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Central obesity and cardiovascular outcomes in patients with acute coronary syndrome: observations from the MERLIN-TIMI 36 trial
  1. Mitul B Kadakia1,2,
  2. Caroline S Fox3,4,
  3. Benjamin M Scirica1,
  4. Sabina A Murphy1,
  5. Marc P Bonaca1,
  6. David A Morrow1
  1. 1Department of Medicine, TIMI Study Group, Cardiovascular Division, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
  2. 2Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
  3. 3NHBLI's Framingham Heart Study, National Heart, Lung, and Blood Institute, Framingham, Massachusetts, USA
  4. 4Division of Endocrinology, Brigham & Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
  1. Correspondence to Dr Mitul B Kadakia, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19103, USA; kadakia{at}


Objective Despite the association of obesity with incident cardiovascular disease, obese patients with acute coronary syndrome (ACS) appear to have more favourable short-term outcomes. A study was undertaken to determine whether this ‘obesity paradox’ persists in the long term and to examine the specific relationship of central obesity with outcomes after ACS.

Methods The relationship was investigated between two measures of obesity—body mass index (BMI) and waist circumference (WC)—and 30-day and 1-year outcomes after ACS. 6560 patients with non-ST elevation ACS in the MERLIN-TIMI 36 trial were followed for 1 year. Patients were stratified into three BMI groups (<25, 25–30, ≥30 kg/m2) and gender-specific tertiles of WC. The primary endpoint was cardiovascular death, myocardial infarction or recurrent ischaemia.

Results Patients with BMI ≥30 kg/m2 had a significantly lower risk of the primary endpoint than those with BMI <25 kg/m2 (HR 0.64; 95% CI 0.51 to 0.81, p<0.0001) at 30 days. However, after the 30-day acute phase, landmark analysis from 30 days to 1 year showed no difference in risk between BMI groups (HR 1.09; 95% CI 0.92 to 1.29, p=0.34). WC tertiles demonstrated a similar relationship. When BMI groups were stratified by WC there was a trend towards more adverse outcomes in higher WC groups among those in lower BMI groups. The group with the lowest BMI and highest WC had the highest risk (HR 2.8; 95% CI 0.93 to 8.3; p=0.067).

Conclusions Obesity is associated with more favourable short-term outcomes after ACS. However, in the longer term the obesity paradox is no longer present and may reverse. Those with WC out of proportion to BMI suggestive of significant central adiposity may be at highest risk following ACS.

  • Obesity
  • myocardial infarction
  • risk factors
  • prevention
  • interventional cardiology
  • acute coronary syndrome
  • quality of care and outcomes
  • acute coronary syndrome
  • biochemical markers
  • prognosis
  • risk stratification
  • acute myocardial infarction

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  • Funding MERLIN-TIMI 36 was supported by CV Therapeutics (now Gilead Science Inc).

  • Competing interests BMS has received grants for clinical research via the TIMI Study Group and Brigham and Women's Hospital from CV Therapeutics, Novartis Pharmaceuticals Corporation, AstraZeneca Pharmaceuticals LP, Daiichi-Sankyo Inc, Merck & Co Inc, Johnson and Johnson Pharmaceutical Research & Development LLC, Bayer HealthCare Pharmaceuticals and Bristol-Myers-Squibb Company and has served as a consultant for AstraZeneca Pharmaceuticals LP, Novartis Pharmaceuticals Corporation, CV Therapeutics, Cogentus, Shionogi & Co Ltd, Gilead Sciences Inc, Merck & Co Inc and Schering-Plough Corporation. DAM has received grants for clinical research via the TIMI Study Group and Brigham & Women's Hospital from CV Therapeutics, served as a consultant for Menarini Group and received honoraria for educational presentations from CV Therapeutics. MBK, CSF, MPB and SAM do not report any potential conflicts.

  • Ethics approval The protocol was approved by the relevant institutional review boards at all participating centres and written informed consent was obtained from all patients.

  • Provenance and peer review Not commissioned; externally peer reviewed.