body water (%) OR 1.61, fat mass index OR 2.62, and Controlling Nutritional Status (CONUT) score OR 1.25. Conclusions: There is substantial rate of misclassification of weight status between BMI and BAI. These findings have significant implications for clinical practice as the boundary between health and disease in malnutrition is crucial to accurately define criteria for intervention. Perhaps BMI cut-offs for classifying weight status in the elderly should be revisited.

The Multifaceted Actions of Curcumin in Obesity

Obesity remains a pervasive health concern worldwide with concomitant comorbidities such as cardiovascular diseases, diabetes, inflammation, and other metabolic disorders. A wealth of data validates dietary and lifestyle modifications such as restricting caloric intake and increasing physical activity to slow the obesity development. Recently, the advent of phytochemicals such as curcumin, the active ingredient in turmeric, has attracted considerable research interest in tracking down their possible effects in protection against obesity and obesity-related comorbidities. According to the existing literature, curcumin may regulate lipid metabolism and suppress chronic inflammation interacting with white adipose tissue, which plays a central role in the complications associated with obesity. Curcumin also inhibits the differentiation of adipocyte and improves antioxidant properties. In the present review, we sought to deliberate the possible effects of curcumin in downregulating obesity and curtailing the adverse health effects of obesity.

High-sensitivity C-reactive protein as a prognostic marker in patients undergoing valve surgery

Introduction

An inflammatory reaction is a local or systemic response of the organs or tissues of the body to many damaging factors. One of the exponents of the inflammatory process is C-reactive protein (CRP).

Aim

To investigate the prognostic value of C-reactive protein (CRP) in patients undergoing valve surgery.

Material and methods

A prospective study was conducted on a group of consecutive patients with haemodynamically significant valve defects who underwent elective valve repair or replacement surgery. The primary end-point was in-hospital death from all causes. Patients were followed by direct observation during hospitalization. The risk of surgery using Euro-SCORE II was calculated for each patient. The plasma levels of C-reactive protein were measured by the Cardiac C-Reactive Protein (Latex) High Sensitive Test (Roche, Germany).

Results

The study group included 562 patients. The mean age in the studied population was 63 (standard deviation (SD) ±12). The mean plasma preoperative CRP level was 0.39 ±0.3 mg/dl. The primary endpoint occurred in 25 patients. At multivariate analysis age (p = 0.01), CRP (p = 0.02) and NT-proBNP (p = 0.03) remained independent predictors of the primary endpoint. A significant correlation was found between the level of CRP and haemoglobin (r = -0.3; p < 0.0001), red cell distribution width (r = 0.22; p < 0.0001), ejection fraction (r = -0.24, p = 0.007), troponin T (r = 0.3; p < 0.0001), creatinine (r = 0.26; p = 0.001) and body mass index (r = -0.29; p = 0.005). The average total time of hospitalization after the operation in patients with occurrence of the primary endpoint was 25 ±13 days.

Conclusions

Elevated preoperative CRP was associated with a poorer outcome following valve surgery.

Underweight and weight loss are predictors of poor outcome in patients with brain metastasis

PURPOSE

Overweight may be associated with favorable outcome whereas tumor cachexia may be associated with worse outcome in patients with metastatic cancer. Here we evaluate the association of abnormal body mass index and weight change with outcome in patients with brain metastasis.

METHODS

Patients with a diagnosis of brain metastasis treated at the University Hospital Zurich (n = 703) were assessed for associations of body mass index, weight change, comorbidities and survival.

RESULTS

Compared with patients with normal body mass index of 18.5-24.9 kg/m² and a median overall survival of 9 months (95% confidence interval 7.5-10.5), overall survival was inferior in patients with body mass index < 18.5 kg/m² (overall survival 6 months, 95% confidence interval 1.6-10.3, p = 0.04), but superior in patients with body mass index > 25 kg/m² (overall survival 13 months, 95% confidence interval 11.0-15.0; p = 0.033). We report a median relative weight loss of 5% within the first 6 months of diagnosis of brain metastasis (95% confidence interval 3.3-6.5), and reduction exceeding the median was associated with an unfavorable outcome (weight loss < 5% 22.0 months, 95% confidence interval 19.2-24.8; weight loss > 5% 14.0 months, 95% confidence interval 11.9-16.).

