The Influence of Body Mass Index on Outcomes in Patients Undergoing Cardiac Surgery: Does the Obesity Paradox Really Exist? Body mass index and mortality in acutely decompensated heart failure across the world: a global obesity paradox. Obesity paradox in coronary artery bypass grafting: myth or reality? Cardiovascular risk in relation to body mass index and use of evidence-based preventive medications in patients with or at risk of atherothrombosis. Is obesity a predictor of mortality, morbidity and readmission after cardiac surgery? Multicenter preoperative stroke risk index for patients undergoing coronary artery bypass graft surgery. Multicenter Study of Perioperative Ischemia (McSPI) Research Group. [Consequences of obesity in outcomes after cardiac surgery. Analysis of ARIAM registry]. Relationship of body mass index with outcomes after coronary artery bypass graft surgery. The impact of body mass index on short- and long-term outcomes inpatients undergoing coronary revascularization. Insights from the bypass angioplasty revascularization investigation (BARI). Perioperative Use of Dobutamine in Cardiac Surgery and Adverse Cardiac Outcome: Propensity-adjusted Analyses The association between duration of storage of transfused red blood cells and morbidity and mortality after reoperative cardiac surgery. Obesity paradox in patients with hypertension and coronary artery disease. 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. Weight loss increases and fat loss decreases all-cause mortality rate: results from two independent cohort studies Impact of education, income and chronic disease risk factors on mortality of adults: does 'a pauper-rich paradox' exist in Latin American societies? Effect of Smoking Status on Clinical Outcome and Efficacy of Clopidogrel in Acute Coronary Syndrome. Influence of obesity on outcomes in atrial fibrillation: yet another obesity paradox. Preoperative statins and infectious complications following cardiac surgery Morbidity and Mortality Following Breast Cancer Surgery in Women: National Benchmarks for Standards of Care Viscoelastic blood coagulation measurement with Sonoclot predicts postoperative bleeding in cardiac surgery after heparin reversal. 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? GLP-1 Plays a Limited Role in Improved Glycemia Shortly After Roux-en-Y Gastric Bypass: A Comparison With Intensive Lifestyle Modification
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 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 OBJECTIVE A high body mass index has been suggested to be protective in patients with coronary artery disease and in those undergoing coronary artery bypass grafting ( CABG ) .  However , these conflicting results might be related to the different risk profiles among the various body mass index categories . We sought to clarify the effect of varying degrees of excessive body weight on hard clinical outcomes in patients undergoing CABG .  METHODS A retrospective analysis of prospect ively collected data was conducted to investigate the effect of a high body mass index on early and late mortality after  first-time isolated CABG . Propensity score matching was used to adjust for confounding factors . RESULTS The study sample consisted of 3269 normal weight , 6662 overweight , 3821 obese , and 211 morbidly obese patients . After matching , early mortality was not affected by overweight ( mean difference , 0.7 % ; 95 % confidence interval [ CI ] , -0.2 % to 1.5 % ) , obesity ( mean difference , 0.5 % ; 95 % CI , -0.7 % to 1.7 % ) , and morbid obesity ( mean difference , 1.6 % ; 95 % CI , -1.0 % to 1.0 % ) , regardless of the patients ' risk profile according to the European system for cardiac operative risk evaluation . Overweight status was not protective for late death ( hazard ratio , 1.05 ; 95 % CI , 0.9 - 1.08 ; P = .4 ) . Compared with normal weight patients , both obese and morbidly obese patients had a higher risk of late death ( hazard ratio , 1.22 ; 95 % CI , 1.07 - 2.66 ; P = .006 for obese patients ; hazard ratio , 1.36 ; 95 % CI , 0.74 - 2.49 ; P = .3 for morbidly obese patients ) . CONCLUSIONS Obesity did not increase operative mortality , but it was associated with reduced late survival in patients undergoing primary isolated CABG . Our results raise concerns in supporting any protective effect of obesity in cardiovascular disease , specifically in patients undergoing surgical myocardial revascularization 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 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 BACKGROUND The paradox of present cardiac surgery is that the more elderly and debilitated patients benefit most from cardiac surgery compared with medical therapy , yet they sustain greater overall risk for morbidity and mortality after cardiac surgery . The goal of the present study was to develop a preoperative index predicting major perioperative neurological events in patients undergoing coronary artery bypass graft surgery .  