Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Remote ischemic conditioning wikipedia , lookup
Saturated fat and cardiovascular disease wikipedia , lookup
Drug-eluting stent wikipedia , lookup
History of invasive and interventional cardiology wikipedia , lookup
Cardiovascular disease wikipedia , lookup
Jatene procedure wikipedia , lookup
Quantium Medical Cardiac Output wikipedia , lookup
Myocardial infarction wikipedia , lookup
Introduction: Prevalence of obesity is increasing all over the world; this increase is noticeable even in countries in which there has not previously been an overweight and obesity problems. 1 Overweight and obesity are associated with increased morbidity and mortality. For example, in the United States, for the first time since the Civil War, there are estimates for a decrease in life expectancy due to diseases and disorders related to obesity; including high blood pressure, dyslipidemia, and some types of cancer.2 Body mass index, weight in kilograms divided by the square of height in meters, is frequently used as a surrogate for assessment of obesity. 3 The association between obesity and classic cardiovascular disease risk factors, such as, diabetes mellitus, hypertension, dyslipidemia and metabolic syndrome, is known for very long time. Moreover, large longitudinal studies in subjects without known CVD have documented an independent positive association of general and central obesity with cardiovascular events.4-6 On the other hand, a contradictory protective effect of obesity as assessed by increased BMI, known as ‘‘obesity paradox,’’ has been previously reported in various groups of cardiovascular patients; an improved prognosis in obese compared to lean subjects has been shown in patients with known or suspected coronary artery disease (CAD) 7-10, heart failure 11, 12, or following coronary angioplasty.4, 13 The association between BMI and angiographic coronary atherosclerosis in patients undergoing coronary angiography has been little studied. The aim of the present study 1 was to determine the association between obesity assessed with BMI and severity of CAD assessed with invasive coronary angiography (ICA) in our locality Methods: This is a prospective study, enrolled 415 consecutive subjects who underwent Invasive Coronary Angiography (ICA) for different indications. (Figure 1) Figure 1: Indications for invasive coronary angiography in the study group. The study was conducted in a single institution (Department of Cardiology, University Hospital of ASSIUT, EGYPT) during a 6 months period, from March to September 2013.Approval for the study obtained from local ethical committee. Written informed consent was obtained from all patients. Patients with suspected or documented congenital heart disease, hypertrophic obstructive cardiomyopathy, as well as those on hemodialysis, were excluded from the study. In all subjects, a full medical history was taken, and a complete physical examination was performed. Cardiovascular risk factors were recorded in detail, and all patients underwent invasive coronary angiography. The study protocol was approved by the local Ethics Committee. The study complied with the Declaration of Helsinki, and all participants provided written informed consent. The cardiovascular risk factors assessed in the present study were age, gender, family history of CAD, smoking habits, hypertension, hypercholesterolemia, and diabetes mellitus. A positive family history of CAD was determined by the presence of a first degree relative with a cardiovascular event at an age <65 years for women and <55 years for men. Smokers were defined as those who were smoking at the time of enrollment or had stopped for <12 months. Hypertension was defined as systolic 2 blood pressure (SBP) >140 mmHg and/or diastolic blood pressure (DBP) >90 mmHg during the initial evaluation or administration of anti-hypertensive medications. Hypercholesterolemia was defined as low-density lipoprotein cholesterol (LDL-c) >160 mg/dl or total cholesterol >240 mg/dl or administration of anti-cholesterolemic medications (statins or fibrates). Diabetes was defined as a fasting blood glucose concentration ≥126 mg/dl or administration of anti-hyperglycemic medications. BMI was calculated as weight in kg divided by the square of height in meters. Obesity was classified according to the BMI using the National Institute of Health (NIH) criteria as: Lean (BMI 18–24.9 kg/m2), overweight (BMI 25–29.9 kg/m2), obese (BMI ≥ 30 kg/m2).14 Coronary angiography was performed according to the standard Judkins techniques through femoral or radial approach (Integris 3000, Philips Medical Systems, Netherlands). Images were acquired in optimal projection angles, at 25 frames per second, and were digitally recorded on Xcelera workstation. Two experienced operators visually assessed all coronary angiograms, and a consensus was reached. Significant CAD was defined as ≥ 50% stenosis in the internal diameter of at least one coronary artery ≥ 2 mm in diameter. To describe the extent of CAD, patients with CAD were distinguished in those with single-vessel versus multivessel disease (MVD): which defined as the presence of significant CAD in ≥ two epicardial coronary arteries. Left main affection was classified into a separate category. Statistical Analysis Continuous variables are expressed as mean and standard deviation, and categorical variables are presented as frequencies and