Body mass index and mortality in acutely decompensated heart failure across the world: a global obesity paradox. Is obesity a predictor of mortality, morbidity and readmission after cardiac surgery? The Influence of Body Mass Index on Outcomes in Patients Undergoing Cardiac Surgery: Does the Obesity Paradox Really Exist? Relationship of body mass index with outcomes after coronary artery bypass graft surgery. Influence of obesity on outcomes in atrial fibrillation: yet another obesity paradox. Obesity paradox in patients with hypertension and coronary artery disease. [Consequences of obesity in outcomes after cardiac surgery. Analysis of ARIAM registry]. The impact of body mass index on short- and long-term outcomes inpatients undergoing coronary revascularization. Insights from the bypass angioplasty revascularization investigation (BARI). 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? Cardiac procedures in patients with a body mass index exceeding 45: outcomes and long-term results. Cardiovascular risk in relation to body mass index and use of evidence-based preventive medications in patients with or at risk of atherothrombosis. Body mass index has no effect on rate of progression of chronic kidney disease in non-diabetic subjects. Diabetes and outcomes of coronary artery bypass graft surgery in patients with severe left ventricular dysfunction: results from The CABG Patch Trial database. The CABG Patch Trial Investigators and Coordinators. The effect of diabetes mellitus on patients undergoing coronary surgery: a risk-adjusted analysis. The obesity paradox in men with coronary heart disease and heart failure: The role of muscle mass and leptin☆☆☆★ "Obesity paradox" in chronic obstructive pulmonary disease. Impact of hypertension on cardiomyopathy, morbidity and mortality in end-stage renal disease. Perioperative Hemodynamic Instability and Fluid Overload are Associated with Increasing Acute Kidney Injury Severity and Worse Outcome after Cardiac Surgery Characteristics, management and outcomes of patients with acute coronary syndrome and prior coronary artery bypass surgery: findings from the second Gulf Registry of Acute Coronary Events. Obesity, Brain Natriuretic Peptide Levels and Mortality in Patients Hospitalized With Heart Failure and Preserved Left Ventricular Systolic Function Obesity and Peritoneal Surface Disease: Outcomes after Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy for Appendiceal and Colon Primary Tumors The relationship between obesity and atherosclerotic progression and prognosis among patients with coronary artery bypass grafts the effect of aggressive statin therapy. Anxiety Predicts Mortality and Morbidity After Coronary Artery and Valve Surgery—A 4-Year Follow-Up Study
OBJECTIVES This study sought to define the relationship between  body mass index ( BMI )  and mortality in heart failure ( HF ) across the world and to identify specific groups in whom BMI may differentially mediate risk . BACKGROUND Obesity is associated with incident HF , but it is paradoxically associated with better prognosis during chronic HF . METHODS We studied 6,142 patients with acute decompensated HF from 12 prospect i ve observational cohorts followed-up across 4 continents . Primary outcome was all-cause mortality . Cox proportional hazards models and net reclassification index described associations of BMI with all-cause mortality . RESULTS Normal-weight patients ( BMI 18.5 to 25 kg/m(2 ) ) were older with more advanced HF and lower cardiometabolic risk . Despite worldwide heterogeneity in clinical features across obesity categories , a higher BMI remained associated with decreased 30-day and 1-year mortality ( 11 % decrease at 30 days ; 9 % decrease at 1 year per 5 kg/m(2 ) ; p < 0.05 ) , after adjustment for clinical risk . The BMI obtained at index admission provided effective 1-year risk reclassification beyond current markers of clinical risk ( net reclassification index 0.119 , p < 0.001 ) . Notably , the " protective " association of BMI with mortality was confined to persons with older age ( > 75 years ; hazard ratio [ HR ] : 0.82 ; p = 0.006 ) , decreased cardiac function ( ejection fraction < 50 % ; HR : 0.85 ; p < 0.001 ) , no diabetes ( HR : 0.86 ; p < 0.001 ) , and de novo HF ( HR : 0.89 ; p = 0.004 ) . CONCLUSIONS A lower BMI is associated with age , disease severity , and a higher risk of death in acute decompensated HF . The " obesity paradox " is confined to older persons , with decreased cardiac function , less cardiometabolic illness , and recent-onset HF , suggesting that aging , HF severity/chronicity , and metabolism may explain the obesity paradox INTRODUCTION Obesity has been described as a risk factor for the development of coronary artery disease , but it has not been determined whether obesity is associated with adverse outcomes after cardiac surgery . Therefore , we analyzed a large cohort of patients who had undergone cardiac surgery to determine whether obesity is a predictor of mortality , morbidity or early readmission to hospital . METHODS At the London Health Sciences Centre , an academic tertiary care centre , we prospect ively entered data from the cardiac surgical data base from July 1999 to April 2002 . We collected data on 1310 consecutive , unselected patients who underwent cardiac surgery during that time . We assessed the degree of obesity using the body mass index ( BMI ) , and we prospect ively documented the occurrence of 10 major complications after surgery . They included stroke , reoperation for bleeding , life-threatening cardiac arrest or arrhythmia , new renal failure requiring dialysis , septicemia , mediastinitis , sternal dehiscence , respiratory failure , postoperative myocardial infa rct ion and low cardiac output necessitating intra-aortic balloon pump use . Univariable and multivariable analyses were conducted to determine the factors associated with and predictive of postoperative death and major complications . RESULTS An increased BMI did not increase the risk of early postoperative death . Furthermore , increased BMI was not a predictor of a patient experiencing