The “Obesity Paradox” in Patients With HFpEF With or Without Comorbid Atrial Fibrillation

Background: Overweight and mildly obese individuals have a lower risk of death than their normal-weight counterparts; this phenomenon is termed “obesity paradox.” Whether this “obesity paradox” exists in patients with heart failure (HF) or can be modified by comorbidities is still controversial. Our current study aimed to determine the association of body mass index (BMI) with outcomes with patients with HF with preserved ejection fraction (HFpEF) with or without coexisting atrial fibrillation (AF).Methods: Patients with HFpEF from the Americas in the TOPCAT trial were categorized into the 3 groups: normal weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2), and obesity (≥30 kg/m2). The Cox proportional-hazards models were used to calculate the adjusted hazard ratios (HRs) and CIs.Results: We identified 1,749 patients with HFpEF, 42.1% of which had baseline AF. In the total population of HFpEF, both overweight (HR = 0.59, 95% CI: 0.42–0.83) and obesity (HR = 0.49, 95% CI: 0.35–0.69) were associated with a reduced risk of all-cause death. Among patients with HFpEF without AF, overweight (HR = 0.51, 95% CI: 0.27–0.95) and obesity (HR = 0.64, 95% CI: 0.43–0.98) were associated with a lower risk of all-cause death. In those with AF, obesity (HR = 0.62, 95% CI: 0.40–0.95) but not overweight (HR = 0.81, 95% CI: 0.54–1.21) was associated with a decreased risk of all-cause death.Conclusions: The “obesity paradox” assessed by BMI exists in patients with HFpEF regardless of comorbid AF.Clinical Trial Registration:https://clinicaltrials.gov, identifier: NCT00094302.

Impact of nutritional status on heart failure mortality: a retrospective cohort study

Background Chronic heart failure (CHF) is one of the most common causes of mortality in industrialized countries despite regular therapeutic advances. Numerous factors influence mortality in CHF patients, including nutritional status. It is known that malnutrition is a risk factor for mortality, whereas obesity may play a protective role, a phenomenon dubbed the “obesity paradox”. However, the effect of the obesity-malnutrition association on mortality has not been previously studied for CHF. Our aim was to study the effect of nutritional status on overall mortality in CHF patients. Methods This retrospective, multicenter study was based on a French nationwide database (PMSI). We included all CHF patients aged ≥18 years admitted to all public and private hospitals between 2012 and 2016 and performed a survival analysis over 1 to 4 years of follow-up. Results Malnutrition led to a significant decrease in life expectancy in CHF patients when compared with normal nutritional status (aHR=1.16 [1.14-1.18] at one year and aHR=1.04 [1.004-1.08] at four years), obese, and obese-malnutrition groups. In contrast, obesity led to a significant increase in life expectancy compared with normal nutritional status (aHR=0.75 [0.73-0.78] at one year and aHR=0.85 [0.81-0.90] at four years), malnutrition, and obese-malnutrition groups. The mortality rate was similar in patients presenting both malnutrition and obesity and patients with normal nutritional status. Conclusions Our results indicate that the protective effect on mortality observed in obese CHF patients seems to be linked to fat massincrease. Furthermore, malnourished obese and normal nutritional status patients had similar mortality rates. Further studies should be conducted to confirm our results and to explore the physiopathological mechanisms behind these effects.

obesity paradox and mortality after pathological hip fractures: a Swedish registry study

Background and purpose — Obesity as measured by BMI has been associated with increased survival in various diseases, a phenomenon known as the “obesity paradox.” It is unknown whether obesity is associated with survival after pathological fractures. We investigated the association between BMI and survival after surgery for pathological hip fracture, to improve survival prognostication, and lay grounds for further interventional nutritional studies. Patients and methods — We analyzed prospectively collected data from Swedish nationwide registry “RIKSHÖFT.” The study cohort included 1,000 patients operated for a pathological hip fracture between 2014 and 2019. BMI registered on admission was available in 449 patients. Overall patient survival was measured according to the Kaplan–Meier method. Multivariable regression was used to evaluate association with other potential factors that influence patient survival. Results — Overweight and obesity were associated with an increased postoperative survival in male patients with surgically treated pathological hip fractures. Multivariable analysis considering potential confounders confirmed this finding. The association was not that strong in women and did not reach statistical significance. Interpretation — BMI, a commonly available clinical parameter, is a good predictor of overall survival for patients operated on for pathological hip fracture. Incorporation of BMI in existent survival prognostication algorithms should be considered. Treatment of malnutrition in this frail group of patients is worth studying.

