Effects of left ventricular geometry and obesity on mortality in women with normal ejection fraction.

Left ventricular (LV) geometry is an independent predictor of cardiovascular morbidity and mortality. Although obesity is a known risk factor for cardiovascular diseases, studies have suggested a paradoxical relation between obesity and prognosis. We retrospectively assessed 26,126 female patients with normal LV ejection fraction to determine the impact of LV geometry, including normal structure, concentric remodeling, and eccentric or concentric LV hypertrophy, and obesity on mortality during an average follow-up of 1.7 years. Abnormal LV geometry occurred more commonly in obese (body mass index ≥30 kg/m(2), n = 10,465) compared with nonobese (body mass index <30 kg/m(2), n = 15,661) patients (56% vs 47%, respectively, p <0.0001). Overall mortality, however, was considerably less in obese compared with nonobese patients (5.6% vs 8.7%, respectively, p <0.0001). In both groups, progressive increases in mortality were observed from normal structure to concentric remodeling and then to eccentric and concentric LV hypertrophy (obese patients 2.9%, 6.5%, 6.7%, and 11.1%, respectively, and nonobese patients 5.3%, 10.6%, 11.4%, and 16.8%, respectively, p <0.0001 for trend). In conclusion, although an obesity paradox exists, in that obesity in women is associated with abnormal LV geometry but less mortality, our data demonstrate that abnormal LV geometric patterns are highly prevalent in both obese and nonobese female patients with normal ejection fraction and are associated with greater mortality.

Relation of body fat categories by Gallagher classification and by continuous variables to mortality in patients with coronary heart disease.

Although obesity is a coronary heart disease risk factor, in cohorts of patients with coronary heart disease, an "obesity paradox" exists whereby patients with obesity have a better prognosis than do leaner patients. Obesity is generally defined by body mass index, with relatively little described regarding body fat (BF). In this study, 581 consecutive patients with coronary heart disease divided into the Gallagher BF categories of underweight (n = 12), normal (n = 189), overweight (n = 214), and obese (n = 166) were evaluated, and 3-year mortality was assessed using the National Death Index. Mortality was U shaped, being highest in the underweight group (25%, p <0.0001 vs all groups) and lowest in the overweight group (2.3%), with intermediate mortality in the normal-BF (6.4%, p = 0.02 vs overweight) and obese (3.6%) groups. In multiple regression analysis, high BF (odds ratio 0.89, 95% confidence interval 0.82 to 0.95) and higher Gallagher class (odds ratio 0.46, 95% confidence interval 0.25 to 0.84) were independent predictors of lower mortality. In conclusion, on the basis of Gallagher BF, an obesity paradox exists, with the highest mortality in the underweight and normal-BF groups and the lowest mortality in the overweight group. Lower BF as a continuous variable and by Gallagher classification as a categorical value were independent predictors of higher mortality.

Body composition and survival in stable coronary heart disease: impact of lean mass index and body fat in the "obesity paradox".

OBJECTIVES: Our goal was to determine the impact of lean mass index (LMI) and body fat (BF) on survival in patients with coronary heart disease (CHD). BACKGROUND: An inverse relationship between obesity and prognosis has been demonstrated (the "obesity paradox") in CHD, which has been explained by limitations in the use of body mass index in defining body composition. METHODS: We studied 570 consecutive patients with CHD who were referred to cardiac rehabilitation, stratified as Low (≤25% in men and ≤35% in women) and High (>25% in men and >35% in women) BF and as Low (≤18.9 kg/m2 in men and ≤15.4 kg/m2 in women) and High LMI, and followed for 3 years for survival. RESULTS: Mortality is inversely related to LMI (p<0.0001). Mortality was highest in the Low BF/Low LMI group (15%), which was significantly higher than in the other 3 groups, and lowest in the High BF/High LMI group (2.2%), which was significantly lower than in the other 3 groups. In Cox regression analysis as categoric variables, low LMI (hazard ratio [HR]: 3.1; 95% confidence interval [CI]: 1.3 to 7.1) and low BF (HR: 2.6; 95% CI: 1.1 to 6.4) predicted higher mortality, and as continuous variables, high BF (HR: 0.91; 95% CI: 0.85 to 0.97) and high LMI (HR: 0.81; 95% CI: 0.65 to 1.00) predicted lower mortality. CONCLUSIONS: In patients with stable CHD, both LMI and BF predict mortality, with mortality particularly high in those with Low LMI/Low BF and lowest in those with High LMI/High BF. Determination of optimal body composition in primary and secondary CHD prevention is needed.