METHODS AND RESULTS As part of a prospect i ve , multicenter , observational study ( McSPI Research Group ) , we enrolled 2417 patients at 24 academic medical centers in the United States . Patients who died intraoperatively or had concomitant open-heart procedures were excluded from analysis , result ing in a total of 2107 for analysis . Sixty-eight patients ( 3.2 % ) developed adverse neurological events , defined as cerebrovascular accident , transient ischemic attack ( TIA ) , or persistent coma . Bivariate analysis was applied to determine associations between preoperative variables and neurological events . Significant bivariate predictors were identified then logically grouped , and for each cluster , a score was calculated based on principal components . Key predictor variables were age , history of previous neurological disease , diabetes , history of vascular disease , previous coronary artery surgery , unstable angina , and history of pulmonary disease , the coefficients for which were used to develop a preoperative stroke risk index that was vali date d by bootstrap ( c-index = 0.778 ) . Stroke risk could then be determined for each patient , calculating a patient 's risk for stroke within 95 % confidence intervals . CONCLUSIONS With the McSPI stroke risk index developed in this study , neurological risk can be estimated , and the most appropriate group for perioperative therapy can be identified . Further refinement and validation of this index , however , are necessary and are under way in current studies 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 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 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 Background : Catecholamines , mainly dobutamine , are often administered without institutional guidelines or prespecified algorithms in cardiac surgery . The current study assessed the consequences on clinical outcome of catecholamines simply based on the clinical judgment of the anesthesiologists after cardiopulmonary bypass in adult cardiac surgery . Methods : Consecutive patients were enrolled in a nonr and omized cohort study . Factors associated with perioperative use of catecholamines and with outcomes were recorded prospect ively to conduct bias adjustment , including propensity scores . Major cardiac morbidity ( i.e. , ventricular arrhythmia , use of an intraaortic balloon pump and postoperative myocardial infa rct ion ) and all-cause intrahospital mortality were the primary and secondary endpoints , respectively . Results are expressed as odds ratio ( OR ) [ 95 % confidence interval ] . Results : During the study , 84 of 657 patients ( 13 % ) received catecholamines , most often dobutamine ( 76 of 84 , 90 % ) . A higher incidence of both major cardiac morbidity ( 30 vs. 9 % ; P < 0.001 ; OR , 4.2 [ 2.5–7.3 ] ) and all-cause intrahospital mortality ( 8 vs. 1 % ; P < 0.001 ; OR , 12.9 [ 3.7–45.2 ] ) was observed in the catecholamine group compared with the control group . After adjusting for channeling bias and confounding factors , catecholamine administration remained significantly associated with major cardiac morbidity after propensity score stratification ( OR , 2.1 [ 1.0–4.4 ] ; P < 0.05 ) , propensity score covariance analysis ( OR , 2.3 [ 1.0–5.0 ] ; P < 0.05 ) , marginal structural models ( OR , 1.8 [ 1.3–2.5 ] ; P < 0.001 ) , and propensity score matching ( OR , 3.0 [ 1.2–7.3 ] ; P < 0.02 ) , but not with all-cause intrahospital mortality . Conclusions : These results suggest that dobutamine should only be administered when the benefit is judged to outweigh the risks Red blood cells ( RBCs ) undergo numerous changes during storage ; however , the clinical relevance of these storage " lesions " is unclear . We hypothesized that the duration of storage of transfused RBCs is associated with mortality after repeat  sternotomy  for cardiac surgery , because these patients are at high risk for both RBC transfusion and adverse outcome . We retrospectively analyzed 434 patients who underwent repeat median sternotomy for coronary artery bypass graft or valve surgery and who received allogeneic RBCs . Three-hundred-twenty-one ( 74 % ) patients met the criteria for eligibility . After adjusting for the effects of confounders and the total number of RBC transfusions , the duration of storage of the oldest RBC unit transfused was found to be associated with both in-hospital mortality ( Cox proportional hazard ratio ( HR ) = 1.151 ; P < 0.0001 ) and out-of-hospital mortality ( HR = 1.116 ; P < 0.0001 ) . The mean duration of storage of transfused RBCs was also an independent predictor of in-hospital mortality ( HR = 1.036 ; P < 0.0001 ) . Independent associations