any of the major complications , except sternal dehiscence . An increased BMI was associated with a higher likelihood of readmission to hospital within 30 days of discharge . CONCLUSION Obesity was not associated with adverse outcomes after cardiac operations , aside from the increased risks of sternal dehiscence and early hospital readmission Purpose Obesity influences risk stratification in cardiac surgery in everyday practice . However , some studies have reported better outcomes in patients with a high body mass index ( BMI ): this is known as the obesity paradox . The aim of this study was to quantify the effect of diverse degrees of high BMI on clinical outcomes after cardiac surgery , and to assess the existence of an obesity paradox in our patients . Methods A total of 2,499 consecutive patients requiring all types of cardiac surgery with cardiopulmonary bypass between January 2004 and February 2009 were prospect ively studied at our institution . Patients were divided into four groups based on BMI : normal weight ( 18.5–24.9 kg∙m−2 ; n = 523 ; 21.4 % ) , overweight ( 25–29.9kg∙m−2 ; n = 1150 ; 47 % ) , obese ( ≥30–≤34.9kg∙m−2 ; n = 624 ; 25.5 % ) and morbidly obese ( ≥35kg∙m−2 ; n = 152 ; 6.2 % ) . Follow-up was performed in 2,379 patients during the first year . Results After adjusting for confounding factors , patients with higher BMI presented worse oxygenation and better nutritional status , reflected by lower PaO2/FiO2 at 24h and higher albumin levels 48h after admission respectively . Obese patients showed a higher risk for Perioperative Myocardial Infa rct ion ( OR : 1.768 ; 95 % CI : 1.035–3.022 ; p = 0.037 ) and septicaemia ( OR : 1.489 ; 95 % CI : 1.282–1.997 ; p = 0.005 ) . In-hospital mortality was 4.8 % ( n = 118 ) and 1-year mortality was 10.1 % ( n = 252 ) . No differences were found regarding in-hospital mortality between BMI groups . The overweight group showed better 1-year survival than normal weight patients ( 91.2 % vs. 87.6 % ; Log Rank : p = 0.029 . HR : 1.496 ; 95 % CI : 1.062–2.108 ; p = 0.021 ) . Conclusions In our population , obesity increases Perioperative Myocardial Infa rct ion and septicaemia after cardiac surgery , but does not influence in-hospital mortality . Although we found better 1-year survival in overweight patients , our results do not support any protective effect of obesity in patients undergoing cardiac surgery BACKGROUND A debate exists whether obesity is a risk factor for operative mortality after  coronary artery bypass graft surgery ( CABG ) . The contradictory findings in the literature may largely be attributable to the variety of method ological approaches used to model the association between body mass index ( BMI ) and post-CABG outcomes . This study aims to investigate this association , and to uncover possible explanations for the lack of consensus across prior studies . METHODS Data were prospect ively collected on 80,792 patients who underwent a CABG procedure during a 14-year period at the 45 Department of Veterans Affairs cardiac surgery programs .  Generalized additive models were used to estimate the relationship of BMI and outcomes after a CABG procedure . RESULTS We found that the relationship of BMI with post-CABG mortality and morbidity is U-shaped with the minimum risk located around a BMI of 30 kg/m2 , indicating that patients classified as overweight have the lowest risk , and those in the lower end of the obese range do not have seriously elevated risk . This U-shape relationship is significantly nonlinear and robust to adjustment for other risk factors . CONCLUSIONS This study demonstrates that BMI is an independent predictor of mortality and morbidity after CABG surgery . Previous studies that model BMI linearly or as categories can not accurately capture this U-shaped relationship and are unlikely to find a significant contribution by including BMI . Further research is needed to determine the mechanisms of risk for patients with low and high BMI and whether interventions to modify BMI may improve patient outcomes BACKGROUND Obese patients have favorable outcomes in congestive heart failure , hypertension , peripheral vascular disease , and coronary artery disease . Obesity also has been linked with increased incidence of atrial fibrillation , but its influence on outcomes in atrial fibrillation patients has not been investigated . The objective of this research is to investigate the effect of obesity on outcomes in atrial fibrillation . METHODS The Atrial Fibrillation Follow-up Investigation of Rhythm Management ( AFFIRM ) study was one of the largest multicenter trials of atrial fibrillation , with 4060 patients . Subjects were r and omized to rate versus rhythm-control strategy . We performed a post hoc analysis of the National Heart , Lung and Blood Institute limited access data set of atrial fibrillation patients who had body mass index ( BMI ) data available in the AFFIRM study . BMI data were not available on 1542 patients . Patients with BMI > or=18.5 were split into normal ( 18.5 - 25 ) , overweight ( 25 - 30 ) , and obese ( > 30 ) categories as per BMI ( kg/m(2 ) ) . Multivariate Cox proportional hazards regression was used on the eligible 2492 patients . End points were all-cause mortality and cardiovascular mortality . RESULTS Over three fourths of all patients in our cohort were overweight or obese . There were 304 deaths ( 103 among normal weight , 108 among overweight , and 93 among obese ) and 148 cardiovascular deaths ( 54 among normal weight , 41 among overweight , and 53 among obese ) over a mean period of 3 years of patient follow-up . On multivariate analysis , overweight ( hazard ratio [ HR ] 0.64 ; 95 % confidence interval [ CI ] , 0.48 - 0.84 ; P=.001 ) and obese ( HR 0.80 ; 95 % CI , 0.68 - 0.93 ; P=.005 ) categories were associated with lower all-cause mortality as compared with normal weight . Overweight ( HR 0.40 ; 95 % CI , 0.26 - 0.60 ; P < .001 ) and obese patients ( HR 0.77 ; 95 % CI , 0.62 - 0.95 ; P=.01 ) also had lower cardiovascular mortality as compared with the normal weight patients . CONCLUSIONS Although in prior studies , obesity has been associated with increased risk of atrial fibrillation , an obesity paradox exists for outcomes in atrial fibrillation . Obese patients with atrial fibrillation appear to have better long-term outcomes than nonobese patients PURPOSE An obesity paradox , a " paradoxical " decrease in morbidity and mortality with increasing body mass index ( BMI ) , has been shown in patients with heart failure and those undergoing percutaneous coronary intervention . However , whether this phenomenon exists in patients with hypertension and coronary artery disease is not known . METHODS A total of 22,576 hypertensive patients with coronary artery disease ( follow-up 61,835 patient years , mean age 66+/-9.8 years ) were r and omized to a verapamil-SR or atenolol strategy . Dose titration and additional drugs ( tr and olapril and /or hydrochlorothiazide ) were added to achieve target blood pressure control according to the Sixth Joint National Committee on Prevention , Detection , Evaluation , and Treatment of High Blood Pressure targets . Patients were classified into 5 groups according to baseline BMI : less than 20 kg/m2 ( thin ) , 20 to 25 kg/m2 ( normal weight ) , 25 to 30 kg/m2 ( overweight ) , 30 to 35 kg/m2 ( class I obesity ) , and 35 kg/m2 or more ( class II-III obesity ) . The primary outcome was first occurrence of death , nonfatal myocardial infa rct ion , or nonfatal stroke . RESULTS With patients of normal weight ( BMI 20 to<25 kg/m2 ) as the reference group , the risk of primary outcome was lower in the overweight patients ( adjusted hazard ratio [ HR ] 0.77 , 95 % confidence interval [ CI ] , 0.70 - 0.86 , P<.001 ) , class I obese patients ( adjusted HR 0.68 , 95 % CI , 0.59 - 0.78 , P<.001 ) , and class II to III obese patients ( adjusted HR 0.76 , 95 % CI , 0.65 - 0.88 , P < .001 ) . Class I obese patients had the lowest rate of primary outcome and death despite having smaller blood pressure reduction compared with patients of normal weight at 24 months ( -17.5+/-21.9 mm Hg/-9.8+/-12.4 mm Hg vs -20.7+/-23.1 mm Hg /-10.6+/-12.5 mm Hg , P<.001 ) . CONCLUSION In a population with hypertension and coronary artery disease , overweight and obese patients had a decreased risk of primary outcome compared with patients of normal weight , which was driven primarily by a decreased risk of all-cause mortality . Our results further suggest a protective effect of obesity in patients with known cardiovascular disease in concordance with data in patients with heart failure and those undergoing percutaneous coronary intervention BACKGROUND AND OBJETIVE Obesity is a disease that affects a large part of the population and has been associated with worse outcomes after cardiac surgery . The aim of our study is to evaluate the consequences of obesity related to postoperative complications , hospital length of stay and mortality . METHODS Observational , prospect i ve , multicenter study of patients included in ARIAM registry of adult cardiac surgery between March 2008 to March 2011 . We analyzed clinical variables , the surgical procedure , postoperative complications and mortality , comparing the group of patients with body mass index ( BMI ) greater or less than 30 kg/m(2 ) . RESULTS The study included 4,172 patients with a mean age of 64.03 ( SD 12.08 ) years , BMI 28.53 ( 4.7 ) and EuroSCORE 5.58 ( 2.91 ) . In 1,490 patients ( 35.7 % ) BMI was greater than 30 . There were no differences in the development of overall postoperative complications ( 33 % in obese and non-obese 35.8 % , P=.07 ) , although there were less appreciated reoperation rate or stroke ( P<.05 ) , as well as further development postoperative renal failure ( P=.009 ) . After adjusting for severity and length of cardio by pass time , obese patients had lower mortality without being statistically significant . OR 0.94 ( 0.79 - 1.04 ) . There were no differences in ICU length of stay , but obese patients had greater Ward length of stay 9.04 ( 10.43 ) vs. 8.18 ( 9.2 ) days , P=.01 . CONCLUSIONS Obese patients undergoing cardiac surgery have a mortality , rate of complications and length of stay similar to non-obese . Obese patients required less reoperations but developed more frequently postoperative renal failure OBJECTIVES We sought to investigate the impact of body mass index ( BMI ) on short- and long-term outcomes after initial revascularization with percutaneous transluminal coronary angioplasty ( PTCA ) or coronary artery bypass graft surgery ( CABG ) .  BACKGROUND Equivocal results exist on the impact of BMI on the risk of in-hospital complications after PTCA or CABG , and no long-term mortality data exist from a large series of revascularized patients . METHODS From the r and omized series and observational registry of the Bypass Angioplasty Revascularization Investigation ( BARI ) , 2,108 patients who had PTCA and 1,526 patients who had CABG were evaluated by taking their BMI at study entry . They were classified as follows : low ( < 20 kg/m(2 ) ) , normal ( 20 to 24.9 kg/m(2 ) ) , overweight ( 25 to 29.9 kg/m(2 ) ) , class I obese ( 30 to 34.9 kg/m(2 ) ) and class II/III obese ( greater-than-or-equal 35 kg/m(2 ) ) . In-hospital complications and short- and long-term mortalities were compared between levels of BMI within each mode of initial revascularization . RESULTS Among patients who had PTCA , each unit increase in BMI was associated with a 5.5 % lower adjusted risk of a major in-hospital event ( death , myocardial infa rct ion , stroke , coma ) ; among patients who had CABG , no difference in the in-hospital outcome was observed according to BMI . In contrast , BMI was not associated with five-year mortality in the PTCA group ; among the CABG group , adjusted relative risks of five-year cardiac mortality according to levels of BMI were 0.0 ( low ) , 1.0 ( normal ) , 2.02 ( overweight ) , 3.16 ( class I obese ) and 4.85 ( class II/III obese ) ( linear p < 0.001 ) . CONCLUSIONS Body mass index appears to have a differential impact on short- and long-term outcomes after coronary revascularization . These results underscore the need for further research to identify