Cardiovascular risk in patients with obesity undergoing metabolic bariatric surgery versus glucagon-like peptide-1 receptor agonists: a systematic review and meta-analysis
J Lima, K Chagas, K Ridolphi, E Savergnini, G Athouguia, Y Lima, F Cardoso, E MachadoAbstract
Background
Glucagon-like peptide-1 receptors agonists (GLP-1 RAs) are highly effective alternatives, achieving optimal clinical response in recent clinical trials. Metabolic bariatric surgery (MBS) remains the current reference treatment for durable improvement of obesity complications, but incretin-based therapies are expanding the therapeutic landscape.
Purpose
This meta-analysis aimed to compare effectiveness and safety of BMS versus GLP-1 RAs in adults with obesity.
Methods
PubMed, Embase, and Cochrane Library databases were searched from inception until February 2025. Randomized clinical trials (RCT) and observational studies comparing any type of MBS with any GLP-1 RA therapy in adults with obesity, reporting changes in body mass index (BMI); glycade hemoglobin (HbA1c); major adverse cardiovascular events (MACE) systolic blood pressure (SBP); diastolic blood pressure (DBP); triglycerides (TG); high-density lipoprotein (HDL); low-density lipoprotein (LDL) were included. A random-effects meta-analysis was conducted with 95% confidence intervals (CI). Heterogeneity was assessed using the I2 statistic.
Results
Of 5,842 screened studies, seven articles (n = 15,594) were included. Regarding BMI, MBS resulted in a significantly greater reduction (SMD 1.61 kg/m²; 95% CI 1.04, 2.18; p<0.01). In the HbA1c, overall analysis showed no difference (SMD 0.03%; 95% CI -0.14, 0.20; p=0.73), though MBS showed a significant reduction after sensitivity analysis (SMD 0.16%; 95% CI 0.08, 0.24; p<0.01). For MACEs, MBS was associated with a significantly lower risk (RR 1.41; 95% CI 1.11, 1.78; p<0.01).P tends to present lower risk with MBS, but not significant (MD 1.95 mmHg; 95% CI -1.98, 5.88; p=0.33), such as DBP (MD 0.91 mmHg, 95% CI -0.21, 2.04; p=0.11). For TG (SMD 0.33 mg/dL; 95% CI -0.64, 1.31; p=0.5), HDL (SMD 0.02 mg/dL; 95% CI -1.05, 1.09; p=0.97) and LDL (SMD 0.33 mg/dL; 95% CI -0.39, 0.39; p=1) no significant difference were found.
Conclusions
Although GLP-1 RAs represent a highly effective pharmacological treatment, MBS currently provides superior outcomes in terms of magnitude of optimal clinical response in weight loss and protection against MACEs. These findings can assist clinicians and patients in shared decision-making, balancing the greater effectiveness of surgery against its invasiveness relative to pharmaceutical approaches.