Metabolic profile and exercise capacity outcomes: their relationship to overweight and obesity in a Canadian cardiac rehabilitation setting

PURPOSE: Obesity remains a significant health problem for cardiac rehabilitation patients. The purpose of this study was to examine the relation of overweight and obesity to cardiovascular risk factors in patients, and to compare the change in cardiovascular risk factor profiles in patients with coronary artery disease undergoing cardiac rehabilitation at a tertiary care hospital center in Ontario, Canada. METHODS: Retrospective analysis of cross-sectional data for 3542 patients, ages 63 +/- 11 years, stratified by body mass index (BMI), was performed. RESULTS: The findings showed that 81% of the patients had a BMI exceeding 25 kg/m(2), and that 35% of the patients were obese (BMI > or =30 kg/m(2)). After adjustment for age, sex, smoking, hypertension, diabetes, and peak power output, BMI was a significant independent predictor of a higher total cholesterol level, higher fasting blood glucose and triglyceride levels, and lower levels of high-density lipoprotein cholesterol. The Adult Treatment Panel III criteria were used to examine the prevalence of the metabolic syndrome for each BMI group. At baseline, 77% of the obese males in classes 2 and 3 had three or more risk factors for the metabolic syndrome, as compared with 68% of the obese females in classes 2 and 3. After 24 weeks of intervention, the outcome data for 1353 patients showed that despite no change in body weight, all the BMI groups demonstrated significant improvements in metabolic profiles and peak exercise capacity. CONCLUSIONS: Cardiac rehabilitation results in significant improvement in the cardiovascular risk profile at all levels of BMI, independently of weight loss. Future studies should examine whether targeting weight loss in cardiac rehabilitation further improves outcomes and the overall cardiovascular risk profile.     

Excess weight at time of presentation of myocardial infarction is associated with lower initial mortality risks but higher long-term risks including recurrent re-infarction and cardiac death

OBJECTIVES: To evaluate the influence of elevated body mass index (BMI) on short- and long-term survival following acute myocardial infarction (AMI). BACKGROUND: Recent studies suggest an obesity survival paradox in individuals undergoing percutaneous coronary intervention with better 30-day and 1-year outcomes in obese relative to normal weight patients. We tested a similar obesity paradox hypothesis following acute myocardial infarction. METHODS: Short- and long-term all-cause mortality, and risk of recurrent AMI were evaluated according to BMI status in 894 consecutive survivors of AMI <80 years of age admitted to the Mayo Clinic Coronary Care Unit between January 1, 1988 and April 16, 2001. Normal weight, overweight and obesity were defined as BMI <25, 25-29.9, and >30 kg/m(2), respectively. RESULTS: Overall mortality following hospital discharge was significantly lower in overweight and obese patients and was mostly attributable to lower 6-month mortality (adjusted HR = 0.47, P = 0.01 for BMI >25 kg/m(2)) relative to normal weight patients, while long-term mortality among 6-month survivors was similar in all 3 groups. The risk of recurrent AMI was higher in patients with BMI >25 kg/m(2) (adjusted HR = 2.30, P = 0.01). Overweight and obese patients were significantly more likely to die from cardiac rather than non-cardiac causes (P < 0.01). CONCLUSIONS: Following AMI, overweight and obese individuals although paradoxically protected from short-term death have a long-term mortality risk that is similar to normal weight individuals. Younger age at the time of initial infarction and fewer non-cardiovascular comorbidities presumably explain the short-lived obesity survival paradox following myocardial infarction.     