factors responsible for the apparent short-term protective effect of a higher BMI in patients undergoing PTCA and to study the impact of weight reduction on the long-term survival of obese patients undergoing CABG The effect of body mass index ( BMI ) on outcomes after coronary artery revascularization remains controversial . We studied 1,203 patients who had multivessel coronary artery disease and underwent stenting ( n = 599 ) or coronary artery bypass grafting ( CABG ; n = 604 ) in the Arterial Revascularization Therapies Study . Patients were assigned to 1 of 3 groups according to BMI : < 25 , 25 to 30 , and > 30 kg/m(2 ) . At 3-year follow-up , the incidence of death , cerebrovascular events , or myocardial infa rct ion was similar for these BMI categories regardless of the revascularization technique used . Rates of repeat revascularization procedures were significantly higher among patients who had been r and omized to stenting but were similar across BMI groups . For patients who had been r and omized to undergo CABG , there was a significant decrease in repeat revascularization procedures in obese patients ( p = 0.03 ) . Among patients who underwent stenting , BMI had no effect on the 3-year combined end point of rate of major adverse cardiac or cerebrovascular events . Among patients who underwent CABG , major adverse cardiac or cerebrovascular event rates were significantly lower for patients who were obese ( 11 % ) or overweight ( 16 % ) compared with patients who had a normal BMI ( 24 % ; p = 0.008 ) . Thus , in a large cohort of patients who had multivessel coronary artery disease and underwent surgical or percutaneous revascularization , BMI had no effect on 3-year outcome of those who underwent stenting . Conversely , among patients who underwent CABG , those who were overweight or obese had a significantly better outcome than did those who had a normal BMI with regard to survival without major adverse cardiac or cerebrovascular events , mainly due to lower rates of repeat revascularization procedures BACKGROUND Obesity has become a public health crisis . Although prior studies in obese patients undergoing cardiac surgical procedures have shown variable effects on outcomes , data are limited for extremely obese patients ( body mass index [ BMI ] > or = 45 ) . We undertook this study to evaluate outcomes in this cohort . METHODS A retrospective analysis was performed on 14,571 patients in our data base who underwent cardiac operations from 1992 to 2005 . Patient demographics , comorbidities , and outcomes were recorded . A univariate analysis between two groups : BMI 21 to 34.9 and BMI 45 or more was performed . Logistic regression models were used to identify independent risk factors for 30-day mortality . Long-term follow-up of the extreme obese group was achieved . RESULTS We identified 128 extreme obese patients , and 480 patients with a BMI of 21.0 to 34.9 were r and omly selected for comparison . Univariate analysis showed significant differences in age , gender , and multiple comorbidities , as well as in cardiopulmonary bypass and cross-clamp times , operative procedure , and transfusion requirements . Extreme obese patients had a higher incidence of infection , acute renal failure , and 30-day mortality . Logistic regression analysis showed BMI , preoperative renal insufficiency , and transfusion status to be independent risk factors for 30-day mortality . Follow-up data did not reveal significant functional improvements . Long-term survival was 33.6 % at 12 years . CONCLUSIONS Extreme obese patients undergoing cardiac surgical procedures have higher perioperative morbidity and mortality compared with a lower BMI group . BMI and preoperative renal insufficiency increase mortality in both groups , whereas transfusion does so only in the extreme obese . These patients can realize acceptable outcomes from cardiac procedures , but continue to suffer from the comorbidities of obesity AIM Explore the relation between body mass index ( BMI ) and cardiovascular disease , and the influence of optimal medical therapy ( OMT ) on this relationship . METHODS AND RESULTS Patients from the REACH cohort , an international , prospect i ve cohort of patients with or at high risk of atherosclerosis with documentation of potential confounders , including treatments and risk factors , were followed up to 4 years ( n = 54 285 ) . Patients were categorized according to baseline BMI ( ranging from underweight to Grade III obesity ) . Optimal medical therapy was defined as the use of the four cardioprotective medication classes ( statins , ACE inhibitors/angiotensin II receptor blockers , β-blockers , and antiplatelet agents ) . The main outcomes were all-cause mortality , cardiovascular ( CV ) mortality , and CV events . In primary and secondary prevention , a reverse J-shaped curve best described the relationship between BMI categories and the incidence of the various outcomes . In secondary prevention , the highest adjusted risks were observed for underweight patients ( 1.97 , P < 0.01 , and 1.29 , P = 0.03 , for CV mortality and CV events ) and the lowest HRs were observed , respectively , in Grade II and Grade III obese patients ( 0.73 , P < 0.01 and 0.80 , P < 0.01 ) . The proportion of patients on OMT increased with BMI from 10.1 to 36 % ( P < 0.001 ) . The apparent CV protection conferred by obesity persisted in patients receiving OMT . CONCLUSION An obesity paradox was observed in both primary and secondary CV prevention patients . The intensity of use of evidence -based preventive medications does not account for the paradoxical CV protection associated with obesity . At extremes of BMI , further interventions beyond OMT may be needed to reduce CV risk BACKGROUND Chronic kidney disease ( CKD ) is increasingly prevalent worldwide . Furthermore , obesity is now a global problem with major health implication s. There is a clear association between obesity and the development of CKD but it is not known whether obesity is a risk factor for the progression of pre-existing kidney disease . We examined the relationship between the  body