Background:
Of various explanations for the ‘obesity paradox’ that lean people with cardiovascular diseases are more likely to have poorer outcomes vs. obese, one hypothesis is that obese patients display a readily identifiable high vascular risk phenotype that may lead to receiving or seeking earlier/more aggressive treatment.
Objective:
To examine whether lean stroke patients are less likely to receive optimal combination treatment (OCT) and explore a differential impact of combination therapy on clinical outcomes in lean stroke patients.
Methods:
We analyzed a clinical trial dataset comprising 3643 recent (<120 days) ischemic stroke patients followed up for 2 years. Subjects were categorized as having lean body mass index (BMI, <25 kg/m2, n=1006), overweight BMI (25 to 29.9 kg/m2, n=1493), and obese BMI 30 <kg/m2, n=1144). Subjects were categorized by level 0 to III depending on the number of the secondary prevention prescription divided by the number of drugs potentially indicated for each patient (0=none of the indicated medications and III=all indicated medications as OCT). Independent associations of each BMI category with all-cause death and major vascular events (stroke/myocardial infarction/vascular death) were assessed.
Results:
All-cause death occurred in 7.3% in lean, 5.5% in overweight, and 5.1% in obese patients. Frequency of OCT (level III) was 45.8% in lean, 51.7% in overweight, and 55.3% in obese patients. Subjects with lower BMI status had lesser frequency of OCT (45.8% in lean, 51.7% in overweight, and 55.3% in obese; P<0.001). Obese (vs. lean) patients were less likely to experience death (HR 0.70; 95% CI: 0.50–0.99, P=0.034), although this decreased risk was slightly attenuated and not significant after multivariable adjustment and was not seen with major vascular events. In multivariable analyses, compared with levels 0 and I, level II and level III were linked to lower risk of major vascular events (0.55; 0.32-0.95 and 0.48; 0.28–0.83) and death (0.44; 0.21-0.96 and 0.23; 0.10–0.54) among lean patients.
Conclusions:
OCT of secondary prevention medication after a recent ischemic stroke is less frequent in lean (vs. obese) patients, but when implemented is related to significantly better clinical outcomes among lean patients.
Optimal combination treatment and vascular outcomes in recent ischemic stroke patients by premorbid risk level