CONCLUSION

High body mass index is associated with better, and underweight with worse outcome in patients with brain metastasis. Conversely, weight loss above median may predict poor outcome. Future studies need to address whether vigorous treatment of tumor cachexia, e.g. by specific nutrition management, might improve outcome of patients with brain metastasis. In contrast, regimens associated with weight loss such as ketogenic diet may be detrimental.

The usefulness of selected biomarkers in patients with valve disease

AIM

The aim of the study was to investigate the prognostic value of selected biomarkers in patients undergoing valve surgery.

MATERIALS & METHODS

A prospective study was conducted on a group of consecutive patients with hemodynamically significant valve defects that underwent elective valve repair or replacement surgery. The primary end point was any major adverse event including death within 30 days.

RESULTS

The study group included 416 patients. The composite end point occurred in 81 patients. At multivariate analysis high-sensitivity C-reactive protein (p = 0.03), red cell distribution width (p = 0.0001) and red blood cell count (p = 0.005) remained independent predictors of the primary end point.

CONCLUSION

Elevated high-sensitivity C-reactive protein, red cell distribution width and red blood cell count were associated with a poorer outcome following valve surgery.

Obesity, metabolic abnormalities, and mortality in older men

BACKGROUND

Older adults are prone to obesity and metabolic abnormalities and recommended to pursue a normal weight especially when obesity and metabolic abnormalities are co-existed. However, few studies have reported the possible differences in the effect of obesity on outcomes between older adults with metabolic abnormalities and those without metabolic abnormalities.

METHODS

A total of 3485 older men were included from 2000 to 2014. All-cause mortality and cardiovascular mortality were obtained during a mean follow-up of five years. Metabolic abnormalities were defined as having established hypertension, diabetes, or dyslipidemia and taking the disease-related medications. All participants were stratified by the presence or absence of metabolic abnormalities.

RESULTS

In the non-metabolic abnormalities group, all-cause and cardiovascular deaths were lowest in overweight participants and highest in obese participants. In the metabolic abnormalities group, mortality was also lowest in overweight participants but highest in participants with normal weight. After adjustment for covariates, hazard ratios (95% CI) for all-cause death and cardiovascular death were 0.68 (0.51, 0.92) and 0.59 (0.37, 0.93), respectively, in overweight participants with metabolic abnormalities. Furthermore, obesity was not associated with mortality risk in both groups. These findings were unchanged in stratified analyses.

CONCLUSIONS

Overweight was negatively associated with mortality risk in older men with metabolic abnormalities but not in those without metabolic abnormalities. Obesity did not increase death risk regardless of metabolic abnormalities. These findings suggest that the recommendation of pursuing a normal weight may be wrong in overweight/obese older men, especially for those with metabolic abnormalities.

The Relationship of Body Mass Index to Percutaneous Coronary Intervention Outcomes: Does the Obesity Paradox Exist in Contemporary Percutaneous Coronary Intervention Cohorts? Insights From the British Cardiovascular Intervention Society Registry

OBJECTIVES

The aims of this study were to examine the relationship between body mass index (BMI) and clinical outcomes following percutaneous coronary intervention (PCI) and to determine the relevance of different clinical presentations requiring PCI to this relationship.

BACKGROUND

Obesity is a growing problem, and studies have reported a protective effect from obesity compared with normal BMI for adverse outcomes after PCI.

METHODS

Between 2005 and 2013, 345,192 participants were included. Data were obtained from the British Cardiovascular Intervention Society registry, and mortality data were obtained through the U.K. Office of National Statistics. Multiple logistic regression was performed to determine the association between BMI group (<18.5, 18.5 to 24.9, 25 to 30 and >30 kg/m²) and adverse in-hospital outcomes and mortality.

RESULTS

At 30 days post-PCI, significantly lower mortality was seen in patients with elevated BMIs (odds ratio [OR]: 0.86 [95% confidence interval (CI): 0.80 to 0.93] 0.90 [95% CI: 0.82 to 0.98] for BMI 25 to 30 and >30 kg/m², respectively). At 1 year post-PCI, and up to 5 years post-PCI, elevated BMI (either overweight or obese) was an independent predictor of greater survival compared with normal weight (OR: 0.70 [95% CI: 0.67 to 0.73] and 0.73 [95% CI: 0.69 to 0.77], respectively, for 1 year; OR: 0.78 [95% CI: 0.75 to 0.81] and 0.88 [95% CI: 0.84 to 0.92], respectively, for 5 years). Similar reductions in mortality were observed for the analysis according to clinical presentation (stable angina, unstable angina or non-ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction).

