Journal of Nuclear Cardiology

, Volume 17, Issue 3, pp 390–397 | Cite as

Impact of weight on long-term survival among patients without known coronary artery disease and a normal stress SPECT MPI

  • Seth Uretsky
  • Azhar Supariwala
  • Padmakshi Singh
  • Prashanth Atluri
  • Surinder S. Khokhar
  • Hari K. Koppuravuri
  • Rajeev Joshi
  • Anupa Mandeva
  • Alan Rozanski
Original Article



While obesity has been shown to be associated with a worse mortality, an “obesity paradox”—lower mortality in obese patients—has been noted among many patients with coronary artery disease (CAD). The extent to which an obesity paradox operates among patients with only suspected CAD, is not well determined.

Methods and Results

A total of 3,673 patients (60 ± 13 years, 36% males) with no history of heart disease and a normal stress SPECT were included in this study. Normal weight was defined as BMI of 18.5-24.9 kg · m2; overweight 25-29.9 kg · m2, obese >30 kg · m2. The baseline clinical risk factors were recorded for each patient. The end point of the study was all-cause mortality. Of patients 942 (26%) were normal weight, 1,261 (34%) were overweight, and 1,470 (40%) were obese. Mean patient follow-up was 7.5 ± 3 years. When compared to normal weight patients (event rate 3.2%/year), there was a lower incidence of death in the overweight (event rate 1.5%/year, P < .0001) and the obese (event rate 1.2%/year, P < .0001) groups. After controlling for baseline risk factors, using a reference HR = 1 for normal weight patients, there was a lower risk of death in the overweight (HR = .54, 95% CI .43-.7) and the obese groups (HR = .49, 95% CI .38-.63).


In patients without known cardiac disease and a normal stress SPECT, overweight and obese patients had a lower rate of all-cause mortality compared to normal weight patients over long-term follow-up. This study substantially extends the spectrum of patients in whom the obesity paradox is present.


Obesity obesity paradox SPECT mortality 



The authors have no disclosures and have received no funding support for this study.


