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49 Cardiovascular Disease in the Bariatric Surgery Patient

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Minimally Invasive Bariatric Surgery

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Abstract

Obesity is a strong risk factor for the development of type 2 diabetes, hypertension, dyslipidemia, and cardiovascular disease (CVD). Diet, exercise, and drug therapies have limited potential to achieve significant and sustainable weight loss. Bariatric surgery has emerged as the most successful long-term strategy both in achieving weight loss and in promoting diabetes, hypertension, and hyperlipidemia remission. The malabsorptive procedures, including Roux-en-Y gastric bypass and biliopancreatic diversion, appear particularly effective in achieving diabetes remission. This impact on CVD risk factors appears to translate to a decrease in actual cardiovascular events for obese patients who have undergone bariatric surgery, with very preliminary data suggesting atherosclerosis regression. There is also some evidence to support a mortality benefit after surgical weight loss. In addition, there is now data demonstrating improvement of obesity-associated abnormalities in myocardial structure and function, such as ventricular hypertrophy, diastolic dysfunction, and subclinical systolic dysfunction, after bariatric procedures. The impact of bariatric surgery on heart failure is an area of current investigation.

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Authors and Affiliations

  1. Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA

    Amanda R. Vest M.B.B.S., M.R.C.P. & James B. Young M.D., F.A.C.C.

Authors
  1. Amanda R. Vest M.B.B.S., M.R.C.P.
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  2. James B. Young M.D., F.A.C.C.
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Corresponding author

Correspondence to James B. Young M.D., F.A.C.C. .

Editor information

Editors and Affiliations

  1. Cleveland Clinic Lerner College of Medicine, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio, USA

    Stacy A. Brethauer

  2. Cleveland Clinic Lerner College of Medicine, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio, USA

    Philip R. Schauer

  3. Department of Surgery, Health Sciences Center, University of Virginia Health System, Charlottesville, Virginia, USA

    Bruce D. Schirmer

Review Questions and Answers

Review Questions and Answers

  1. 1.

    Which of the following statements regarding coronary artery disease epidemiological risk factors is correct?

    1. (a)

      LDL serum concentration is inversely associated with cardiovascular mortality.

    2. (b)

      Systolic blood pressure is an independent coronary artery disease risk factor.

    3. (c)

      The strongest predictor of cardiovascular risk in the Framingham equation is body mass index (BMI).

    4. (d)

      Obesity is not an independent predictor of coronary artery disease risk.

    5. (e)

      HDL serum concentration has been observed to rise significantly within the first postoperative week of Roux-en-Y gastric bypass (RYGB).

      Correct answer: (b) Systolic blood pressure is one of the six major epidemiological risk factors for coronary artery disease development and cardiovascular events. The other major risk factors are advancing age, smoking, family history, elevated serum LDL or total cholesterol, low serum HDL, and diabetes. Diabetes is usually considered as a “coronary artery disease equivalent” in terms of risk prevention, because patients with diabetes and no known coronary artery disease have a similar risk of cardiovascular events as patients without diabetes who have a known coronary artery disease diagnosis. Obesity is also an independent predictor of coronary artery disease development, although it is a weaker association than the six major risk factors. The strongest predictor of cardiovascular risk in any risk equation, including the Framingham Risk Score, is patient age. Serum HDL, for which higher levels confer cardiovascular risk benefits, was observed by Garcia-Marirrodriga et al. [69] to decrease by 13.0 % at 6 months and then steadily increase by 3.8 % at 12 months and 19.3 % at 18 months.

  2. 2.

    Which of the following statements regarding adipokines and gut hormones is correct?

    1. (a)

      Circulating leptin levels are consistently low in obese individuals, compared to normal-weight controls.

    2. (b)

      Resistin, a cysteine-rich protein secreted primarily by adipose tissue, promotes insulin sensitivity and is anti-inflammatory.

    3. (c)

      CRP is an independent predictor of future cardiovascular risk in asymptomatic women and has been observed to fall significantly in the months after bariatric surgery.

    4. (d)

      GLP-1 agonists are a group of new diabetes medications that show significant reductions in glycemic parameters but with the adverse effect of weight gain in many patients.

    5. (e)

      Ghrelin is the gut hormone with the strongest evidence for mediation of the post-RYGB effects on glycemia.