Body composition and coronary heart disease mortality--an obesity or a lean paradox?

OBJECTIVE: To determine the combined effects of body mass index (BMI) and body fat (BF) on prognosis in coronary heart disease (CHD) to better understand the obesity paradox. PATIENTS AND METHODS: We studied 581 patients with CHD between January 1, 2000, and July 31, 2005, who were divided into low (<25) and high BMI (≥25), as well as low (≤25% men and ≤35% women) and high BF (>25% in men and >35% in women). Four groups were analyzed by total mortality during the 3-year follow-up by National Death Index: low BF/low BMI (n=119), high BF/low BMI (n=26), low BF/high BMI (n=125), and high BF/high BMI (n=311). RESULTS: During the 3-year follow-up, mortality was highest in the low BF/low BMI group (11%), which was significantly (P<.001) higher than that in the other 3 groups (3.9%, 3.2%, and 2.6%, respectively); using the high BF/high BMI group as a reference, the low BF/low BMI group had a 4.24-fold increase in mortality (confidence interval [CI], 1.76-10.23; P=.001). In multivariate logistic regression for mortality, when entered individually, both high BMI (odds ratio [OR], 0.79; CI, 0.69-0.90) and high BF (OR, 0.89; CI, 0.82-0.95) as continuous variables were independent predictors of better survival, whereas low BMI (OR, 3.60; CI, 1.37-9.47) and low BF (OR, 3.52; CI, 1.34-9.23) as categorical variables were independent predictors of higher mortality. CONCLUSION: Although both low BF and low BMI are independent predictors of mortality in patients with CHD, only patients with combined low BF/low BMI appear to be at particularly high risk of mortality during follow-up. Studies are needed to determine optimal body composition in the secondary prevention of CHD.

Value of weight reduction in patients with cardiovascular disease.

OPINION STATEMENT: Obesity is an independent risk factor for cardiovascular (CV) disease and contributes markedly to individual CV risk factors, including hypertension, diabetes mellitus, dyslipidemia, and other chronic conditions, such as osteoarthritis, obstructive sleep apnea, and physical deconditioning. Obesity, defined as a body mass index ≥30 kg/m(2), is associated with increased morbidity and mortality, particularly in severely obese patients with a body mass index ≥35 kg/m(2). Physical activity, healthy eating and behavioral modification are three pivotal approaches to treating obesity. Some individuals may benefit from pharmacologic agents to achieve meaningful weight loss. Unfortunately, there are few such agents at present with proven efficacy and safety profiles. In this review, we discuss the obesity epidemic and its detrimental effects on the CV system, and focus on exercise training and on established pharmacologic agents as well as those on the horizon. We conclude by summarizing the surgical therapeutic options available to treat obesity and the evidence supporting the CV benefits of surgery, and discuss the potential adverse effects of both pharmacologic and surgical options.

Clinical impact of left ventricular hypertrophy and implications for regression.

Left ventricular hypertrophy (LVH) is an independent risk factor and predictor of cardiovascular (CV) events and all-cause mortality. Patients with LVH are at increased risk for stroke, congestive heart failure, coronary heart disease, and sudden cardiac death. Left ventricular hypertrophy represents both a manifestation of the effects of hypertension and other CV risk factors over time as well as an intrinsic condition causing pathologic changes in the CV structure and function. We review the risk factors for LVH and its consequences, concentric remodeling, and its prognostic significance, clinical benefits and supporting evidence for LVH regression, and its implications for management. We conclude our review summarizing the various pharmacological and nonpharmacological therapeutic options approved for the treatment of hypertension and LVH regression and the supporting clinical trial data for these therapeutic strategies.

The obesity paradox, weight loss, and coronary disease.

