Association between adiposity and lean mass with long-term cardiovascular events in patients with coronary artery disease: No paradox

Background--Prognosis based on body fat percentage (BF%) in patients with coronary artery disease has not been extensively studied. We tested the hypothesis that patients with coronary artery disease and increased BF% have a higher risk for major adverse cardiovascular events (MACEs) and that fat-free mass is associated with better prognosis. Methods and Results--We included 717 patients referred to cardiac rehabilitation after coronary artery disease events or procedures who underwent air displacement plethysmography to assess BF%; 75% were men, with a mean age 61.4±11.4 years and a mean body mass index of 30±5.4 kg/m². Follow-up was performed using a record linkage system. Patients were classified in sex-specific quartiles of BF% and fat-free mass index. The composite outcome of MACEs included acute coronary syndromes, coronary revascularization, stroke, or death from any cause. After a median follow-up of 3.9 years, 201 patients had a MACE. After adjusting for covariates, body mass index was not associated with MACEs (P=0.12). However, the risk of MACEs for those in the highest BF% quartile was nearly double when compared with those in the lowest quartile (hazard ratio, 1.89; 95% confidence interval, 1.30-2.77; P=0.0008). In contrast, fat-free mass was inversely associated with MACEs. The risk of MACEs for those in the fourth fat-free mass quartile was lower (adjusted hazard ratio, 0.53; 95% confidence interval, 0.35-0.82; P=0.004), when compared with those in the first quartile. Conclusions--In patients with coronary artery disease, there is no obesity paradox when measuring BF% instead of body mass index. BF% is associated with a higher risk of MACEs, whereas fat-free mass is associated with a lower risk of MACEs. Body mass index was not associated with MACEs.