CONCLUSIONS

A paradox regarding the independent association of elevated BMI with reduced mortality after PCI is still evident in contemporary U.K. practice. This is seen in both stable and more acute clinical settings.

Elevated fasting blood glucose, but not obesity, is associated with coronary artery disease in patients undergoing elective coronary angiography in a referral hospital in Jordan

BACKGROUND

Obesity and its metabolic complications are endemic in the Middle East, but the cardiovascular consequences are not well defined in local studies.

OBJECTIVE

To assess the association between fasting blood glucose (FBG), obesity and coronary artery disease (CAD) in Jordan.

DESIGN

A cross-sectional, hospital-based study.

SETTING

A referral hospital in Amman, Jordan.

PATIENTS AND METHODS

Patients with complete anthropomorphic data who were referred for elective coronary angiography were included in the analysis. Associations between CAD, FBG and obesity were assessed in multivariate logistic regression models, adjusting for known risk factors.

MAIN OUTCOME MEASURE

The presence of CAD.

SAMPLE SIZE

434 subjects.

RESULTS

Only those who underwent coronary angiography and had complete anthropometric data were included in the study: 291 (67.1%) had CAD and 143 (32.9%) had a normal coronary angiogram.The mean body mass index, waist circumference and FBG of the study participants was 30.0 kg/m2, 106.0 cm and 8.8 mmol/L, respectively. The mean FBG was significantly higher in patients with CAD compared to those without CAD (9.5 vs. 7.3 mmol/L, P less than .001). Waist circumference was significantly higher in women with CAD compared to women without CAD (111.0 vs. 105.9 cm, P=.036), but no significant difference was observed in men. In a multivariate analysis, FBG was a strong and significant predictor of CAD; however, none of the measures of obesity were significantly associated with CAD. The findings were robust in a sensitivity analysis that excluded patients with known diabetes mellitus.

CONCLUSIONS

Elevated FBG, but not obesity, predicted CAD in a Middle Eastern population. Improved prevention, detection and management of type 2 diabetes should be a priority in this setting.

LIMITATIONS

The cross-sectional design cannot control for temporal changes in risk factors and/or reverse causation.

CONFLICT OF INTEREST

None.

Obesity phenotypes and their paradoxical association with cardiovascular diseases

The pro-inflammatory state of the visceral adipose tissue (VAT) is supposed to accelerate cardiovascular (CV) and metabolic diseases in obese subjects. Some studies have recently reported an improved CV prognosis in certain obese and overweight patients as compared with leaner ones. This phenomenon, known as the "obesity paradox" (OP), has been described in many chronic diseases. This narrative review is based on the material searched for and obtained via PubMed and Web of Science up to May 2017. The search terms we used were: "obesity, paradox, adipose tissue" in combination with "cardiovascular, coronary heart disease, heart failure, arrhythmias". Using the current Body Mass Index (BMI)-based obesity definition, individuals with different clinical and biochemical characteristics are gathered together in the same category. Emerging evidence point to the existence of many "Obesity phenotypes" with different association with CV risk, accordingly to physical and life-style features. In this narrative review, we discussed if obesity phenotypes may be associated with a different CV risk, potentially explaining the OP. As a globally accepted definition of obesity is still lacking, we emphasized the need of a new approach, which should consider the heterogeneity of obesity. Better defining "obesities" and related CV risk is critical to markedly improve the classical BMI-based definition of obesity.

Obesity paradox in patients undergoing coronary intervention: A review

There is strong relationship between obesity and cardiovascular disease including coronary artery disease (CAD). However, the literature has shown better outcomes in higher obese patients who undergo percutaneous cardiovascular interventions for CAD, a phenomenon known as the obesity paradox (OX). In this review, we performed extensive search for OX in patients undergoing percutaneous coronary intervention. We also discussed possible mechanism OX and disparities in different race and sex.

Study of association of severity of sleep disordered breathing and functional outcome in stroke patients

OBJECTIVE

Sleep disordered breathing (SDB) is a prevalent yet underrecognized condition that may have major adverse consequences for those affected by it. We performed a prospective observational study to seek a correlation of severity of SDB with the severity of stroke and its functional outcome.

