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Obesity paradox and perioperative myocardial infarction/injury in non-cardiac surgery

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Abstract

Background

The impact of obesity on the incidence of perioperative myocardial infarction/injury (PMI) and mortality following non-cardiac surgery is not well understood.

Methods

We performed a prospective diagnostic study enrolling consecutive patients undergoing non-cardiac surgery, who were considered at increased cardiovascular risk. All patients were screened for PMI, defined as an absolute increase from preoperative to postoperative sensitive/high-sensitivity cardiac troponin T (hs-cTnT) concentrations. The body mass index (BMI) was classified according to the WHO classification (underweight< 18 kg/m2, normal weight 18–24.9 kg/m2, overweight 25–29.9 kg/m2, obesity class I 30–34.9 kg/m2, obesity class II 35–39.9 kg/m2, obesity class III > 40 kg/m2). The incidence of PMI and all-cause mortality at 365 days, both stratified according to BMI.

Results

We enrolled 4277 patients who had undergone 5413 surgeries. The median BMI was 26 kg/m2 (interquartile range 23–30 kg/m2). Incidence of PMI showed a non-linear relationship with BMI and ranged from 12% (95% CI 9–14%) in obesity class I to 19% (95% CI 17–42%) in the underweight group. This was confirmed in multivariable analysis with obesity class I. showing the lowest risk (adjusted OR 0.64; 95% CI 0.49–0.83) for developing PMI. Mortality at 365 days was lower in all obesity groups compared to patients with normal body weight (e.g., unadjusted OR 0.54 (95% CI 0.39–0.73) and adjusted OR 0.52 (95% CI 0.38–0.71) in obesity class I).

Conclusion

Obesity class I was associated with a lower incidence of PMI, and obesity in general was associated with a lower all-cause mortality at 365 days.

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Abbreviations

ASA:

American Society of Anesthesiologists

BMI:

Body mass index

CAD:

Coronary artery disease

CI:

Confidence interval

COPD:

Chronic obstructive pulmonary disease

ECG:

Electrocardiography

ESC:

European Society of Cardiology

ESA:

European Society of Anesthesiology

HR:

Hazard ratio

Hs-cTnT:

High-sensitivity cardiac troponin T

IQR:

Interquartile range

s-cTnI:

Sensitive cardiac troponin I

METS:

Metabolic equivalent

OR:

Odds ratio

PMI:

Perioperative myocardial injury

RCRI:

Revised Cardiac Risk Index

TIA:

Transient ischemic attack

TNF-α:

Tumor necrosis factor-α

WHO:

World Health Organization

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Acknowledgement

Thomas Wolff: Division of Vascular Surgery, University Hospital Basel, University of Basel, Switzerland; Karin Wildi: Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital of Basel, University of Basel, Switzerland; Alessandro Genini: Department of Anaesthesiology, University Hospital Basel, University of Basel, Switzerland; Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital of Basel, University of Basel, Switzerland; Raphael Twerenbold: Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital of Basel, University of Basel, Switzerland; Lorraine Sazgary: Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital of Basel, University of Basel, Switzerland; Luca Koechlin: Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital of Basel, University of Basel, Switzerland; Desiree Wussler: Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital of Basel, University of Basel, Switzerland; Tobias Breidthardt: Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital of Basel, University of Basel, Switzerland; Dayana Flores: Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital of Basel, University of Basel, Switzerland; Stefan Osswald: Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital of Basel, University of Basel, Switzerland; Katharina Rentsch: Department of Laboratory Medicine, University Hospital Basel, University of Basel, Switzerland.

Funding

This study was supported by research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, the Stiftung Für Kardiovaskuläre Forschung Basel, the University of Basel, the University Hospital Basel, Abbott and Roche, Forschungsfond Kantonsspital Aarau.

Author information

Author notes

  1. Reka Hidvegi and Christian Puelacher contributed to this manuscript and should be considered co-first authors.

Authors and Affiliations

  1. Cardiovascular Research Institute Basel (CRIB) and Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland

    Reka Hidvegi, Christian Puelacher, Danielle M. Gualandro, Joan Walter, Marcel Liffert, Ivo Strebel, Johanna Gueckel, Stella Marbot, Ketina Arslani, Jasper Boeddinghaus, Thomas Nestelberger, Tobias Zimmermann, Michael Freese & Christian Mueller

  2. Department of Anesthesia, University Hospital Basel, University of Basel, Basel, Switzerland

    Reka Hidvegi, Joan Walter, Marcel Liffert, Daniel Bolliger & Luzius Steiner

  3. Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland

    Christian Puelacher, Andreas Lampart, Johanna Gueckel, Stella Marbot, Ketina Arslani & Tobias Zimmermann

  4. Department of Cardiology, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil

    Danielle M. Gualandro

  5. Department of Anesthesia, University Hospital Düsseldorf, Düsseldorf, Germany

    Giovanna Lurati Buse

  6. Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland

    Angelika Hammerer-Lerchner

  7. Department of Anesthesia, Kantonsspital Aarau, Aarau, Switzerland

    Christoph Kindler & Jaqueline Espinola

  8. Department of Vascular Surgery, University Hospital Basel, University of Basel, Basel, Switzerland

    Lorenz Guerke & Edin Mujagic

  9. Department of Traumatology and Orthopedics, University Hospital Basel, University of Basel, Basel, Switzerland

    Daniel Rikli

  10. Department of Hematology and Blood Bank, University Hospital Basel, University of Basel, Basel, Switzerland

    Andreas Buser

Authors
  1. Reka Hidvegi
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  2. Christian Puelacher
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Consortia

for the BASEL-P.M.I. Investigators

  • Thomas Wolff
  • , Karin Wildi
  • , Alessandro Genini
  • , Raphael Twerenbold
  • , Lorraine Sazgary
  • , Luca Koechlin
  • , Desiree Wussler 
  • , Tobias Breidthardt
  • , Dayana Flores
  • , Stefan Osswald
  •  & Katharina Rentsch

Corresponding author

Correspondence to Christian Puelacher.

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Conflicts of interest

Mr. Christian Puelacher PhD, MD has received research support from Roche Diagnostic. Prof. Mueller has received research support from the Swiss National Science Foundation, the Swiss Heart Foundation, the European Union, the Kommission für Technologie & Innovation, the Stiftung für kardiovaskuläre Forschung Basel, the University of Basel, the University Hospital Basel, Abbott, Beckman Coulter, Biomerieux, Brahms, Idorsia, Novartis, Ortho Clinical Diagnostics, Quidel, Roche, Sanofi, Siemens, Singulex, Sphingotec, as well as speaker honoraria/consulting honoraria from Acon, Amgen, Astra Zeneca, Bayer, Biomerieux, Boehringer Ingelheim, BMS, Brahms, Novartis, Roche, Sanofi, Siemens, and Singulex. Dr. Twerenbold has received research support from the Swiss National Science Foundation (P300PB-167803_1), the Swiss Heart Foundation, the Swiss Society of Cardiology, the University Hospital Basel, and the Cardiovascular Research Foundation; and has received speaker honoraria/consulting honoraria from Abbott, Amgen, Brahms, Roche, Siemens, and Singulex. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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Hidvegi, R., Puelacher, C., Gualandro, D.M. et al. Obesity paradox and perioperative myocardial infarction/injury in non-cardiac surgery. Clin Res Cardiol 109, 1140–1147 (2020). https://doi.org/10.1007/s00392-020-01605-0

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