- Email: [email protected]
Obesity Paradox in Contemporary Cardiology Practice∗
JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 10, NO. 13, 2017
ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jcin.2017.03.048
EDITORIAL COMMENT
Obesity Paradox in Contemporary Cardiology Practice* Debabrata Mukherjee, MD, Chandra Ojha, MD
T
he prevalence of obesity, considered a risk
PCI and report that an independent association of
factor for cardiovascular diseases (CVD) is
elevated BMI to reduced mortality after PCI still exists
increasing in the United States and globally.
in contemporary UK practice. Despite some limitations
A recent analysis reported that the age-adjusted prev-
of
alence of obesity (body mass index [BMI] $30 kg/m 2)
confounders, lack of complete data on optimal
in the United States was 35.0% among men and 40.4%
evidence-based medical therapies across groups, and
among women (1). The corresponding values for class
lack of data on marked recent weight loss and frailty,
3 obesity (BMI $40 kg/m 2) were 5.5% for men and
this large study is consistent with several recent
9.9% for women (1). Obesity is associated with higher
observations (4,5,8). The study raises important
plasma lipids, blood pressure, glucose or insulin
questions regarding implication for these findings and
resistance, and inflammation and excess risk of coro-
how we translate these observations into meaningful
nary heart disease and stroke (2). There is evidence
advice for clinical practitioners. The study authors
that that the entire spectrum of CVD is increased in
suggest that reduction in bleeding was likely driven to
obesity, including coronary heart disease, stroke, hy-
some extent by higher rates of radial access in patients
pertension, heart failure, peripheral vascular disease,
with greater BMI (48% vs. 44%) and that dosing of
arrhythmias, and atrial fibrillation (3). However, of
anticoagulation may be suboptimal in those with low
considerable interest is the finding that overweight
BMI, particularly in the acute coronary syndrome
and obesity patients with established CVD do better
setting with possible overdosing.
this
registry
study,
such
as
unrecognized
than do their leaner counterparts for subsequent
Although BMI may not necessarily be the most
events and when they undergo invasive procedures.
accurate measure of adiposity, as it is a height-
The so-called obesity paradox has been reported in
normalized sum of fat mass and fat-free mass (i.e.,
patients undergoing coronary revascularization pro-
total body weight divided by squared height), it
cedures (coronary artery bypass grafting and percuta-
remains the most commonly used metric to delineate
neous coronary intervention [PCI]) (4) and in those
obesity and is a strong predictor of CVD outcomes
with chronic heart failure (5) and in several other car-
(2,9). Although several reasons have been suggested
diac disease states (6).
to explain the obesity paradox (i.e., marked weight loss or frailty in those with low or normal BMI,
SEE PAGE 1283
In
this
issue
of
the
JACC:
younger age at presentation among the obese, less Cardiovascular
tobacco use, and possibly unmeasured confounders
Interventions, Holroyd et al. (7) examine the relation-
and genetic factors), cardiorespiratory fitness appears
ship between BMI and clinical outcomes following
to be an important mediator of outcomes. Cardiorespiratory or physical fitness appears to have significant prognostic implications among the obese and
*Editorials published in the JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology. From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Texas Tech University, El Paso, Texas. Both authors
overweight individuals. In fact, there is evidence that cardiorespiratory fitness modulates and modifies the relationship between obesity and CVD outcomes (6). McAuley et al. (10) investigated the associations of
have reported that they have no relationships relevant to the contents of
cardiorespiratory fitness and adiposity with CVD out-
this paper to disclose.
comes in men with known or suspected coronary heart
1294
Mukherjee and Ojha
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO. 13, 2017 JULY 10, 2017:1293–4
BMI and Outcomes After PCI
disease and reported that cardiorespiratory fitness
appropriately in all individuals irrespective of BMI,
greatly modifies the relation of adiposity to outcomes
use radial access for PCI in centers with adequate
with higher risk of all-cause mortality associated with
expertise, and very importantly stress and promote
low physical fitness across the BMI categories of
cardiorespiratory fitness. We should emphasize the
normal weight and class I, II, and III obese individuals.
