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Stephan von Haehling, Wolfram Doehner, Stefan D Anker, The evolving obesity paradigm story: from heart failure to atrial fibrillation, European Heart Journal, Volume 40, Issue 19, 14 May 2019, Pages 1550–1552, https://doi.org/10.1093/eurheartj/ehz082
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This editorial refers to ‘Relationship between body mass index and outcomes in patients with atrial fibrillation treated with edoxaban or warfarin in the ENGAGE AF-TIMI 48 trial’†, by G. Boriani et al., on page 1541.
The obesity paradox holds the unexpected evidence that, despite being a cardiovascular risk factor, higher body mass index (BMI) relates to better prognosis in many patient groups. This was shown for patients with a broad spectrum of chronic diseases, including cancer, chronic kidney disease, and chronic obstructive pulmonary disease, as well as a wide spectrum of cardiovascular diseases.1 It was originally identified in the late 1990s in a group of patients on haemodialysis.2 Its existence has been so robust and reproducible across virtually the entire spectrum of cardiovascular disease conditions that it was considered appropriate to shift from the rather perplexing term ‘obesity paradox’ to the appropriate description of an ‘obesity paradigm’.3
In validated risk score assessments in heart failure (HF), overweight and moderate obesity were identified as beneficial factors, carrying a survival benefit for the patients.4 , 5 Accordingly, the HF guidelines of the European Society of Cardiology6 now proclaim that ‘in patients with HF with moderate degrees of obesity (BMI <35 kg/m2), weight loss cannot be recommended.’ However, HF is a deadly disease with a poor prognosis, and obesity may have different effects in different cardiovascular disease conditions even though large numbers of research groups have found evidence of an obesity paradigm in patients with HF, atrial fibrillation (AF), coronary heart disease, or even arterial hypertension.7 Other researchers have called the obesity paradox into question, suggesting that rather a ‘lean paradox’ exists, with normal weight or underweight having a poorer prognosis with respect to cardiovascular diseases as a result of a progressive catabolic state and lean mass loss.7 Others have suggested confounders to play a major role such as different treatment approaches in patients with higher or lower body weight.