percentages. Patients were divided into 3 three groups according to BMI class. Baseline patient's characteristics were compared using analysis of variance (ANOVA) for continuous variables, a chi-square (X2) test for dichotomous variables, and fisher exact test for dichotomous variables with fewer than 5 patients in the category. Univariate analysis was performed using X2 test with Yates’ correction when necessary. Multivariate logistic and linear regression analyses were performed using all potentially relevant variables to identify baseline independent predictors of CAD intensity. All p-values were two-tailed, and statistical significance was defined if p <0.05. All analyses were performed with SPSS version 16.0 statistical software (SPSS Inc., Chicago, IL, USA). Results: This cohort comprised of 415 consecutive subjects. Baseline characteristic patients are shown in Table 1. The mean BMI of the study group was 31.2 ± 4.8 kg / m2. Lean patients were 89 (21.5%) with mean BMI of 23.6±1.2 kg / m2 (range 20.2-24.9), over weight patients were 121 (29.1%) with mean BMI of 27.6±1.4 kg / m2 (range 25.129.9) meanwhile, obese patients were 205 (49.2%) with mean BMI of 32.8±2.3 kg / m2 (range 30.1-40.4). Obese patients were associated with higher prevalence of hypertension, diabetes and hypercholesterolemia (Table 1). A non significant trend toward younger age in obese patients at time of ICA, and a higher prevalence of smoking was present. There was no significant difference in the overall incidence of significant CAD between the three groups where almost 90% of lean, obese and overweight patients had CAD (Table 1). Results of ICA in different BMI classes are presented in Table 2. There's no significant difference in the angiographic procedure, radiation exposure, fluoroscopy time, contrast amount and coronary anatomy between the three groups. The 4 prevalence of single, two or three vessel disease did not differ significantly between the 3 BMI classes. Furthermore, the prevalence of LM disease was comparable between different groups as shown in Table 2. Multivariate regression showed that advanced age (OR=1.1, 95 % CI =1.02-6.1), hypertension (OR=2.46, 95 % CI= 1.155.90), diabetes mellitus (OR= 3.1,95 % CI = 1.9-5.7) and dyslipidemia (OR=1.2, 95 % CI = 1.01-6.86) were independent predictors of MVD. On the other hand, obesity (OR=1.23, 95 % CI=0.65- 2.2), and overweight (OR=1.12, 95 % CI=0.65- 2.2) did not predict presence of MVD in our study population (Table 3). Left main affection, also did not had significant relationship with neither over weight (OR= 0.84, 95 % CI=0.25-2.2), nor obesity (OR=1.01, 95 % CI =0.34-3.65) (Table 3). 5 Discussion: The findings of this study indicated that increased BMI class was not related to a higher incidence of significant angiographic CAD in patients underwent ICA. Although obese patients had higher prevalence of hypertension, diabetes and hypercholesterolemia, higher BMI class failed to predict the prevalence of three vessels or left main affection, after adjusting for other major CAD risk factors. Obesity and overweight has traditionally been considered a cardiovascular risk factor and has been associated with an increased risk of developing CAD and mortality in the general population. Thus, it may be speculated that obese patients should have worse outcomes than their non obese counterparts 5, 6, 15. Nevertheless, among patients with known CAD 7-10, heart failure 11, 12or multiple risk factors 16, and post coronary angioplasty 4, 13, a paradoxically improved prognosis has been described in obese compared to lean patients (obesity paradox). In accordance with our results, Hodgson et al18, and Rossi el al19 reported that there was no significant association between BMI and the presence or extent of angiographic CAD in patients at risk for CAD. On the other hand, Rubinshtein et al.17 Found that obesity was not only non predictor, but also, it was associated with less severe coronary artery disease among patients undergoing coronary angiography. Obese patients were found to have a low prevalence of high-risk coronary anatomy (HRCA) compared to non obese comparators. They attributed their results to early referral of obese persons for coronary angiography. This could not apply on current study because most of patients had acute coronary syndrome. However, in the current study, obese and overweight patients tend to be younger than lean patients. 6 Several studies have reported inconsistent results regarding the association of BMI with the occurrence and severity of angiographic CAD. In patients referred for angiography with suspected CAD or acute coronary syndromes, BMI was inversely associated with the presence and severity of CAD 17-19; in one study, this association was lost after adjustment for risk factors 16. The potential mechanisms underlying the ‘‘obesity paradox’’ have been little studied. It has been suggested that these findings was explained by the lack of discriminatory power of BMI to differentiate between body fat and lean mass20. In contrast to BMI, central obesity measured by waist circumference has been proposed to be more appropriate for the assessment of the obesity-related cardiovascular risk in patients with 9, 21 or without 5, 9, 21, 22 known CVD. Another explanation of those negative results is the lack of physical fitness assessment. Low cardiorespiratory fitness is a strong predictor of CVD and all-cause mortality in men and women23, 24. Cardiorespiratory fitness alters obesity dynamics such that obese men survive better only if they register high fitness. Similarly, it explains why some obese individuals are not at risk and why a substantial reduction in mortality risk is even observed in obese adults with moderate fitness compared with those with low fitness 23, 24. Quantitative assessment of physical activity is difficult, most of studies that tested the relationship between CAD and obesity did not examine physical activity of their patients. 