between the duration of storage of transfused RBCs and acute renal dysfunction and intensive care unit and hospital length of stay were also observed . The duration of storage of RBCs is associated with adverse outcome after repeat sternotomy for cardiac surgery . The clinical significance of this finding should be investigated in a large , r and omized , blinded clinical trial 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 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 OBJECTIVE : In epidemiological studies , weight loss is usually associated with increased mortality rate . Contrarily , among obese people , weight loss reduces other risk factors for disease and death . We hypothesised that this paradox could exist because weight is used as an implicit adiposity index . No study has considered the independent effects of weight loss and fat loss on mortality rate . We studied mortality rate as a function of weight loss and fat loss . DESIGN : Analysis of ‘ time to death ’ in two prospect i ve population -based cohort studies , the Tecumseh Community Health Study ( 1890 subjects ; 321 deaths within 16 y of follow-up ) and the Framingham Heart Study ( 2731 subjects ; 507 deaths within 8 y of follow-up ) , in which weight and fat ( via skinfolds ) loss were assessable . RESULTS : In both studies , regardless of the statistical approach , weight loss was associated with an increased , and fat loss with a decreased , mortality rate ( P<0.05 ) . Each st and ard deviation ( s.d . ) of weight loss ( 4.6 kg in Tecumseh , 6.7 kg in Framingham ) was estimated to increase the hazard rate by 29 % ( 95 % confidence interval CI ) , ( 14 % , 47 % , respectively ) and 39 % ( 95 % CI , 25 % , 54 % respectively ) , in the two sample s. Contrarily , each s.d . of fat loss ( 10.0 mm in Tecumseh , 4.8 mm in Framingham ) was estimated to reduce the hazard rate 15 % ( 95 % CI , 4 % , 25 % ) and 17 % ( 95 % CI , 8 % , 25 % ) in Tecumseh and Framingham , respectively . Generalisability of these results to severely ( that is , body mass index BMI ) ≥34 ) obese individuals is unclear . CONCLUSIONS : Among individuals that are not severely obese , weight loss is associated with increased mortality rate and fat loss with decreased mortality rate OBJECTIVES To test the hypothesis that an inverse association exists between socio-economic position and all-cause mortality  in a developing country in Latin America . STUDY DESIGN Prospect i ve cohort study carried out in Chile using data from a simple r and om sample of 920 apparently healthy subjects ( weighted population 11,600 aged 30 - 89 years ) followed for 8 years . METHODS Education level ( 0 - 8 years , 9 - 12 years and > or = 13 years ) and income quartiles were established at the outset of the study , along with behavioural and biological risk factors for chronic diseases : smoking , alcohol use , obesity , diabetes , hypertension , lipids and family history of death by cardiovascular disease . Relative risks of all-cause mortality were estimated using age-adjusted Cox regression models . RESULTS During the follow-up period , 46 deaths were observed . Adjusting for age , gender , and behavioural and biological risk factors , the mortality risk for increasing categories of education after controlling for income was 1.0 , 0.76 and 0.33 ( P for trend<0.01 ) . In contrast , the relative risk for increasing levels of income after controlling for education was 1.0 , 0.98 , 1.33 and 1.17 ( P for trend=0.07 ) . CONCLUSION While education level had a protective effect on mortality risk of Chilean adults , income had a slightly unfavourable effect on survival . This finding is described as suggestive of a ' pauper-rich paradox ' , since the higher income quantiles in this study correspond with the lower income levels in most developed countries . Nevertheless , due to the small number of deaths , additional research is required to assess the validity of these findings BACKGROUND The " smoker 's paradox " is an otherwise unexplained phenomenon in which the mortality of smokers after acute myocardial infa rct ion is reduced , contrary to expectations . It has been suggested that an association with antiplatelet agents exists , but the true mechanism remains largely unidentified . METHODS AND RESULTS The analysis included 6,195 consecutive patients who underwent percutaneous coronary intervention ( PCI ) for acute coronary syndrome , registered in the Japanese multicenter PCI registry . Smokers were significantly younger and had less comorbidity than non-smokers .  