Orlando, FL - Don't waste
time discussing weight loss in patients with chronic heart
failure (CHF) who are obese, advises Dr Stefan Anker
(National Heart and Lung Institute, London, UK). According
to Anker, who heads the ELITE II substudy on obesity and survival
in CHF, lower weight and weight loss in CHF patients are indicators
of bad prognosis. Anker presented the substudy results at
the American College of Cardiology 50th Annual Scientific
Session.
The relationship of body weight and body weight change to
survival in CHF patients has not been examined in large contemporary
populations. Anker and colleagues prospectively collected
data on BMI at baseline and body weight change in 3088 CHF
patients in the ELITE II trial, and related the findings to
survival.
Anker et al found BMI was an independent determinant of survival
in the CHF patients, with one BMI point increase associated
with a 5.4% risk reduction in total mortality (p<0.0001).
When patients were grouped according to baseline BMI (into
quintiles), those with BMI of around 28 to 29 (obese patients)
were at lowest risk of mortality, while patients with smaller
BMIs showed 60-150% higher risk levels.
Relationship between BMI and survival in the ELITE II CHF
study population
BMI quartile (approximate
range of BMI)
RR of total mortality
(Q4 set as reference)
p value
Q1 (<23)
2.50
<0.0001
Q2 (23-25)
1.80
0.0002
Q3 (25-27)
1.60
0.003
Q4 (27-29)
1.00
--
Q5 (>29)
1.28
0.13
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Anker et al also showed that significant
weight loss (cachexia) in the CHF cohort was associated with
increased risk for mortality. Although cachexia was not reported
at baseline, the authors evaluated cachexia at an arbitrary
6-month time point. They report 5% of patients demonstrated
cachexia at 6 months. These patients had a 96% increase in the
risk of mortality, as compared to noncachexia patients at 6
months (p=0.0004).
Anker concludes, "In chronic heart failure, obesity is not an
adverse risk factor." He advises heartwire clinicians,
"In the case of morbid obesity - which for me is BMI >40 - you
should not talk to [the patient] about their obesity, because
their being obese is a sign of the absence of [cachexia]." Anker
suggests that doctors make better use of the little time they
get with CHF patients to discuss priority issues, "Really spend
your time explaining how to take their diuretics and how to
manage their life and how to do exercise."
The fact that Anker gives this advice based purely on observational
data, does not sit well with some. As Dr Darren McGuire
(Duke Clinical Research Institute, Durham, NC) noted in an interview
with heartwire, "There is no doubt that cachexia
of CHF should be associated with worse outcome, but there are
no randomized trials evaluating whether intentional weight loss
through a diet and exercise program is not beneficial." "In
fact," says McGuire, "the bulk of the data suggest that it would
benefit these patients."
Uric
acid - dramatic adverse risk marker in HF
In
addition to defining the relationship between
weight and survival in CHF patients, Anker
et al also reported a significant association
between elevated serum uric acid (UA) levels
and increased risk of mortality in the ELITE
II CHF patients. Anker says this adds to accumulating
data that UA is a dramatic adverse risk marker
in heart failure patients.
In the ELITE II substudy, elevated UA levels
(320-600 mmol/L) were associated with significant
increases in mortality. At the extreme, patients
with >600 mmol/L had a 186% increase in risk,
as compared to patients with normal UA levels
(p<0.0001). "If you want to assess at a low
cost but with a high sensitivity and specificity
the risk in heart failure patients - UA is
probably one of your best bets," says Anker.
Notably, losartan, which was tested in the
ELITE II trial, has a uricosuric effect (it
lowers UA levels). Anker says, he cannot conclude
from the present work whether losartan performs
better than other agents in CHF patients with
elevated UA. However, he told heartwire
he is working on that question, looking into
the effects of losartan and captopril in this
study.
Kat
Rother
kat@conceptis.com
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