importance of physical activity for everyone across
Similar findings were reported by Lavie et al. (11) in
all BMI levels, with 30 to 60 min of moderate-
patients with systolic heart failure, where no obesity
intensity aerobic activity, such as brisk walking, at
paradox was noted in those with high cardiorespira-
least 5 days and preferably 7 days per week (13).
tory fitness. A recent prospective cohort study that
Consistent
included 5,344 participants 55 years of age or older
recommend that patients with established CVD un-
from the population-based Rotterdam Study exam-
dergo risk assessment with a physical activity his-
ined the association between overweight and obesity
tory or an exercise test before starting an exercise
and CVD risk as a function of physical activity levels
program (13).
with
national
guidelines,
we
also
and reported that the beneficial impact of physical activity on CVD might outweigh the negative impact
ADDRESS FOR CORRESPONDENCE: Dr. Debabrata
of BMI among middle-aged and elderly people (12).
Mukherjee, Texas Tech University, Internal Medi-
Finally, for the practicing clinician it is important to dose medications including anticoagulant agents
cine, 4800 Alberta, El Paso, Texas 79905. E-mail: [email protected].
REFERENCES 1. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in obesity among adults in the United States, 2005 to 2014. JAMA 2016;315:2284–91. 2. Global Burden of Metabolic Risk Factors for Chronic Diseases C, Lu Y, Hajifathalian K, et al. Metabolic mediators of the effects of body-mass index, overweight, and obesity on coronary heart disease and stroke: a pooled analysis of 97 prospective cohorts with 1.8 million participants. Lancet 2014;383:970–83. 3. Ortega FB, Lavie CJ, Blair SN. Obesity and cardiovascular disease. Circ Res 2016;118:1752–70. 4. Sharma A, Vallakati A, Einstein AJ, et al. Relationship of body mass index with total mortality, cardiovascular mortality, and myocardial infarction after coronary revascularization: evidence from a meta-analysis. Mayo Clin Proc 2014;89:1080–100.
6. Lavie CJ, McAuley PA, Church TS, Milani RV, Blair SN. Obesity and cardiovascular diseases: implications regarding fitness, fatness, and severity in the obesity paradox. J Am Coll Cardiol 2014;63: 1345–54. 7. Holroyd EW, Sirker A, Kwok CS, et al. 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. J Am Coll Cardiol Intv 2017;10:1283–92. 8. Tan XF, Shi JX, Chen AM. Prolonged and intensive medication use are associated with the obesity paradox after percutaneous coronary intervention: a systematic review and meta-analysis of 12 studies. BMC Cardiovasc Disord 2016;16:125.
5. Sharma A, Lavie CJ, Borer JS, et al. Meta-anal-
9. Ortega FB, Sui X, Lavie CJ, Blair SN. Body mass index, the most widely used but also widely criti-
ysis of the relation of body mass index to all-cause and cardiovascular mortality and hospitalization in patients with chronic heart failure. Am J Cardiol 2015;115:1428–34.
cized index: would a criterion standard measure of total body fat be a better predictor of cardiovascular disease mortality? Mayo Clin Proc 2016;91: 443–55.
10. McAuley PA, Artero EG, Sui X, et al. The obesity paradox, cardiorespiratory fitness, and coronary heart disease. Mayo Clin Proc 2012;87:443–51. 11. Lavie CJ, Cahalin LP, Chase P, et al. Impact of cardiorespiratory fitness on the obesity paradox in patients with heart failure. Mayo Clin Proc 2013;88:251–8. 12. Dhana K, Koolhaas CM, Schoufour JD, Ikram MA, Kavousi M, Franco OH. Impact of physical activity on the association of overweight and obesity with cardiovascular disease: The Rotterdam Study. Eur J Prev Cardiol 2017;24:934–41. 13. Smith SC Jr., Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 2011;124:2458–73.