Elevated body mass index and intermediate-term clinical outcomes after acute coronary syndromes

PURPOSE: Obesity is a coronary disease risk factor, but its independent effect on clinical outcomes following acute coronary syndromes has not been quantified. We evaluated the relationship between elevated body mass index (BMI) and 30-day, 90-day, and 1-year clinical outcomes postacute coronary syndromes. SUBJECTS AND METHODS: Using 15 071 patients (normal weight [BMI = 18.5-24.9 kg/m(2)], overweight [BMI = 25-29.9 kg/m(2)], obese [BMI = 30-34.9 kg/m(2)] or very obese [BMI > or =35 kg/m(2)]) randomized from 1997-1999 in the SYMPHONY (Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes) and 2nd SYMPHONY trials, we evaluated the relationships between BMI and 30-day, 90-day, and 1-year mortality and 30-day and 90-day death or myocardial infarction. RESULTS: Increasing BMI was associated with younger age, multiple comorbidities, and greater cardiac medication and procedure use; however, systolic function and coronary disease extent were similar for all BMI categories. Unadjusted Kaplan-Meier mortality estimates were higher for normal-weight patients than for all other BMI groups. After multivariable adjustment, the 30-day mortality hazard ratios (95% confidence interval [CI]) were: overweight, 0.66 (95% CI: 0.47 to 0.94); obese, 0.61 (95% CI: 0.39 to 0.97); very obese, 0.89 (95% CI: 0.48 to 1.64). Adjusted hazard ratios were similar for 90-day and 1-year mortality. There were no statistically significant differences among BMI groups in 30-day and 90-day death or myocardial infarction (unadjusted or adjusted). CONCLUSION: Overweight and obese BMI classifications were associated with better intermediate-term survival after acute coronary syndromes than normal weight and very obese, but death or myocardial infarction rates were similar. Further study is required to understand the apparent association of overweight and moderate obesity with better intermediate-term outcomes.     

Impact of cardiac rehabilitation on coronary risk factors, inflammation, and the metabolic syndrome in obese coronary patients

Obesity is a coronary heart disease (CHD) risk factor and is prevalent in patients with CHD. The authors reviewed data in 235 consecutive patients before and after formal cardiac rehabilitation and exercise training (CRET) programs and analyzed data in 72 lean patients (body mass index [BMI] <25 kg/m(2)) vs 73 obese patients (BMI>or=30 kg/m(2)). At baseline, obese patients were significantly younger (P<.0001); had higher percentage of body fat (P<.0001) and more dyslipidemia, including higher triglycerides (TG; P<.01), lower high-density lipoprotein (HDL) cholesterol (P<.0001), and higher TG/HDL ratio (P<.0001); and had higher prevalence of metabolic syndrome (61% vs 26%; P<.01) compared with lean patients. Following CRET, obese patients had small, but statistically significant, improvements in obesity indices, including weight (P<.01), BMI (P<.01), and percentage of fat (P=.03), and had more significant improvements in peak exercise capacity (P<.001), HDL cholesterol (P<.001), C-reactive protein (P<.01), behavioral characteristics, and quality of life (P<.0001). The prevalence of metabolic syndrome fell (62% to 51%; P=.1). These results support the benefits of CRET to reduce overall risk in obese patients with CHD.     

Impact of body mass index on in-hospital outcomes following percutaneous coronary intervention (report from the New York State Angioplasty Registry)

Although obesity traditionally has been considered a risk factor for coronary revascularization, recent data from registry studies have shown a possible protective effect of obesity on outcomes after percutaneous coronary intervention (PCI). Using data from the New York State Angioplasty database over a 4-year period, we analyzed 95,435 consecutive patients who underwent PCI. Classification of body mass index (BMI) was: underweight (<18.5 kg/m(2)), healthy weight (18.5 to 24.9 kg/m(2)), overweight (25 to 29.9 kg/m(2)), moderate obesity (class I) (30 to 34.9 kg/m(2)), severe obesity (class II) (35 to 39.9 kg/m(2)), and very severe obesity (class III) (>40 kg/m(2)). In-hospital postprocedural mortality and complications were compared among these groups. Compared with healthy weight patients, patient with class I or II obesity had lower in-hospital mortality and major adverse cardiac events (MACE) (combined death, myocardial infarction, and emergency surgery), whereas patients at the extremes of BMI (underweight and class III obese patients) had significantly higher mortality and MACE rates. Adjusted hazards ratios for in-hospital mortality according to BMI were: underweight (2.69), healthy weight (1.0), overweight (0.90), class I obese (0.74), class II obese (0.67), and class III obese (1.63). Patients at the extremes of BMI (<18.5 and >40 kg/m(2)) were at increased risk of MACEs, including mortality after PCI, whereas patients who were moderately to severely obese (BMIs 30 to 40 kg/m(2)) were at lower risk than healthy weight patients.     

