The protective effect of obesity on mortality in acute coronary syndromes (ACS) patients
remains debated. We aimed at evaluating the impact of obesity on ischemic and bleeding
events as possible explanations to the obesity paradox in ACS patients. For the purpose
of this substudy, patients enrolled in the START-ANTIPLATELET registry were stratified
according to body mass index (BMI) into 3 groups: normal, BMI <25 kg/m2; overweight, BMI: 25 to 29.9 kg/m2; obese, BMI ≥30 kg/m2. The primary end point was net adverse clinical end points (NACE), defined as a composite
of all-cause death, myocardial infarction, stroke, and major bleeding. In n = 1,209
patients, n = 410 (33.9%) were normal, n = 538 (44.5%) were overweight and n = 261
(21.6%) were obese. Compared to the normal weight group, obese and overweight patients
had a higher prevalence of cardiovascular risk factors but were younger, with a better
left ventricular ejection fraction and lower PRECISE-DAPT score. At 1-year follow-up
net adverse clinical endpoints was more frequently observed in normal than in overweight
and obese patients (15.1%, 8.6%, and9.6%, respectively; p = 0.004), driven by a significantly
higher rate of all-cause death (6.3%, 2.6%, and 3.8%, respectively; p = 0.008), whereas
no significant differences were noted in terms of myocardial infarction, stroke, and
major bleeding. When correcting for confounding variables, BMI loses its power in
independently predicting outcomes, failing to confirm the obesity paradox in a real-world
ACS population. In conclusion, our study conflicts the obesity paradox in real-world
ACS population, and suggest that the reduced rate of adverse events and mortality
in obese patients may be explained by relevant differences in the clinical risk profile
and medications rather than BMI per se.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Obesity and cardiovascular disease.Circ Res. 2016; 118 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/27230640. Accessed February 1, 2019): 1752-1770
- Obesity.N Engl J Med. 1997; 337 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/9241130. Accessed February 1, 2019): 396-407
- Years of life lost due to obesity.JAMA. 2003; 289 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/12517229. Accessed February 13, 2019): 187-193
- Mortality risk factors in patients treated by chronic hemodialysis.Nephron. 1982; 31 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/7121651. Accessed February 6, 2019): 103-110
- Body mass index and mortality in heart failure: a meta-analysis.Am Heart J. 2008; 156 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/18585492. Accessed February 6, 2019): 13-22
- Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies.Lancet. 2006; 368 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/16920472. Accessed February 6, 2019): 666-678
- Evidence for obesity paradox in patients with acute coronary syndromes: a report from the Swedish Coronary Angiography and Angioplasty Registry.Eur Heart J. 2013; 34 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/22947610. Accessed February 6, 2019): 345-353
- Low-normal or excessive body mass index: newly identified and powerful risk factors for death and other complications with percutaneous coronary intervention.Am J Cardiol. 1996; 78 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/8831397. Accessed February 6, 2019): 642-646
- Effect of body mass index on clinical events after acute coronary syndromes.Am J Cardiol. 2017; 120 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/28916239. Accessed February 4, 2019): 1453-1459
- Impact of body mass index on 5-year clinical outcomes in patients with ST–segment elevation myocardial infarction after everolimus-eluting or bare-metal stent implantation.Am J Cardiol. 2017; 120: 1460-1466
- The Italian START-Register on Anticoagulation with Focus on Atrial Fibrillation.PLoS One. 2015; 10 (Available at: http://dx.plos.org/10.1371/journal.pone.0124719. Accessed February 8, 2019)e0124719
- Impact of chronic renal failure on ischemic and bleeding events at 1 year in patients with acute coronary syndrome (from the Multicenter START ANTIPLATELET Registry).Am J Cardiol. 2018; 122 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/30057232. Accessed March 8, 2019): 936-943
- Gender-related differences in antiplatelet therapy and impact on 1-year clinical outcome in patients presenting with ACS: the START ANTIPLATELET Registry.Angiology. 2019; 70 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/29969919. Accessed March 11, 2019): 257-263
- Prevalence and predictors of dual antiplatelet therapy prolongation beyond one year in patients with acute coronary syndrome.PLoS One. 2017; 12 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/29059255. Accessed March 11, 2019)e0186961
