Should we target obesity in advanced heart failure?

Obesity is a risk factor for the development of heart failure (HF), but has been associated with improved survival in patients with established HF. Weight loss should clearly be recommended and supported for obese individuals without cardiac pathology to prevent cardiomyopathy development. Clinical recommendations at the other end of the obesity heart failure spectrum are also relatively clear. Morbidly obese individuals (BMI ≥ 40 kg/m(2)) aged <50 years with severely depressed systolic function and NYHA class III-IV symptoms should be considered for malabsorptive bariatric surgery at an experienced center. The goal is either improved systolic function and symptoms, or sufficient weight loss for heart transplant eligibility. Recommendations for patients falling between these extremes are more challenging. Overweight and mildly obese HF patients (25-35 kg/m(2)) may be somewhat protected from cardiac cachexia and weight loss is not expected to enhance survival, but may offer symptomatic benefits.