Effect of body mass index on early outcomes in patients undergoing coronary artery bypass surgery

OBJECTIVES: This study sought to quantify the effect of body mass index (BMI) on early clinical outcomes following coronary artery bypass grafting (CABG). BACKGROUND: Obesity is considered a risk factor for postoperative morbidity and mortality after cardiac surgery, although existing evidence is contradictory. METHODS: A concurrent cohort study of consecutive patients undergoing CABG from April 1996 to September 2001 was carried out. Main outcomes were early death; perioperative myocardial infarction; infective, respiratory, renal, and neurological complications; transfusion; duration of ventilation, intensive care unit, and hospital stay. Multivariable analyses compared the risk of outcomes between five different BMI groups after adjusting for case-mix. RESULTS: Out of 4,372 patients, 3.0% were underweight (BMI <20 kg/m(2)), 26.7% had a normal weight (BMI >or=20 and <25 kg/m(2)), 49.7% were overweight (BMI >or=25 and <30 kg/m(2)), 17.1% obese (BMI >or=30 and <35 kg/m(2)) and 3.6% severely obese (BMI >or=35 kg/m(2)). Compared with the normal weight group, the overweight and obese groups included more women, diabetics, and hypertensives, but fewer patients with severe ischemic heart disease and poor ventricular function. Underweight patients were more likely than normal weight patients to die in hospital (odds ratio [OR] = 4.0, 95% CI 1.4 to 11.1), have a renal complication (OR = 1.9, 95% confidence interval [CI] 1.0 to 3.7), or stay in hospital longer (>7 days) (OR = 1.7, 95% CI 1.1 to 2.5). Overweight, obese, and severely obese patients were not at higher risk of adverse outcomes than normal weight patients, and were less likely than normal weight patients to require transfusion (ORs from 0.42 to 0.86). CONCLUSIONS: Underweight patients undergoing CABG have a higher risk of death or complications than normal weight patients. Obesity does not affect the risk of perioperative death and other adverse outcomes compared to normal weight, yet obese patients appear less likely to be selected for surgery than normal weight patients.     

Effects of insulin on left ventricular function during dynamic exercise in overweight and obese subjects.

AIMS: We designed this study in order to determine the effect of insulin on cardiac function in overweight and obese subjects during exercise. METHODS AND RESULTS: The cardiac function of 62 normal glucose tolerant subjects, aged 30-40 and divided into normal weight (group 1, n=22, BMI 20-24.9 kg/m(2)), overweight (group 2, n=20, BMI 25-29.9 kg/m(2)), and obesity (group 3, n=20, BMI 30-35 kg/m(2)) was evaluated at rest and during dynamic exercise through angiocardioscintigraphy, when on hyperinsulinaemic euglycaemic clamp (test A) and when on normal saline infusion (test B). Left ventricular function at rest was statistically greater (P<0.05) in both tests in overweight and obese subjects compared with normal weight controls, with no statistical difference (P=0.057) within groups between insulin and normal saline infusion. During exercise, cardiac function improved in all the subjects in both tests. The increase was lower in overweight and obese patients, even if statistically significant only in obese vs. control subjects in both tests (P<0.05). Insulin sensitivity showed a significant correlation (P< or =0.001) with left ventricular ejection fraction (LVEF) at rest and with change in LVEF during clamp. CONCLUSION: Our findings suggest a metabolic pathogenesis for the impaired LV function in obesity.     