KEY WORDS cardiorespiratory fitness, cardiovascular diseases, coronary intervention, obesity
VOL. 10, NO. 13, 2017
ª 2017 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jcin.2017.03.048
EDITORIAL COMMENT
Obesity Paradox in Contemporary Cardiology Practice* Debabrata Mukherjee, MD, Chandra Ojha, MD
T
he prevalence of obesity, considered a risk
PCI and report that an independent association of
factor for cardiovascular diseases (CVD) is
elevated BMI to reduced mortality after PCI still exists
increasing in the United States and globally.
in contemporary UK practice. Despite some limitations
A recent analysis reported that the age-adjusted prev-
of
alence of obesity (body mass index [BMI] $30 kg/m 2)
confounders, lack of complete data on optimal
in the United States was 35.0% among men and 40.4%
evidence-based medical therapies across groups, and
among women (1). The corresponding values for class
lack of data on marked recent weight loss and frailty,
3 obesity (BMI $40 kg/m 2) were 5.5% for men and
this large study is consistent with several recent
9.9% for women (1). Obesity is associated with higher
observations (4,5,8). The study raises important
plasma lipids, blood pressure, glucose or insulin
questions regarding implication for these findings and
resistance, and inflammation and excess risk of coro-
how we translate these observations into meaningful
nary heart disease and stroke (2). There is evidence
advice for clinical practitioners. The study authors
that that the entire spectrum of CVD is increased in
suggest that reduction in bleeding was likely driven to
obesity, including coronary heart disease, stroke, hy-
some extent by higher rates of radial access in patients
pertension, heart failure, peripheral vascular disease,
with greater BMI (48% vs. 44%) and that dosing of
arrhythmias, and atrial fibrillation (3). However, of
anticoagulation may be suboptimal in those with low
considerable interest is the finding that overweight
BMI, particularly in the acute coronary syndrome
and obesity patients with established CVD do better
setting with possible overdosing.
this
registry
study,
such
as
unrecognized
than do their leaner counterparts for subsequent
Although BMI may not necessarily be the most
events and when they undergo invasive procedures.
accurate measure of adiposity, as it is a height-
The so-called obesity paradox has been reported in
normalized sum of fat mass and fat-free mass (i.e.,
patients undergoing coronary revascularization pro-
total body weight divided by squared height), it
cedures (coronary artery bypass grafting and percuta-
remains the most commonly used metric to delineate
neous coronary intervention [PCI]) (4) and in those
obesity and is a strong predictor of CVD outcomes
with chronic heart failure (5) and in several other car-
(2,9). Although several reasons have been suggested
diac disease states (6).
to explain the obesity paradox (i.e., marked weight loss or frailty in those with low or normal BMI,
SEE PAGE 1283
In
this
issue
of
the
JACC:
younger age at presentation among the obese, less Cardiovascular
tobacco use, and possibly unmeasured confounders
Interventions, Holroyd et al. (7) examine the relation-
and genetic factors), cardiorespiratory fitness appears
ship between BMI and clinical outcomes following
to be an important mediator of outcomes. Cardiorespiratory or physical fitness appears to have significant prognostic implications among the obese and
*Editorials published in the JACC: Cardiovascular Interventions reflect the views of the authors and do not necessarily represent the views of JACC: Cardiovascular Interventions or the American College of Cardiology. From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Texas Tech University, El Paso, Texas. Both authors
overweight individuals. In fact, there is evidence that cardiorespiratory fitness modulates and modifies the relationship between obesity and CVD outcomes (6). McAuley et al. (10) investigated the associations of
have reported that they have no relationships relevant to the contents of
cardiorespiratory fitness and adiposity with CVD out-
this paper to disclose.
comes in men with known or suspected coronary heart
1294
Mukherjee and Ojha
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 10, NO. 13, 2017 JULY 10, 2017:1293–4
BMI and Outcomes After PCI
disease and reported that cardiorespiratory fitness
appropriately in all individuals irrespective of BMI,
greatly modifies the relation of adiposity to outcomes
use radial access for PCI in centers with adequate
with higher risk of all-cause mortality associated with
expertise, and very importantly stress and promote
low physical fitness across the BMI categories of
cardiorespiratory fitness. We should emphasize the
normal weight and class I, II, and III obese individuals.
