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Obesity and Cardiovascular Disease

Obesity and Cardiovascular Disease. Is there a Paradox?. Matthew Blair, D.O. - Hospitalist at MetroHealth Hospital. Disclosures. The authors have no financial disclosures related to this talk. Seriously? Is he on to something?. Relative Risk of All-cause Mortality and

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Obesity and Cardiovascular Disease

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  1. Obesity and Cardiovascular Disease Is there a Paradox? Matthew Blair, D.O. - Hospitalist at MetroHealth Hospital

  2. Disclosures • The authors have no financial disclosures related to this talk

  3. Seriously? Is he on to something?

  4. Relative Risk of All-cause Mortality and Cardiovascular Mortality Based upon Weight (Obese = BMI > 25) and Fitness Level Lee C D, et al. Am J Clin Nutr. 1999; 69:373.

  5. Relative Risk of Certain Conditions in Overweight Individuals (BMI>27.8) Van Itallie TB, et al. Ann Int Med. 1985; 103:983.

  6. According to Framingham data, the rate of sudden cardiac death is 40 times higher in obese men and women NHANES III: 30% of obese patients with IGT had a prolonged QTc Arrhythmias

  7. CAD • Obesity is an independent predictor of CAD • Framingham Heart Study • Manitoba study • Harvard public health nurses study • Framingham • Men < 50 had a 2 fold increase in CAD • Women had a 2.4 fold increase • All adjusted for the influence of other major CAD risk factors

  8. CHF Framingham Heart Study After adjustment for established risk factors there was a calculated increase in the risk of developing heart failure by 5% in men and 7% in women for each increment of 1 above a BMI of 30.

  9. I need it bad…

  10. The Advantage of Obesity? • So, obesity certainly contributes to a number of conditions which are known to lead to atherosclerotic disease and also to the development of coronary artery disease itself. • However once CAD has developed and these patients require revascularization, the picture is not as clear cut. In fact, FAT PEOPLE MAY DO BETTER!!!

  11. Is there a CAD paradox? How do overweight and obese patients fare once they are diagnosed with CAD? Let’s look at the data.

  12. Percutaneous Complications • In an article by Nicholas Cox, et al. published in the American Journal of Cardiology in 2004, the group collected data on 5234 consecutive patients undergoing cardiac catheterization at the Brigham and Women’s Hospital in Boston, Massacusetts as well as the Western Hospital in Fottscray, Victoria, Australia between January 2002 and July 2003. • They retrospectively looked at complication rates of those patients in comparison to their body mass indices. Cox N, et al. Am J Card. 2004; 94:1174.

  13. Vascular Complication Rate Based Upon BMI Cox N, et al. Am J Card. 2004; 94:1174.

  14. Vascular Complications by Obesity Group Cox N, et al. Am J Card. 2004; 94:1174.

  15. PCI looks good. How about stents? • So, they have fewer or at least no increase in complications from the PCI procedure… • Taxus-IV trial: Looked at the impact of obesity on restenosis rates in the era of drug-eluting versus bare metal stents • 1307 randomized patients • Stratified by baseline BMI: <25, 25-30 and >30

  16. TAXUS -IV • Bare Metal stents • Overweight and Obese patients had higher rates of restenosis: 29.2% and 30.5% vs 9.3%. • Also had higher rates of 1 year Major Adverse Cardiac Events 20.8% and 23.2% vs 11.1% respectively • Paclitaxel-Eluting stents • No significant difference in restenosis: 7.6% and 9.3% vs 4.9% • MACE: 11.3% and 10.4% vs 10.1% • “Paclitaxel-elutin stents attenuate the increased risk associated with obesity such that the intermediate-term prognosis after PCI is independent of weight

  17. Taxus-IV Clinical Outcomes at 1 Year Nikolsky E, et al. Am J Card. 2005; 95:709.

  18. Taxus-IV Restenosis Rates BMI < 25 (White) BMI 25-30 (Gray) BMI 30 or greater (Black) Nikolsky E, et al. Am J Card. 2005; 95:709.

  19. CABG and Obesity • It is clear that obese patients undergoing percutaneous interventions do not have increased complications AND with the advent of drug-eluting stents increased restenosis rates no longer seem to be a problem. • But what about obese patients who require surgical revascularization?

  20. CABG – Procedural Results • Obesity is frequently cited as a risk factor for adverse outcomes with CABG surgery. • Nancy Birkmeyer, et al. in a study published in Circulation in 1998 prospectively looked at 11,101 consecutive patients undergoing CABG between 1992 and 1996 at medical centers in Maine, New Hampshire, and Vermont. • Patients were categorized into the following groups: non-obese (BMI<30), obese (BMI 31-36), and severely obese (BMI>36) and were evaluated for procedural and in-hospital complications. Birkmeyer N, et al. Circulation. 1998; 97:1689.

  21. CABG – Procedural Results Birkmeyer N, et al. Circulation. 1998; 97:1689.

  22. CABG – Long-term Results • The ARTS trial was a multicenter, randomized trial that compared PCI plus stenting with CABG in patients who had multi-vessel CAD. • A total of 1205 patients from 67 participating centers worldwide were enrolled between April 1997 and June 1998. • The obesity analysis was based upon the 3-year outcomes from this trial. Gruberg L, et al. American Journal of Cardiology. 2005; 95:439.

  23. CABG – Long-term Results Gruberg L, et al. American Journal of Cardiology. 2005; 95:439.

  24. Summary for the Obesity Paradox • Obese patients requiring revascularization procedures compared to their non-obese counterparts: • Have a equal or lower procedural risk at cardiac catheterization. • Do not have increased rates of restenosis, since the advent of drug-eluting stents. • Have overall equal risk of undergoing surgical revascularization, with decreased periprocedural bleeding. • Have better long-term outcomes after undergoing CABG in regard to survival, free of major adverse cardiac events.

  25. Bring on the Bacon

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