Assessing obesity and overweight in a high mountain Pakistani population

OBJECTIVES: To estimate the prevalence of obesity and overweight among adults in a high mountain rural population of Pakistan, and to determine the correlates of excess body weight. Design Cross-sectional study. METHODS: A random sample of 4203 adults (aged 18 years and over) was selected by stratified random sampling from 16 villages in north Pakistan. Trained medical students measured height, weight and blood pressure. Trained interviewers obtained information from participants on sociodemographic variables, use of snuff, daily cigarette consumption, hypertension and family history of hypertension. Body mass index (BMI) calculated as kg/m(2) was used to define overweight (BMI > or = 25 kg/m(2)) and obesity (BMI > or = 30 kg/m(2)). RESULTS: Using weight and height data available for 1391 men and 2754 women, mean BMI was 22.4 (95% CI 21.9, 22.9) for men and 22.6 (95% CI 21.9, 23.2) for women. The age-adjusted prevalence of BMI > or = 25 (overweight/obesity) was 13.5% for men and 14.1% for women. Overweight/obesity increased with age and the increase per year was identical for both men and women [adjusted odds ratio (AOR) = 1.01, 95% CI 1.01, 1.03]. Overweight/obese men and women were more likely to be hypertensive (men, AOR = 3.32, 95% CI 2.16, 5.09; women, AOR = 1.70, 95% CI 1.21, 2.39). Overweight/obese women were more likely to work in business or as skilled workers (AOR = 6.24, 95% CI 1.18, 32.83) while overweight/obese men were more likely to work as government employees (AOR = 2.59, 95% CI 1.66, 4.03). Family history of hypertension was a significant correlate of overweight/obesity in men (P value 0.004) and women (P value 0.000). Overweight/obese men and women were less likely to use smokeless tobacco (men, AOR = 0.65, 95% CI 0.43, 0.97; women, AOR = 0.54, 95% CI 0.35, 0.85). CONCLUSION: The prevalence of risk factors for non-communicable diseases (NCDs) in Pakistan is expected to increase as further epidemiologic, nutritional and demographic changes occur. The assessment of excess body weight, and patterns and determinants of other risk factors for NCDs is important to provide useful guidelines in the planning of interventions to counter a growing problem.     

超重和肥胖与动脉僵硬度的相关性研究

目的 分析超重和肥胖与动脉僵硬度的关系.方法 选取2007至2009年江苏省社区自然人群4585名为研究对象进行回顾性研究.以体质指数(BMI)评价超重和肥胖,肱踝脉搏波传导速度(baPWV)评价动脉僵硬度.将BMI分别作为连续变量(以l kg/m2递增)和等级变量(体重正常、体重过轻、超重和肥胖)进行logistic多因素逐步回归分析,评价高动脉僵硬度风险和人群归因危险度百分比,并通过受试者工作(ROC)曲线分析BMI对高动脉僵硬度的预测价值.结果 (1)控制年龄后,男性和女性的BMI与baPWV均呈正相关(r值分别为0.213和0.186,P均＜0.01).超重、肥胖人群baPWV和高动脉僵硬度发生率均高于正常组(P均＜0.01).(2)logistic回归模型校正年龄、性别、高血压因素后,连续变量BMI致高动脉僵硬度的OR值为1.146(95％CI:1.117～1.175,P＜0.01);当BMI为等级变量时,体重过轻OR值为0.369(95％ CI:0.141～0.962,P＜0.05),超重和肥胖OR值分别为1.576(95％CI:1.333～1.863,P＜0.01)和2.087(95％CI:1.615 ～2.698,P＜0.01).超重和肥胖者高动脉僵硬度的人群归因危险度百分比分别为19.1％和11.6％.(3) BMI评估高动脉僵硬度的ROC曲线下面积为0.661(95％ CI:0.645 ～0.678,P＜0.01),BMI预测高动脉僵硬度的最佳分割值为24.25 kg/m2.结论 超重和肥胖人群的动脉僵硬度高于体重正常人群.超重和肥胖是独立于年龄、性别、高血压之外的高动脉僵硬度危险因素.     