METHODS

Patients with history of recent-onset stroke were recruited and underwent overnight polysomnography (PSG) after the acute phase of the stroke was over; for defining hypopneas, 3% and 4% desaturation limits were used, and the apnea-hypopnea index was respectively calculated as AHI_3% and AHI_4%. Stroke severity was graded using the Scandinavian Stroke Scale. Functional disability and neurological impairment was evaluated six weeks after the PSG using the Barthel Index (<80 = functional dependence; ≥80 = functional independence) and modified Rankins Scale (>2 = poor outcome; ≤2 = good outcome).

RESULTS

A total of 50 patients were enrolled, 30 (60%) with ischemic stroke and 20 (40%) with hemorrhagic strokes. Of the patients, 39 (78%) had an AHI_4% of >5/h, 23 (46%) had an AHI_4% of >15/h, and 9 (18%) had an AHI_4% of >30/h. Multivariate analysis showed that body mass index (odds ratio [OR] = 1.26; 95% confidence interval [CI] = 1.04-1.54, p = 0.019) and Scandinavian Stroke Scale score (stroke severity) (OR = 0.86; 95% CI = 0.76-0.96, p = 0.009) were significant risk factors for predicting SDB (AHI_4% > 15) in patients of stroke. When we looked for factors predicting outcomes, only AHI_4% (OR = 1.20; 95% CI 1.01-1.43, p value 0.041) was predictive of the functional dependence (based on Barthel Index) of the patient and AHI_4% (OR = 1.14; 95% CI 1.03-1.25, p = 0.008) and body mass index (OR = 0.75; 95% CI 0.59-0.96, p = 0.024) were found to be predictive of poor outcome (based on modified Rankins Scale). We obtained similar results, regardless of the hypopnea definition used.

CONCLUSION

In conclusion, given the high frequency of SDB in stroke patients and its correlation with poor outcome, screening for obstructive sleep apnea in all stroke and transient ischemic attack patients may be warranted.

Augmentation index (AI) in a dose-response relationship with smoking habits in males: The Tanushimaru study

We investigated the relationship between augmentation index (AI) and smoking habits in community-dwelling Japanese.This cross-sectional study enrolled 1926 subjects (769 males and 1157 females) aged 40 to 95 years who underwent a health check-up in a Japanese cohort of the Seven Countries Study, in Tanushimaru, a typical farming town in Kyushu Island in 2009. The subjects' medical history, alcohol intake, smoking habit, and current medications for hypertension, dyslipidemia, and diabetes were ascertained by questionnaire. Radial arterial pressure wave analysis was used to obtain AI. We analyzed the data stratified by gender.Age-adjusted means of AI in males showed a clear dose-response relationship in 4 categories of smoking habits (P = 0.010). There was no significant relationship between AI and smoking habits in females (P = 0.127). The significant dose-response relationship (P = 0.036) in males between AI and 4 categories of smoking habits still remained even after adjustment for age, body mass index, systolic blood pressure, estimated glomerular filtration rate, glucose, hypertensive medication, and alcohol intake.The present study demonstrated that AI values were significantly associated with smoking habits in a dose-dependent manner in Japanese males.

Neck circumference as a screening measure of overweight/obesity among Indian adults

Neck circumference (NC) is an anthropometric measurement of differentiating body fat distributions and a marker of upper subcutaneous adiposity. The present study highlights the association and importance of NC as a suitable proxy screening measure of overweight/obesity as compared to the conventional anthropometric variables used among Indian adults. The present community based cross-sectional study was undertaken among 1169 Karbi adults (males: 625; females: 544) residing in Karbi Anglong district of Assam, Northeast India, who were selected through a multistage stratified random sampling method. Height, weight, waist circumference (WC), hip circumference (HC) and NC were recorded using standard procedures. The body mass index (BMI) was calculated and prevalence of overweight/obesity was assessed using standard cut-offs. The prevalence of obesity using BMI (≥25.00 kg m-2) was 15.52% and 15.26% among males and females, respectively (p≥0.05).The prevalence of obesity using NC was observed to be significantly higher among males (48.80%) than females (19.12%) (p<0.01). The binary logistic regression analysis showed that NC predicted obesity over the conventional anthropometric variables with reasonable accuracy (p<0.01). The ROC-AUC analysis showed a relatively greater significant association between BMI, WC and HC and NC for obesity (p<0.01). Thus, NC appears to be a potentially simple, easyto- use screening measure for predicting obesity among adults. Further studies are required to validate its use for screening of obesity among other ethnic populations in India.

