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• W1976465511 abstract "Increased body mass index (BMI), a parameter of total body fat content, is associated with an increased mortality in the general population. However, recent studies have shown a paradoxic relation between BMI and mortality in specific patient populations. This study investigated the association of BMI with long-term mortality in patients with known or suspected coronary artery disease. In a retrospective cohort study of 5,950 patients (mean age 61 ± 13 years; 67% men), BMI, cardiovascular risk markers (age, gender, hypertension, diabetes, current smoking, angina pectoris, old myocardial infarction, heart failure, hypercholesterolemia, and previous coronary revascularization), and outcome were noted. The patient population was categorized as underweight, normal, overweight, and obese based on BMI according to the World Health Organization classification. Mean follow-up time was 6 ± 2.6 years. Incidences of long-term mortality in underweight, normal, overweight, and obese were 39%, 35%, 24%, and 20%, respectively. In a multivariate analysis model, the hazard ratio (HR) for mortality in underweight patients was 2.4 (95% confidence interval [CI] 1.7 to 3.7). Overweight and obese patients had a significantly lower mortality than patients with a normal BMI (HR 0.65, 95% CI 0.6 to 0.7, for overweight; HR 0.61, 95% CI 0.5 to 0.7, for obese patients). In conclusion, BMI is inversely related to long-term mortality in patients with known or suspected coronary artery disease. A lower BMI was an independent predictor of long-term mortality, whereas an improved outcome was observed in overweight and obese patients. Increased body mass index (BMI), a parameter of total body fat content, is associated with an increased mortality in the general population. However, recent studies have shown a paradoxic relation between BMI and mortality in specific patient populations. This study investigated the association of BMI with long-term mortality in patients with known or suspected coronary artery disease. In a retrospective cohort study of 5,950 patients (mean age 61 ± 13 years; 67% men), BMI, cardiovascular risk markers (age, gender, hypertension, diabetes, current smoking, angina pectoris, old myocardial infarction, heart failure, hypercholesterolemia, and previous coronary revascularization), and outcome were noted. The patient population was categorized as underweight, normal, overweight, and obese based on BMI according to the World Health Organization classification. Mean follow-up time was 6 ± 2.6 years. Incidences of long-term mortality in underweight, normal, overweight, and obese were 39%, 35%, 24%, and 20%, respectively. In a multivariate analysis model, the hazard ratio (HR) for mortality in underweight patients was 2.4 (95% confidence interval [CI] 1.7 to 3.7). Overweight and obese patients had a significantly lower mortality than patients with a normal BMI (HR 0.65, 95% CI 0.6 to 0.7, for overweight; HR 0.61, 95% CI 0.5 to 0.7, for obese patients). In conclusion, BMI is inversely related to long-term mortality in patients with known or suspected coronary artery disease. A lower BMI was an independent predictor of long-term mortality, whereas an improved outcome was observed in overweight and obese patients. In this study, we evaluated the effect of body mass index (BMI) on long-term mortality of patients with known or suspected coronary artery disease (CAD) after controlling for coronary risk factors. We retrospectively studied 5,950 adult patients with known or suspected CAD who were referred to the outpatient clinics of the Erasmus University Medical Center (Rotterdam, The Netherlands) between January 1993 and January 2005. Our study population consisted of high-risk patients referred to the vascular clinic for evaluation of systemic atherosclerosis, CAD or peripheral arterial disease, and for management of underlying risk