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Obesity cardiomyopathy – what is inside matters

Comment by Gal Tsaban, EAPC Young Community Representative

Preventive Cardiology
Heart Failure

Mid-life visceral adiposity is linked with increased risk for later life heart failure.

New evidence links midlife visceral adiposity with later life risk of heart failure – an underattended risk in primary prevention. A recent Atherosclerosis Risk in Communities (ARIC) study analysis shows that midlife visceral adiposity index (VAI) is linked with a higher risk for heart failure in later life (1). In this study, 15,792 patients with a mean age of 54 and 55.4% females were assessed for visceral adiposity index (VAI) at baseline (midlife) and followed for a median duration of 22.5 years for incident heart failure. VAI was calculated based on a previously validated sex-specific formula which includes waist circumference, body mass index, triglycerides, and high-density lipoprotein cholesterol levels and thus relates both to anthropometric measures and insulin resistance reflecting metabolic status.

The investigators divided the study population into three categories according to their calculated VAI, the first category being the lowest and the last being the highest VAI tertial. As expected, participants with higher VAI were slightly older and had higher rates of cardiometabolic complications, such as hypertension and diabetes, at baseline. Importantly, these patients also had a slightly higher rate of renal dysfunction.

In multivariable survival models, adjusting for all accountable possible confounders, increased VAI was associated with increased long-term risk for heart failure. Continuously restricted cubic spline regressions showed that VAI was linearly related to long-term heart failure risk, with reduced risk among patients with VAI lower than two and higher risk in those with a calculated VAI above 2. In a fully adjusted model, for each 1 unit of VAI, the risk for VAI increased by 8%. Notably, the association between VAI and the risk of long-term heart failure was significantly higher among patients younger than 55 at baseline (p-for-interaction=0.011). In a subgroup of patients with follow-up echocardiogram examinations, increased VAI was associated with increased left ventricular mass and diameter and higher rates of diastolic, but not systolic, dysfunction, again highlighting the crucial role of obesity and adiposity in promoting heart failure with preserved ejection fraction.

The results of this study shed light on the importance of cardiometabolic assessment in patients during midlife to stratify the risk for cardiometabolic complications, among which is the long-term risk of heart failure and diastolic dysfunction. Whether interventions to promote weight loss and increase insulin sensitivity might reduce the risk of heart failure among such patients remains to be determined. However, this study reinforces the importance of implementing strategies to reduce obesity and adiposity in the broad population and performing a thorough clinical cardiometabolic assessment as a part of the integral risk stratification among primary prevention population, which may lead to early interventions and treatments with the potential to reduce long-term risk for heart failure. 


Gal Tsaban commented on this article:

1. Chaoguang Xu, Yue Guo, Shaozhao Zhang, Yuhui Lai, Mengting Huang, Rongjian Zhan, Menghui Liu, Zhenyu Xiong, Yiquan Huang, Rihua Huang, Xinxue Liao, Xiaodong Zhuang, Zhixiong Cai, Visceral adiposity index and the risk of heart failure, late-life cardiac structure, and function in ARIC study, European Journal of Preventive Cardiology, 2023;, zwad099, 

Notes to editor

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.