Fast track — ArticlesAssociation of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies
Introduction
The American Heart Association and American College of Cardiology guidelines for secondary prevention in coronary artery disease (CAD) list obesity as a major modifiable cardiovascular risk factor.1 About two-thirds of patients who have had myocardial infarction (MI) have a higher than normal body-mass index (BMI) of 25 or above.
There are several pathophysiological pathways by which obesity increases the risk for developing CAD and adverse cardiovascular events. Obesity reduces insulin sensitivity, enhances free fatty acid turnover, increases basal sympathetic tone, induces a hypercoagulable state, and promotes systemic inflammation, all of which contribute to the development and progression of CAD.2 In addition, obesity is a “conditional” risk for developing cardiovascular risk factors such as diabetes, dyslipidemia, hypertension, and obstructive sleep apnoea.3, 4 Although obesity is clearly a risk factor for developing CAD, once CAD has been established, the correlation of obesity with total mortality, cardiovascular mortality, infarction, and revascularisation is unclear. The relation between obesity and mortality in patients with CAD has so far only been investigated by post-hoc analysis of cohort studies, which have produced contradictory results.5, 6, 7, 8, 9
In view of the high prevalence of obesity in patients with CAD,10 we need a more accurate estimate of the link between obesity, and cardiovascular events and total mortality. Our aim was to undertake a systematic review of cohort studies and perform a meta-analysis to better estimate the effect of bodyweight and other measures of obesity on total mortality, cardiovascular mortality, reinfarction, and revascularisation in patients with established CAD.
Section snippets
Search strategy and selection criteria
We searched, with no language restrictions, the OVID/MEDLINE electronic database from 1966 to December, 2005, for studies reporting total mortality and cardiovascular events in patients with established CAD, on the basis of bodyweight or other measures of fat distribution. We used terms related to bodyweight (eg, body mass index, bodyweight, obesity, overweight, central obesity, body fat), mortality and other cardiovascular events (eg, cardiac death, cardiovascular death, survival, mortality,
Results
Of the 1560 articles and 34 abstracts identified, 54 studies met the inclusion criteria. On the whole, both reviewers were in agreement over which studies should be included (κ=0·79). Figure 1 shows details of study selection.
40 studies had weight groups based on BMI and the rest had BMI reported as a continuous variable or used another measure of obesity. The BMI group studies represented the core of this analysis and included 250 152 patients with CAD, with a mean follow-up of 3·8 years
Discussion
Our study shows that after grouping cohort studies with adjusted risks, a low BMI is strongly associated with an increased long-term risk of total mortality and other cardiovascular events. Overweight patients were consistently associated with a better survival and lower cardiovascular events. Obesity was associated with a higher total mortality only in patients with history of CABG. Severe obesity was associated with a significantly higher cardiovascular mortality but not with an increased
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