The Official Journal of EuroPCR and the European Association of Percutaneous Coronary Interventions (EAPCI)

The Obesity Paradox Revisited: Body Mass Index and Long-Term Outcomes After PCI From a Large Pooled Patient-Level Database

DOI: 10.4244/EIJ-D-19-00467

1. Institute of Cardiology, Warsaw, Poland; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; Division of Cardiology, Columbia University Medical Center, New York, NY, USA
2. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; Division of Cardiology, Columbia University Medical Center, New York, NY, USA, United States
3. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
4. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
5. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA
6. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; Division of Cardiology, Columbia University Medical Center, New York, NY, USA; Sahlgrenska University Hospital, Gothenburg, Sweden
7. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; Division of Cardiology, Columbia University Medical Center, New York, NY, USA
8. Division of Cardiology, Maasstad Hospital, Rotterdam, the Netherlands
9. Thoraxcentrum Twente, Department of Cardiology, Medisch Spectrum Twente, Enschede, the Netherlands; Department Health Technology and Services Research, Faculty of Behavioural, Management and Social Sciences, Technical Medical Centre, University of Twente
10. Centre for International Cardiovascular Health, Imperial College, London, United Kingdom
11. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
12. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; Division of Cardiology, Columbia University Medical Center, New York, NY, USA
13. Clinical Trials Center, Cardiovascular Research Foundation, New York, NY, USA; The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Aims: To evaluate the relationship between body mass index (BMI) and outcomes in patients with coronary artery disease undergoing percutaneous revascularization. 

Methods and results: In 13 randomized trials 22,922 patients were stratified (in kg/m2) as underweight (BMI <18.5), normal weight (18.5≤BMI<25, used as reference), overweight (25≤BMI<30), and obese (Class I [30≤BMI<35], Class II [35≤BMI<40], or Class III [BMI≥40]). The primary endpoint was all-cause death at 5 years. Secondary endpoints were cardiac and non-cardiac death, target (TLR) and non-target lesion revascularization (NTLR), myocardial infarction (MI), and definite/probable stent thrombosis. Despite adjustment for multiple confounders, overweight and Class I obesity were associated with lower all-cause mortality vs normal weight (HR 0.83; 95%CI 0.71-0.96 and HR 0.83; 95%CI 0.69-0.96 respectively); however, non-cardiac death was the major contributor to this effect (HR 0.77; 95% CI 0.63-0.94 for overweight). Conversely, cardiac mortality was higher in severely obese individuals (HR 1.62; 95%CI 1.05-2.51 for Class III obesity). Obesity was associated with higher rates of NTLR (HR 1.28, 95%CI 1.04-1.58 for Class II obesity) but not with TLR, MI and stent thrombosis. 

Conclusions: Moderately increased BMI is associated with improved survival post-PCI, mostly due to lower non-cardiac but not cardiac mortality.

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