factors. In these patients, BMI was measured at the time of the first visit and cardiac risk factors were noted. We categorized patients as having known (n = 2,486; 42%) or suspected (n = 3,464; 58%) CAD. Known CAD was indicated by the presence of angina pectoris, previous myocardial infarction (MI), or previous coronary revascularization (i.e., previous percutaneous coronary intervention and/or coronary artery bypass grafting). Patients with atypical chest pain, dyspnea, atypical electrocardiographic abnormalities (i.e., ST-segment changes without Q waves), or ≥2 cardiac risk factors (male gender, current smoker, hypertension, renal dysfunction, hypercholesterolemia, and diabetes) were considered to have suspected CAD.1Goldman L. Hashimoto B. Cook E.F. Loscalzo A. Comparative reproducibility and validity of systems for assessing cardiovascular functional class: advantages of a new specific activity scale.Circulation. 1981; 64: 1227-1234Crossref PubMed Scopus (762) Google Scholar The hospital medical ethical committee approved the study protocol. Clinical data were obtained by thorough review of medical records and electronic databases and included age, height, weight, previous MI, angina pectoris, coronary artery revascularization, heart failure (HF), diabetes mellitus (fasting glucose level ≥7.0 mmol/L or requirement of hypoglycemic agents), hypertension (blood pressure ≥140/90 mm Hg or intake of antihypertensive medications), current smoker, hypercholesterolemia (plasma cholesterol level ≥5.5 mmol/L [213 mg/dl] or intake of lipid-lowering agents), and renal dysfunction (serum creatinine level ≥2.0 mg/dl [177 μmol/L] or requirement of dialysis). HF was considered if a patient had a history of shortness of breath on exertion or at rest, decreased physical ability, or swelling of lower limbs proved clinically or at echocardiography upon medical consultation to be valid for signs of cardiac decompensation.2Remme W.J. Swedberg K. European Society of Cardiology Comprehensive guidelines for the diagnosis and treatment of chronic heart failure Task force for the diagnosis and treatment of chronic heart failure of the European Society of Cardiology.Eur J Heart Fail. 2002; 4: 11-22Crossref PubMed Scopus (195) Google Scholar Patients were assessed for cardiac medication use. BMI was calculated as body weight (kilograms) divided by height squared (meters). Accordingly, patients were grouped according to BMI classifications of the World Health Organization3Energy and protein requirements: report of a joint FAO/WHO/UNU Expert Consultation.World Health Organ Tech Rep Ser. 1985; 724: 1-206PubMed Google Scholar and the National Institutes of Health4National Institutes of HealthEvidence-Based Guidelines: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: Executive Summary. National Heart, Lung, and Blood Institute, Bethesda, MD2002Google Scholar as underweight (BMI <18.5 kg/m2), normal weight (18.5 to 24.9 kg/m2), overweight (25 to 29.9 kg/m2), or obese (≥30 kg/m2). End points were death from all causes and hard cardiac events (cardiac death or MI). Cardiac death was defined as death from any cardiac cause including sudden cardiac death, MI, congestive HF, cardiac arrhythmias, and death in which there is evidence of a primary cardiac cause that could not be classified as mentioned above. Sudden cardiac death was defined as unexpected natural death due to cardiac causes within 1 hour of onset of acute symptoms. Criteria of MI diagnosis included ≥2 of the following: high cardiac enzyme levels (creatine kinase [CK] level >190 U/L and CK-MB level >14 U/L, or CK-MB fraction >6% of total CK, or cardiac troponin T level >0.1 ng/ml), development of typical electrocardiographic changes (new Q waves >1 mm or >30 ms at electrocardiography), and typical chest pain. Events were verified by review of hospital records or contacting general practitioners, civil registry, or participants’ families (by questionnaires in