Clinical
Biomarker evaluation as a potential cause of gender differences in obesity paradox among patients with STEMI

https://doi.org/10.1016/j.carrev.2015.12.012Get rights and content

Highlights

  • Higher risk for MACE was shown in group BMI ≤ 24.9 kg/m2 compared to BMI 25.0–29.9 kg/m2.

  • The study showed no association between HDL-c (p = 0.55) or LDL-c (p = 0.10) and MACE.

  • No gender difference between MACE and BMI could be detected (p = 0.16).

Abstract

Background

Obesity with its worldwide growing prevalence is an established cardiovascular risk factor with increased morbidity and mortality. However, the phenomenon, that mild to moderate obesity seems to represent a protective effect on diseases has been termed the “obesity paradox”.

Methods

We retrospectively assessed 529 patients (72.6% male, mean age 59.7 ± 12.7 years) admitted with ST-elevation myocardial infarction (STEMI). The female and male study populations were separated into four body mass index (BMI) groups: ≤ 24.9 kg/m2, 25.0–29.9 kg/m2, 30.0–34.9 kg/m2 and ≥ 35.0 kg/m2. Blood samples of high-density lipoprotein cholesterol (HDL-c) and low-density lipoprotein cholesterol (LDL-c) were analyzed.

Results

With increasing BMI group the rate of major adverse cardiac events (MACE) decreased in all patients (test for trend p = 0.041). No gender difference between MACE and BMI could be noticed (p = 0.16). A higher risk for MACE was indicated in group BMI ≤ 18.5 kg/m2 in comparison to group BMI 25.0–29.9 kg/m2 (OR: 7.93; 95% CI: 1.75–35.89; p = 0.0091), whereas group BMI 30.0–34.9 kg/m2 was significant associated with a lower risk in comparison to group BMI 25.0–29.9 kg/m2 (OR: 0.65; 95% CI: 0.21–1.96; p = 0.044). An association between HDL-c (p = 0.55) or LDL-c (p = 0.10) and MACE could not be detected.

Conclusion

The study demonstrates that patients with STEMI and a BMI of 30.0–34.9 kg/m2 have a decreased risk for MACE compared to patients with normal BMI. No gender related differences were indicated. An association between MACE and lipoproteins could not be detected.

Introduction

Obesity is a serious public health care problem in industrialized nations with growing prevalence [1]. In overweight patients the risk of all-cause mortality is markedly increased over all age groups in men and women [2], [3], [4]. As a well-established risk factor for developing diabetes and hypertension, obesity has a substantial impact on cardiovascular diseases and mortality [2], [4], [5]. Dyslipidemia is caused by obesity and especially the combination of low high-density lipoprotein cholesterol (HDL-c) and high low-density lipoprotein cholesterol (LDL-c) levels as well as elevated triglyceride levels are a predictor for cardiovascular events [3], [6].

Surprisingly several previously published studies indicated, that mild obesity has a protective role in patients with obstructive lung disease, end-stage renal disease, advanced cancer as well as in several cardiovascular disorders [3], [7], [8], [9], [10]. Thus it is discussed that even patients with acute myocardial infarction might benefit from mild obesity [11], [12]. In the literature there are only a few studies focusing on gender differences in the “obesity paradox” achieving inconsistent results [13], [14]. There are indications that overweight women may have a decreased risk for acute myocardial infarction, whereas their male counterparts have an increased risk [15].

The purpose of the present study was to investigate gender related differences and the influence of different biomarkers reflecting the nutritional status and body mass index (BMI) on in-hospital major adverse cardiac events (MACE) in patients with ST-elevation myocardial infarction (STEMI).

Section snippets

Study design and patient population

We retrospectively evaluated during January 2002 to December 2013 803 patients with STEMI undergoing primary emergency percutaneous coronary intervention (PCI). The criteria for STEMI, identified in 12-lead electrocardiogram, were ST-elevation > 0.1 mV in two consecutively standard leads or ST-elevation at the J point > 0.2 mV in men and > 1.5 mV in women in two consecutively precordial leads, typical angina > 20 min or new left bundle branch block according to the AHA/ACC/ESC guidelines [16].