mass index ( BMI )  and the rate of progression of CKD in non-diabetic adults . METHODS The Chronic Renal Insufficiency St and ards Implementation Study ( CRISIS ) is a prospect i ve observational study in a predominantly white population in Greater Manchester . From the CRISIS data base , we assessed rate of progression of CKD in 499 adults attending the hospital . Baseline measurements including  BMI  were obtained and  estimated glomerular filtration rate ( eGFR ) was monitored . The rate of deterioration of eGFR was derived over time , defined as ΔeGFR ( mL/min/1.73 m2/year ) and assessed using univariate analysis of variance . RESULTS In the groups as a whole , no relationship between BMI and ΔeGFR was shown . Dividing the subjects into obese ( BMI ≥30 ) and non-obese ( BMI < 30 ) groups and further breakdown into CKD stages 3 , 4 and 5 , also showed no relationship between BMI and ΔeGFR . Univariate analysis of variance was used . CONCLUSIONS Neither BMI as a continuous variable nor obesity ( BMI ≥30 ) as a categorical variable was associated with an increased rate of progression of existing CKD in this predominantly white population OBJECTIVES We examined the relationship between diabetes mellitus and outcomes after  coronary artery bypass graft ( CABG ) surgery  in patients with severe left ventricular ( LV ) dysfunction . BACKGROUND Although diabetes is associated with poor outcomes after CABG surgery among unselected patients , the relationship between diabetes and mortality after CABG surgery among patients with LV dysfunction is less certain . METHODS Using data from The CABG Patch Trial , a study of implantable cardiac defibrillator therapy , we analyzed 900 patients with ejection fraction < 0.36 who underwent CABG surgery from 1990 to 1996 . RESULTS Diabetics comprised 38 % of the patients , and 48 % of diabetics were prescribed insulin . Diabetes was associated with hypertension , peripheral vascular disease , history of stroke , clinical heart failure and rales on physical exam . Diabetics were at higher risk for postoperative superficial sternal wound infection and renal failure . With an average follow-up time of 32 + /-16 months , actuarial all-cause mortality 48 months after CABG surgery was 26 % in diabetics and 24 % in nondiabetics ( p = 0.66 , log-rank test ) . Diabetes was not associated with long-term mortality in Cox multiple regression analyses . Actuarial re-hospitalization rates 48 months after CABG surgery were 85 % in diabetics and 69 % in nondiabetics ( p = 0.0001 , log-rank test ) . Diabetics had a 44 % higher risk of re-hospitalization for any cause ( p = 0.0001 ) and a 24 % higher risk of re-admission for cardiac causes ( p < 0.05 ) . Unexpectedly , fewer arrhythmic events were found in diabetics . CONCLUSIONS Diabetes was not a predictor of mortality after CABG surgery among patients with LV dysfunction despite associated comorbidities . However , diabetes was associated with increased postoperative complications and re-hospitalization BACKGROUND Surgical case-mix is seriously worsening , and the results of surgical revascularization on high-risk cohorts should be continuously evaluated . This study investigates the influence of diabetes mellitus on the short and midterm outcome in the modern era of coronary surgery . METHODS AND RESULTS Patients who underwent first-time coronary artery bypass grafting from April 1996 to October 2003 were classified into diabetic and nondiabetic groups . Data were prospect ively collected and retrospectively analyzed . A total of 5259 patients were studied , and of these 877 ( 17 % ) were diabetic . Patients with diabetes were more likely to be female , have a higher body mass index , be in an advanced New York Heart Association class and Canadian Cardiovascular Society class , have a history of congestive heart failure , have a poor ejection fraction , renal failure , and more extensive coronary artery disease than the nondiabetic group ( P < .001 for all ) . In-hospital mortality was 2.2 % and 1 % for diabetic and nondiabetic patients , respectively ; however , diabetes was not found to be an independent risk factor for in-hospital mortality ( odds ratio = 1.63 ; 95 % confidence interval 0.92 - 2.88 ; P = .089 ) . Postoperative complications were comparable in the two groups , with only renal , neurologic , and gastrointestinal complications significantly associated with diabetes ( all P < or = .05 ) . There was no association between diabetes mellitus and postoperative infective complications . Diabetes remained an independent predictor of 5-year mortality ( hazard ratio 1.55 ; 95 % confidence interval 1.22 - 1.96 ; P < .001 ) and of lower 5-year cardiac-related event-free survival . CONCLUSION Despite a worsening cohort , diabetic patients could be surgically revascularized with low morbidity and mortality , comparable with control patients . The negative effect of diabetes mellitus on the longer-term mortality and morbidity remains a problem Aims We have investigated the role of muscle mass , natriuretic peptides and adipokines in explaining the obesity paradox . Background The obesity paradox relates to the association between obesity and increased survival in patients with coronary heart disease ( CHD ) or heart failure ( HF ) . Methods Prospect i ve study of 4046 men aged 60–79 years followed up for a mean period of 11 years , during which 1340 deaths occurred . The men were divided according to the presence of doctor diagnosed CHD and HF : ( i ) no CHD or HF ii ) , with CHD ( no HF ) and ( iii ) with HF . Results Overweight ( BMI 25–9.9 kg/m2 ) and obesity ( BMI ≥ 30 kg/m2 ) were associated with lower mortality risk compared to men with normal weight ( BMI 18.5–24.9 kg/m2 ) in those with CHD [ hazards ratio ( HR ) 0.71 ( 0.56,0.91 ) and 0.77 ( 0.57,1.04 ) ; p = 0.04 for trend ] and in those with HF [ HR 0.57 ( 0.28,1.16 ) and 0.41 ( 0.16,1.09 ; p = 0.04 for trend ) . Adjustment for muscle mass and NT-proBNP attenuated the inverse association in those with CHD ( no HF ) [ HR 0.78 ( 0.61,1.01 ) and 0.96 ( 0.68,1.36 ) p = 0.60 for trend ) but made minor differences to