5. Study Limitations: This was a prospective cohort observational study single center with relatively small number of patients. Assessment of waist circumference and physical activity is an important confounder which affects morbidity and mortality in obese persons. Larger 7 registries with assessment of these confounders are needed to confirm or counteract our results especially in our locality. 6. Conclusion: Obesity and overweight, measured by BMI, were not related to the severity of CAD in patients underwent ICA. Conflict of interest: Nothing to declare 8 Reference List 1. Lavie CJ, Milani RV, Ventura HO. Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss. J Am Coll Cardiol 2009; 53:1925-32. 2. Olshansky SJ, Passaro DJ, Hershow RC, et al. A Potential Decline in Life Expectancy in the United States in the 21st Century. N Engl J Med 2005; 352:1138-45. 3. Hainer V, Aldhoon-Hainerová I. Obesity Paradox, Does Exist. Diabetes Care 2013; 36:S276-S281 4. Gruberg L, Weissman NJ, Waksman R, et al. The impact of obesity on the shortterm and long-term outcomes after percutaneous coronary intervention: the obesity paradox? J Am Coll Cardiol 2002; 39:578-84. 5. Yusuf S, Hawken S, Ounpuu S, et al. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case-control study. Lancet 2005; 366:1640-1649. 6. Murphy NF, MacIntyre K, Stewart S, et al. Long-term cardiovascular consequences of obesity: 20-year follow-up of more than 15 000 middle-aged men and women (the Renfrew-Paisley study). Eur Heart J 2006; 27:96-106. 7. Galal W, van Domburg RT, Feringa HH, et al. Relation of body mass index to outcome in patients with known or suspected coronary artery disease. Am J Cardiol 2007; 99:1485-90. 8. Romero-Corral A, Montori VM, Somers VK, et al. Association of bodyweight with total mortality and cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet 2006; 368:666-78. 9 9. Lee SH, Park JS, Kim W, et al. Impact of body mass index and waist-to-hip ratio on clinical outcomes in patients with ST-segment elevation acute myocardial infarction (from the Korean Acute Myocardial Infarction Registry). Am J Cardiol 2008; 102:957-65. 10. Ikeda N, Nakajima R, Utsunomiya M, et al. Higher body mass index at the time of acute myocardial infarction is associated with a favorable long-term prognosis (8year follow-up). Heart Vessels 2011; 26:495-501. 11. von Haehling S, Doehner W, Anker SD. Revisiting the obesity paradox in heart failure: new insights? Eur J Heart Fail 2011; 13:130-132. 12. Fonarow GC. The relationship between body mass index and mortality in patients hospitalized with acute decompensated heart failure. Am Heart J 2007; 154:e21. 13. Hastie CE, Padmanabhan S, Slack R, et al. Obesity paradox in a cohort of 4880 consecutive patients undergoing percutaneous coronary intervention. Eur Heart J 2010; 31:222-26. 14. Flegal KM, Kit BK, Orpana H, et al. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 2013; 309:71-82. 15. Wormser D, Kaptoge S, Di AE, et al. Separate and combined associations of body-mass index and abdominal adiposity with cardiovascular disease: collaborative analysis of 58 prospective studies. Lancet 2011; 377:1085-95. 16. Johnson NP, Wu E, Bonow RO, et al. Relation of exercise capacity and body mass index to mortality in patients with intermediate to high risk of coronary artery disease. Am J Cardiol 2008; 102:1028-33? 10 17. Rubinshtein R, Halon DA, Jaffe R, et al. Relation between obesity and severity of coronary artery disease in patients undergoing coronary angiography. Am J Cardiol 2006; 97:1277-80. 18. Niraj A, Pradhan J, Fakhry H, et al. Severity of coronary artery disease in obese patients undergoing coronary angiography: "obesity paradox" revisited. Clin Cardiol 2007;30:391-96. 19. Phillips SD, Roberts WC. Comparison of body mass index among patients with versus without angiographic coronary artery disease. Am J Cardiol 2007; 100:1822. 20. Bechlioulis A, Vakalis K, Naka KK, et al. Paradoxical protective effect of central obesity in patients with suspected stable coronary artery disease. Obesity (Silver Spring) 2013;21:E314-E321. 21. Coutinho T, Goel K, Correa de SD, et al. Central obesity and survival in subjects with coronary artery disease: a systematic review of the literature and collaborative analysis with individual subject data. J Am Coll Cardiol 2011;57:1877-86. 22. Balkau B, Deanfield JE, Despres JP, et al. International Day for the Evaluation of Abdominal Obesity (IDEA): a study of waist circumference, cardiovascular disease, and diabetes mellitus in 168,000 primary care patients in 63 countries. Circulation 2007; 116:1942-51. 23. Barnes JN, Joyner MJ. Physical activity and cardiovascular risk: 10 metabolic equivalents or bust. Mayo Clin Proc 2013; 88:1353-55. 24. Zhao G, Ford ES, Li C, et al. Are United States adults with coronary heart disease meeting physical activity recommendations? Am J Cardiol 2008; 101:557-61. 11