European Heart Journal Advance Access originally published online on October 24, 2007
European Heart Journal 2007 28(23):2950-2951; doi:10.1093/eurheartj/ehm461
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Effects of obesity on mortality in patients with unstable angina or non-ST-elevation myocardial infarction: reply
Interventional Cardiology
Herz-Zentrum Bad Krozingen
Südring 15
D-79189 Bad Krozingen
Germany
Department of Internal Medicine
University Hospital
Basel
Switzerland
Tel: +49 7633 4020 Fax: +49 7633 402409 E-mail address: achim.buettner{at}herzzentrum.de
We fully agree with Drs Barton and Husmann that findings from observational studies like ours should be interpreted with caution. In addition, it is important to emphasize that observational studies document associations and are hypotheses generating, but can hardly ever prove causality. However, we disagree with some other points. (i) It was the primary aim of our study to compare the outcome of obese and normal weight patients. Even after adjustment for all possible confounders in the multivariable analysis, obesity was associated with a 50% reduction in mortality.1 In their letter, Drs Barton and Husmann focus very much on baseline characteristics in the very obese patients. Obviously, the subgroup of very obese patients in our cohort is too small to allow meaningful statistical analysis or definite conclusions. Because of a more linear correlation between body mass index (BMI) and mortality in our cohort when compared with a U-shaped correlation in other studies, comparison of all obese patients vs. normal BMI patients seemed to be justified in our analysis.1,2
(ii) Drs Barton and Husmann find it ‘daring to propose a beneficial effect of obesity’. We consider it our scientific obligation to report and discuss findings as open and unbiased as possible. The ‘obesity paradox’ is well described also for heart failure. Increased BMI is associated with an increase in heart failure.3 However, after contemporary treatment of symptomatic heart failure, the adjusted mortality risk for patients with lower BMI categories is in the range of 1.2–1.7 when compared with patients with BMI between 30 and 34.9.4 Some of the most important advances in medicine have been the result of unbiased and thoughtful evaluation of findings that at first sight questioned prevailing dogmas.5
Importantly, our finding of an improved outcome for obese patients after unstable angina/non-ST-elevation myocardial infarction treated with early revascularization should not be misinterpreted. Weight loss reduces the risk for diabetes and cardiovascular disease. Prevention of an acute coronary event is certainly preferable to a relatively better outcome thereafter.
References
- Buettner HJ, Mueller C, Gick M, Ferenc M, Allgeier J, Comberg T, Werner KD, Schindler C, Neumann FJ. The impact of obesity on mortality in unstable angina/non-ST segment elevation myocardial infarction. Eur Heart J (2007) 28:1694–1701.
[Abstract/Free Full Text] - Romero-Corral A, Montori VM, Somers VK, Korinek J, Thomas RJ, Allison TG, Mookadam F, Lopez-Jimenez F. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. JAMA (2006) 368:666–678.
- Kenchaiah S, Evans JC, Levy D, Wilson PW, Benjamin EF, Larson MG, Kannel WB, Vasan RS. Obesity and the risk of heart failure. N Engl J Med (2002) 347:305–313.
[Abstract/Free Full Text] - Kenchaiah S, Pocock SJ, Wang D, Finn PV, Zornoff LA, Skali H, Pfeffer MA, Yusuf S, Swedberg K, Michelson EL, Granger CB, McMurray JJ, Solomon SD. Body mass index and prognosis in patients with chronic heart failure. Insights from the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program. Circulation. 116. Published online ahead of print July 16, 2007.
- Packer M, Bristow MR, Cohn JN, Colucci WS, Fowler MB, Gilbert EM, Shusterman NH. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. U.S. Carvedilol Heart Failure Study Group. N Engl J Med (1996) 334:1349–1355.
[Abstract/Free Full Text]
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