Department of Cardiology, National University Heart Center, National University Hospital, Singapore, Singapore.
Department of Cardiology, National University Heart Center, National University Hospital, Singapore, Singapore.
Am J Cardiol. 2022 Sep 1;178:112-118. doi: 10.1016/j.amjcard.2022.05.018. Epub 2022 Jun 25.
Although current evidence is in favor of metabolic health and nonobesity in the reduction of incident cardiovascular disease, little is known regarding the prognosis across the metabolic phenotypes once cardiovascular disease occurs. This study examined the prognosis of patients with significant aortic stenosis (AS) on the basis of the presence of metabolic health and obesity. This a retrospective cohort study on consecutive patients who presented with moderate-to-severe AS to a tertiary hospital between 2010 and 2015. Patients were allocated into 4 groups on the basis of obesity and metabolic health: metabolically healthy obese (MHO), metabolically healthy nonobese (MHNO), metabolically unhealthy obese (MUO), and metabolically unhealthy nonobese (MUNO). Metabolic health was defined in accordance to the Adult Treatment Panel III criteria. The primary outcome was all-cause mortality. Cox regression examined independent associations between mortality and metabolic phenotypes, adjusting for aortic valve area, ejection fraction, age, gender, chronic kidney disease, and aortic valve replacement as a time-dependent covariate. Of 727 patients, the majority (51.6%) were MUNO, followed by MUO (32.7%), MHNO (11.4%), and MHO (4.3%). MHNO had the highest mortality (43.0%), followed by the MUNO (37.5%), MUO (30.0%), and MHO (6.9%) groups (p = 0.001). Compared with MHNO, MHO (hazard ratio 0.159, 95% confidence interval 0.038 to 0.668, p = 0.012) and MUO (hazard ratio 0.614, 95% confidence interval 0.403 to 0.937, p = 0.024) were independently associated with lower all-cause mortality rates after adjusting for confounders. In patients who are obese, metabolic health had favorable survival compared with metabolically unhealthy (p = 0.015), but this protective impact of metabolic health was not observed in patients with overweight or normal weight. Obesity had favorable survival compared with overweight and normal weight in both patients who are metabolically healthy (p = 0.002) and unhealthy (p = 0.007). In conclusion, patients who are MHO with AS have the most favorable prognosis, whereas the seemingly healthy MHNO group had the worst survival. There should be a paradigm shift toward prioritizing metabolic health rather than weight reduction in patients with significant AS.
尽管目前的证据支持代谢健康和非肥胖与降低心血管疾病的发生率有关，但对于心血管疾病发生后代谢表型的预后知之甚少。本研究根据代谢健康和肥胖情况，研究了严重主动脉瓣狭窄（AS）患者的预后。这是一项回顾性队列研究，纳入了 2010 年至 2015 年在一家三级医院就诊的中重度 AS 连续患者。根据肥胖和代谢健康，患者被分为 4 组：代谢健康肥胖（MHO）、代谢健康非肥胖（MHNO）、代谢不健康肥胖（MUO）和代谢不健康非肥胖（MUNO）。代谢健康根据成人治疗小组 III 标准定义。主要结局是全因死亡率。Cox 回归分析了死亡率与代谢表型之间的独立相关性，调整了主动脉瓣面积、射血分数、年龄、性别、慢性肾脏病和主动脉瓣置换作为时变协变量。在 727 名患者中，大多数（51.6%）为 MUNO，其次是 MUO（32.7%）、MHNO（11.4%）和 MHO（4.3%）。MHNO 的死亡率最高（43.0%），其次是 MUNO（37.5%）、MUO（30.0%）和 MHO（6.9%）组（p=0.001）。与 MHNO 相比，MHO（危险比 0.159，95%置信区间 0.038 至 0.668，p=0.012）和 MUO（危险比 0.614，95%置信区间 0.403 至 0.937，p=0.024）在调整混杂因素后与较低的全因死亡率独立相关。在肥胖患者中，与代谢不健康相比，代谢健康具有更好的生存优势（p=0.015），但在超重或体重正常的患者中，代谢健康的这种保护作用并未观察到。肥胖患者在代谢健康（p=0.002）和不健康（p=0.007）的患者中均具有较好的生存优势，超重和体重正常。总之，患有 AS 的 MHO 患者的预后最佳，而看似健康的 MHNO 组的生存最差。在患有严重 AS 的患者中，应该从重视代谢健康而不是体重减轻的角度来改变观念。