telephone calls) if needed. Statistical analysis was performed using the syntax commands of SPSS 13.0 for Windows (SPSS, Inc., Chicago, Illinois). Categorical variables are expressed as percentages and were compared using Pearson’s chi-square test. Continuous variables are presented as mean ± SD and were compared using Student’s t test. Primary end points were all-cause mortality and hard cardiac events (cardiac death and/or nonfatal MI). Cox proportional hazards models were used to determine univariate and multivariate predictors of mortality. Results on all-cause mortality, cardiac death, and MI were generated by Kaplan-Meier estimates and differences in mortality were compared using log-rank test. Hazard ratios (HRs) and 95% confidence intervals (CIs) were derived from a Cox proportional hazard stepwise regression model. Assumptions of the proportional hazard model (proportional hazard, lack of interaction, and linearity of continuous variables) were tested and found valid unless otherwise indicated. Proportional hazards assumptions were tested by constructing interaction terms between variables and time to each end point. Cox regression analyses showed no statistically significant interactions with time (each p value >0.05). Model selection is based on the stepwise principle, where the limits for entering and removing variables were 0.05. BMI was divided into its quartiles in all statistical examinations. The group of normal weight patients served in analyses as the reference group (i.e., HR 1), and the risk of the other 3 BMI groups compared with this group was estimated by HRs from the proportional hazard models. Multivariate analysis was done by adjusting for all baseline characteristics including age, gender, and dobutamine stress echocardiographic results (to eliminate any significant interaction with other confounders). For all tests, a p value <0.05 (2-sided) was considered statistically significant. Distribution of BMI in the population was approximately normal, with a mean of 25.4 ± 4.0 kg/m2 (Figure 1). Only 3% of the study population was underweight, 42% was normal or overweight, and 14% was obese. Clinical characteristics of the 4 BMI categories are presented in Table 1. Mean age was 60.8 ± 13 years and was not different across different BMI subsets. There were more men in the normal and overweight groups and more women in the underweight group. Current smokers were more prevalent in the underweight group. Diabetes and hypertension were noted more frequently in obese patients. Distribution of coronary risk factors across different groups is presented in Figure 2.Table 1Clinical characteristics of 5,950 patients according to body mass indexVariableNo. of Patients (%)BMI (kg/m2)p Value<18.5 (n = 178, 3%)18.5–24.9 (n = 2,499, 42%)25–29.9 (n = 2,439, 41%)>30 (n = 834, 14%)Age, mean ± SD60.8 ± 12.660.7 ± 14.861.7 ± 13.361.7 ± 11.259.0 ± 11.30.7Men4,001 (67%)98 (55%)1,752 (70%)1,730 (71%)421 (50%)<0.01Current smoker1,741 (29%)53 (30%)839 (34%)673 (28%)176 (21%)<0.01Hypertension2,737 (46%)61 (35%)1,050 (42%)1,173 (48%)453 (54%)<0.01Angina pectoris1,369 (23%)32 (18%)545 (22%)560 (23%)232 (28%)<0.01Previous MI1,964 (33%)53 (30%)819 (33%)841 (35%)251 (31%)0.13Renal disease363 (6%)32 (18%)172 (7%)108 (4%)51 (6%)<0.01Chronic obstructive pulmonary disease313 (5%)6 (4%)163 (7%)116 (5%)27 (3%)<0.01History of HF846 (14%)20 (12%)372 (15%)332 (14%)123 (15%)0.51Diabetes mellitus883 (15%)6 (4%)267 (11%)393 (16%)217 (26%)<0.01Hypercholesterolemia2,093 (35%)27 (15%)800 (32%)924 (38%)342 (41%)<0.01Previous coronary by pass929 (16%)12 (7%)359 (14%)421 (17%)137 (16%)<0.01Previous percutaneous coronary intervention933 (16%)16 (9%)361 (14%)394 (16%)162 (19%)<0.01Known CAD2,486 (42%)51 (36%)1,023 (41%)1,085 (44%)327 (39%)0.01Suspected CAD3,464 (58%)92 (64%)149 (59%)1,374 (56%)507 (61%)0.01Dobutamine stress echocardiography Wall motion abnormalities at rest2,296 (38%)98 (55%)1,014 (41%)949 (39%)235 (25%)<0.01 New wall motion abnormalities1,857 (31%)68 (38%)827 (33%)787 (32%)175 (21%)<0.01 Open table in a new tab Figure 2Categorical distribution of clinical characteristics and identified cardiac risk factors according to BMI indicating underweight (black bars), normal weight (dotted bars), overweight (white bars), or obesity (bars with horizontal stripes). CABG = coronary artery bypass grafting; COPD = chronic obstructive pulmonary disease; DM = diabetes mellitus; PCI = percutaneous coronary intervention.