Obesity in heart failure: impact on survival and treatment modalities

Abstract

Heart failure (HF) and obesity are commonly seen in the USA. Although obesity is associated with traditional cardiovascular disease, its relationship with HF is complex. Obesity is an accepted risk factor for incident HF. However, in patients with established HF, there exists a paradoxical correlation, with escalating BMI incrementally protective against adverse outcomes. Despite this relationship, patients with HF may desire to lose weight to reduce comorbidities or to improve quality of life. Thus far, studies have shown that intentional weight loss in obese patients with HF does not increase risk, with strategies including dietary modification, physical activity, pharmacotherapy, and/or surgical intervention.

Keywords: :

• cardiomyopathy
• heart failure
• heart transplant
• obesity
• ventricular assist device
• weight loss

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • The prevalence of heart failure (HF) and obesity are both increasing at a rapid rate in the USA and industrialized countries.

• • Obesity is strongly associated with incident HF with a >100% increased risk in the majority of studies to date. This increased risk is attributed partially to hemodynamic and anatomic changes. It also involves dysregulation of metabolic, inflammatory and hormonal pathways, which may include adipokine resistin, leptin and adiponectin.

• • For patients with established HF, there is an obesity paradox, with elevated BMI being protective against adverse outcomes that is incremental beyond the normal weight range.

• • Proposed explanations for the obesity paradox may include earlier diagnosis of HF due to competing symptoms of dyspnea from obesity. Other mechanisms may include increased tolerance of cardioprotective medications, adiposity serving as an energy reserve in the catabolic disease state of HF and altered regulation of inflammatory pathways.

• • Obesity can be prohibitive for heart transplant candidacy and is associated with poor post-transplant outcomes for BMI ≥ 35 kg/m².

• • The relationship between obesity and outcomes after mechanical circulatory support implantation is not well-established.

• • Treatment strategies for obesity in HF can include dietary modification, increased exercise, pharmacotherapy, surgery, or a combination of these. Despite the obesity paradox, intentional weight loss has not been proven to be detrimental.

Notes