Body mass index and cardiovascular outcomes in patients with acute coronary syndrome by diabetes status: the obesity paradox in a Korean national cohort study

Se-Jun Park, Kyoung Hwa Ha, Dae Jung Kim, Se-Jun Park, Kyoung Hwa Ha, Dae Jung Kim

Abstract

Background: The "obesity paradox" has not been elucidated in the long-term outcomes of acute coronary syndrome (ACS). We investigated the association between obesity and cardiovascular (CV) outcomes in ACS patients with and without diabetes.

Methods: We identified 6978 patients with ACS aged 40-79 years from the Korean National Health Insurance Service-Health Screening Cohort between 2002 and 2015. Baseline body mass index (BMI) was categorized as underweight (< 18.5 kg/m2), normal weight (18.5-22.9 kg/m2), overweight (23.0-24.9 kg/m2), obese class I (25.0-29.9 kg/m2), and obese class II (≥ 30.0 kg/m2). The primary outcome was major adverse CV events (MACE)-CV death, myocardial infarction (MI), and stroke. The secondary outcomes were the individual components of MACE, hospitalization for heart failure (HHF), and all-cause death.

Results: After adjustment for confounding variables, compared to normal-weight patients without diabetes (reference group), obese class I patients with and without diabetes had a lower risk of MACE, but only significant in patients without diabetes (with diabetes: hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.78-1.14; without diabetes: HR 0.78, 95% CI 0.62-0.97). Obese class II patient with diabetes had a higher risk of MACE with no statistical significance (HR 1.14, 95% CI 0.82-1.59). Underweight patients with and without diabetes had a higher risk of MACE, but only significant in patients with diabetes (with diabetes: HR 1.79, 95% CI 1.24-2.58; without diabetes: HR 1.23, 95% CI 0.77-1.97).

Conclusion: In ACS patients, obesity had a protective effect on CV outcomes, especially in patients without diabetes.

Keywords: Acute coronary syndrome; Diabetes mellitus; Obesity; Obesity paradox.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flowchart of the study population. ACS, acute coronary syndrome
Fig. 2
Fig. 2
Hazard ratio of cardiovascular outcomes in patients with acute coronary syndrome by diabetes status and body mass index. Adjusted for sex, age, body mass index, systolic blood pressure, fasting glucose, total cholesterol, alcohol consumption, smoking status, physical activity, household income, concurrent medications, comorbidities, and index year. BMI body mass index, MACE major adverse cardiovascular events

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