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Patients were followed for a mean period of 6 ± 2.6 years. Minimum follow-up period was 6 months. In total, 3,828 of 5,950 patients (64%) were referred for dobutamine stress echocardiography after their initial visit. Stress-induced myocardial ischemia was assessed in 1,205 of 1,750 patients (69%) with known CAD and in 651 of 2,078 patients (31%) with suspected CAD. In total 1,786 of 5,950 patients underwent major vascular noncardiac surgery during the follow-up period. Of 1,786 patients, 38 (2.1%) died in the perioperative period. During follow-up, 1,697 patients (29%) died. Of these, 1,235 patients (21%) died from cardiac causes. Univariate associations between risk factors and long-term outcome are presented in Table 2. Underweight patients had a poor long-term outcome for all-cause and cardiac mortalities, whereas overweight and obese patients had more favorable long-term outcomes in terms of all-cause and cardiac deaths (Table 2). In a multivariable stepwise Cox regression model (Table 3), overweight and obese patients remained at significantly lower risk for all-cause mortality and cardiac mortality/MI. Underweight patients represented a high-risk category for all-cause mortality and cardiac death/MI.Table 2Univariate association of clinical data with all-cause mortality and cardiac death/acute myocardial infarction mortality in univariate regression analysisVariableTotal MortalityCardiac Death/Acute MINo. of PatientsHR95% CINo. of PatientsHR95% CIAge1.051.05–1.071.031.02–1.04Men1,3332.11.8–2.41,2342.01.8–2.3Current smoker6001.71.5–1.95571.61.4–1.8Hypertension8481.31.1–1.48161.41.2–1.5Angina pectoris3350.80.7–0.93380.90.8–1.0Previous MI6591.41.3–1.66861.91.7–2.2Diabetes mellitus3011.41.2–1.62751.31.1–1.6History of HF3562.11.8–2.53121.81.6–2.2Hypercholesterolemia4510.60.6–0.75351.20.8–1.5 Treated with statins920.80.6–1.01411.81.4–2.2 Untreated3590.60.5–0.73940.80.7–1.0Chronic obstructive pulmonary disease1663.12.5–4.01563.02.4–3.8Renal disease734.52.9–7.0742.92.0–4.4Coronary bypass surgery2541.10.9–1.32521.31.1–1.6 <5 yrs660.50.4–0.7620.70.4–0.8Percutaneous coronary intervention1340.40.3–0.51740.70.6–0.9 <5 yrs720.60.4–1.0920.80.5–1.4Dobutamine stress echocardiography Wall motion abnormalities at rest7241.301.16–1.467041.361.21–1.53 New wall motion abnormalities6081.371.21–1.546041.501.33–1.69BMI groups Underweight691.691.21–2.38581.531.08–2.16 Overweight5960.630.55–0.714220.750.66–0.85 Obese1630.470.39–0.571170.580.48–0.69 Open table in a new tab Table 3Multivariable regression analysis of total (all-cause) mortality and cardiac death/acute myocardial infarction mortality hazard adjusted for all patient variablesVariableTotal MortalityCardiac Death/Acute MINo. of PatientsHR95% CINo. of PatientsHR95% CIAge1.041.04–1.051.021.02–1.03Men1,3331.91.7–2.21,2341.71.5–2.0Current smoker6001.61.4–1.95571.51.3–1.7Hypertension8481.31.2–1.58161.41.2–1.6Previous MI6591.51.3–1.76862.01.7–2.3Diabetes mellitus3011.51.3–1.82751.41.2–1.7History of HF3562.01.7–2.43121.61.4–2.0Hypercholesterolemia4510.80.7–0.95351.21.0–1.4 Using statins920.90.7–1.21411.81.5–2.2 Untreated3590.80.7–0.93941.00.8–1.2Chronic obstructive pulmonary disease1662.41.8–3.21562.31.8–3.1Renal disease734.42.8–7.0744.22.6–6.6Coronary bypass surgery2541.00.8–1.12521.00.8–1.1 <5 yrs1230.60.5–0.81110.80.5–0.9Percutaneous coronary intervention1340.40.3–0.51740.60.5–0.7 <5 yrs880.70.5–1.1911.00.6–1.6Dobutamine