Journal
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
Volume 72, Issue 7, Pages 707-717Publisher
ELSEVIER SCIENCE INC
DOI: 10.1016/j.jacc.2018.05.049
Keywords
bariatric surgery; body mass index; coronary microvascular dysfunction; obesity; prognosis
Categories
Funding
- National Institutes of Health [T32 HL094301, T32 HL076136, R01HL132021, K23HL135438]
- Gilead Sciences Research Scholars Program in Cardiovascular Disease
- Medtronic
- Amarin
- Amgen
- AstraZeneca
- Bristol-Myers Squibb
- Chiesi
- Eisai
- Ethicon
- Forest Laboratories
- Ironwood
- Ischemix
- Lilly
- Pfizer
- Roche
- Sanofi
- Medicines Company
- Spectrum Dynamics
- General Electric
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BACKGROUND Besides body mass index (BMI), other discriminators of cardiovascular risk are needed in obese patients, who may or may not undergo consideration for bariatric surgery. Coronary microvascular dysfunction (CMD), defined as impaired coronary flow reserve (CFR) in the absence of flow-limiting coronary artery disease, identifies patients at risk for adverse events independently of traditional risk factors. OBJECTIVES The study sought to investigate the relationship among obesity, CMD, and adverse outcomes. METHODS Consecutive patients undergoing evaluation for coronary artery disease with cardiac stress positron emission tomography demonstrating normal perfusion (N = 827) were followed for median 5.6 years for events, including death and hospitalization for myocardial infarction or heart failure. RESULTS An inverted independent J-shaped relationship was observed between BMI and CFR, such that in obese patients CFR decreased linearly with increasing BMI (adjusted p < 0.0001). In adjusted analyses, CFR but not BMI remained independently associated with events (for a 1-U decrease in CFR, adjusted hazard ratio: 1.95; 95% confidence interval: 1.41 to 2.69; p < 0.001; for a 10-U increase in BMI, adjusted hazard ratio: 1.20; 95% confidence interval: 0.95 to 1.50; p = 0.125) and improved model discrimination (C-index 0.71 to 0.74). In obese patients, individuals with impaired CFR demonstrated a higher adjusted rate of events (5.7% vs. 2.6%; p = 0.002), even in those not currently meeting indications for bariatric surgery (6.4% vs. 2.6%; p = 0.04). CONCLUSIONS In patients referred for testing, CMD was independently associated with elevated BMI and adverse outcomes, and was a better discriminator of risk than BMI and traditional risk factors. CFR may facilitate management of obese patients beyond currently used markers of risk. (c) 2018 by the American College of Cardiology Foundation.
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