Should We Target Obesity in Advanced Heart Failure?
- 240 Downloads
Obesity is a risk factor for the development of heart failure (HF), but has been associated with improved survival in patients with established HF. Weight loss should clearly be recommended and supported for obese individuals without cardiac pathology to prevent cardiomyopathy development. Clinical recommendations at the other end of the obesity heart failure spectrum are also relatively clear. Morbidly obese individuals (BMI ≥ 40 kg/m2) aged <50 years with severely depressed systolic function and NYHA class III-IV symptoms should be considered for malabsorptive bariatric surgery at an experienced center. The goal is either improved systolic function and symptoms, or sufficient weight loss for heart transplant eligibility. Recommendations for patients falling between these extremes are more challenging. Overweight and mildly obese HF patients (25–35 kg/m2) may be somewhat protected from cardiac cachexia and weight loss is not expected to enhance survival, but may offer symptomatic benefits.
KeywordsObesity Heart failure Left ventricular dysfunction Echocardiography Adipokines Bariatric surgery Obesity paradox
Compliance with Ethics Guidelines
Conflict of Interest
Dr. Amanda R Vest received travel/accommodations expenses covered or reimbursed by the American Heart Association and is employed by the Cleveland Clinic. Dr. James B Young declares that he has no conflicts of interest. The authors did not receive funding for this work, and they have no financial relationships or other industry disclosures to make.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 2.World Health Organization. World Health Statistics, 2011. WHO. 2011;1–171.Google Scholar
- 5.Djoussé L, Bartz TM, Ix JH, Zieman SJ, Delaney JA, Mukamal KJ, et al. Adiposity and incident heart failure in older adults: the Cardiovascular Health Study. Obesity. 2011;20(9):1936–41.Google Scholar
- 7.•Loehr LR, Rosamond WD, Poole C, McNeill AM, Chang PP, Folsom AR, et al. Association of multiple anthropometrics of overweight and obesity with incident heart failure. Circ Heart Fail. 2009;2(1):18–24. A 14,641-patient longitudinal cohort analysis demonstrating the association between generalized obesity and central adiposity over 16 years' median follow-up. This study demonstrates that the anthropomorphic metrics of BMI, waist circumference, and waist-hip ratio are essentially equivalent in their prediction of HF risk and that the elevated HF risk persists after adjustment for key confounders such as age, smoking, and educational level.PubMedCentralPubMedCrossRefGoogle Scholar
- 8.••Hu G, Jousilahti P, Antikainen R, Katzmarzyk PT, Tuomilehto J. Joint effects of physical activity, body mass index, waist circumference, and waist-to-hip ratio on the risk of heart failure. Circulation. 2010;121(2):237–44. Builds on the observations of Loehr et al. with a large cohort of 59,178 Finnish participants followed for HF incidence over a mean of 18.4 years. General and central adiposity was independently associated with HF risk, whereas moderate or high levels of physical activity reduced the risk of HF development. This paper showed a protective effect of physical activity at all levels of BMI, which highlights the value of a comprehensive lifestyle intervention for HF prevention.PubMedCrossRefGoogle Scholar
- 22.••Voulgari C, Tentolouris N, Dilaveris P, Tousoulis D, Katsilambros N, Stefanadis C. Increased heart failure risk in normal-weight people with metabolic syndrome compared with metabolically healthy obese individuals. J Am Coll Cardiol. 2011;58(13):1343–50. Five hundred and fifty nondiabetic patients enrolled in a prospective, community-based study were studied for HF development over 6 years. Subjects with metabolic syndrome who were normal weight, overweight, or obese with had approximately 2.3, 2.6, and 2.1 times higher adjusted odds of developing HF, respectively, compared with subjects without metabolic syndrome. The strength of the relationship between metabolic syndrome and HF incidence persisted after adjustment for age, sex, current smoking, physical inactivity, lipids, glycemic, and inflammation profile. In contradiction to many of the above studies, obesity status and BMI were not independent predictors of 6-year HF risk in this cohort. This could be because of the relatively small cohort size, or perhaps because obesity is actually a surrogate for metabolic dysfunction in studies such as Loehr et al. and Hu et al., rather than a true etiological factor.PubMedCrossRefGoogle Scholar
- 23.McManus DD, Lyass A, Ingelsson E, Massaro JM, Meigs JB, Aragam J, et al. Relations of circulating resistin and adiponectin and cardiac structure and function: the Framingham Offspring Study. Obesity. 2012;20(9):1882–6.Google Scholar
