Predictors of weight change in overweight patients with myocardial infarction

doi:10.1016/j.ahj.2007.06.006

American Heart Journal

Volume 154, Issue 4, October 2007, Pages 711-717

https://doi.org/10.1016/j.ahj.2007.06.006 Get rights and content

Background

Weight loss is recommended among overweight survivors of myocardial infarction (MI). This study describes patterns of weight change among overweight patients with MI and identifies factors associated with weight change.

Methods

A prospective cohort of 1253 overweight or heavier (body mass index [BMI] ≥25 kg/m²) post-MI patients were enrolled in the 19-center PREMIER study and followed up for 1 year to determine changes in weight. Patients were categorized at 1 month as overweight (BMI = 25-29.9 kg/m²), obese (BMI = 30-39.9 kg/m²), or morbidly obese (BMI ≥40 kg/m²). Unadjusted percent weight change was assessed at 1 year, and multivariable linear regression was used to identify independent correlates of change.

Results

Mean weight change was −0.2% and varied by the severity of baseline obesity (+0.4% for overweight patients, −0.5% for obese patients, and −3.7% for morbidly obese patients [P < .001]). Multivariable analyses revealed the following to be significantly associated with weight change: depression 1 month post-MI (+2.7%, P = .001), lack of health insurance (+2%, P = .01), smoking cessation 1 month post-MI (+2.7% vs current smokers, P < .001), morbid obesity (+4.7% vs overweight patients, P < .0001), and increasing age (−0.8% per decade, P = .001). An interaction between smoking cessation and weight class was detected in that overweight patients who quit had a mean increase of 5.3% (95% CI 3.1%-7.4%), whereas no significant change was observed among obese and morbidly obese patients who quit.

Conclusions

Although post-MI patients had negligible weight loss over 1 year, several sociodemographic, clinical, and lifestyle characteristics were associated with weight change. New, targeted interventions will likely be needed to improve weight management after an MI.

Section snippets

Patient population

A total of 2498 MI patients were enrolled in the PREMIER study from 19 US centers between January 1, 2003, and June 28, 2004. Details of this study have been described previously.⁸ In brief, all patients 18 years or older with an elevated troponin or creatinine kinase–MB level from blood test during the initial 24 hours of admission for suspected acute MI were screened for possible inclusion. Patients were eligible only if they had other evidence supporting the diagnosis of acute MI, including

Results

Of the 1423 patients at the beginning of the study, 1253 patients were alive and provided 1-year follow-up data. This cohort consisted of 53% overweight, 42% obese, and 5% morbidly obese post-MI patients. Table I describes the characteristics of the study population at the baseline assessment and their distributions by weight class. The mean age of the study population was 59 ± 12 years, with 71% being male, 79% being white, and approximately half obtaining some education beyond high school.

Discussion

Despite the well-recognized epidemic of obesity and the association of obesity with cardiovascular risk, this is the first study to describe, in post-MI patients, patterns associated with weight change along with patient and treatment characteristics associated with weight change. Our study of post-MI patients found a higher prevalence of overweight and obesity than in the general population,² possibly due to the added risk of coronary events that is associated with obesity. We also found that