those with HF [ p = 0.05 ] . Leptin related positively to mortality in men without HF but inversely to mortality in those with HF ; adjustment for leptin abolished the BMI mortality association in men with HF [ HR 0.82 ( 0.31,2.20 ) and 0.99 ( 0.27,3.71 ) ; p = 0.98 for trend ] . Conclusion The lower mortality risk associated with excess weight in men with CHD without HF may be due to higher muscle mass . In men with HF , leptin ( possibly reflecting cachexia ) explain the inverse association BACKGROUND The " obesity paradox " is defined as an inverse association of good health , survival and obesity . Usually in healthy persons the more obese you are the more metabolic complications you have ; however , thin patients with chronic obstructive pulmonary disease ( COPD ) have more cardiovascular complications and a higher mortality rate . OBJECTIVES To explore whether atherosclerosis and peripheral artery disease ( PAD ) contribute to the higher morbidity and mortality of patients with COPD . METHODS This prospect i ve study included 87 patients with chronic COPD who were treated in the pulmonary outpatient clinic ; all signed a consent form before enrollment . We documented their  lung function ( FEV1 % ) , body mass index ( BMI ) and ankle brachial index ( ABI ) . The primary endpoints were to find an association between atherosclerosis and BMI in patients with COPD , and between atherosclerosis and severity of lung disease . RESULTS Average ABI was 1.01 + /- 0.20 , BMI was 29.33 + /- 7.48 kg/m2 , and the abdominal circumference was 107.34 + /- 18.87 cm . A positive correlation was found between BMI and ABI ( P=0.001 ) and between abdominal circumference and ABI ( P=0.000 ) . Patients with peripheral artery disease were older ( 73.6 + /- 11.5 vs. 68.1 + /- 11.6 years old , P= 0.04 ) , were thinner ( average BMI 25.5 + /- 6.2 vs. 31.06 + /- 7.3 , P= 0.001 ) , and had a lower abdominal circumference ( 97.7 + /- 18.3 vs. 111.7 + /- 17.5 cm , P=0.001 ) . No such difference was observed for years of smoking . Male PAD patients with COPD had a lower BMI ( 25.2 + /- 5.6 vs. 29.9 + /- 7.4 , P = 0.016 ) , and their abdominal circumference was smaller ( 96.1 + /- 18.0 vs. 110.2 + /- 16.5 cm , P=0.004 ) . Female PAD patients with COPD had a lower BMI ( 26.3 + /- 8.2 vs. 33.1 + /- 7.0 , P=0.045 ) , but their abdominal circumference was not different from females without PAD ( 102.0 + /- 19.7 vs. 114.0 + /- 19.4 cm , P=0.162 ) . Patients with PAD had a worse lung disease ( FEV1 % 34 + /- 8 % vs. 45 + /- 16 % , P=0.01 ) . During the 1 year of follow-up five patients died : two PAD patients due to acute myocardial infa rct ion and three non-PAD patients died from pulmonary insufficiency ( two patients ) and pulmonary emboli ( one patient ) . DISCUSSION We found that COPD patients with PAD were older and thinner and had a lower abdominal circumference and a more progressive lung disease . Extensive atherosclerosis in patients with COPD may partly explain the " obesity paradox " observed in patients with COPD A cohort of 432 ESRD ( 261 hemodialysis and 171 peritoneal dialysis ) patients was followed prospect ively for an average of 41 months . Baseline and annual demographic , clinical and echocardiographic assessment s were performed , as well as serial clinical and laboratory tests measured monthly while on dialysis therapy . The average mean arterial blood pressure level during dialysis therapy was 101 + /- 11 mm Hg . After adjusting for age , diabetes and ischemic heart disease , as well as hemoglobin and serum albumin levels measured serially , each 10 mm Hg rise in mean arterial blood pressure was independently associated with : the presence of concentric LV hypertrophy ( OR 1.48 , P = 0.02 ) , the change in LV mass index ( beta = 5.4 g/m2 , P = 0.027 ) and cavity volume ( beta = 4.3 ml/m2 , P = 0.048 ) on follow-up echocardiography , the development of de novo cardiac failure ( RR 1.44 , P = 0.007 ) , and the development of de novo ischemic heart disease ( RR 1.39 , P = 0.05 ) . The association with LV dilation was of borderline statistical significance ( OR 1.48 , P = 0.06 ) . Mean arterial blood pressures greater than 106 mm Hg were associated with both echocardiographic and clinical endpoints . Paradoxically , low mean arterial blood pressure ( RR 1.36 per 10 mm Hg fall , P = 0.009 ) was independently associated with mortality . The association of low blood pressure with mortality was a marker for having had cardiac failure prior to death . We conclude that even moderate hypertension worsens the echocardiographic and clinical outcome in ESRD patients , especially in those without previous clinical cardiac disease Purpose : The study aim ed to investigate patients ' characteristics , fluid and hemodynamic management , and outcomes according to the severity of cardiac surgery-associated acute kidney injury ( CSA-AKI ) . Methods : In a single-center , prospect i ve cohort study , we enrolled 282 adult cardiac surgical patients . In a secondary analysis , we assessed preoperative patients ' characteristics , physiological variables , and medication for intra- and postoperative fluid and hemodynamic management and outcomes according to CSA-AKI stages by the Renal risk , Injury , Failure , Loss , End-stage renal disease ( RIFLE ) classification . Variables of fluid and hemodynamic management were further assessed with regard to the need for postoperative renal replacement therapy ( RRT ) and in-hospital mortality by the area under the curve for the receiver operating characteristic ( AUC-ROC ) and multivariate regression analysis . Results : Patients with worsening RIFLE stage , were significantly older , had lower estimated glomerular filtration rate and higher body mass index , more peripheral vascular and chronic obstructive pulmonary disease , atrial fibrillation , and prolonged duration of cardiopulmonary bypass ( all p < 0.01 ) . Patients with more severe AKI stage stayed longer in the intensive care and hospital , had higher in-hospital mortality , and requirement for RRT ( all p < 0.001 ) . Also , with worsening RIFLE stage , patients had lower