importance of physical activity for everyone across
Similar findings were reported by Lavie et al. (11) in
all BMI levels, with 30 to 60 min of moderate-
patients with systolic heart failure, where no obesity
intensity aerobic activity, such as brisk walking, at
paradox was noted in those with high cardiorespira-
least 5 days and preferably 7 days per week (13).
tory fitness. A recent prospective cohort study that
Consistent
included 5,344 participants 55 years of age or older
recommend that patients with established CVD un-
from the population-based Rotterdam Study exam-
dergo risk assessment with a physical activity his-
ined the association between overweight and obesity
tory or an exercise test before starting an exercise
and CVD risk as a function of physical activity levels
program (13).
with
national
guidelines,
we
also
and reported that the beneficial impact of physical activity on CVD might outweigh the negative impact
ADDRESS FOR CORRESPONDENCE: Dr. Debabrata
of BMI among middle-aged and elderly people (12).
Mukherjee, Texas Tech University, Internal Medi-
Finally, for the practicing clinician it is important to dose medications including anticoagulant agents
cine, 4800 Alberta, El Paso, Texas 79905. E-mail: [email protected].
REFERENCES 1. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in obesity among adults in the United States, 2005 to 2014. JAMA 2016;315:2284–91. 2. Global Burden of Metabolic Risk Factors for Chronic Diseases C, Lu Y, Hajifathalian K, et al. Metabolic mediators of the effects of body-mass index, overweight, and obesity on coronary heart disease and stroke: a pooled analysis of 97 prospective cohorts with 1.8 million participants. Lancet 2014;383:970–83. 3. Ortega FB, Lavie CJ, Blair SN. Obesity and cardiovascular disease. Circ Res 2016;118:1752–70. 4. Sharma A, Vallakati A, Einstein AJ, et al. Relationship of body mass index with total mortality, cardiovascular mortality, and myocardial infarction after coronary revascularization: evidence from a meta-analysis. Mayo Clin Proc 2014;89:1080–100.
6. Lavie CJ, McAuley PA, Church TS, Milani RV, Blair SN. Obesity and cardiovascular diseases: implications regarding fitness, fatness, and severity in the obesity paradox. J Am Coll Cardiol 2014;63: 1345–54. 7. Holroyd EW, Sirker A, Kwok CS, et al. 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. J Am Coll Cardiol Intv 2017;10:1283–92. 8. Tan XF, Shi JX, Chen AM. Prolonged and intensive medication use are associated with the obesity paradox after percutaneous coronary intervention: a systematic review and meta-analysis of 12 studies. BMC Cardiovasc Disord 2016;16:125.
5. Sharma A, Lavie CJ, Borer JS, et al. Meta-anal-
9. Ortega FB, Sui X, Lavie CJ, Blair SN. Body mass index, the most widely used but also widely criti-
ysis of the relation of body mass index to all-cause and cardiovascular mortality and hospitalization in patients with chronic heart failure. Am J Cardiol 2015;115:1428–34.
cized index: would a criterion standard measure of total body fat be a better predictor of cardiovascular disease mortality? Mayo Clin Proc 2016;91: 443–55.
10. McAuley PA, Artero EG, Sui X, et al. The obesity paradox, cardiorespiratory fitness, and coronary heart disease. Mayo Clin Proc 2012;87:443–51. 11. Lavie CJ, Cahalin LP, Chase P, et al. Impact of cardiorespiratory fitness on the obesity paradox in patients with heart failure. Mayo Clin Proc 2013;88:251–8. 12. Dhana K, Koolhaas CM, Schoufour JD, Ikram MA, Kavousi M, Franco OH. Impact of physical activity on the association of overweight and obesity with cardiovascular disease: The Rotterdam Study. Eur J Prev Cardiol 2017;24:934–41. 13. Smith SC Jr., Benjamin EJ, Bonow RO, et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 2011;124:2458–73.
KEY WORDS cardiorespiratory fitness, cardiovascular diseases, coronary intervention, obesity