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BMI was calculated at the time of the index procedure but was not reevaluated during the follow-up. However, it has been shown that, in obese patients, there is only a small decrease in body weight in the first year after MI.24 Our analysis does not take into account the difference between peripheral versus abdominal obesity or waist circumference.
Patients with high body mass index (BMI) seem to have better outcomes after percutaneous coronary intervention than normal-weight patients. However, contrasting results have been reported on the “obesity paradox” in patients presenting with ST-elevation myocardial infarction (STEMI). The aim of our study was to investigate the impact of BMI on mortality in the population enrolled in the Evaluation of the Xience-V stent in Acute Myocardial INfArcTION (EXAMINATION) trial. The EXAMINATION trial randomized 1,498 patients with STEMI to a bare-metal stent or an everolimus-eluting stent. In this substudy patients were stratified into 3 groups according to BMI values: normal (BMI < 25 kg/m²), overweight (BMI = 25 to 29.9 kg/m²), and obese (BMI ≥ 30 kg/m²). The coprimary end points were the all-cause and cardiac deaths among the groups at the 5-year follow-up. BMI was available in 1,421 patients, divided in 401 (28.2%) normal, 702 (49.4%) overweight, and 318 (22.4%) obese. Obese patients were younger (p = 0.012) compared with the other groups, but with a worse cardiovascular risk profile. They were more frequently female (p <0.001) and with a higher rate of obesity-related co-morbidity conditions such as diabetes mellitus (p = 0.005), arterial hypertension (p <0.001), and hyperlipidemia (p = 0.001) compared with the other groups. At the 5-year follow-up, all-cause and cardiac deaths were less frequent in obese patients than in the other groups (p = 0.003 and p = 0.030, respectively). After adjustment for confounding variables, BMI was an independent predictor of all-cause death (hazard ratio 0.765, 95% confidence interval 0.599 to 0.979, p = 0.033), but not of cardiac death, without any interaction with the stent type. In conclusion, in patients with STEMI who underwent primary PCI, the long-term all-cause death rate decreased as BMI increased, confirming the obesity paradox, irrespective of the stent type.
Current theoretical bases for nutrition intervention and their uses
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This chapter discusses contemporary theoretical basis for dietary interventions for disease prevention and management and their applications in practice. This chapter (1) introduces key concepts related to the application of theory in understanding and improving diet and eating-related behaviors, (2) reviews behavioral issues related to adopting healthful diets, (3) discusses dietary interventions, and (4) highlights important issues and constructs that cut across theories. Six theoretical models that are in current use and can be particularly useful for understanding the processes of changing eating habits in clinical and community settings are described: social cognitive theory, the stages of change construct from the transtheoretical model, consumer information processing, the theory of planned behavior, multiattribute utility theory, and the social ecological model. The central elements of each theory and how they can be used to guide dietary interventions are described in this chapter.
Excess weight and life expectancy after acute myocardial infarction: The obesity paradox reexamined
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First, we used BMI values recorded at the index hospitalization only and thus were unable to evaluate changes in BMI over time. Nevertheless, prior studies have found that most patients neither lose nor gain weight in the year after AMI,26 which would suggest that weight changes during follow-up are unlikely to affect our results. Second, we lacked information on other anthropometric measures to measure adiposity such as waist circumference or body fat percentage.
An “obesity paradox” has been described in patients with acute myocardial infarction (AMI), whereby obese and overweight patients have a lower risk of short-term mortality after AMI than normal-weight patients. However, the long-term association of obesity with mortality after AMI remains unknown.
We used data from the Cooperative Cardiovascular Project, a prospective medical record study of Medicare beneficiaries hospitalized with AMI with 17 years of follow-up (N = 124,981), to evaluate the association of higher body mass index (BMI) with short- and long-term survival after AMI. Cox proportional hazards models were used to estimate life expectancy after AMI and the years of potential life lost or gained attributable to excess weight.
Approximately 41.5% of patients were classified as normal weight; 38.7%, as overweight; 14.3%, as obese; and 5.5%, as morbidly obese. Normal-weight patients had the highest crude mortality at all follow-up time points, whereas obese patients had the lowest. Adjustment for patient and treatment characteristics reduced this difference, but the survival benefit persisted in overweight and obese patients at all time points. Morbidly obese and normal-weight patients had a comparable risk of death at 17 years. Life expectancy estimates were generally lowest for morbidly obese patients and highest for overweight patients. Differences in life expectancy between BMI groups were most pronounced in younger patients. After adjustment, overweight and obesity were associated with greater life years at all ages; however, morbid obesity was only associated with better survival in patients ≥75 years of age at the time of AMI.
Overweight and obesity are associated with improved short- and long-term survival after AMI, which results in moderate gains in life expectancy relative to normal-weight patients. These findings suggest that higher BMI confers a protective advantage over the entire remaining lifespan in older patients with AMI.
Glycosylated hemoglobin is associated with decreased endothelial function, high inflammatory response, and adverse clinical outcome in non-diabetic STEMI patients
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A significant proportion of patients maintain their weights while others loose or even gain weight, resulting in an overall negligible weight loss or anthropometric change at 3-months and 12-months [34–36]. Furthermore, morbidly obese patients are more prone to weight loss after STEMI [34–36]. In our cohort there were very few morbidly obese patients (0.7%, data not shown), which is probably due to the exclusion of diabetic patients.