stress echocardiography Wall motion abnormalities at rest7241.61.3–1.97041.71.4–2.0 New wall motion abnormalities6081.10.9–1.366041.31.0–1.6BMI groups Underweight692.41.7–3.6582.11.5–3.1 Overweight5960.70.6–0.84220.80.7–0.9 Obese1630.60.5–0.81170.80.6–0.9 Open table in a new tab Kaplan-Meier survival curves of the 4 BMI categories for an average interval of 6 ± 2.6 years are presented in Figure 3. Incidences of long-term mortality in underweight, normal, overweight, and obese patients were 39%, 35%, 24%, and 20%, respectively. In the same order, incidences of cardiac death/MI were 33%, 26%, 17%, and 14%. As shown in Figure 3, mortality hazard was inversely proportional to BMI (p <0.001) for either type of mortality. Results were subsequently analyzed separately in patients with known CAD and in those with suspected CAD. An inverse relation between BMI and survival was observed in patients with suspected CAD (all-cause mortality, p <0.001; cardiac death, p <0.001) and in patients with known CAD (all-cause mortality, p <0.001; cardiac death, p <0.001; Figure 4). In patients with suspected CAD, the underweight group had 2 short temporary shifts of improved survival over the normal weight group (4.5 to 5.5 and 6.5 to 8.5 years of follow-up), but eventually followed the same inverse relation with BMI at the commencement of follow-up. Overweight and obese populations showed the same paradoxic trend with BMI over the normal weight and underweight populations.Figure 4Examination of patients with known versus suspected CAD for (A) total death and (B) cardiac mortality/MI.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The main finding of this study is that an inverse relation exists between BMI and incident all-cause and cardiac mortalities during long-term follow-up of patients with known or suspected CAD. Underweight patients had a greater than twofold increased risk of mortality compared with normal weight patients, with 40% less mortality and 20% less cardiac death in the obesity group. This reversed trend persisted after adjustment for coronary risk factors and was observed in patients with known CAD and those with suspected CAD. Our population represented a cohort of ambulatory patients with normal distribution of risk factors and clinical suspicion and/or presentation of CAD. This population was composed of a broader spectrum of patients in contrast to previous studies conducted in isolated groups or after acute event or specific interventions. Previous studies have pointed out the prognostic influence of BMI in moribund patients with very limited functional capacity and/or short expectancy.5Kalantar-Zadeh K. Abbott K.C. Salahudeen A.K. Kilpatrick R.D. Horwich T.B. Survival advantages of obesity in dialysis patients.Am J Clin Nutr. 2005; 81: 543-554PubMed Scopus (527) Google Scholar, 6Davos C.H. Doehner W. Rauchhaus M. Cicoira M. Francis D.P. Coats A.J. Clark A.L. Anker S.D. Body mass and survival in patients with chronic heart failure without cachexia: the importance of obesity.J Card Fail. 2003; 9: 29-35Abstract Full Text Full Text PDF PubMed Scopus (257) Google Scholar, 7Snyder J.J. Foley R.N. Gilbertson D.T. Vonesh E.F. Collins A.J. Body size and outcomes on peritoneal dialysis in the United States.Kidney Int. 2003; 64: 1838-1844Crossref PubMed Scopus (140) Google Scholar, 8Halabi S. Small E.J. Vogelzang N.J. Elevated body mass index predicts for longer overall survival duration in men with metastatic hormone-refractory prostate cancer.J Clin Oncol. 