- Epidemiology and management of patients with acute coronary syndromes in contemporary real-world practice: evolving trends from the EYESHOT Study to the START-ANTIPLATELET Registry.Angiology. 2018; 69 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/29544348. Accessed March 8, 2019): 795-802
- Antiplatelet treatment in acute coronary syndrome patients: real-world data from the START-Antiplatelet Italian Registry.PLoS One. 2019; 14 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/31306454. Accessed August 19, 2019)e0219676
- American Heart Association call to action: obesity as a major risk factor for coronary heart disease. AHA Nutrition Committee.Circulation. 1998; 97 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/9626167. Accessed February 8, 2019): 2099-2100
- 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults.J Am Coll Cardiol. 2014; 63 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/24239920. Accessed February 8, 2019): 2985-3023
- Standardized end point definitions for coronary intervention trials: the academic research consortium-2 consensus document.Circulation. 2018; 137 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/29891620. Accessed August 30, 2018): 2635-2650
- An updated definition of stroke for the 21st century.Stroke. 2013; 44 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/23652265. Accessed February 13, 2019): 2064-2089
- Randomized trial of primary PCI with or without routine manual thrombectomy.N Engl J Med. 2015; 372 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/25853743. Accessed January 31, 2018): 1389-1398
- Derivation and validation of the predicting bleeding complications in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE-DAPT) score: a pooled analysis of individual-patient datasets from clinical trials.Lancet. 2017; 389 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/28290994. Accessed February 8, 2019): 1025-1034
- Obesity and antiplatelets-does one size fit all?.Thromb Res. 2015; 136 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/26205154. Accessed August 13, 2019): 712-716
- Dual antiplatelet therapy duration based on ischemic and bleeding risks after coronary stenting.J Am Coll Cardiol. 2019; 73 (Available at:https://www.sciencedirect.com/science/article/pii/S0735109718395421?via%3Dihub. Accessed March 8, 2019): 741-754
- Impact of left ventricular function in relation to procedural outcomes following percutaneous coronary intervention: insights from the British Cardiovascular Intervention Society.Eur Heart J. 2014; 35 (Available at: https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehu303. Accessed February 13, 2019): 3004-3012
- Prognostic value of ejection fraction in patients admitted with acute coronary syndrome: a real world study.Medicine (Baltimore). 2017; 96 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/28248882. Accessed February 13, 2019): e6226
- Clinical and angiographic predictors of short- and long-term ischemic events in acute coronary syndromes.Circ Cardiovasc Interv. 2010; 3 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/20647564. Accessed February 13, 2019): 308-316
- Antithrombotic therapy and body mass: an expert position paper of the ESC Working Group on Thrombosis.Eur Heart J. 2018; 39 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/29509886. Accessed February 3, 2019): 1672-1686f
- A call for action in bleeding prevention.Aging (Albany NY). 2019; 11 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/30636170. Accessed March 8, 2019): 287-288
- Associations with weight loss and subsequent mortality risk.Ann Epidemiol. 2005; 15 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/16029840. Accessed February 13, 2019): 483-491
- Body mass index and acute coronary syndromes: paradox or confusion?.Eur Hear J Acute Cardiovasc Care. 2015; 4 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/24923461. Accessed August 6, 2019): 158-164
- Radial versus femoral access and bivalirudin versus unfractionated heparin in invasively managed patients with acute coronary syndrome (MATRIX): final 1-year results of a multicentre, randomised controlled trial.Lancet. 2018; 392 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/30153988. Accessed March 11, 2019): 835-848
- From femoral to radial approach in coronary intervention.Angiology. 2017; 68 (Available at: http://www.ncbi.nlm.nih.gov/pubmed/27401210. Accessed March 11, 2019): 281-287
Article info
Publication history
Published online: September 06, 2019
Received in revised form:
August 21,
2019
Received:
June 10,
2019
Identification
Copyright
© 2019 Elsevier Inc. All rights reserved.