- 53.••Oreopoulos A, Padwal R, Kalantar-Zadeh K, Fonarow GC, Norris CM, McAlister FA. Body mass index and mortality in heart failure: a meta-analysis. Am Heart J. 2008;156(1):13–22. A meta-analysis of 28,209 patients across 9 studies, mainly ad hoc analyses of HF therapy trials, which supports the obesity survival paradox. Compared with patients with normal BMI, obesity and overweight were both associated with a lower risk of adjusted all-cause mortality (adjusted HR 0.88, 95% CI 0.83–0.93 and adjusted HR 0.93, 95% CI 0.89–0.97, respectively), which was a consistent finding across the component studies. Conversely, underweight/low-normal-weight patients had a higher risk-adjusted mortality (adjusted HR 1.11, 95% CI 1.01–1.23). This provides some of the strongest evidence that well-managed HF patients derive some mortality benefit from their adiposity.PubMedCrossRefGoogle Scholar
- 60.Ather S, Chan W, Bozkurt B, Aguilar D, Ramasubbu K, Zachariah AA, et al. Impact of noncardiac comorbidities on morbidity and mortality in a predominantly male population with heart failure and preserved vs. reduced ejection fraction. J Am Coll Cardiol. 2012;59(11):998–1005.PubMedCrossRefGoogle Scholar
- 61.Abdulla J, Kober L, Abildstrøm SZ, Christensen E, James WPT, Torp-Pedersen C. Impact of obesity as a mortality predictor in high-risk patients with myocardial infarction or chronic heart failure: a pooled analysis of five registries. 2008;29(5):594–601.Google Scholar
- 63.Kenchaiah S, Pocock SJ, Wang D, Finn PV, Zornoff LAM, Skali H, et al. Body mass index and prognosis in patients with chronic heart failure: insights from the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) Program. Circulation. 2007;116(6):627–36.PubMedCrossRefGoogle Scholar
- 71.•Sjöström L, Peltonen M, Jacobson P, Sjöström CD, Karason K, Wedel H, et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307(1):56–65. A key cardiovascular paper in the bariatric surgery field, demonstrating the potential for surgical weight loss to achieve long-term reductions in cardiovascular events and mortality. This publication reported on 2,010 obese participants who underwent bariatric surgery in the Swedish Obese Subjects (SOS) trial and 2,037 contemporaneously matched obese controls who received usual care. Bariatric surgery was associated with a reduced number of cardiovascular deaths (adjusted HR 0.47, 95% CI 0.29–0.76, P = 0.002) and fewer cardiovascular events (adjusted HR, 0.67, 95% CI 0.54-0.83; P < 0.001) during median 14.7 years' follow-up. However this study was non-randomized and selection bias could have contributed to the favorable post-surgical outcome.PubMedCrossRefGoogle Scholar
- 72.••Rider OJ, Francis JM, Ali MK, Petersen SE, Robinson M, Robson MD, et al. Beneficial cardiovascular effects of bariatric surgical and dietary weight loss in obesity. J Am Coll Cardiol. 2009;54(8):718–26. The first rigorous imaging assessment of myocardial structure and function pre and postweight loss, comparing 30 otherwise healthy obese subjects who underwent cardiac MRI before and 1 year after significant weight loss. Both dietary and surgical weight loss led to significant decreases in biventricular mass, end-diastolic volume, and diastolic dysfunction. This illustrates both the potential for weight loss to significantly alter the adverse structural effects of obesity and the utility of MRI in evaluating these changes.PubMedCrossRefGoogle Scholar
- 75.Woelnerhanssen B, Peterli R, Steinert RE, Peters T, Borbély Y, Beglinger C. Effects of postbariatric surgery weight loss on adipokines and metabolic parameters: comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy—a prospective randomized trial. Surg Obes Relat Dis. 2011;7(5):561–8.PubMedCrossRefGoogle Scholar
- 76.Ikonomidis I, Mazarakis A, Papadopoulos C, Patsouras N, Kalfarentzos F, Lekakis J, et al. Weight loss after bariatric surgery improves aortic elastic properties and left ventricular function in individuals with morbid obesity: a 3-year follow-up study. J Hypertens. 2007;25(2):439–47.PubMedCrossRefGoogle Scholar
- 80.Pournaras DJ, Le Roux CW. Ghrelin and metabolic surgery. Int J Peptides. 2010;(217267):1–5.Google Scholar
- 83.Perego L, Pizzocri P, Corradi D, Maisano F, Paganelli M, Fiorina P, et al. Circulating leptin correlates with left ventricular mass in morbid (grade III) obesity before and after weight loss induced by bariatric surgery: a potential role for leptin in mediating human left ventricular hypertrophy. J Clin Endocrinol Metab. 2005;90(7):4087–93.PubMedCrossRefGoogle Scholar
- 92.Gill RS, Karmali S, Nagandran J, Frazier HO, Sherman V. Combined Ventricular Assist Device Placement with adjustable gastric Band (VAD-BAND): a promising new technique for morbidly obese patients awaiting potential cardiac transplantation. J Clin Med Res. 2012;4(2):127–9.PubMedCentralPubMedGoogle Scholar