Unadjusted in-hospital mortality rate , general complication rate , and bleeding complication rate were lower in smokers than in non-smokers . After adjustment , the trend persisted and smoking was not associated with overall mortality ( odds ratio [ OR ] , 0.90 ; 95 % confidence interval [ CI ] : 0.61 - 1.34 ; P=0.62 ) , and was associated with lower overall ( P=0.032 ) and bleeding complication events ( P=0.040 ) . Clopidogrel effectively reduced the occurrence of in-hospital complications and major adverse cardiac events in smokers compared with non-smokers ( OR , 0.55 ; 95 % CI : 0.53 - 0.98 vs. OR , 1.20 ; 95 % CI : 0.87 - 1.67 ; and OR , 0.37 ; 95 % CI : 0.20 - 0.70 vs. OR , 1.48 ; 95 % CI : 0.90 - 2.43 , respectively ) . CONCLUSIONS The smoker 's paradox was largely explained by confounding factors related to the lower risk profile of smokers , and they benefited from a positive modification of the efficacy of clopidogrel . ( Circ J 2016 ; 80 : 1590 - 1599 ) 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 ABSTRACT Purpose : Recent observational studies have suggested that statins can decrease the incidence and severity of various infections including pneumonia and bacteremia . However , the effect of statins on post-cardiac surgery infection has not been adequately evaluated . Therefore we sought to determine whether preoperative statin use result ed in a reduction in infection following cardiac surgery . Methods : This was a cohort evaluation of all consecutive patients who underwent coronary artery bypass graft ( CABG ) and /or valve surgery at our institution between January 1 , 2004 and August 31 , 2006 . Our primary outcome measure was the occurrence of at least one of the following postoperative infectious complications ( pneumonia , bacteremia , sternal wound , leg vein harvest site infection , urinary tract infection , or tracheotomy site infection ) . We used multivariable logistic regression to control for potential confounding and to calculate adjusted odds ratios ( AORs ) and 95 % confidence intervals ( CIs ) . Results : A total of 1934 patients were included in this evaluation of which 1248 received a statin preoperatively and 686 did not . Our study population was 66.3 ± 11.6 years of age , 71.3 % male ; 37.2 % underwent complex surgery , 3.6 % were morbidly obese , and 32.0 % were diabetic ( each being previously identified as an independent predictor of infection following cardiac surgery ) . Patients receiving a statin preoperatively and not receiving a statin preoperatively varied in respect to a number of important pre- and peri- operative characteristics . Patients receiving preoperative statin  therapy were more likely to have had a history of diabetes , chronic obstructive pulmonary disease or high cholesterol and to be smokers , but less likely to be undergoing urgent/emergent surgery or surgery utilizing a cardiopulmonary bypass pump ( p < 0.05 for all comparisons ) . In total , 151 ( 7.8 % ) patients developed an infectious complication . Upon multivariable logistic regression , preoperative statin use was associated with a significant reduction in the development of infection ( AOR ; 0.67 ( 95 % CI 0.46–0.99 ) , p = 0.04 ) . The use of a statin was not associated with a statistically significant reduction in any individual infection on its own ( p > 0.08 for all ) . Limitations : Patients were not r and omized to receive statins or not . We did not have adequate power to evaluate individual infections . Conclusions : Preoperative statin use is associated with a reduction in patients ’ odds of developing a postoperative infection following cardiac surgery Background : Most reports on postoperative ( OP ) morbidity and mortality following breast cancer surgery ( BCS ) are limited by relatively small sample size result ing in a lack of national benchmarks for quality of care . This paper reports the 30-day morbidity and mortality following BCS in women using a large prospect i ve multi-institutional data base . Methods : The National Surgical Quality Improvement Program Patient Safety in Surgery , prospect ively collected inpatient and outpatient 30 day postoperative morbidity and mortality data on patients undergoing surgery at 14 university and 4 community centers . Using the procedure CPT code , the data base was queried for all women undergoing mastectomy ( MT ) or lumpectomy with an axillary procedure ( L-ANP ) .  Morbidity and mortality were categorized as mortality , wound , cardiac , renal , pulmonary , and central nervous system . Logistic regression models for the prediction of wound complications were developed . Preoperative variables having bivariate relationships with postoperative wound complications with P ≤ 0.20 were su bmi tted for consideration . Results : We identified 1660 and 1447 women who underwent MT and l-ANP , respectively . The mean age was 55.9 years . The majority of procedures were under general anesthesia . The 30-day postoperative mortality for MT and l-ALNP were 0.24 % and 0 % , respectively . The most frequent morbid complication was wound infection , more commonly occurring in the mastectomy ( 4.34 % ) group