Publish in this journal
Journal Information
Vol. 69. Issue 10.
Pages 990-992 (October 2016)
Scientific letter
DOI: 10.1016/j.rec.2016.04.055
Full text access
Prognostic Effect of Body Mass Index in Patients With an Implantable Cardioverter-defibrillator for Primary Prevention of Sudden Death
Influencia del índice de masa corporal en el pronóstico de pacientes con desfibrilador automático implantable en prevención primaria de muerte súbita
Visits
...
María Cristina González-Cambeiroa,
Corresponding author
cambe_cris@hotmail.com

Corresponding author:
, Moisés Rodríguez-Mañerob, Alba Abellas-Sequeirosc, José Moreno-Arribasd, David Filgueira-Ramae, José Ramón González-Juanateyb
a Servicio de Cardiología, Complejo Hospitalario de Pontevedra, Pontevedra, Spain
b Servicio de Electrofisiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
c Servicio de Cardiología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
d Servicio de Electrofisiología, Hospital Universitario de San Juan, San Juan de Alicante, Alicante, Spain
e Servicio de Electrofisiología, Hospital Clínico San Carlos, Madrid, Spain
This item has received
...
Visits
(Daily data update)
Article information
Full Text
Bibliography
Download PDF
Statistics
Figures (1)
Tables (1)
Table. Demographic Characteristics
Full Text
To the Editor,

Implantable cardioverter-defibrillators (ICD) are an important therapeutic option for patients with heart diseases that confer a high risk of sudden death (SD).1,2 Randomized studies have demonstrated that ICD implantation in patients with heart failure (HF) and severe ventricular dysfunction reduces mortality.

In addition, the prevalence of obesity has increased notably in recent years. Several studies have demonstrated an association between obesity and overweight and the presence of cardiovascular disease such as ischemic heart disease, HF, and SD. However, recent studies have found a paradoxically favorable prognosis for several diseases (such as HF, ischemic heart disease, atrial fibrillation, and diabetes mellitus)3–6 in patients who are overweight or obese, with lower cardiovascular hospitalization and lower total and cardiovascular mortality. However, prognosis as a function of body mass index (BMI) is unknown for patients with HF and a primary prevention ICD.

We designed a multicenter retrospective study, which was conducted in 15 Spanish hospitals with experience in the field of ICD implantation and follow-up. We enrolled 1174 patients who had received a primary prevention ICD between 2008 and 2014. Eleven patients were lost to follow-up. Only patients with a BMI measurement at the time of ICD implantation were considered; therefore, the final population was 651 patients.

In the study population, 135 individuals had a normal BMI, 283 were overweight, and 233 were obese. The baseline patient characteristics for each group are shown in the Table. The mean age was 61.70 ± 11.13 years, and 120 (18.4%) were women. The mean BMI was 28.37 (range, 18.5-55.36). Of the patients studied, 35.79% were obese, and 79.26% were obese or overweight. Patients with a higher BMI had a higher prevalence of hypertension, diabetes mellitus, dyslipidemia, and obstructive sleep apnea. No significant differences were found between BMI groups regarding treatment with lipid-lowering therapy, beta-blockers, angiotensin-converting enzyme inhibitors, anticoagulants, aldosterone antagonists, amiodarone, and digoxin.

Table.