intraoperative mean arterial pressure ( MAP ) ; p = 0.047 , despite higher doses of norepinephrine ( p < 0.001 ) . The intraoperative MAP showed the best discriminatory ability ( AUC-ROC : > 0.8 ) for and was independently associated with RRT and in-hospital mortality . Moreover , with increasing AKI severity , patients received significantly more fluid infusion , and required higher dose of furosemide ; nonetheless , they had increased postoperative fluid balance . Conclusions : In this cohort , reduced MAP and increased fluid balance were independently associated with increased mortality and need for RRT after cardiac surgery OBJECTIVES To evaluate the baseline demographic/ clinical characteristics , in-hospital treatment and outcomes among patients with or without prior coronary artery bypass graft surgery ( CABG ) presenting as acute coronary syndrome ( ACS ) from six Middle East countries . METHODS Data was derived from a prospect i ve , multinational , multicenter registry of 7881 consecutive patients hospitalized with ACS in six Middle East countries . Data were analyzed according to their history of prior CABG . RESULTS Of 7881 ACS patients , 336 ( 4.2 % ) had a history of CABG . Patients with prior CABG were older ( mean 63 ± 10.8 vs. 56 ± 12.6 years ; P = 0.001 ) and more frequently to be men ( 76 % ) with significantly more prior angina , infa rct ion and percutaneous revascularization . They were more likely to have hypertension , diabetes , hyperlipidemia , prior congestive heart failure , stroke , renal failure , peripheral arterial disease and had higher prevalence of previous treatment with  evidence -based medications . They were more likely to present with unstable angina ( 45.5 % vs. 23.4 % ) , followed by non-ST elevation myocardial infa rct ion ( STEMI ) ( 43.8 % vs. 29.5 % ) , STEMI ( 10.7 % vs. 47.1 % ) ( All P = 0.001 ) with less prominent peak values of cardiac biomarkers than patients without prior CABG . Patients with prior CABG were more likely to present with significantly worse Killip class ( ≥ 2 ) , higher Global Registry of Acute Coronary Events ( GRACE ) risk score , multivessel disease , severe left ventricular ( LV ) dysfunction ( LV ejection fraction ≤ 30 % ) and developed significantly higher cardiogenic shock and major bleeding . In patients with prior CABG , no significant difference was observed in in-hospital mortality ( 4.2 % vs. 4.6 % , P=0.735 ) or mortality at one month ( 6.5 % vs. 8.2 % , P=0.277 ) or after one year ( 15 % vs. 12.4 % , P=0.204 ) when compared to patients without prior CABG . CONCLUSIONS ACS patients from Middle East countries with prior CABG have adverse baseline characteristics , reported higher GRACE risk score , multivessel disease , more severe LV dysfunction , cardiogenic shock , in-hospital major bleeding , but with less incidence of STEMI with less prominent surge of cardiac biomarkers . However , there was no significant difference in mortality during hospitalization , at 30 days and at one year between ACS patients with and without prior CABG . The reasons for this ' risk-mortality ' paradox need to be further evaluated Background : An inverse relationship between brain natriuretic peptide ( BNP ) levels and body mass index ( BMI ) has been described for patients with left ventricular ( LV ) systolic dysfunction . In this study , the association of BMI , BNP levels and mortality in patients hospitalized for heart failure with preserved LV systolic function ( HFpLVF ) was investigated . Methods : One hundred fifty consecutive patients ( 98 % men ) who were hospitalized with HFpLVF and had BNP levels measured on admission were analyzed . Patients were divided into categories of BMI : normal ( BMI < 25 kg/m2 ) , overweight ( BMI 25–29.9 kg/m2 ) and obese ( BMI ≥ 30 kg/m2 ) . Relevant clinical and echocardiographic characteristics and all-cause mortality were obtained through chart review . Results : BNP levels were significantly lower in obese ( median = 227 pg/mL ) and overweight ( median = 396 pg/mL ) patients compared with those with normal BMI ( median = 608 pg/mL , P = 0.003 ) . Higher BMI predicted BNP levels of < 100 pg/mL. Compared with patients with normal BMI , overweight and obese patients had a significantly lower risk of total mortality , even after adjusting for other clinical characteristics , including log-transformed BNP levels , atrial fibrillation , the use of beta-blockers at discharge , age , hemoglobin levels and the presence of pulmonary congestion on admission . Higher BNP levels also independently predicted mortality . Conclusions : An inverse relationship between BMI and BNP levels exists in patients hospitalized with HFpLVF . Higher BMI is associated with lower mortality , whereas higher BNP levels predict higher mortality in male patients with HFpLVF . These findings should be confirmed in a larger multicenter setting Background It is estimated that 37 % of the U.S. population is obese . It is unknown how obesity influences the operative and survival outcomes of cytoreductive surgery (CRS)/hyperthermic intraperitoneal chemotherapy ( HIPEC ) procedures . Methods A retrospective analysis of a prospect i ve data base of 1,000 procedures was performed . Type of malignancy , performance status , resection status , hospital and intensive care unit stay , comorbidities , morbidity , mortality , and survival were review ed . Results A total of 246 patients with body mass index ( BMI ) of > 30 kg/m2 underwent 272 CRS/HIPEC procedures . Ninety-five ( 38.6 % ) were severely obese ( BMI > 35 kg/m2 ) . A total of 135 ( 49.6 % ) procedures were performed for appendiceal and 60 ( 22.1 % ) for colon cancer . Median follow-up was 52 months . Both major and minor morbidity were similar for obese and non-obese patients . The 30-day mortality rates for obese and non-obese patients were 1.5 and 2.5 % , respectively . Median intensive care unit and hospital stay were 1 and 9 days , regardless of BMI . The 30-day readmission rate was similar between obese and non-obese patients ( 24.8 vs. 19.4 % , p = 0.11 ) . Median survival for low- grade appendiceal cancer ( LGA ) was 