  1. 1.
    Adams KF, Schatzkin A, Harris TB, Kipnis V, Mouw T, Ballard-Barbash R, et al. Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old. N Engl J Med 2006;355:763-78.CrossRefPubMedGoogle Scholar
  2. 2.
    Batty GD, Shipley M, Jarrett J, Breeze E, Marmot M, Davey Smith G. Obesity and overweight in relation to disease-specific mortality in men with and without existing coronary heart disease in London: The original Whitehall study. Heart 2006;92:886–92.CrossRefPubMedGoogle Scholar
  3. 3.
    Calle EE, Thun MJ, Petrelli JM, Rodriguez C, Heath CW Jr. Body-mass index and mortality in a prospective cohort of U.S. adults. N Engl J Med 1999;341:1097-105.CrossRefPubMedGoogle Scholar
  4. 4.
    Cui R, Iso H, Toyoshima H, Date C, Yamamoto A, Kikuchi S, et al. Body mass index and mortality from cardiovascular disease among Japanese men and women: The JACC study. Stroke 2005;36:1377-82.CrossRefPubMedGoogle Scholar
  5. 5.
    Flegal KM, Graubard BI, Williamson DF, Gail MH. Excess deaths associated with underweight, overweight, and obesity. Jama 2005;293:1861-7.CrossRefPubMedGoogle Scholar
  6. 6.
    Grundy SM, Pasternak R, Greenland P, Smith S Jr, Fuster V. AHA/ACC scientific statement: Assessment of cardiovascular risk by use of multiple-risk-factor assessment equations: A statement for healthcare professionals from the American Heart Association and the American College of Cardiology. J Am Coll Cardiol 1999;34:1348-59.CrossRefPubMedGoogle Scholar
  7. 7.
    Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: A 26-year follow-up of participants in the Framingham Heart Study. Circulation 1983;67:968-77.PubMedGoogle Scholar
  8. 8.
    Jee SH, Sull JW, Park J, Lee SY, Ohrr H, Guallar E, et al. Body-mass index and mortality in Korean men and women. N Engl J Med 2006;355:779-87.CrossRefPubMedGoogle Scholar
  9. 9.
    Jousilahti P, Tuomilehto J, Vartiainen E, Pekkanen J, Puska P. Body weight cardiovascular risk factors, and coronary mortality. 15-year follow-up of middle-aged men and women in eastern Finland. Circulation 1996;93:1372-9.PubMedGoogle Scholar
  10. 10.
    Manson JE, Willett WC, Stampfer MJ, Colditz GA, Hunter DJ, Hankinson SE, et al. Body weight and mortality among women. N Engl J Med 1995;333:677-85.CrossRefPubMedGoogle Scholar
  11. 11.
    Pischon T, Boeing H, Hoffmann K, Bergmann M, Schulze MB, Overvad K, et al. General and abdominal adiposity and risk of death in Europe. N Engl J Med 2008;359:2105-20.CrossRefPubMedGoogle Scholar
  12. 12.
    Jensen MK, Chiuve SE, Rimm EB, Dethlefsen C, Tjonneland A, Joensen AM, et al. Obesity, behavioral lifestyle factors, and risk of acute coronary events. Circulation 2008;117:3062-9.CrossRefPubMedGoogle Scholar
  13. 13.
    Wilson PW, D’Agostino RB, Sullivan L, Parise H, Kannel WB. Overweight and obesity as determinants of cardiovascular risk: The Framingham experience. Arch Intern Med 2002;162:1867-72.CrossRefPubMedGoogle Scholar
  14. 14.
    Burke GL, Bertoni AG, Shea S, Tracy R, Watson KE, Blumenthal RS, et al. The impact of obesity on cardiovascular disease risk factors and subclinical vascular disease: The Multi-Ethnic Study of Atherosclerosis. Arch Intern Med 2008;168:928-35.CrossRefPubMedGoogle Scholar
  15. 15.
    Cox N, Resnic FS, Popma JJ, Simon DI, Eisenhauer AC, Rogers C. Comparison of the risk of vascular complications associated with femoral and radial access coronary catheterization procedures in obese versus nonobese patients. Am J Cardiol 2004;94:1174-7.CrossRefPubMedGoogle Scholar
  16. 16.
    Curtis JP, Selter JG, Wang Y, Rathore SS, Jovin IS, Jadbabaie F, et al. The obesity paradox: Body mass index and outcomes in patients with heart failure. Arch Intern Med 2005;165:55-61.CrossRefPubMedGoogle Scholar
  17. 17.
    Fonarow GC, Srikanthan P, Costanzo MR, Cintron GB, Lopatin M. An obesity paradox in acute heart failure: Analysis of body mass index and inhospital mortality for 108, 927 patients in the Acute Decompensated Heart Failure National Registry. Am Heart J 2007;153:74-81.CrossRefPubMedGoogle Scholar
  18. 18.
    Gruberg L, Mercado N, Milo S, Boersma E, Disco C, van Es GA, et al. Impact of body mass index on the outcome of patients with multivessel disease randomized to either coronary artery bypass grafting or stenting in the ARTS trial: The obesity paradox II? Am J Cardiol 2005;95:439-44.CrossRefPubMedGoogle Scholar
  19. 19.
    Gurm HS, Brennan DM, Booth J, Tcheng JE, Lincoff AM, Topol EJ. Impact of body mass index on outcome after percutaneous coronary intervention (the obesity paradox). Am J Cardiol 2002;90:42-5.CrossRefPubMedGoogle Scholar
  20. 20.
    Kang X, Shaw LJ, Hayes SW, Hachamovitch R, Abidov A, Cohen I, et al. Impact of body mass index on cardiac mortality in patients with known or suspected coronary artery disease undergoing myocardial perfusion single-photon emission computed tomography. J Am Coll Cardiol 2006;47:1418-26.CrossRefPubMedGoogle Scholar
  21. 21.
    Lavie CJ, Osman AF, Milani RV, Mehra MR. Body composition and prognosis in chronic systolic heart failure: The obesity paradox. Am J Cardiol 2003;91:891-4.CrossRefPubMedGoogle Scholar
  22. 22.