PURPOSE: Because obesity is a cardiovascular risk factor but is associated with a more favorable prognosis among cohorts of cardiac patients, we assessed this "obesity paradox" in overweight and obese patients with coronary heart disease enrolled in a cardiac rehabilitation and exercise training (CRET) program, making this assessment in patients classified as overweight/obese using both traditional body mass index (BMI) and percent body fat assessments. Additionally, we assessed the efficacy and safety of purposeful weight loss in overweight and obese coronary patients. PATIENTS AND METHODS: We retrospectively studied 529 consecutive CRET patients following major coronary events before and after CRET, and compared baseline and post program data in 393 overweight and obese patients (body mass index [BMI] > or =25 kg/m(2)) divided by median weight change (median=-1.5%; mean +2% vs -5%, respectively). In addition, we assessed 3-year total mortality in various baseline BMI categories as well as compared mortality in those with high baseline percent fat (>25% in men and >35% in women) versus those with low baseline fat. RESULTS: Following CRET, the overweight and obese with greater weight loss had improvements in BMI (-5%; P <.0001), percent fat (-8%; P <.0001), peak oxygen consumption (+16%; P <.0001), low-density lipoprotein cholesterol (-5%; P <.02), high-density lipoprotein cholesterol (+10%; P <.0001), triglycerides (-17%; P <.0001), C-reactive protein (-40%; P <.0001), and fasting glucose (-4%; P=.02), as well as marked improvements in behavioral factors and quality-of-life scores. Those with lower weight loss had no significant improvements in percent fat, low-density lipoprotein cholesterol, triglycerides, C-reactive protein, and fasting glucose. During 3-year follow-up, overall mortality trended only slightly lower in those with baseline overweightness/obesity who had more weight loss (3.1% vs 5.1%; P=.30). However, total mortality was considerably lower in the baseline overweight/obese (BMI > or =25 kg/m(2)) than in 136 CRET patients with baseline BMI <25 kg/m(2) (4.1% vs 13.2%; P <.001), as well as in those with high baseline fat compared with those with low fat (3.8% vs 10.6%; P <.01). CONCLUSIONS: Purposeful weight loss with CRET in overweight/obese coronary patients is associated with only a nonsignificant trend for lower mortality but is characterized by marked improvements in obesity indices, exercise capacity, plasma lipids, and inflammation, as well as behavioral factors and quality of life. Although an "obesity paradox" exists using either baseline BMI or baseline percent fat criteria, these results support the safety and potential long-term benefits of purposeful weight loss in overweight and obese patients with coronary heart disease.

Disparate effects of obesity and left ventricular geometry on mortality in 8088 elderly patients with preserved systolic function.

BACKGROUND: Although left ventricular (LV) geometry has predicted cardiovascular (CV) prognosis, including in elderly cohorts, the role of obesity on CV prognosis has been more controversial. OBJECTIVE: To assess the independent effects of obesity and LV geometry on all-cause mortality in a large cohort of elderly patients with preserved LV systolic function. PATIENTS AND METHODS: We retrospectively assessed 8088 elderly patients (> 70 years) with an LV ejection fraction (LVEF) > or = 50% who were referred for echocardiography at a large primary, secondary, and tertiary health care system in New Orleans. We specifically assessed clinical and echocardiographic features to determine the impact of body mass index (BMI) and LV geometric patterns, including concentric remodeling (CR) and LV hypertrophy (LVH) on all-cause mortality during an average 3.1-year follow-up. RESULTS: Although abnormal LV geometry (P < 0.01) and LVH (P < 0.001) progressively increased with more obesity, total mortality was strongly and inversely (P < 0.0001) related with BMI. However, in each BMI subgroup, mortality progressively increased with abnormal LV geometry from normal, CR, eccentric LVH, and concentric LVH (P < 0.001 for all trends). In a multivariate analysis, abnormal LV geometry, including increased relative wall thickness (Chi-square 16; P < 0.0001) and LV mass index (Chi-square 12; P < 0.0001), and lower BMI (Chi-square 33; P < 0.0001) were independent predictors of mortality. CONCLUSION: Although an obesity paradox exists, in that obesity is associated with abnormal LV geometry but lower mortality, our data demonstrate that LV geometric abnormalities are prevalent in elderly patients with preserved systolic function and are associated with progressive increases in mortality.