Obesity and Cardiovascular Disease: a Risk Factor or a Risk Marker?

In the USA, 69 % of adults are either overweight or obese and 35 % are obese. Obesity is associated with an increased incidence of various cardiovascular disorders. Obesity is a risk marker for cardiovascular disease, in that it is associated with a much higher prevalence of comorbidities such as diabetes, hypertension, and metabolic syndrome, which then increase the risk for cardiovascular disease. However, in addition, obesity may also be an independent risk factor for the development of cardiovascular disease. Furthermore, although obesity has been shown to be an independent risk factor for several cardiovascular diseases, it is often associated with improved survival once the diagnosis of the cardiovascular disease has been made, leading to the term "obesity paradox." Several pathways linking obesity and cardiovascular disease have been described. In this review, we attempt to summarize the complex relationship between obesity and cardiovascular disorders, in particular coronary atherosclerosis, heart failure, and atrial fibrillation.

Treatment of Type 2 Diabetes: From "Guidelines" to "Position Statements" and Back: Recommendations of the Israel National Diabetes Council

Given the increased prevalence of type 2 diabetes worldwide, most patients are treated by their primary health care team (PHCT). PHCTs need guidance in choosing the best treatment regimen for patients, since the number of glucose-lowering agents (GLAs) is rapidly increasing, as is the amount of clinical data regarding these drugs. The American Diabetes Association/European Association for the Study of Diabetes Position Statement emphasizes the importance of personalized treatment and lists drug efficacy, risk of hypoglycemia, effect on weight, side effects, and cost as important parameters to consider when choosing GLAs. The suggested Israeli guidelines refocus earlier international recommendations from 2012 and 2015, based on emerging data from cardiovascular outcome trials as well as what we believe are important issues for patient care (i.e., durability, hypoglycemia risk, and weight gain).

Interleukin-6 and C-reactive protein, successful aging, and mortality: the PolSenior study

BACKGROUND

In the elderly, chronic low-grade inflammation (inflammaging) is a risk factor for the development of aging-related diseases and frailty. Using data from several thousand Eastern Europeans aged 65 years and older, we investigated whether the serum levels of two proinflammatory factors, interleukin-6 (IL-6) and C-reactive protein (CRP), were associated with physical and cognitive performance, and could predict mortality in successfully aging elderly.

RESULTS

IL-6 and CRP levels systematically increased in an age-dependent manner in the entire study group (IL-6: n = 3496 individuals, p < 0.001 and CRP: n = 3632, p = 0.003), and in the subgroup of successfully aging individuals who had never been diagnosed with cardiovascular disease, myocardial infarction, stroke, type 2 diabetes, or cancer, and had a Mini Mental State Examination (MMSE) score ≥24 and a Katz Activities of Daily Living (ADL) score ≥5 (IL-6: n = 1258, p < 0.001 and CRP: n = 1312, p < 0.001). In the subgroup of individuals suffering from aging-related diseases/disability, only IL-6 increased with age (IL-6: n = 2238, p < 0.001 and CRP: n = 2320, p = 0.249). IL-6 and CRP levels were lower in successfully aging individuals than in the remaining study participants (both p < 0.001). Higher IL-6 and CRP levels were associated with poorer physical performance (lower ADL score) and poorer cognitive performance (lower MMSE score) (both p < 0.001). This association remained significant after adjusting for age, gender, BMI, lipids, estimated glomerular filtration rate, and smoking status. Longer survival was associated with lower concentrations of IL-6 and CRP not only in individuals with aging-related diseases/disability (HR = 1.063 per each pg/mL, 95 % CI: 1.052-1.074, p < 0.001 and HR = 1.020 per each mg/L, 95 % CI: 1.015-1.025, p < 0.001, respectively) but also in the successfully aging subgroup (HR = 1.163 per each pg/mL, 95 % CI: 1.128-1.199, p < 0.001 and HR = 1.074 per each mg/L, 95 % CI: 1.047-1.100, p < 0.001, respectively). These associations remained significant after adjusting for age, gender, BMI, lipids and smoking status. The Kaplan-Meier survival curves showed similar results (all p < 0.001).

CONCLUSIONS

Both IL-6 and CRP levels were good predictors of physical and cognitive performance and the risk of mortality in both the entire elderly population and in successfully aging individuals.