Prevalence and prognostic impact of clinical obesity in heart failure with preserved ejection fraction: a prospective, registry cohort study
J L Chen, J Liu, R N Xiao, J A Kleeberger, L D I Venanzio, T T Cai, F Paneni, D Y ZhangAbstract
Background
Obesity is an important contributor to heart failure with preserved ejection fraction (HFpEF), but body mass index (BMI) may inadequately reflect excess adiposity and its clinical consequences, especially in Asian populations where BMI tends to be lower despite a high prevalence of central adiposity. The European Association for the Study of Obesity (EASO) recently proposed a framework defining clinical obesity as a chronic systemic disease with excess adiposity and obesity-related organ dysfunction, but its prevalence and prognostic impact in HFpEF are still unknown.
Purpose
The study aimed to quantify the prevalence of clinical obesity according to the EASO framework and compare it with traditional anthropometric definitions, investigate the association between clinical obesity and clinical outcomes.
Methods
In this prospective cohort, hospitalized HFpEF patients were enrolled between November 2020 and July 2024. In addition to BMI, the Clinical Obesity Framework integrates a variety of indicators of excess fat, such as waist circumference, waist-to-hip ratio and body fat percentage. Besides, HFpEF is considered to be an organ dysfunction associated with obesity. The primary endpoint was a composite of worsening heart failure events or cardiovascular death.
Results
Among 426 patients with HFpEF (median age 74 years, 38% women), 319 (74.9%) were classified as having clinical obesity, markedly exceeding the prevalence of BMI-defined obesity (BMI ≥28 kg/m², 14.8%), while only 36 patients (8.4%) had a BMI ≥30 kg/m². Clinical obesity was common even among patients with normal BMI. During a median follow-up of 907 days, patients with clinical obesity experienced higher incidence rates of the composite endpoint (35.24 vs 15.82 per 100 person-years). Clinical obesity was associated with an increased risk of the composite endpoint (adjusted HR 2.19; 95% CI 1.54–3.13) and worsening heart failure events (aHR 2.49; 95% CI 1.69–3.68), whereas no significant associations were observed with cardiovascular or all-cause mortality. In contrast, BMI-defined obesity was not associated worsening HF event, CV-death or all-cause mortality. Replacing BMI with clinical obesity in prognostic models was associated with improved risk stratification, with significant net reclassification improvement (NRI 0.507 at 1 year, 0.731 at 2 years, and 0.793 at 3 years) and corresponding gains in integrated discrimination (IDI 0.037, 0.063, and 0.041), compared with the established HFpEF-ABA score.
Conclusions
Clinical obesity appears to be highly prevalent in Chinese patients with HFpEF and is associated with a higher risk of heart failure–related events. A clinical obesity framework may provide complementary prognostic information beyond conventional anthropometric measures and could help refine risk stratification in HFpEF, and clinical obesity should be regarded as a major comorbidity in HFpEF, rather than a simple descriptor of body size.Clinical Obesity PrevalenceCumulative Incidence of Study Outcomes