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The Obesity Paradox: T he Importance for Long-term Outcomes in Non-ST-Elevation Myocardial Infarction – The CRUSADE Experience. E mily O’Brien, Emil Fosbol, Andrew Peng, Karen Alexander, Matthew Roe, Eric Peterson. Disclosures. None. Obesity in the United States.

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E mily o brien emil fosbol andrew peng karen alexander matthew roe eric peterson

The Obesity Paradox: The Importance for Long-term Outcomes in Non-ST-Elevation Myocardial Infarction – The CRUSADE Experience

Emily O’Brien, Emil Fosbol, Andrew Peng, Karen Alexander, Matthew Roe, Eric Peterson

Obesity in the united states
Obesity in the United States

CDC. Behavioral Risk Factor Surveillance System: 2010 survey data. Atlanta, GA: US Department of Health and Human Services, CDC; 2011.

E mily o brien emil fosbol andrew peng karen alexander matthew roe eric peterson

The Paradox



HR (95% CI)


RR (95% CI)
















Int Jour of Obes.2002; 26, 1046-1053. 

Eur Heart J. 2013 ;34(5):345-53.

The obesity paradox
The Obesity Paradox

  • First used to describe counterintuitive survival advantages in 19991

  • Reported for diabetes2, heart failure3, chronic kidney disease4, and CAD5

  • What is still unclear:

    • Whether the paradox exists among older, NSTEMI patients

    • Persistence of effects over long periods of followup

    • Differential mortality associations by metabolic status

1Kidney Int. 1999;55(4):1560-1567.

2JAMA. 2012;308(6):581-590.

3Am J Cardiol. 2003;91(7):891-894

4Am J ClinNutr. 2005;81(3):543-554

5Am J Med. Oct 2007;120(10):863-870


  • To determine the association between body mass index (BMI) and risk of all-cause mortality over three years in a population of elderly NSTEMI patients

  • To determine whether BMI associations differ by “metabolically healthy” status


  • Data Sources

    • CRUSADE linked to CMS data (2001-2006)

    • National NSTEMI Quality Improvement Initiative

    • Exclusions

      • Patients transferred out (N=4474)

      • Patients missing information on height and/or weight (N=2300)

      • Non-index admissions for patients with multiple records (N=1329)

      • Died during hospitalization (N=2623)

  • Final Sample: N=34,465

  • Body mass index bmi
    Body Mass Index (BMI)

    • Calculated from weight and height on admission

    • WHO categories(kg/m2)6

      • <18.5 Underweight

      • 18.5-24.9 Normal Weight

      • 25-29.9 Overweight

      • 30-34.9 Obese class I

      • 35-39.9 Obese class II

      • >=40 Obese class III

    6World Health Organ Tech Rep Ser. 2000;894:i-xii, 1-253.

    Objective ii
    Objective II

    • Metabolically healthy or “benign” obese

      • Preserved insulin sensitivity

      • Lower visceral fat accumulation

    • Metabolically Unhealthy7

      • Two or more of the following:

        1. High blood pressure (>130/85 mmHG) or


        2. Diabetes mellitus

        3. High triglycerides (>150 mg/dl)

        4. Low HDL (<40 mg/DL in men, <50 mg/DL in women)

    7Eur Heart J. 2013;34(5):389-397

    Statistical analysis
    Statistical Analysis

    • Cox proportional hazards modeling with censoring on death

    • All-cause mortality over 3-years

    • CRUSADE long-term mortality model8




    Family Hx of CAD

    Smoking status

    Prior MI

    Prior CABG

    Prior PCI

    Prior CHF

    Prior stroke

    Heart rate

    HF at presentation

    ECG findings

    Initial HCT

    Initial troponin

    8Am Heart J. 2011;162(5):875-883.


    All-Cause Mortality

    Metabolically unhealthy
    Metabolically Unhealthy


    BMI Category (kg/m2)

    Sensitivity analysis
    Sensitivity Analysis

    All-Cause Mortality

    Metabolically Healthy Patients

    Sensitivity analysis1
    Sensitivity Analysis

    All-Cause Mortality

    Metabolically Unhealthy Patients

    Potential explanations
    Potential Explanations

    • Selection bias: “healthiest” patients survive long enough to develop MI

    • Obese patients with more severe events may have greater metabolic reserve and increased resistance to catabolic burden

    • Cachexia  abnormal cytokine & neurohormonallevels, mortality

    • BMI categories may have heterogeneous groups


    • No followup after 3 years

    • “Metabolically Healthy” classification couldn’t be made in 1/3 of patients because HDL & triglycerides were not measured

    • No information on cause of death, which may be important to obesity paradox

    Conclusions future directions
    Conclusions & Future Directions

    • The obesity paradox persists over the long term for NSTEMI

    • Similar associations between BMI and all-cause mortality for metabolically healthy patients

    • Further studies on metabolism and BMI are needed