76 months for obese patients and 107 months for non-obese patients ( p = 0.32 ) . Survival was worse for severely obese patients ( median survival 54 months ) versus non-obese patients with LGA ( p = 0.04 ) . Survival was similar for obese and non-obese patients with peritoneal surface disease ( PSD ) from colon cancer or high- grade appendiceal cancer . Conclusions Obesity does not influence postoperative morbidity or mortality of patients with PSD , regardless of primary tumor . Severe obesity is associated with decreased long-term survival only in patients with LGA primary disease ; however , application of CRS/HIPEC still offers meaningful prolongation of life . Obesity should not be considered a contraindication for CRS/HIPEC procedures OBJECTIVES This study examines whether obesity accelerates atherogenic progression or adverse outcomes after coronary artery bypass graft ( CABG ) surgery . BACKGROUND Obesity is a major risk factor for developing coronary heart disease . Whether obesity accelerates disease progression after CABG is unclear . METHODS We examined how body mass index ( BMI ) related to atherosclerotic graft progression and a clinical composite outcome of death , nonfatal myocardial infa rct ion , stroke , CABG surgery , or angioplasty among 1,314 participants in the Post CABG trial . Participants who had undergone CABG surgery were r and omly assigned in a 2 x 2 factorial design to warfarin versus placebo and aggressive low-density lipoprotein cholesterol ( LDL-C ) lowering with lovastatin 40 to 80 mg/day ( to achieve LDL-C of 60 to 85 mg/dl ) versus moderate LDL-C lowering with lovastatin 2.5 to 5 mg/day ( to achieve LDL-C of 130 to 140 mg/dl ) . Angiographic progression was assessed by coronary angiography at 4 to 5 years . RESULTS Higher BMI was associated with a higher likelihood of angiographic progression ( p trend = 0.003 ) after adjustment for demographic factors , treatment assignment , smoking status , and years since CABG surgery , but not with clinical events ( p trend = 0.81 ) . In stratified analyses , higher BMI was associated with angiographic progression in the low-dose lovastatin group ( p trend < 0.001 ) but not in the high-dose group ( p = 0.03 for test for interaction of BMI and statin treatment ) . In the high-dose lovastatin group , higher BMI appeared to be protective against clinical events ( p trend = 0.06 , test of interaction : 0.02 ) . CONCLUSIONS Higher BMI is strongly associated with atherogenic progression after CABG surgery . Aggressive statin therapy may be protective against obesity-related acceleration of coronary heart disease Objective : To explore the long-term effect of anxiety and depression on outcome after cardiac surgery . To date , the relationship between psychosocial factors and future cardiac events has been investigated mainly in population -based studies , in patients after cardiac catheterization or myocardial infa rct ion . Methods : In total , 180 patients who underwent cardiac surgery using cardiopulmonary bypass  were prospect ively studied and followed up for 4 years . Anxiety ( Spielberger State-Trait Anxiety Inventory , STAI-S/STAI-T ) , depression ( Beck Depression Inventory , BDI ) , living alone , and education level along with clinical risk factors and perioperative characteristics  were assessed . Psychological self-report question naires were completed preoperatively and 6 , 12 , 24 , 36 , and 48 months after discharge . Clinical end-points were mortality and cardiac events requiring hospitalization during follow-up . Results : Average preoperative STAI-T score was 44.6 ± 10 . Kaplan-Meier analysis showed a significant effect of preoperative STAI-T > 45 points ( p = .008 ) on mortality . In multivariate models , postoperative congestive heart failure ( OR : 10.8 ; 95 % confidence interval [CI]:2.9–40.1 ; p = .009 ) and preoperative STAI-T ( score OR : 1.07 ; 95 % CI : 1.01–1.15 ; p = .05 ) were independently associated with mortality . The occurrence of cardiovascular hospitalization was independently associated with postoperative intensive care unit days ( OR : 1.41 ; 95 % CI : 1.01–1.96 ; p = .045 ) and post discharge 6th month STAI-T ( OR : 1.06 ; 95 % CI:1.01–1.13 ; p = .03 ) . Conclusions : The results of the present study suggest that the assessment of psychosocial factors , particularly the ongoing assessment of anxiety , could help in risk stratification and identification of patients at risk of mortality and cardiovascular morbidity after cardiac surgery . BDI = Beck Depression Inventory ; STAI-S = state anxiety subscale ; STAI-T = trait anxiety subscale of Spielberger State-Trait Anxiety Inventory ; CPB = cardiopulmonary bypass ; CABG = coronary artery bypass grafting ; CHF = congestive heart failure ; CHD = coronary heart disease ; ICU = intensive care unit ; MI = myocardial infa rct ion ; PTSD = posttraumatic stress disorder
In the present series , overweight and obese patients had similar or slightly lower in-hospital mortality rates after cardiac surgery compared with normal-weight individuals .
Conversely , postoperative complication rates increased with higher BMI levels .
Most studies included in the review showed that overweight and obese patients had at least the same mortality rate as normal-weight patients , or even a lower death risk .
Pooled- data of the meta- analysis provided evidence on the association between higher BMI levels and a lower all-cause in-hospital mortality rate after cardiac surgery
The relationship between higher body mass index ( BMI ) , decreased morbidity and mortality is known as the " obesity paradox " , and has been described in cohorts of patients with hypertension , diabetes , heart failure , coronary and peripheral artery diseases , non-cardiac surgery , and end-stage renal disease .
Here we investigated the relationship between BMI and short-term outcomes after adult cardiac surgery to explore the existence of an obesity paradoxical effect .
A secondary objective was to perform an up date d systematic review to further analyze the association between BMI and 30-day in-hospital mortality after cardiac surgery .