2005; 23: 2434-2435Crossref PubMed Scopus (25) Google Scholar, 9Gustafsson F. Kragelund C.B. Torp-Pedersen C. Seibaek M. Burchardt H. Akkan D. Thune J.J. Kober L. DIAMOND Study GroupEffect of obesity and being overweight on long-term mortality in congestive heart failure: influence of left ventricular systolic function.Eur Heart J. 2005; 26: 58-64Crossref PubMed Scopus (127) Google Scholar The effect of obesity on long-term outcomes in moribund patients with preserved functional capacity is an important issue. Our findings also show the contribution of coronary risk factors and other co-morbidities to the hazard of death in populations with different weights. In this regard, old MI remained a significant predictor of all-cause mortality (HR 1.5, 95% CI 1.3 to 1.7) and for cardiac death (HR 2.0, 95% CI 1.7 to 2.3) after correction for all other confounders. In this population, crude death rate was 29% during a mean follow-up of 6 ± 3 years. Cardiac deaths were responsible for 73% of all deaths. Major risk factors (renal disease, diabetes, male gender, and smoking) were associated with increased long-term all-cause and cardiac mortality. As expected, co-morbid conditions (e.g., diabetes and hypertension) were more prominent in the obese population, whereas smoking and renal dysfunction were more prevalent in the underweight population. As shown by Kaplan-Meier survival curves (Figure 4) patients with suspected CAD and those with proved CAD had similar long-term outcomes. The reason for this similar outcome might be related to the high incidence of asymptomatic CAD in patients with proved vascular disease.10Hertzer N.R. Beven E.G. Young J.R. O’Hara P.J. Ruschhaupt III, W.F. Graor R.A. Dewolfe V.G. Maljovec L.C. Coronary artery disease in peripheral vascular patients A classification of 1000 coronary angiograms and results of surgical management.Ann Surg. 1984; 199: 223-233Crossref PubMed Scopus (1209) Google Scholar The paradoxic relation, a “protective effect,” of obesity on survival had been observed recently in several patient populations, such as patients with chronic HF or renal disease.5Kalantar-Zadeh K. Abbott K.C. Salahudeen A.K. Kilpatrick R.D. Horwich T.B. Survival advantages of obesity in dialysis patients.Am J Clin Nutr. 2005; 81: 543-554PubMed Scopus (527) Google Scholar, 9Gustafsson F. Kragelund C.B. Torp-Pedersen C. Seibaek M. Burchardt H. Akkan D. Thune J.J. Kober L. DIAMOND Study GroupEffect of obesity and being overweight on long-term mortality in congestive heart failure: influence of left ventricular systolic function.Eur Heart J. 2005; 26: 58-64Crossref PubMed Scopus (127) Google Scholar, 11Curtis J.P. Selter J.G. Wang Y. Rathore S.S. Jovin I.S. Jadbabaie F. Kosiborod M. Portnay E.L. Sokol S.I. Bader F. Krumholz H.M. The obesity paradox: body mass index and outcomes in patients with heart failure.Arch Intern Med. 2005; 165: 55-61Crossref PubMed Scopus (678) Google Scholar Curtis et al11Curtis J.P. Selter J.G. Wang Y. Rathore S.S. Jovin I.S. Jadbabaie F. Kosiborod M. Portnay E.L. Sokol S.I. Bader F. Krumholz H.M. The obesity paradox: body mass index and outcomes in patients with heart failure.Arch Intern Med. 2005; 165: 55-61Crossref PubMed Scopus (678) Google Scholar examined a cohort of 7,767 outpatients with an established history of HF controlled under digitalis treatment. Higher BMIs were associated with a lower mortality.11Curtis J.P. Selter J.G. Wang Y. Rathore S.S. Jovin I.S. Jadbabaie F. Kosiborod M. Portnay E.L. Sokol S.I. Bader F. Krumholz H.M. The obesity paradox: body mass index and outcomes in patients with heart failure.Arch Intern Med. 2005; 165: 55-61Crossref PubMed Scopus (678) Google Scholar These data confirmed previous survival data of 4,700 hospitalized patients with congestive HF associating an increased BMI with lower mortality (p <0.0001).9Gustafsson F. Kragelund C.B. Torp-Pedersen C. Seibaek M. Burchardt H. Akkan D. Thune J.J. Kober L. DIAMOND Study GroupEffect of obesity and being overweight on long-term mortality in congestive heart failure: influence of left ventricular systolic function.Eur Heart J. 2005; 26: 58-64Crossref PubMed Scopus (127) Google Scholar Recently, Gruberg et al12Gruberg L. Mercado N. Milo S. Boersma E. Disco C. van Es G.A. Lemos P.A. Ben Tzvi M. Wijns W. Unger F. Beyar R. Serruys P.W. Arterial Revascularization Therapies Study InvestigatorsArterial Revascularization Therapies Study Investigators Impact of body mass index on the outcome of patients with multivessel disease randomized to either coronary artery bypass grafting or stenting in the ARTS trial: the obesity paradox II?.Am J Cardiol. 