LETTER TO THE EDITOR
Obesity, weight reduction and survival in heart failure: Reply
Gregg C. Fonarow, MD, FACCa,
Tamara B. Horwich, MDa,
Michele A. Hamilton, MD, FACCa,
W. Robb MacLellan, MD, FACCa and
Jan H. Tillisch, MDa
a Ahmanson–UCLA Cardiomyopathy Center 47-123 CHS 10833 LeConte AvenueLos Angeles, California, USA 90095
gfonarow{at}mednet.ucla.edu
We appreciate the interest of Lavie et al. with regard to our recent analysis of obesity’s role in the prognosis of advanced heart failure (HF) (1) and the supporting data they have provided from their own institution (2). Our study has found that obese HF patients have similar to improved prognosis compared with normal or underweight HF patients, and we maintain that weight reduction as a therapeutic goal needs to be more closely examined in the population of advanced HF patients.
We concur that the associations observed in our study and in the other studies in this area prevent making any firm conclusions regarding lack of benefit or increased risk of weight loss in overweight and obese patients with HF. We also noted that even if obesity is not associated with worse HF survival, weight loss may be desirable if it results in improved functional capacity and reduced symptoms. Furthermore, we noted that preoperative obesity may increase morbidity and mortality with heart transplantation, as well as make it more difficult to find a suitable donor.
With regard to mortality, based on the associations observed in our study and in the absence of clinical trials demonstrating benefit, we do not believe raising the possibility that weight loss in patients with established HF may be an ineffective or even potentially harmful treatment represents a "sweeping" conclusion. Because there is potential risk to weight-loss therapies, it does not seem unreasonable to raise the issue regarding what degree of benefit, if any, could be expected. Severe calorie restriction in patients with advanced HF has the potential to worsen cardiac muscle function (3). In addition, fad diets and pharmacologic weight-loss agents are associated with risk; for example, the pro-adrenergic weight-loss agent sibutramine may raise heart rate and blood pressure (4). Although weight loss may be helpful in the prevention of coronary artery disease and HF, the data to support a mortality benefit with weight loss in advanced HF patients is limited. No randomized controlled trials of weight reduction in HF powered for clinical end points have been conducted to date.
There is clear and compelling evidence from multiple clinical trials that medical therapies, including beta-blockers, angiotensin-converting enzyme inhibitors and aldosterone antagonists, improve symptoms and prolong survival in patients with severe, chronic HF (5). We maintain that promotion and implementation of therapies proven to be life-prolonging take precedence over therapies for which clinical trial evidence is lacking. Based on the available evidence we disagree with Lavie et al. that weight reduction is a treatment for HF until proven otherwise. Clinical trials are clearly needed to provide definitive guidance. Given the public health implications, we hope the issues we and Lavie and colleagues have raised will encourage well-designed clinical trials to address this important issue. In the absence of definite clinical trial evidence, physicians should carefully weigh both the potential risks and potential benefits of weight loss in their overweight and obese HF patients.
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References
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1. Horwich TB, Fonarow GC, Hamilton MA, MacLellan WR, Woo MA, Tillisch JH. The relationship between obesity and mortality in patients with advanced heart failure. J Am Coll Cardiol. 2001;38:789–795[Abstract/Free Full Text]
2. Osman AF, Mehra MR, Lavie CJ, Nunez E, Milani RV. Response to "Ideal weight, body composition and lipid levels: an unresolved dilemma?". J Am Coll Cardiol. 2001;37:2010–2011[Free Full Text]
3. Alden PB, Madoff TD, Stahl TJ, Lakatua DJ, Ring WS, Cerra FB. Left ventricular function in malnutrition. Am J Physiol. 1987;253:H380–387[Medline]
4. McMahon FG, Fujioka K, Singh BN, et al. Efficacy and safety of sibutramine in obese white and African American patients with hypertension. Arch Intern Med. 2000;160:2185–2191[Abstract/Free Full Text]
5. Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. J Am Coll Cardiol. 2001;38:2101–2113[Free Full Text]
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C. J. Lavie, R. V. Milani, and H. O. Ventura
Obesity and cardiovascular disease: risk factor, paradox, and impact of weight loss.
J. Am. Coll. Cardiol.,
May 26, 2009;
53(21):
1925 - 1932.
[Abstract]
[Full Text]
[PDF]
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