versus the lumpectomy group ( 1.97 % ) . Cardiac and pulmonary complications occurred infrequently in the mastectomy group ( cardiac : MT , 0.12 % ; and pulmonary : MT , 0.66 % ) . There were no cardiac or pulmonary complications in the lumpectomy group . CNS morbidities were rare in both surgical groups ( MT , 0.12 % ; and l-ALNP , 0.07 % ) . Development of a UTI was more common in women who underwent a mastectomy ( 0.66 % ) when compared with women that had a lumpectomy ( 0.14 % ) . The only significant predictors of a wound complication were morbid obesity ( BMI > 30 ) , having had a MT , low preoperative albumin and hematocrit greater than 45 % . Conclusion : Morbidity and mortality rates following BCS in women are low , limiting their value in assessing quality of care . Mastectomy carries higher complication rate than l-ANP with wound infection being the most common OBJECTIVES The aim of the study was to determine if Sonoclot with its sensitive glass bead-activated , viscoelastic test can predict postoperative bleeding in patients undergoing cardiac surgery at predefined time points . DESIGN A prospect i ve , observational clinical study . SETTING A teaching hospital , single center . PARTICIPANTS Consecutive patients undergoing cardiac surgery ( N = 300 ) . INTERVENTIONS Besides routine laboratory coagulation studies and heparin management with st and ard ( kaolin ) activated clotting time , additional native blood sample s were analyzed on a Sonoclot using glass bead-activated tests . Glass bead-activated clotting time , clot rate , and platelet function were recorded immediately before anesthesia induction and at the end of surgery after heparin reversal but before chest closure . MEASUREMENTS AND MAIN RESULTS Primary outcome was postoperative blood loss ( chest tube drainage at 4 , 8 , and 12 hours postoperatively ) . Secondary outcome parameters were transfusion requirements , need for surgical re-exploration , time of mechanical ventilation , length of intensive care unit and hospital stay , and hospital morbidity and mortality . Patients were categorized into " bleeders " and " nonbleeders . " Patient characteristics , operations , preoperative st and ard laboratory parameters , and procedural times were comparable between bleeders and nonbleeders except for sex and age . Bleeders had higher rates of transfusions , surgical re-explorations , and complications . Only glass bead measurements by Sonoclot after heparin reversal before chest closure but not preoperatively were predictive for increased postoperative bleeding . CONCLUSIONS Sonoclot with its glass bead-activated tests may predict the risk for postoperative bleeding in patients undergoing cardiac surgery at the end of surgery after heparin reversal but before chest closure 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 Rapid glycemic improvements following Roux-en-Y gastric bypass ( RYGB ) are frequently attributed to the enhanced GLP-1 response , but causality remains unclear . To determine the role of GLP-1 in improved glucose tolerance after surgery , we compared glucose and hormonal responses to a liquid meal test in 20 obese participants with type 2 diabetes mellitus who underwent RYGB or nonsurgical intensive lifestyle modification ( ILM ) ( n = 10 per group ) before and after equivalent short-term weight reduction . The GLP-1 receptor antagonist exendin(9–39)-amide ( Ex-9 ) was administered , in r and om order and in double-blinded fashion , with saline during two separate visits after equivalent weight loss . Despite the markedly exaggerated GLP-1 response after RYGB , changes in postpr and ial glucose and insulin responses did not significantly differ between groups , and glucagon secretion was paradoxically augmented after RYGB . Hepatic insulin sensitivity also increased significantly after RYGB . With Ex-9 , glucose tolerance deteriorated similarly from the saline condition in both groups , but postpr and ial insulin release was markedly attenuated after RYGB compared with ILM . GLP-1 exerts important insulinotropic effects after RYGB and ILM , but the enhanced incretin response plays a limited role in improved glycemia shortly after surgery . Instead , enhanced hepatic metabolism , independent of GLP-1 receptor activation , may be more important for early postsurgical glycemic improvements
Conclusions : Obesity is associated with lower risks after cardiac surgery , with consistent effects noted in multiple analyses attempting to address residual confounding and reverse causation
Background : In an apparent paradox , morbidity and mortality are lower in obese patients undergoing cardiac surgery  , although the nature of this association is unclear .
We sought to determine whether the obesity paradox observed in cardiac surgery is attributable to reverse epidemiology , bias , or confounding .