2005; 95: 439-444Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar studied patients who underwent percutaneous coronary intervention or coronary artery bypass grafting. The long-term mortality risk was similar across all BMI categories irrespective of type of revascularization procedure. Thus, overweight or obesity had no effect on crude survival at 3 years.12Gruberg L. Mercado N. Milo S. Boersma E. Disco C. van Es G.A. Lemos P.A. Ben Tzvi M. Wijns W. Unger F. Beyar R. Serruys P.W. Arterial Revascularization Therapies Study InvestigatorsArterial Revascularization Therapies Study Investigators Impact of body mass index on the outcome of patients with multivessel disease randomized to either coronary artery bypass grafting or stenting in the ARTS trial: the obesity paradox II?.Am J Cardiol. 2005; 95: 439-444Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar Sierra-Johnson et al13Sierra-Johnson J. Wright S.R. Lopez-Jimenez F. Allison T.G. Relation of body mass index to fatal and nonfatal cardiovascular events after cardiac rehabilitation.Am J Cardiol. 2005; 96: 211-214Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar followed 389 patients undergoing cardiac rehabilitation and found an inverse relation between BMI and total and cardiovascular mortalities, although only the relation with cardiovascular mortality was statistically significant after adjustment for age and gender. Kragelund14Kragelund C. Hassager C. Hildebrandt P. Torp-Pedersen C. Kober L. Impact of obesity on long-term prognosis following acute myocardial infarction.Int J Cardiol. 2005; 98: 123-131Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar examined the effect of BMI on survival in 6,676 consecutive patients with acute MI during 10-year follow-up. Overall obesity was inversely related to mortality from all causes, There was no association between obesity assessed as BMI and mortality (men, adjusted relative risk 0.90, 95% confidence interval 0.85 to 1.14, p = 0.3; women, adjusted relative risk 0.90, 95% confidence interval 0.74 to 1.10, p = 0.2).14Kragelund C. Hassager C. Hildebrandt P. Torp-Pedersen C. Kober L. Impact of obesity on long-term prognosis following acute myocardial infarction.Int J Cardiol. 2005; 98: 123-131Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar Similar results were reported by Kennedy et al15Kennedy L.M. Dickstein K. Anker S.D. Kristianson K. Willenheimer R. OPTIMAAL Study Group The prognostic importance of body mass index after complicated myocardial infarction.J Am Coll Cardiol. 2005; 45: 156-158Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar who had examined BMI for all-cause mortality and cardiac death in 5,388 patients with complicated AMI. Comparable results were assessed in patients with renal disease.5Kalantar-Zadeh K. Abbott K.C. Salahudeen A.K. Kilpatrick R.D. Horwich T.B. Survival advantages of obesity in dialysis patients.Am J Clin Nutr. 2005; 81: 543-554PubMed Scopus (527) Google Scholar, 16Kalantar-Zadeh K. Causes and consequences of the reverse epidemiology of body mass index in dialysis patients.J Ren Nutr. 2005; 15: 142-147Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar When a large cohort of patients with renal failure requiring dialysis (n = 418,021) was examined for survival, overweight and obese patients using dialysis had longer survival than did those with lower BMI.7Snyder J.J. Foley R.N. Gilbertson D.T. Vonesh E.F. Collins A.J. Body size and outcomes on peritoneal dialysis in the United States.Kidney Int. 2003; 64: 1838-1844Crossref PubMed Scopus (140) Google Scholar The reason for the paradoxic relation of BMI with mortality in the aforementioned patient populations is not understood. Although