Short-term effects of a hypocaloric diet and a physical activity programme on weight loss and exercise capacity in obese subjects with chronic ischaemic heart disease: a study in everyday practice

OBJECTIVE: The objective of this paper is to describe the effects of a rehabilitation programme in obese patients affected with chronic ischaemic heart disease; to identify the factors that influence weight loss and improvement in exercise capacity in everyday practice. METHODS AND RESULTS: We studied 562 white patients (381 men) who followed a 23.3 +/- 3.9 days in-hospital programme. They attended daily sessions of aerobic activity (cycloergometer, walking, and strength exercise); a low-calorie diet was set at approximately 80% of resting energy expenditure. By the end of the programme BMI decreased from 38.0 +/- 4.9 to 36.7 +/- 4.8 kg/m2 (P < 0.001 ). Attained metabolic equivalents (METs) increased from 6.2 +/- 2.5 METs to 7.3 +/- 2.7 (P < 0.001). Age, sex, presence of diabetes and education level were significantly related to the outcomes. Patients who took beta-blockers and statins had less BMI improvement: -1.2 +/- 0.7 kg/m2 vs. -1.4 +/- 0.6 (P = 0.013) and -1.3 +/- 0.6 vs. -1.4 +/- 0.7 (P = 0.023), respectively. Patients that took diuretics and angiotensin receptor blockers (ARB) had less improvement in exercise capacity: 0.9 +/- 1.0 METS vs. 1.3 +/- 1.3 (P < 0.001) and 0.8 +/- 1.3 vs. 1.2 +/- 1.3 (P = 0.011 ), respectively. After a median interval of 358 days, 152 patients were seen at a follow-up visit: their BMI increased by 1.0 +/- 2.4 kg/m2 and only 21% of patients lost weight. CONCLUSIONS: Rehabilitation improves exercise capacity and induces significant weight loss in obese patients with stable IHD, but women, diabetic, elderly and poorly educated subjects obtained unsatisfactory results. Use of diuretics and ARB seem to worsen the results. At follow-up only a small percentage of patients further improves BMI.     

Increases in clinically severe obesity in the United States, 1986-2000

BACKGROUND: We know that Americans are increasingly becoming overweight, but we do not know whether this trend applies to clinically severe obesity (>100 lbs [45 kg] overweight), which is believed to have different causes than typical weight gain. Severe obesity is more serious for an individual's health and creates different challenges for the health care system. This study estimates trends for extreme weight categories between the years 1986 and 2000. METHODS: The data come from the Behavioral Risk Factor Surveillance System. The dependent variable is weight category according to the body mass index (BMI; calculated as weight in kilograms divided by the square of height in meters) based on self-reported weight and height. Regression models adjust for changes in population characteristics and state participation. RESULTS: Between 1986 and 2000, the prevalence of a BMI (self-reported) of 40 or greater (about 100 lbs [45 kg] overweight) quadrupled from about 1 in 200 adult Americans to 1 in 50; the prevalence of a BMI of 50 or greater increased by a factor of 5, from about 1 in 2000 to 1 in 400. In contrast, obesity based on a BMI of 30 or greater roughly doubled during the same period, from about 1 in 10 to 1 in 5. CONCLUSIONS: The prevalence of clinically severe obesity is increasing much faster than obesity. The widely published trends for overweight/obesity underestimate the consequences for physician practices, hospitals, and health plans because comorbidities and resulting service use are much higher among severely obese individuals. Accommodating severely obese patients will no longer be a rare event, and providers have to prepare to treat such patients on a regular basis.     

