Impact of Body Composition Indices on Ten-year Mortality After Revascularization of Complex Coronary Artery Disease (From the Syntax Extended Survival Trial)

Masafumi Ono,Kuniaki Takahashi,Yoshinobu Onuma,Michael J Mack,Hironori Hara,Stuart J Head,Arie Pieter Kappetein,Hideyuki Kawashima,Jan J Piek,Patrick W Serruys,Rutao Wang,David R Holmes,John W Mcevoy,Mohr W Friedrich,Chao Gao,Thilo Noack,Marie Claude Morice ,Daniel J F M Thuijs ,Piroze Davierwala ,Neil O’leary

doi:10.1016/j.amjcard.2021.04.008

Abstract

Numerous studies have demonstrated a paradoxical association between higher baseline body mass index (BMI) and lower long-term mortality risk after coronary revascularization, known as the "obesity paradox", possibly relying on the single use of BMI. The current study is a post-hoc analysis of the SYNTAX Extended Survival (SYNTAXES) trial, which is the extended follow-up of the SYNTAX trial comparing percutaneous coronary intervention (PCI) versus coronary artery bypass graft (CABG) in patients with left-main coronary artery disease (LMCAD) or three-vessel disease (3VD). Patients were stratified according to baseline BMI and/or waist circumference (WC). Out of 1,800 patients, 1,799 (99.9%) and 1,587 (88.2%) had available baseline BMI and WC data, respectively. Of those, 1,327 (73.8%) patients had High BMI (≥25 kg/m2), whereas 705 (44.4%) patients had High WC (>102 cm for men or >88 cm for women). When stratified by both BMI and WC, 10-year mortality risk was significantly higher in patients with Low BMI/Low WC (adjusted hazard ratio [HR]: 1.65; 95% confidence interval [CI]: 1.09 to 2.51), Low BMI/ High WC (adjusted HR: 2.74; 95% CI: 1.12 to 6.69), or High BMI/High WC (adjusted HR: 1.59; 95% CI: 1.11 to 2.27) compared to those with High BMI/Low WC. In conclusion, the "obesity paradox" following coronary revascularization would be driven by low long-term mortality risk of the High BMI/Low WC group. Body composition should be assessed by the combination of BMI and WC in the appropriate evaluation of the long-term risk of obesity in patients with LMCAD or 3VD.

Highlights

Obesity is a major health problem worldwide and contributes to progression of cardiovascular disease, including coronary artery disease (CAD), leading to poor prognosis.[1]
There was no significant difference in terms of age between patients with High body mass index (BMI)/Low waist circumference (WC) and those with High BMI/High WC
When stratified by both BMI and WC, patients with High BMI/Low WC had the lowest crude 10-year mortality rate, which contributed to the favorable outcome of High BMI group (Figure 4)

Summary

Introduction

Obesity is a major health problem worldwide and contributes to progression of cardiovascular disease, including coronary artery disease (CAD), leading to poor prognosis.[1]. The exact biological and prognostic significance of the “obesity paradox” remains unclear far, one major hypothesis is that BMI itself would be a poor and indirect indicator of obesity-related cardiovascular risk aDepartment of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; bDepartment of Cardiology, National University of Ireland, Galway (NUIG), Galway, Ireland; cDepartment of Cardiology, Radboud University, Nijmegen, The Netherlands; dDepartment of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas; eDepartment of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota; fDepartement of Cardiologie, H^opital prive Jacques Cartier, Generale de Sante Massy, France; gDepartment of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands; hUniversity Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany; and iNHLI, Imperial College.

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