Association Between Adiposity and Lean Mass With Long‐Term Cardiovascular Events in Patients With Coronary Artery Disease: No Paradox

Abstract

BackgroundPrognosis based on body fat percentage (BF%) in patients with coronary artery disease has not been extensively studied. We tested the hypothesis that patients with coronary artery disease and increased BF% have a higher risk for major adverse cardiovascular events (MACEs) and that fat‐free mass is associated with better prognosis.Methods and ResultsWe included 717 patients referred to cardiac rehabilitation after coronary artery disease events or procedures who underwent air displacement plethysmography to assess BF%; 75% were men, with a mean age 61.4±11.4 years and a mean body mass index of 30±5.4 kg/m2. Follow‐up was performed using a record linkage system. Patients were classified in sex‐specific quartiles of BF% and fat‐free mass index. The composite outcome of MACEs included acute coronary syndromes, coronary revascularization, stroke, or death from any cause. After a median follow‐up of 3.9 years, 201 patients had a MACE. After adjusting for covariates, body mass index was not associated with MACEs (P=0.12). However, the risk of MACEs for those in the highest BF% quartile was nearly double when compared with those in the lowest quartile (hazard ratio, 1.89; 95% confidence interval, 1.30–2.77; P=0.0008). In contrast, fat‐free mass was inversely associated with MACEs. The risk of MACEs for those in the fourth fat‐free mass quartile was lower (adjusted hazard ratio, 0.53; 95% confidence interval, 0.35–0.82; P=0.004), when compared with those in the first quartile.ConclusionsIn patients with coronary artery disease, there is no obesity paradox when measuring BF% instead of body mass index. BF% is associated with a higher risk of MACEs, whereas fat‐free mass is associated with a lower risk of MACEs. Body mass index was not associated with MACEs.

Fat Mass Index Better Identifies Metabolic Syndrome: Insights from Patients in Early Outpatient Cardiac Rehabilitation

“…According to the obesity paradox, a higher BMI may be protective against CAD. However, recent findings suggest that this paradox may be a fallacy [15]. Medina-Inojosa et al [15] suggest that the number of major adverse cardiovascular events is greater with increased body fat percentage and decreased lean body mass-not simply with increased BMI-which shows the importance of assessment of fat and lean mass.…”

“…However, recent findings suggest that this paradox may be a fallacy [15]. Medina-Inojosa et al [15] suggest that the number of major adverse cardiovascular events is greater with increased body fat percentage and decreased lean body mass-not simply with increased BMI-which shows the importance of assessment of fat and lean mass. Our results are consistent with their data in that our cohort had greater metabolic abnormalities in the excess fat and obese groups when FMI was used for analysis than with BMI use [23].…”

“…The FMI facilitates accurate classification of patients into fat mass categories and may more precisely identify those at increased risk for future heart failure, atrial fibrillation, and death [24][25][26][27][28]. Quantification of fat and lean mass provides additional prognostic information because lean mass is associated with lower risk of major adverse cardiovascular events [15]. In CR programs, clinical staff can apply this knowledge in the design of effective individualized treatment plans, exercise prescriptions, and nutritional interventions aimed at increasing lean mass and reducing fat mass.…”

Body composition and mortality in the general population: A review of epidemiologic studies

“…33 Recently, several studies showed some evidence that body composition, especially lean body mass (muscle) may play an independent role on survival in patients with disease such as cancer and cardiovascular diseases. [34][35][36] Body composition has a potential to provide important prognostic information to improve survival among patients, and thus more studies are warranted to better understand this association in diverse patient populations.…”

Physical Activity: The Secret—Not So Secret—to Prevent and Revert Metabolic Dysregulation in People of All Sizes

“…8 Although this cohort comprised healthy individuals, in those with CVD the obesity paradox disappears when body fat is measured instead of body mass index (BMI). 9 Higher body fat was associated with adverse cardiovascular events, and, on the contrary, higher fat-free mass was associated with a lower risk of events. 9 Recent work by Zaccardi et al 10 aimed to address the inherent issues with reporting hazard ratios by estimating residual life expectancy across fitness and BMI levels.…”