Demographic Characteristics

Characteristics  BMI < 25 (n = 135)  BMI 25–30 (n = 283)  BMI ≥ 30 (n = 233)  P 
Age, y  61 ± 11.94  62 ± 11.01  61 ± 10.80  .374 
Women  25 (18.50)  47 (16.65)  48 (20.60)  .508 
Hypertension  72 (53.30)  178 (62.90)  163 (70.00)  .006 
Diabetes mellitus  36 (26.70)  77 (27.20)  87 (37.30)  .024 
Dyslipidemia  55 (40.70)  135 (47.70)  129 (55.40)  .022 
Smoking  37 (27.40)  81 (28.60)  72 (30.90)  .748 
COPD  11 (8.10)  33 (11.70)  35 (15.00)  .143 
OSAS  2 (1.50)  14 (4.90)  20 (8.60)  .014 
Peripheral arterial disease  9 (6.70)  30 (10.60)  17 (7.30)  .274 
CVE/TIA  7 (5.20)  27 (9.50)  12 (5.20)  .097 
Cancer  6 (4.40)  8 (2.80)  7 (3.00)  .663 
GFR by MDRD, mL/min/1.74 m2  76.20 ± 32.57  75.01 ± 23.52  74.11 ± 27.16  .778 
LVEF, %  26.00 [10-60]  25.50 [10-62]  26.27 [10-72]  .389 
Sinus rhythm  108 (80.00)  220 (77.70)  171 (73.40)  .088 
AF  42 (31.10)  93 (32.90)  96 (41.20)  .064 
Heart rate, bpm  70 [40-133]  67 [30-126]  70 [35-139]  .016 
Ischemic heart disease  78 (57.80)  164 (58.00)  121 (51.90)  .340 
NYHA III-IV  56 (41.50)  93 (32.90)  89 (38.20)  .188 
QRS duration, ms  124 [78-219]  125 [80-210]  120 [80-210]  .939 
QRS > 120 ms  76 (56.30)  148 (52.30)  121 (51.90)  .578 
Hemoglobin, g/dL  13.30 [9.00-17.80]  13.65 [8.40-17.80]  13.90 [9.60-17.40]  .024 
NT-proBNP, pg/mL  2535 [78-21118]  1276 [116-13 706]  1426 [13-19 098]  .035 
Digoxin  21 (15.60)  41 (14.50)  37 (15.90)  .901 
Beta-blockers  117 (86.70)  239 (84.50)  206 (88.40)  .424 
Calcium channel blockers  4 (3.00)  4 (1.40)  11 (4.70)  .085 
Amiodarone  81 (60.00)  186 (65.70)  134 (57.50)  .147 
Aldosterone antagonists  68 (50.40)  133 (47.00)  109 (46.80)  .771 
ACEI  123 (91.10)  249 (88.00)  212 (91.00)  .447 
Statins  81 (60.00)  186 (65.70)  134 (57.50)  .147 
Antiplatelet agents  70 (51.90)  151 (53.40)  124 (53.20)  .956 
Anticoagulants  38 (28.10)  95 (33.60)  86 (36.90)  .230 
Cardiovascular admission  34 (25.20)  70 (24.70)  54 (23.20)  .878 
Inappropriate shocks  7 (5.20)  31 (11.00)  22 (9.40)  .158 
Appropriate therapies (shocks and/or discharge)  20 (14.81)  53 (18.72)  49 (21.03)  .339 
Electrical storm  1 (0.70)  12 (4.20)  8 (3.40)  .162 
CRT responders  31 (26.9)  78 (27.8)  81 (34.5)  .171 
CRT hyperresponders  5 (3.70)  16 (5.70)  13 (5.50)  .680 
CRT nonresponders  23 (17.2)  29 (13.94)  30 (12.8)  .510 
Mortality  24 (17.80)  46 (16.30)  34 (14.60)  .713 

ACEI, angiotensin converting enzyme inhibitor; AF, atrial fibrillation; BMI, body mass index; COPD, chronic obstructive pulmonary disease; CRT, cardiac resynchronization therapy; CVE, cerebrovascular event; GFR, glomerular filtration rate; LVEF, left ventricular ejection fraction; MDRD, modification of diet in renal disease; NT-proBNP, N-terminal pro-brain natriuretic peptide; NYHA, New York Heart Association functional class; OSAS, obstructive sleep apnea syndrome; TIA, transient ischemic attack.

Values are expressed as no. (%), mean ± standard deviation or mean [interquartile range].

During the 8.65 ± 0.34 years of follow-up, 104 deaths (16%) were registered. Specifically, 24 patients (17.80%) with a normal BMI, 46 (16.30%) overweight patients, and 34 (14.60%) obese patients died. No differences were observed between the 3 groups regarding the number of hospital admissions. The response to cardiac resynchronization therapy was also similar between groups. No differences were found in terms of appropriate shocks, inappropriate shocks, or electrical storms. Likewise, the Kaplan-Meier survival curves showed no differences in mortality for obese and overweight patients vs normal weight patients (Figure).

Figure.

Kaplan-Meyer survival curves according to body mass index.

(0.09MB).