Chronic dysglycemia was recently identified as a predictor for adverse outcomes in patients with ST-elevation myocardial infarction (STEMI) treated by percutaneous coronary intervention. Data for non-diabetic patients who underwent thrombolysis is scarce. In this context, we aimed to study the effect of HbA1c on cardiovascular outcome after STEMI.
A prospective cohort of 326 non-diabetic STEMI individuals was used for the analyses. We measured plasma glucose, hemoglobin A_1c [HbA_1c], lipid profile, C-reactive protein (CRP), and nitrate/nitrite (NOx) upon admission and five days after STEMI (D5). Flow-mediated dilation (FMD) was performed 30 days after STEMI. During clinical follow-up, we assessed patients for incident diabetes (progression to HbA1c ≥ 6.5%) and major adverse cardiac events (MACE), defined as a composite of fatal and non-fatal MI, sudden cardiac death, and angina requiring hospitalization.
Using ROC-curve analysis, a 5.8% HbA1c best predicted MACE with a sensitivity of 75% and specificity of 53% (AUC 0.673, p = 0.001). Patients were categorized as high HbA1c if ≥ 5.8% and low HbA1c if <5.8%. Compared with patients with low HbA1c, those with high HbA1c presented with 20% higher CRP-D5 (p = 0.009) and 19% higher ΔCRP (p = 0.01), a 32% decrease in ΔNOx (p < 0.001), and 33% lower FMD (p < 0.001). After a median follow-up of 1.9 (1.1–2.8) years, patients with high HbA_1c had more incident diabetes (HR 2.3 95% CI 1.01–5.2; p = 0.048) and MACE (HR 3.32 95% CI 1.09–10.03; p = 0.03).
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Weight change in patients attempting to quit smoking post-myocardial infarction
2014, American Journal of Medicine
Citation Excerpt :
Three studies examined patterns in weight change post-myocardial infarction, and a recent study examined the effect of weight gain after smoking cessation on the occurrence of cardiovascular events. The Prospective Registry Evaluating Myocardial Infarction: Event and Recovery study examined patterns of weight change and factors associated with weight change in a population of patients post-myocardial infarction.11 The authors found that weight gain varied by level of obesity (average weight gain: 0.3 kg, 0.5 kg, and 4.6 kg, for overweight, obese, and morbidly obese individuals, respectively) and that smoking abstinence was associated with greater weight gain (odds ratio, 2.67; 95% CI, 1.08, 4.27) at 12 months post-myocardial infarction.
Current guidelines recommend smoking cessation and weight management for secondary prevention in patients post-myocardial infarction. However, little is known about the effects of smoking cessation on weight change post-myocardial infarction.
We examined patterns of weight change and its effects on blood pressure and glycemic control using data from a randomized trial investigating the effect of bupropion on smoking cessation in patients post-myocardial infarction. Weight change was compared among 3 groups of patients: those who were completely abstinent (n = 92), those who smoked intermittently (n = 49), and those who smoked persistently (n = 38) during the 12-month follow-up. Analyses were restricted to patients who attended all follow-up visits.
The median weight at baseline was 77.1 kg (interquartile range [IQR], 66.0, 87.5), and 64.3% of patients were overweight/obese (body mass index ≥25.0 kg/m²). The median weight gain at 12 months was 4.0 kg (IQR, 0-7.0), with more than one third gaining >5 kg. The proportion of patients who were overweight/obese increased by approximately 10%, and 23.2% of patients moved up a body mass index category. Abstainers gained a median of 4.8 kg (IQR, 1.0, 8.6), intermittent smokers gained a median of 2.0 kg (IQR, −2.0, 5.0), and persistent smokers gained a median of 3.0 kg (IQR, −0.8, 6.0). Weight gain was associated with an increase in blood pressure and requirements for hypoglycemic medications at 12 months.
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: This work was supported by CV Therapeutics, Palo Alto, CA, and CV Outcomes, Inc (Kansas City, MO). Dr Spertus discloses that he has leadership responsibilities for CV Outcomes, Inc, Health Outcomes Sciences, and Outcomes Instruments; is a consultant for Amgen and United Healthcare; receives research grant support from the National Institutes of Health, Amgen, Lilly, Roche Diagnostics, and the American College of Cardiology-National Cardiovascular Data Registry; owns the copyrights for the Seattle Angina Questionnaire, the Kansas City Cardiomyopathy Questionnaire, and the Peripheral Artery Questionnaire; and previously received grant support and was a consultant for CV Therapeutics. Dr Masoudi discloses he has served on advisory boards for Takeda NA, Amgen, and United Healthcare; has contracts with the Oklahoma Foundation for Medical Quality; and is an associate editor of Journal Watch Cardiology of the Massachusetts Medical Society. Dr Krumholz discloses that he has research contracts with the Colorado Foundation for Medical Care and the American College of Cardiology, serves on the advisory boards for Amgen, Alere, and UnitedHealthcare, is a subject matter expert for VHA, Inc, and is editor-in-chief of Journal Watch Cardiology. No other authors have conflicts of interest to disclose related to this article.

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Clinical InvestigationsAcute Ischemic Heart DiseasePredictors of weight change in overweight patients with myocardial infarction

Background

Methods

Results

Conclusions

Section snippets

Patient population

Results

Discussion

Am Heart J

Am J Cardiol

J Subst Abuse

Circulation

Behavioral risk factor surveillance system

Obesity and long-term clinical and economic outcomes in coronary artery disease patients

Obes Res

Excess deaths associated with underweight, overweight, and obesity

JAMA

Overweight and obesity and weight change in middle aged men: impact on cardiovascular disease and diabetes

J Epidemiol Community Health

The obesity epidemic: can we turn the tide?

Heart

AHA/ACC scientific statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology

Circulation

The PHQ-9: validity of a brief depression severity measure

J Gen Intern Med

Enhancing recovery in coronary heart disease patients (ENRICHD): study design and methods

Am Heart J

Clinical Investigations
Acute Ischemic Heart Disease
Predictors of weight change in overweight patients with myocardial infarction