    Romero-Corral A, Montori VM, Somers VK, Korinek J, Thomas RJ, Allison TG, et al. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: A systematic review of cohort studies. Lancet 2006;368:666-78.CrossRefPubMedGoogle Scholar
  23. 23.
    Galal W, van Domburg RT, Feringa HH, Schouten O, Elhendy A, Bax JJ, et al. Relation of body mass index to outcome in patients with known or suspected coronary artery disease. Am J Cardiol 2007;99:1485-90.CrossRefPubMedGoogle Scholar
  24. 24.
    Galal W, van Gestel YR, Hoeks SE, Sin DD, Winkel TA, Bax JJ, et al. The obesity paradox in patients with peripheral arterial disease. Chest 2008;134:925-30.CrossRefPubMedGoogle Scholar
  25. 25.
    Lavie CJ, Milani RV, Ventura HO, Cardenas GA, Mehra MR, Messerli FH. Disparate effects of left ventricular geometry and obesity on mortality in patients with preserved left ventricular ejection fraction. Am J Cardiol 2007;100:1460-4.CrossRefPubMedGoogle Scholar
  26. 26.
    Canoy D, Boekholdt SM, Wareham N, Luben R, Welch A, Bingham S, et al. Body fat distribution and risk of coronary heart disease in men and women in the European Prospective Investigation Into Cancer and Nutrition in Norfolk cohort: A population-based prospective study. Circulation 2007;116:2933-43.CrossRefPubMedGoogle Scholar
  27. 27.
    Yusuf S, Hawken S, Ounpuu S, Bautista L, Franzosi MG, Commerford P, et al. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: A case-control study. Lancet 2005;366:1640-9.CrossRefPubMedGoogle Scholar
  28. 28.
    Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N, et al. Heart disease and stroke statistics—2008 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2008;117:e25-146.CrossRefPubMedGoogle Scholar
  29. 29.
    Uretsky S, Messerli FH, Bangalore S, Champion A, Cooper-Dehoff RM, Zhou Q, et al. Obesity paradox in patients with hypertension and coronary artery disease. Am J Med 2007;120:863-70.CrossRefPubMedGoogle Scholar
  30. 30.
    Ashton WD, Nanchahal K, Wood DA. Body mass index and metabolic risk factors for coronary heart disease in women. Eur Heart J 2001;22:46-55.CrossRefPubMedGoogle Scholar
  31. 31.
    Seidell JC, Verschuren WM, van Leer EM, Kromhout D. Overweight, underweight, and mortality. A prospective study of 48, 287 men and women. Arch Intern Med 1996;156:958-63.CrossRefPubMedGoogle Scholar
  32. 32.
    McAuley P, Myers J, Abella J, Froelicher V. Body mass, fitness and survival in veteran patients: Another obesity paradox? Am J Med 2007;120:518-24.CrossRefPubMedGoogle Scholar
  33. 33.
    Feldman AM, Combes A, Wagner D, Kadakomi T, Kubota T, Li YY, et al. The role of tumor necrosis factor in the pathophysiology of heart failure. J Am Coll Cardiol 2000;35:537-44.CrossRefPubMedGoogle Scholar
  34. 34.
    Messerli FH. Cardiovascular adaptations to obesity and arterial hypertension: Detrimental or beneficial? Int J Cardiol 1983;3:94-7.CrossRefPubMedGoogle Scholar
  35. 35.
    Messerli FH, Sundgaard-Riise K, Reisin E, Dreslinski G, Dunn FG, Frohlich E. Disparate cardiovascular effects of obesity and arterial hypertension. Am J Med 1983;74:808-12.CrossRefPubMedGoogle Scholar
  36. 36.
    Diercks DB, Roe MT, Mulgund J, Pollack CV Jr, Kirk JD, Gibler WB, et al. The obesity paradox in non-ST-segment elevation acute coronary syndromes: results from the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association Guidelines Quality Improvement Initiative. Am Heart J 2006;152:140-8.CrossRefPubMedGoogle Scholar
  37. 37.
    Berman DS, Wong ND, Gransar H, Miranda-Peats R, Dahlbeck J, Hayes SW, et al. Relationship between stress-induced myocardial ischemia and atherosclerosis measured by coronary calcium tomography. J Am Coll Cardiol 2004;44:923-30.CrossRefPubMedGoogle Scholar
  38. 38.
    Kragelund C, Omland T. A farewell to body-mass index? Lancet 2005;366:1589-91.CrossRefPubMedGoogle Scholar
  39. 39.
    Lee SH, Park JS, Kim W, Shin DG, Kim YJ, Kim DS, et al. Impact of body mass index and waist-to-hip ratio on clinical outcomes in patients with ST-segment elevation acute myocardial infarction (from the Korean Acute Myocardial Infarction Registry). Am J Cardiol 2008;102:957-65.CrossRefPubMedGoogle Scholar
  40. 40.
    de Koning L, Merchant AT, Pogue J, Anand SS. Waist circumference and waist-to-hip ratio as predictors of cardiovascular events: Meta-regression analysis of prospective studies. Eur Heart J 2007;28:850-6.CrossRefPubMedGoogle Scholar
  41. 41.
    Gruberg L, Weissman NJ, Waksman R, Fuchs S, Deible R, Pinnow EE, et al. The impact of obesity on the short-term and long-term outcomes after percutaneous coronary intervention: The obesity paradox? J Am Coll Cardiol 2002;39:578-84.CrossRefPubMedGoogle Scholar

Copyright information

© American Society of Nuclear Cardiology 2010

Authors and Affiliations

  • Seth Uretsky
    • 1
  • Azhar Supariwala
    • 1
  • Padmakshi Singh
    • 1
  • Prashanth Atluri
    • 1
  • Surinder S. Khokhar
    • 1
  • Hari K. Koppuravuri
    • 1
  • Rajeev Joshi
    • 1
  • Anupa Mandeva
    • 1
  • Alan Rozanski
    • 1
  1. 1.Division of Cardiology, Department of Medicine, St. Luke’s and Roosevelt HospitalsColumbia University College of Physicians and SurgeonsNew YorkUSA

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