The parameters shown to be predictors of mortality included age, valve disease, heart rate > 70 bpm, anemia (hemoglobin < 13 mg/dL), dyslipidemia, female sex, atrial fibrillation, left ventricular dysfunction (left ventricular ejection fraction < 25%), and renal failure (creatinine > 1.3 mg/dL). No relationship was found between BMI and mortality.

On multivariable analysis, there were no differences in mortality between the overweight and obese subgroups (overweight, hazard ratio [HR] = 0.94; 95% confidence interval [95%CI], 0.57-1.54; P = .805; obesity, HR = 0.837; 95%CI, 0.49-1.42; P = .507). Similarly, there were no differences in the number of admissions for cardiovascular causes (obesity, HR = 0.986; 95%CI, 0.547-1.468; P = .663; overweight, HR = 0.981; 95%CI, 0.611-1.575; P = .936).

The conclusion drawn from this study, based on BMI analysis, is that obesity and overweight show no prognostic differences compared with normal weight for cardiovascular mortality, cardiovascular hospitalization, and appropriate and inappropriate therapies in this population of patients with HF and an ICD implant for primary prevention of SD.

However, the interpretation of these study results should take into account the limitations of the study. First, the conclusions are drawn from BMI analysis, which does not differentiate body fat from lean body mass. Second, we did not analyze distribution of body weight (peripheral vs abdominal) or other measurements of adiposity such as body fat percentage. In addition, no information was available on the proinflammatory and nutritional status of the study population. Furthermore, the available information on BMI was taken from the time of implantation only; therefore, possible changes in this parameter at follow-up were not considered. Lastly, the retrospective design of the study increased the risk of bias.

References
[1]
C.M. Tracy, A.E. Epstein, D. Darbar, J.P. DiMarco, S.B. Dunbar, N.A. Estes, et al.
2012 ACCF/AHA/HRS focused update of the 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
J Am Coll Cardiol., 60 (2012), pp. 1297-1313
[2]
J.J. McMurray, S. Adamopoulos, S.D. Anker, A. Auricchio, M. Bohm, K. Dickstein, ESC Committee for Practice Guidelines, et al.
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: the task force for the diagnosis and treatment of acute and chronic heart failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC.
Eur Heart J., 14 (2012), pp. 803-869
[3]
C. Millán Longo, M. García Montero, D. Tebar Márquez, L. Beltrán Romero, J.R. Banegas, J. García Puig.
Obesidad y episodios vasculares en la diabetes mellitus tipo 2.
Rev Esp Cardiol., 68 (2015), pp. 151-153
[4]
T. Puig, A. Ferrero-Gregori, E. Roig, R. Vázquez, J.R. González-Juanatey, D. Pascual-Figal, et al.
Valor pronóstico del índice de masa corporal y el perímetro de cintura en los pacientes con insuficiencia cardiaca crónica (Registro Español REDINSCOR).
Rev Esp Cardiol., 67 (2014), pp. 101-106
[5]
A. Oreopoulos, R. Padwal, K. Kalantar-Zadeh, G.C. Fonarow, C.M. Norris, F.A. McAlister.
Body mass index and mortality in heart failure: a meta-analysis.
Am Heart J., 156 (2008), pp. 13-22
[6]
B. Choy, E. Hansen, A.J. Moss, S. McNitt, W. Zareba, I. Goldenberg, Multicenter Automatic Defibrillator Implantation Trial-IIInvestigators; Multicenter Automatic Defibrillator Implantation Trial-II Investigators.
Relation of body mass index to sudden cardiac death and the benefit of implantable cardioverter-defibrillator in patients with left ventricular dysfunction after healing of myocardial infarction.
Am J Cardiol., 105 (2010), pp. 581-586
Idiomas
Revista Española de Cardiología (English Edition)

Subscribe to our newsletter

Article options
Tools
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

es en
Política de cookies Cookies policy
Utilizamos cookies propias y de terceros para mejorar nuestros servicios y mostrarle publicidad relacionada con sus preferencias mediante el análisis de sus hábitos de navegación. Si continua navegando, consideramos que acepta su uso. Puede cambiar la configuración u obtener más información aquí. To improve our services and products, we use "cookies" (own or third parties authorized) to show advertising related to client preferences through the analyses of navigation customer behavior. Continuing navigation will be considered as acceptance of this use. You can change the settings or obtain more information by clicking here.