Cardiopulmonary function and exercise capacity in patients with morbid obesity

INTRODUCTION AND OBJECTIVES: The effect of obesity on cardiac function is still under discussion. The objective of this study was to assess cardiopulmonary capacity in morbidly obese patients.Patients and method. A symptom-limited cardiopulmonary exercise stress test was carried out in 31 morbidly obese patients (BMI 50 9 kg/m2) and 30 normal controls (BMI 24 2 kg/m2. Cardiovascular function was evaluated using the oxygen pulse (oxygen uptake/heart rate). RESULTS: There were no differences in age, sex and height between both groups. During the effort the obese subjects presented greater oxygen uptake, heart rate, systolic arterial pressure and minute ventilation and shorter test duration than control group (14 3 vs 27 4 min; p < 0.001). Oxygen pulse values were higher in obese patients. However, after oxygen uptake indexation by fat free mass, these differences disappeared, suggesting a similar cardiovascular function. At the end of the exercise, the control group reached 96% of their age-predicted maximal heart rate and their respiratory exchange ratio was 1 0.2. Obese patients only reached 86% and 0.87 0.2, respectively. CONCLUSIONS: Due to their need of more energy output to move total body mass morbidly obese patients have a reduced exercise capacity. They finish the test having done a submaximal exercise. However, during this effort they show a normal cardiopulmonar capacity.     

Impact of obesity on revascularization and restenosis rates after bare-metal and drug-eluting stent implantation (from the TAXUS-IV trial)

The effect of obesity on repeat coronary revascularization and restenosis in patients who undergo stent implantation has not been reported. We therefore examined the database from the multicenter randomized TAXUS-IV trial to determine the effect of body mass index (BMI) on outcomes after bare-metal and drug-eluting stent implantation. In TAXUS-IV, patients were randomized to receive a slow-release, polymer-based, paclitaxel-eluting stent or a bare-metal stent. Outcomes were stratified by baseline BMI. Of the 1,307 randomized patients who had documented BMI, 233 (17.8%) had normal weight (BMI <25 kg/m2), 531 (40.6%) were overweight (BMI < or =25 to 30 kg/m2), and 543 (41.5%) were obese (BMI > or =30 kg/m2). Patients who had been assigned to receive bare-metal stents and were overweight and obese compared with those who had normal weight had higher rates of 9-month binary restenosis (29.2% and 30.5% vs 9.3%, respectively; p = 0.01) and 1-year major adverse cardiac events (20.8% and 23.2% vs 11.1%, respectively; p = 0.02), whereas rates of these events did not differ significantly among those who received a paclitaxel-eluting stent (7.6% and 9.3% vs 4.9%, respectively for binary restenosis; p = 0.65; 11.3% and 10.4% vs 10.1%, respectively; p = 0.82 for major adverse cardiac events). By multivariate analysis, BMI > or =30.0 kg/m2 independently predicted binary restenosis (hazard ratio 4.26, p = 0.005), 1-year target vessel revascularization (hazard ratio 1.95, p = 0.04), and major adverse cardiac events (hazard ratio 1.95, p = 0.004) in patients who received bare-metal stents but not paclitaxel-eluting stents. In conclusion, obesity is an important risk factor for clinical and angiographic restenosis and for composite major adverse cardiac events in patients who receive bare-metal stents. Paclitaxel-eluting stents attenuate the increased risk associated with obesity, such that the intermediate-term prognosis after percutaneous coronary intervention is independent of weight.     

Obesity not associated with medium-term prognosis among Japanese male survivors hospitalized for acute myocardial infarction

BACKGROUND: Obesity is an established risk factor for coronary heart disease. However, data on the relationship between obesity and prognosis following acute myocardial infarction (AMI) are still lacking in Japan. METHODS AND RESULTS: In the present study, 1,458 AMI patients were enrolled in the AMI-Kyoto Multi-Center Risk Study between January 2000 and December 2003. Among survivors of hospitalized AMI, clinical characteristics and medium-term prognosis were retrospectively compared between 240 normal weight male patients [body mass index (BMI) 18.5-25.0 kg/m2, normal weight group], and 116 obese male patients (BMI > or = 25.0 kg/m2, obese group), who could be followed up after hospital discharge. The obese group were younger and had higher prevalence of smoking and hypercholesterolemia than the normal weight group. The two groups had similar angiographic findings and outcomes of primary percutaneous coronary intervention. During the follow-up period (mean 2.18 years for normal weight, 2.15 years for obese), overall mortality rate as well as event-free survival rate did not differ significantly between the two groups. Multivariate analysis showed the presence of previous myocardial infarction, diabetes mellitus, and age were predictors of medium-term mortality, but BMI was not. CONCLUSIONS: These results suggest that obesity is not associated with increased medium-term mortality and cardiac morbidity in Japanese male survivors hospitalized for AMI.     

