Author + information
- Received March 26, 2018
- Revision received May 17, 2018
- Accepted May 21, 2018
- Published online August 6, 2018.
- Navkaranbir S. Bajaj, MD, MPHa,∗,
- Michael T. Osborne, MDa,b,∗,
- Ankur Gupta, MD, PhDa,
- Ali Tavakkoli, MDc,
- Paco E. Bravo, MDa,
- Tomas Vita, MDa,
- Courtney F. Bibbo, MSa,
- Jon Hainer, BSa,
- Sharmila Dorbala, MD, MPHa,d,
- Ron Blankstein, MDa,d,
- Deepak L. Bhatt, MD, MPHd@DLBHATTMD,
- Marcelo F. Di Carli, MDa,d and
- Viviany R. Taqueti, MD, MPHa,d,∗ (, )@BrighamWomens@VTaqMD
- aCardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- bCardiac MR/PET/CT Program, Departments of Medicine and Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
- cCenter for Weight Management and Metabolic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- dBrigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. Viviany R. Taqueti, Cardiovascular Imaging, Brigham and Women’s Hospital, ASB-L1 037-G, 75 Francis Street, Boston, Massachusetts 02115.
Background Besides body mass index (BMI), other discriminators of cardiovascular risk are needed in obese patients, who may or may not undergo consideration for bariatric surgery. Coronary microvascular dysfunction (CMD), defined as impaired coronary flow reserve (CFR) in the absence of flow-limiting coronary artery disease, identifies patients at risk for adverse events independently of traditional risk factors.
Objectives The study sought to investigate the relationship among obesity, CMD, and adverse outcomes.
Methods Consecutive patients undergoing evaluation for coronary artery disease with cardiac stress positron emission tomography demonstrating normal perfusion (N = 827) were followed for median 5.6 years for events, including death and hospitalization for myocardial infarction or heart failure.
Results An inverted independent J-shaped relationship was observed between BMI and CFR, such that in obese patients CFR decreased linearly with increasing BMI (adjusted p < 0.0001). In adjusted analyses, CFR but not BMI remained independently associated with events (for a 1-U decrease in CFR, adjusted hazard ratio: 1.95; 95% confidence interval: 1.41 to 2.69; p < 0.001; for a 10-U increase in BMI, adjusted hazard ratio: 1.20; 95% confidence interval: 0.95 to 1.50; p = 0.125) and improved model discrimination (C-index 0.71 to 0.74). In obese patients, individuals with impaired CFR demonstrated a higher adjusted rate of events (5.7% vs. 2.6%; p = 0.002), even in those not currently meeting indications for bariatric surgery (6.4% vs. 2.6%; p = 0.04).
Conclusions In patients referred for testing, CMD was independently associated with elevated BMI and adverse outcomes, and was a better discriminator of risk than BMI and traditional risk factors. CFR may facilitate management of obese patients beyond currently used markers of risk.
↵∗ Drs. Bajaj and Osborne contributed equally to this work and serve as joint first authors.
This work was supported by National Institutes of Health grant numbers T32 HL094301 to Drs. Bajaj, Gupta, Bravo, and Vita; T32 HL076136 to Dr. Osborne; R01HL132021 to Dr. Di Carli; and K23HL135438 to Dr. Taqueti. This independent research was supported in part by the Gilead Sciences Research Scholars Program in Cardiovascular Disease. Dr. Tavakkoli has served as a consultant for and received consulting fees from Medtronic. Dr. Dorbala has served as a consultant for GE Healthcare. Dr. Bhatt has served on the advisory board for Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, and Regado Biosciences; has served on the board of directors of the Boston VA Research Institute and Society of Cardiovascular Patient Care; has served as the chair of American Heart Association Quality Oversight Committee; has served on the data monitoring committees of the Cleveland Clinic, Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, and Population Health Research Institute; has received honoraria from the American College of Cardiology (senior associate editor, Clinical Trials and News, ACC.org), Belvoir Publications (Editor-in-Chief, Harvard Heart Letter), Duke Clinical Research Institute (clinical trial steering committees), Harvard Clinical Research Institute (clinical trial steering committee), HMP Communications (Editor-in-Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (guest editor; associate editor), Population Health Research Institute (clinical trial steering committee), Slack Publications (chief medical editor, Cardiology Today Intervention), Society of Cardiovascular Patient Care (secretary/treasurer), and WebMD (CME steering committees); has served as the deputy editor for Clinical Cardiology; has served as the chair of the NCDR-ACTION Registry Steering Committee and VA CART Research and Publications Committee; has received research funding from Amarin, Amgen, AstraZeneca, Bristol-Myers Squibb, Chiesi, Eisai, Ethicon, Forest Laboratories, Ironwood, Ischemix, Lilly, Medtronic, Pfizer, Roche, Sanofi, and The Medicines Company; has received royalties from Elsevier (editor, Cardiovascular Intervention: A Companion to Braunwald’s Heart Disease); has served as a site co-investigator for Biotronik, Boston Scientific, and St. Jude Medical (now Abbott); has served as a trustee of the American College of Cardiology; and has performed unfunded research for FlowCo, PLx Pharma, and Takeda. Dr. Di Carli has received research grant support from Spectrum Dynamics; and consulting fees from Sanofi and General Electric. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 26, 2018.
- Revision received May 17, 2018.
- Accepted May 21, 2018.
- 2018 American College of Cardiology Foundation
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