Clinical characteristics and laboratory data of the study cohort

The final study population consisted of 529 patients with a mean age of 61.4 ± 13.5 years, the majority of the patients being male (72.6%). The female group was significantly older (65.9 ± 14.4 vs. 59.7 ± 12.7 years; p < 0.0001) with a higher incidence of hypertension (52.9% vs. 70.3%; p = 0.0003). Diabetes mellitus as a CVRF showed no significant difference and contributed equally in both groups (male: 25.0% vs. female: 20.7%; p = 0.36), whereas smokers were more common in the male group (male: 60.9% vs.

Discussion

The WHO Global status report on Noncommunicable Diseases 2014 revealed the frightening data that nearly 1.9 billion adults worldwide were overweight (BMI 25.1–30.0 kg/m2) and over 600 million obese (BMI ≥ 30.1 kg/m2). Obesity with its growing prevalence has a substantial impact on the social health care system with sharply increasing mortality rates.

Calle et al. showed in 1999 that healthy subjects with no smoking history and all-cause mortality were the lowest at the BMI group 23.5–24.9 kg/m2 for

Conclusion

In patients with STEMI, patients with a BMI of 30.0–34.9 kg/m2 have a decreased risk for in-hospital MACE compared to patients with a normal BMI. There were no differences between men and women in the incidence of in-hospital MACE. While BMI could be identified as an independent predictor for in-hospital MACE, decreased HDL-c and elevated LDL-c where not independently associated with MACE.

Acknowledgements

This study is supported by the DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung — German Centre for Cardiovascular Research) and by the BMBF (German Ministry of Education and Research).

References (31)

  • C. Lazzeri et al.

    Impact of age on the prognostic value of body mass index in ST-elevation myocardial infarction

    Nutr Metab Cardiovasc Dis

    (2013)
  • J. Wlodarczyk et al.

    Incidence, predictors and outcomes of major bleeding in patients following percutaneous coronary interventions in Australia

    Heart Lung Circ

    (2016)
  • S. Payvar et al.

    In-hospital outcomes of percutaneous coronary interventions in extremely obese and normal-weight patients: findings from the NCDR (National Cardiovascular Data Registry)

    J Am Coll Cardiol

    (2013)
  • Obesity: preventing and managing the global epidemic. Report of a WHO Consultation

    World Health Organ Tech Rep Ser

    (2000)
  • E.E. Calle et al.

    Body-mass index and mortality in a prospective cohort of U.S. adults

    N Engl J Med

    (1999)
  • Cited by (6)

    • Lipid paradox in patients with acute myocardial infarction: Potential impact of malnutrition

      2019, Clinical Nutrition
      Citation Excerpt :

      A similar phenomenon is the obesity paradox, which refers to the reverse epidemiology observed in patients with end-stage renal disease, chronic obstructive pulmonary disease, and AMI [42–44]. Significantly fewer major adverse cardiovascular events were observed in patients with STEMI and BMIs of 30.0–34.9 kg/m2 compared with patients with normal BMIs [45]. Third, serum lipoprotein might be a buffering factor involved in the modification of systemic inflammation in malnourished patients.

    • Body mass index as a biomarker for the evaluation of the “Obesity Paradox” among inpatients

      2019, Clinical Nutrition
      Citation Excerpt :

      In the majority of these publications, the authors confirmed the existence of an “overweight paradox”, “obesity paradox”, “BMI paradox” or at least a similar risk of mortality and/or morbidity among inpatients with increased BMI in comparison with hospitalized patients of normal weight. These publications concerned the following conditions: adults undergoing cardiac surgery [5,31,32], patients with acute heart failure [33], patients with in-hospital cardiac arrest [34], patients with ST-segment elevation myocardial infarction (STEMI) [35], patients after percutaneous coronary intervention (PCI) [36], patients undergoing vascular surgery [37], patients undergoing hip replacement surgery [38], older nursing-home residents [39], and patients with hyperglycemia and diabetes, regardless of glycemic status [40]. In our study, we modified BMI ranges for older patients and patients aged below 65 y (Table 3).

    Disclosures: All authors declare that there is no conflict of interest.

    1

    The first two authors contributed equally.

    View full text