Major recent trials in cardiovascular diseases.

This article provides information and commentary on recent clinical trials related to primary prevention in cardiovascular diseases including lipids, hypertension, and diabetes. It also focuses on novel therapeutic advances in heart failure with devices and therapeutic agents. In addition, we explore trials looking at the effects of the investigational agents azimilide and dronedarone in the treatment of arrhythmias, application of established therapies/devices to larger populations, and the impact of hypercoagulability and aortic arch plaques on the incidence of stroke. Finally, we conclude with trials from the interventional arena evaluating new agents in the treatment of myocardial infarction, comparing percutaneous coronary intervention with coronary artery bypass grafting surgery in patients with diabetes, and reporting registry data on long-term treatment with dual antiplatelet therapy. Some of the preliminary data presented are from unpublished reports and may be subject to change in the final publications.

Obesity and hypertension, heart failure, and coronary heart disease-risk factor, paradox, and recommendations for weight loss.

Obesity prevalence has reached epidemic proportions and is independently associated with numerous cardiovascular disease (CVD) risk factors, including diabetes mellitus, hypertension, dyslipidemia, cancers, sleep apnea, and other major CVDs. Obesity has significant negative impact on CVD, including hypertension, coronary heart disease, heart failure, and arrhythmias via its maladaptive effects on individual CVD risk factors and cardiac structure and function. Despite this negative association between obesity and the incidence and prevalence of CVD, many studies have demonstrated that obese patients with established CVD might have better short- and long-term prognosis, suggesting an "obesity paradox." This intriguing phenomenon has been well documented in populations with heart failure, coronary heart disease, and hypertension. This review summarizes the adverse effects of obesity on individual CVD risk factors; its role in the genesis of CVDs, including heart failure, coronary heart disease, and hypertension; and the obesity paradox observed in these populations and the potential underlying mechanisms behind this puzzling phenomenon and concludes with a discussion on the potential benefits of weight reduction.

Impact of obesity on the risk of heart failure and its prognosis.

Obesity is becoming a global epidemic in both children and adults, and it is associated with numerous comorbidities such as coronary heart disease, stroke/cerebrovascular disease, type 2 diabetes, hypertension, certain cancers, and sleep-disordered breathing. Over the past 2 decades, the incidence of and mortality from coronary heart disease and cardiovascular diseases has been continuously declining. In contrast, the incidence of and mortality from heart failure (HF) have been increasing, with HF diagnosed in approximately 5 million Americans and 550,000 new cases diagnosed each year and a death rate looming at 300,000 per year. Over the years, conventional risk factors including hypertension, type 2 diabetes, and dyslipidemia have been implicated for these unsavory statistics, and recently many studies have highlighted the important role of obesity as an independent risk factor for HF. Here, the authors review the available literature on the effects of overweight and obesity on a variety of cardiac structural adaptations and alterations, the effects on left ventricular systolic and diastolic function, and their role in the development and prognosis of HF. Numerous studies have demonstrated an "obesity paradox" regarding prognosis, however, in that obese patients with established HF tend to have a more favorable prognosis than do lean patients. Finally, the authors discuss the role of cardiopulmonary exercise testing in the risk stratification of obese patients with advanced HF.

The obesity paradox: impact of obesity on the prevalence and prognosis of cardiovascular diseases.

Obesity has reached global epidemic proportions and is associated with numerous comorbidities such as hypertension (HTN), type 2 diabetes mellitus, dyslipidemia, certain cancers, and chronic kidney disease (CKD). Obesity, via its direct maladaptive effects on cardiac structure and through its impact on conventional risk factors, is strongly associated with cardiovascular (CV) diseases such as heart failure (HF) and coronary heart disease (CHD). Despite these adverse associations, numerous studies indicate an "obesity paradox" in that being overweight or obese is associated with a favorable prognosis in many patients with established CV disease, particularly in patients with HTN, HF, and CHD. This review summarizes the adverse effects of obesity on CV disease risk factors and its role in the genesis of HTN, HF, CHD, and the obesity paradox. It concludes with a discussion on the potential benefits of weight loss in these patient populations.