Relation among body mass index, exercise training, and outcomes in chronic systolic heart failure

Exercise training (ET) in patients with heart failure (HF), as demonstrated in the Heart Failure: A Controlled Trial Investigating Outcomes of Exercise TraiNing (HF-ACTION), was associated with improved exercise tolerance and health status and a trend toward reduced mortality or hospitalization. The present analysis of the HF-ACTION cohort examined the effect of ET in overweight and obese subjects compared to normal weight subjects with HF. Of 2,331 subjects with systolic HF randomized to aerobic ET versus usual care in the HF-ACTION, 2,314 were analyzed to determine the effect of ET on all-cause mortality, hospitalizations, exercise parameters, quality of life, and body weight changes by subgroups of body mass index (BMI). The strata included normal weight (BMI 18.5 to 24.9 kg/m(2)), overweight (BMI 25.0 to 29.9 kg/m(2)), obese I (BMI 30 to 34.9 kg/m(2)), obese II (BMI 35 to 39.9 kg/m(2)), and obese III (BMI ≥40 kg/m(2)). At enrollment, 19.4% of subjects were normal weight, 31.3% were overweight, and 49.4% were obese. A greater BMI was associated with a nonsignificant increase in all-cause mortality or hospitalization. ET was associated with nonsignificant reductions in all-cause mortality and hospitalization in each weight category (hazard ratio 0.98, 0.95, 0.92, 0.89, and 0.86 in the normal weight, overweight, obese I, obese II, and obese III categories, respectively; all p >0.05). Modeled improvement in exercise capacity (peak oxygen consumption) and quality of life in the ET group was seen in all BMI categories. In conclusion, aerobic ET in subjects with HF was associated with a nonsignificant trend toward decreased mortality and hospitalization and a significant improvement in quality of life across the range of BMI categories.     

The relationship of body mass index to outcomes after percutaneous coronary intervention

OBJECTIVES: To evaluate the effect of body mass index (BMI) on in-hospital outcomes in patients undergoing percutaneous coronary intervention (PCI) at a tertiary care hospital center in Ontario, Canada. BACKGROUND: Obesity is present in a large population of patients undergoing revascularization with PCI. METHODS: Retrospective analysis of 4,631 patients aged 62.0 +/- 12 years, stratified by BMI into five groups: nonobese (<25 kg/m2); overweight (25-29.9 kg/m2); class I obese (30-34.9 kg/m2); class II obese (35-39.9 kg/m2); and class III obese (> or =40 kg/m2). RESULTS: A BMI >25 kg/m2 was present in 79% of patients, and 35% were obese (BMI > or =30 kg/m2). Obese patients, particularly the class III obese, were significantly younger and had higher prevalence of diabetes, hypertension, and dyslipidemia (P < 0.0001). After adjustment for several covariates, lower BMI was independently associated with higher risk of major bleeding requiring transfusion (adjusted odds ratio [OR]= 1.40, 95% confidence interval [CI] 1.04-1.88, P = 0.025), and femoral hematoma (adjusted OR = 1.14, 95% CI 1.05-1.25, P = 0.003) in lean (<20 kg/m2) and normal BMI (20-24.9 kg/m2) patients. Obesity was not associated with death, myocardial infarction, repeat PCI, coronary artery bypass grafting, or major adverse cardiac event. CONCLUSIONS: Obesity is not associated with increased risk of adverse postprocedural in-hospital outcomes. These findings, however, do not discount the need for sustained efforts in secondary prevention of obesity and its consequences.     