      Correct answer: (c) Ridker et al. [51] described the relationships between CRP, the metabolic syndrome, and incident cardiovascular events among 14,719 apparently healthy women who were followed up for an 8-year period for myocardial infarction, stroke, coronary revascularization, or cardiovascular death. At all levels of severity of the metabolic syndrome, CRP added prognostic information on subsequent risk. Circulating leptin levels are elevated in obese states other than that due to leptin gene mutation, due to leptin resistance. Resistin is an adipokine that promotes insulin resistance, gluconeogenesis, and a pro-inflammatory state. The GLP-1 agonists are subcutaneously injected diabetes medications that also promote small but significant decreases in body weight during treatment duration. Ghrelin responses after RYGB are quite heterogeneous and are therefore less likely to explain reduced appetite and improved glucose homeostasis postoperatively than some of the other gut hormones and adipokines.

  3. 3.

    An asymptomatic 50-year-old patient with a BMI of 45 kg/m2 and diagnoses of coronary artery disease and diabetes presents for bariatric surgery evaluation. Which of the following statements are incorrect?

    1. (a)

      Compensated systolic heart failure is not a contraindication to bariatric surgery.

    2. (b)

      Markers of inflammation and endothelial function improve in the weeks and months after bariatric surgery.

    3. (c)

      He must undergo cardiac catheterization, with angioplasty of any significant coronary stenosis, before proceeding to the surgery.

    4. (d)

      Existing data suggests a lower rate of future cardiovascular events for patients who undergo bariatric surgery, compared to obese matched controls.

    5. (e)

      Large trials have demonstrated decreases in long-term cardiovascular events in patients who undergo bariatric surgery, compared to patients who receive optimal medical therapy, but none of these studies to date have been randomized.

      Correct answer: (c) Preoperative noninvasive cardiac stress testing or cardiac catheterization is only indicated in a select group of high-risk surgical candidates and not in patients with stable chronic coronary artery disease. Answers (a) and (b) are true statements. Although several studies have performed robust matching techniques in the selection of nonsurgical control groups, none of the studies of cardiovascular event or mortality studies has been randomized controlled trials. Therefore, (d) and (e) are also true statements.

  4. 4.

    Which of the following statements regarding myocardial structure and function is correct?

    1. (a)

      Left ventricular hypertrophy reduces more than right ventricular hypertrophy after surgical weight loss.

    2. (b)

      Obesity is a strong risk factor for diastolic dysfunction, and significant improvements in parameters of myocardial relaxation have been seen within the first postoperative year of bariatric surgery.

    3. (c)

      Reductions in left ventricular hypertrophy after RYGB are solely dependent on the postoperative reduction in systolic blood pressure.

    4. d)

      The left ventricular ejection fraction consistently increases postoperatively, both in patients with preexisting heart failure and in patients without prior cardiomyopathies.

    5. (e)

      Left ventricular ejection fraction is the most sensitive and widely used method of measuring mild reductions in systolic function.

      Correct answer: (b) Obesity, diabetes, and hypertension all increase the risk of diastolic dysfunction, in which ventricular filling during diastole is abnormal. Improvements in left ventricular hypertrophy and echocardiographic parameters of diastolic dysfunction have been seen as early as 3 months postoperatively. In an MRI study by Rider et al. [90], right ventricular wall thickening was seen to regress by a much greater degree than left ventricular wall thickening. Several authors have demonstrated that post-bariatric surgery improvements in left ventricular hypertrophy are independent of systolic blood pressure. In patients without preexisting systolic heart failure, stroke volume and left ventricular ejection fraction tend to decrease slightly with weight loss. There is limited data to suggest that some patients with systolic heart failure may experience a postoperative improvement in their left ventricular ejection faction. The ejection fraction is a relatively crude assessment of systolic function, and echocardiographic techniques such as strain and strain rate measurement offer much more sensitive assessments of subclinical abnormalities of systolic function.

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Vest, A.R., Young, J.B. (2015). 49 Cardiovascular Disease in the Bariatric Surgery Patient. In: Brethauer, S., Schauer, P., Schirmer, B. (eds) Minimally Invasive Bariatric Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-1637-5_49

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  • DOI: https://doi.org/10.1007/978-1-4939-1637-5_49

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  • Online ISBN: 978-1-4939-1637-5

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