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Cardiac rehabilitation programs markedly improve high-risk profiles in coronary patients with high psychological distress.

OBJECTIVES: Adverse behavioral profiles, particularly depression and hostility, increase the risk of coronary artery disease (CAD) and affect recovery after CAD events. We sought to determine the effects of outpatient phase II cardiac rehabilitation and exercise training (CRET) programs in CAD patients with high levels of psychological distress. METHODS: We studied 500 consecutive patients both before and after phase II CRET programs and compared 109 patients with the highest quintile of psychological distress (HD) with 115 patients with the lowest quintile of psychological distress (LD). RESULTS: At baseline, patients with HD were younger (P < 0.001), had higher weight (+11%; P < 0.001), body mass indices (BMI) (+9%; P < 0.01), triglycerides (+66%; P < 0.0001), and glycosylated hemoglobin (+9%; P = 0.03), and had higher scores for depression, hostility, anxiety, and somatization (all P < 0.0001), but had lower values for exercise capacity (-15%; P = 0.02), high-density lipoprotein (HDL) cholesterol (-10%; P < 0.01), and total quality of life (QoL) (-26%; P < 0.0001), and all 6 major components of QoL compared with LD. After CRET, patients with HD had significant reductions in weight (-2%; P < 0.01), % fat (-6%; P < 0.001), BMI (-2%, P < 0.01), and scores for anxiety (-49%), depression (-47%), somatization (-34%) and hostility (-38%) (all P < 0.0001), and increases in exercise capacity (+54%; P < 0.0001), HDL cholesterol (+10%; P < 0.0001), and total QoL (+23%; P < 0.0001), and the 6 components of QoL studied. Compared with patients with LD, those with HD had statistically greater improvements in HDL (P = 0.03), triglycerides (P = 0.03), BMI (P = 0.02), as well as all behavioral characteristics and QoL (P < 0.0001), and had similar improvements in all other factors assessed. CONCLUSIONS: These data support the routine assessment of high-risk behavioral characteristics in patients with CAD and demonstrate the marked improvements that occur after phase II CRET programs in CAD patients with high psychological distress.

Fish oil in primary and secondary cardiovascular prevention.

Omega-3 fatty acid therapy shows great promise in both primary and secondary prevention of cardiovascular (CV) diseases, especially coronary heart disease (CHD). In this review, we discuss the evidence available from prospective and retrospective observational epidemiologic studies and controlled clinical trials demonstrating the effects of omega-3 fatty acids (fish oil) in primary and especially secondary prevention of major CV events, including CV mortality, fatal and nonfatal myocardial infarction (MI), and sudden cardiac death (SCD). Significant reductions in total mortality and SCD to the extent of 20% to 50% have been found in studies using doses ranging from 0.85 to 4.0 g/d. We review the compelling evidence that indicates all clinicians should strongly consider therapy with fish oil, specifically eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), for patients with known CV disease and for patients at increased risk for CV disease, particularly patients at increased risk for SCD. The target DHA + EPA consumption levels are about 800 to 1000 mg/d for individuals with known CHD and at least 500 mg/d for individuals without disease.

The obesity paradox and discrepancy between peak oxygen consumption and heart failure prognosis--it's all in the fat.

The authors present the case of an obese patient with advanced heart failure that demonstrates the paradox between obesity and heart failure prognosis. In addition, the authors discuss the rationale for the correction of cardiopulmonary stress data (used as predictors of survival and listing for cardiac transplantation) for lean weight (as opposed to total body weight), a consideration that may be particularly important in obese patients with a high percentage of body fat.

Psychological factors and cardiac risk and impact of exercise training programs-a review of ochsner studies.

Although under-emphasized, substantial evidence indicates that psychological distress, especially depression, hostility, and anxiety, are risk factors for coronary heart disease (CHD) and affect recovery following major coronary heart disease events. We review several major studies from Ochsner Medical Center demonstrating the high prevalence of psychological distress in CHD patients and the marked benefits that occur following formal cardiac rehabilitation and exercise training programs. These benefits include reductions in psychological stress, improvements in CHD risk factors that accompany high stress, and reduced all-cause mortality. These data support the benefits of exercise training and increased levels of fitness to improve psychological stress and subsequent prognosis.