this pathomodulatory phenomenon is quite obscure, several influences can be suggested in our study. It had been previously demonstrated that peripheral adiposity (i.e., gynoid obesity) poses cardiovascular benefits due to secretion of adiponectin, which has anti-inflammatory, insulin-sensitizing, and antiatherogenic effects in addition to an association with lower total body fat content and the fact that subcutaneous body fat is relatively “inert” in metabolic and inflammatory/mediation terms.17McCarty M.F. A paradox resolved: the postprandial model of insulin resistance explains why gynoid adiposity appears to be protective.Med Hypotheses. 2003; 61: 173-176Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar Abdominal obesity is associated with higher total body fat content, more insulin-resistance, more other co-morbid associations, and more metabolic activity and inflammatory cascading influences. Thus, an obesity paradox might be reflected from a higher prevalence of 1 obesity type (i.e., peripheral) over another (i.e., central), with its decelerating influences becoming more manifest as BMI increases to reach higher levels (i.e., >30 kg/m2). It had been suggested that hypercholesterolemia and high levels of serum low-density lipoproteins associated with obesity serve a scavenging action against unbound circulating lipopolysaccharides with consequent anti-inflammatory response and improved long-term outcomes.18Rauchhaus M. Clark A.L. Doehner W. Davos C. Bolger A. Sharma R. Coats A.J. Anker S.D. The relationship between cholesterol and survival in patients with chronic heart failure.J Am Coll Cardiol. 2003; 42: 1933-1940Abstract Full Text Full Text PDF PubMed Scopus (349) Google Scholar In the other extreme, it can be inferred from our population characteristics that active smokers were mostly in the normal BMI and underweight groups, an unsurprising finding knowing that those were the 2 groups with lowest survival. Loss of weight in geriatric patients, which might be related to malnutrition, multiorgan dysfunction, or unidentified occult malignancies (especially in the smoking population), had been identified as a significant predictor of mortality.19Knudtson M.D. Klein B.E. Klein R. Shankar A. Associations with weight loss and subsequent mortality risk.Ann Epidemiol. 2005; 15: 483-491Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar, 20Su D. Body mass index and old-age survival: a comparative study between the Union Army Records and the NHANES-I Epidemiological Follow-Up Sample.Am J Hum Biol. 2005; 17: 341-354Crossref PubMed Scopus (25) Google Scholar In this instance, those patients who presented at the time of evaluation with a BMI <18.5 kg/m2 at ≥60 years of age represented a subcohort of patients at a higher risk of mortality. Most offending coronary risk factors were associated with a BMI >25 kg/m2. Those patients with symptomatic co-morbidities were expected to have had consulted medical care, with a high probability that they were maintained on drugs proved to improve survival in a CAD population such as β blockers, statins, α2 agonists and angiotensin-converting enzyme inhibitors. One limitation of the study is its retrospective design. Due to time limits, we could not extend our follow-up beyond the date of conclusion. Data regarding waist circumference and waist/hip ratio that measures abdominal obesity were not routinely available. A more precise differentiation between peripheral adiposity and central compartment adiposity would have served to support the suggested hypothetical explanation about the role of a high BMI in prolonging survival in our patient population. Regarding the detection of our end points, a number of nonfatal asymptomatic MIs might have not been reported, especially if these occurred outside the hospital. Unfortunately, we have no data regarding a particular cause of cardiac death." @default.
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