Body mass index and outcomes in ischaemic versus non-ischaemic heart failure across the spectrum of ejection fraction

Abstract

Aims Obesity is related to better prognosis in heart failure with either reduced (HFrEF; left ventricular ejection fraction (LVEF) <40%) or preserved LVEF (HFpEF; LVEF ≥50%). Whether the obesity paradox exists in patients with heart failure and mid-range LVEF (HFmrEF; LVEF 40–49%) and whether it is independent of heart failure aetiology is unknown. Therefore, we aimed to test the prognostic value of body mass index (BMI) in ischaemic and non-ischaemic heart failure patients across the whole spectrum of LVEF. Methods Consecutive ambulatory heart failure patients were enrolled in two tertiary centres in Italy and Spain and classified as HFrEF, HFmrEF or HFpEF, of either ischaemic or non-ischaemic aetiology. Patients were stratified into underweight (BMI <18.5 kg/m2), normal-weight (BMI 18.5–24.9 kg/m2), overweight (BMI 25–29.9 kg/m2), mild-obese (BMI 30–34.9 kg/m2), moderate-obese (BMI 35–39.9 kg/m2) and severe-obese (BMI ≥40 kg/m2) and followed up for the end-point of five-year all-cause mortality. Results We enrolled 5155 patients (age 70 years (60–77); 71% males; LVEF 35% (27–45); 63% HFrEF, 18% HFmrEF, 19% HFpEF). At multivariable analysis, mild obesity was independently associated with a lower risk of all-cause mortality in HFrEF (hazard ratio, 0.78 (95% confidence interval (CI) 0.64–0.95), p = 0.020), HFmrEF (hazard ratio 0.63 (95% CI 0.41–0.96), p = 0.029), and HFpEF (hazard ratio 0.60 (95% CI 0.42–0.88), p = 0.008). Both overweight and mild-to-moderate obesity were associated with better outcome in non-ischaemic heart failure, but not in ischaemic heart failure. Conclusions Mild obesity is independently associated with better survival in heart failure across the whole spectrum of LVEF. Prognostic benefit of obesity is maintained only in non-ischaemic heart failure.

Re-appraisal of the obesity paradox in heart failure: a meta-analysis of individual data

“…Numerous studies have found generally lower risk in overweight and obese patients with HF, as compared to patients with normal body weight [5,10] and nicely summarised in a recent meta-analysis [12], unless obesity is extreme [13]. Some exceptions have been described based on HF aetiology (ischaemic vs. non-ischaemic) [14,15] or the presence of diabetes [16]. Physiology in HF may change, and factors that increase the risk of HF such as obesity might become unimportant or even protective.…”

Impact of obesity on echocardiographic parameters and N-terminal pro-brain natriuretic peptide levels in patients with heart failure with mid-range ejection fraction: unanswered questions

“…У пациентов с СН в 30-40% случаев диагностируется избыточный вес и до 49% случаев выявляется ожирение, при этом данный "метаболический" клинический фенотип преобладает среди больных СНсФВ [8]. В то же время диапазон встречаемости ожирения в подгруппе пациентов с СНпФВ различной этиологии по данным некоторых обсервационных наблюдательных и оригинальных исследований довольно широк и составляет от 25 до 57% [9][10][11].…”

Overweight and obesity: time to reconsider their role in heart failure

“…In this issue of EJPC, Gentile et al explored the prognostic value of BMI in patients with HF. 13 A total of 5155 patients with either ischaemic or nonischaemic HF were followed up for the end point of 5-year all-cause mortality. The vast majority of patients had heart failure with reduced ejection fraction (HFrEF; left ventricular ejection fraction (LVEF) <40%; 63%), while the rest were equally distributed between heart failure with mid-range EF (HFmEF, LVEF 40-49%; 18%) and heart failure with preserved ejection fraction (HFpEF, LVEF 50%; 19%).…”

“…Gentile and colleagues 13 should be congratulated for performing a large study with a comprehensive and robust statistical approach. The authors evaluated the independent association of different BMI categories with mortality, after adjusting for important demographic and clinical factors (i.e.…”

“…12 The current study by Gentile et al significantly adds to the existing literature regarding HF and the obesity paradox. 13 Although the patient population was heterogeneous, the authors tried to homogenise their data by performing subgroup analyses, according to LVEF (HFpEF, HFmEF, HFrEF) and HF aetiology (ischaemic, non-ischaemic) (Figure 1). Notably, underweight was an independent predictor of mortality in all subanalyses, while the prognostic value of higher BMI varied across the different subgroups of patients.…”