Impact of obesity on disease-specific health status after percutaneous coronary intervention in coronary disease patients

OBJECTIVE: Several investigators have focused on obesity as a specific risk factor for mortality in patients undergoing bypass surgery, but few have examined it as a risk factor among patients undergoing percutaneous coronary interventions (PCI). In addition, none have evaluated the impact of obesity on post-PCI quality of life or disease-specific health status. This study examined whether obesity is a risk factor for poor quality of life or diminished health status 12-months postprocedure among a large cohort of PCI patients. RESEARCH METHODS AND PROCEDURES: A total of 1631 consecutive PCI patients were enrolled into the study and classified as underweight (BMI <20 kg/m2), normal weight range (BMI >/=20 and <25 kg/m2), overweight (BMI >/=25 and <30 kg/m2), class I obese (BMI >/=30 kg/m2), or class II and III obese (BMI >/=35 kg/m2). The 12-month postprocedure outcomes included need for repeat procedure, survival, quality of life and health status, assessed using the Seattle Angina Questionnaire (SAQ) and the Short Form-12. RESULTS: Obese patients with and without a history of revascularization were significantly younger than overweight, normal weight range, or underweight patients at the time of PCI. However, obese patients demonstrated similar long-term recovery and improved disease-specific health status and quality of life when compared to patients in the normal weight range after PCI. In addition, mortality and risk for repeat procedure was similar to those patients in the normal weight range patients at 12-months postrevascularization. Underweight patients who had no previous history of revascularization reported lower quality of life (F=3.02; P=0.018) and poorer physical functioning (F=2.82; P=0.024) than other BMI groups. CONCLUSION: Obese patients presenting for revascularization were younger when compared to patients in the normal weight range, regardless of previous history of revascularization. However, weight status was not a significant predictor of differences in long-term disease-specific health status, quality of life, repeat procedures, or survival. Underweight patients demonstrated less improvement in quality of life and physical functioning than other BMI groups.     

Relation of body mass index to fatal and nonfatal cardiovascular events after cardiac rehabilitation

The aim of the present study was to determine whether body mass index (BMI) influences survival and recurrent cardiovascular events in a cardiac rehabilitation population. We followed 389 consecutive entrants to cardiac rehabilitation for 6.4 +/- 1.8 years. Patients were stratified into 3 groups: normal (BMI 18 to 24.9 kg/m(2)), overweight (BMI 25 to 29.9 kg/m(2)), and obese (BMI > or =30 kg/m(2)). Total and cardiovascular mortality were inversely associated with BMI category in bivariate models. However, only cardiovascular mortality was significant after adjustment for age and gender (p < 0.044), with cardiovascular death rates of 10% in normal, 8% in overweight, and 2% in obese patients. The rates of nonfatal recurrent events were 10% in normal, 24% in overweight, and 25% in obese patients. Our data indicate that BMI is inversely related to cardiovascular mortality but positively related to the risk of nonfatal recurrent events.     

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] ≥25 kg/m²) 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 ≥25 kg/m²) than in 136 CRET patients with baseline BMI <25 kg/m² (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.     

Physical Activity, Weight Loss, and Cardiac Rehabilitation to Reduce Recurrent Cardiovascular Events

Contemporary studies now suggest that multifactorial risk factor modification—especially smoking cessation, more intensive dietary modifications, pharmacotherapies to control hyperlipidemia, antihypertensive regimens, weight reduction, and regular moderate-to-vigorous physical activity—may reduce the risk of recurrent cardiovascular events. Although better outcomes for cardiovascular and all-cause mortality have been reported in some overweight and moderately obese cohorts of patients with cardiovascular disease (the “obesity paradox”), numerous reports now support purposeful weight reduction in this escalating patient population. Moreover, cardiorespiratory fitness is one of the strongest prognostic indicators in persons with coronary disease, irrespective of traditional risk factors, body habitus, and left ventricular function. Accordingly, sedentary patients should be counseled to become more physically active and/or fit by starting an exercise program, increasing lifestyle activity, or both. Despite the effectiveness and safety of cardiac rehabilitation, these services remain vastly underutilized. Cardiac rehabilitation has been shown to markedly improve the cardiovascular risk factor profile and is associated with significant reductions in all-cause and cardiac mortality.