Obesity as a risk factor for heart failure: overview of systematic reviews

The overweight and population with obesity has an increased risk of mortality from HF. However, some studies point to the existence of an "obesity paradox" where there could be a protective effect on the relative risk of death by HF in these populations with high BMI. In this way, the present study aimed to investigate obesity as a risk factor for heart failure. For this, an overview of systematic reviews was performed by selecting articles from the following databases: "Pubmed", "Scopus" and "SciElo”. A total of 615 articles were found from this initial search, leaving 59 articles for full-text reading, of which 22 articles were included for data extraction using the predefined inclusion criteria. From these 22 studies 73% were meta-analysis and 64% of the studies are of high methodological quality according to AMSTAR-2. Overweight and obesity have demonstrated a close relationship with the onset and increase of mortality by HF, studies have even been found that point to a gene interference in this relationship. In studies reporting on the obesity paradox, the results pointed to a momentary protection from mortality risk.

Another Look at Obesity Paradox in Acute Ischemic Stroke: Association Rule Mining

Though obesity is generally associated with the development of cardiovascular disease (CVD) risk factors, previous reports have also reported that obesity has a beneficial effect on CVD outcomes. We aimed to verify the existing obesity paradox through binary logistic regression (BLR) and clarify the paradox via association rule mining (ARM). Patients with acute ischemic stroke (AIS) were assessed for their 3-month functional outcome using the modified Rankin Scale (mRS) score. Predictors for poor outcome (mRS 3–6) were analyzed through BLR, and ARM was performed to find out which combination of risk factors was concurrently associated with good outcomes using maximal support, confidence, and lift values. Among 2580 patients with AIS, being obese (OR [odds ratio], 0.78; 95% CI, 0.62–0.99) had beneficial effects on the outcome at 3 months in BLR analysis. In addition, the ARM algorithm showed obese patients with good outcomes were also associated with an age less than 55 years and mild stroke severity. While BLR analysis showed a beneficial effect of obesity on stroke outcome, in ARM analysis, obese patients had a relatively good combination of risk factor profiles compared to normal BMI patients. These results may partially explain the obesity paradox phenomenon in AIS patients.

Associations between body mass index and bladder cancer survival: Is the obesity paradox short-lived?

Introduction: We investigated the associations of pre-surgical body mass index (BMI) with bladder cancer outcomes in patients treated with radical cystectomy. Methods: We retrospectively analyzed data from 488 bladder cancer patients treated with radical cystectomy between 1994 and 2007 and followed up until 2016. Cox regression with step function (time-segment analysis) was conducted for overall survival because the proportional hazard assumption was violated. Results: Of 488 bladder cancer patients, 155 (31.8%) were normal weight, 186 (38.1%) were overweight, and 147 (30.1%) were obese. During the median followup of 59.5 months, 363 (74.4%) patients died, including 197 (40.4%) from bladder cancer. In adjusted Cox regression analyses, BMI was not significantly associated with bladder cancer-specific survival for overweight (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.57–1.10, p=0.16) or obese (HR 0.76, 95% CI 0.52–1.09, p=0.13) patients. In the Cox regression with step function for overall survival, the time interaction was significant overall (p=0.020) and specifically for overweight patients (p=0.006). In the time-segment model, the HR for overweight during the first 63 months was 0.66 (95% CI 0.49–0.90, p=0.008), whereas it was 1.41 (95% CI 0.89–2.23, p=0.14) after 63 months. Although not statistically significant, a similar pattern was observed for obese patients. Conclusions: Our findings suggest that overweight and obese bladder cancer patients had better outcomes within the first five years after radical cystectomy; however, there were no differences in longer-term survival. These data suggest that the obesity paradox in bladder cancer patients treated with radical cystectomy may be short-lived.