Discordances between predicted and actual risk in obese patients with suspected cardiac ischaemia

Sheldon E. Litwin, Adrian Coles, C. Larry Hill, Brooke Alhanti, Neha Pagidipati, Kerry L. Lee, Patricia A. Pellikka, Daniel B. Mark, James E. Udelson, Lawton Cooper, Jean Claude Tardif, Udo Hoffmann, Pamela S. Douglas

Research output: Contribution to journalArticle

Abstract

Objectives: To test the relationship between increasing severity of obesity, calculated risk and observed outcomes. Methods: Patients with symptoms suggestive of coronary artery disease (CAD) (n=10 003) were stratified according to body mass index (BMI). We compared risk factors, pooled risk scores and physicians' perception of risk. Cox regression tested the association between BMI and (1) presence of obstructive CAD and (2) composite clinical endpoints (death, cardiovascular death, unstable angina hospitalisation and myocardial infarction). Results: BMI was ≥30 kg/m2 in 48% of patients and ≥35 in 20%. Increasingly obese patients were younger, female and non-smoking but with higher prevalence of hypertension, diabetes, black race and sedentary lifestyle. Pooled risk estimates of CAD were highest in those with mid-range BMI. In contrast, physicians' estimation of the likelihood of significant CAD based on clinical impression increased progressively with BMI. For a 10% increase in the Diamond-Forrester probability of CAD, the adjusted OR for obstructive CAD was 1.5 (95% CI 1.4 to 1.5) in patients with BMI <35, but only 1.2 (95% CI 1.1 to 1.3) in those with BMI ≥35 (interaction p<0.001). Framingham Risk Score increased across increasing BMI categories. However, there was a strong and consistent inverse relationship between degree of obesity and all three composite clinical endpoints over a median 25 months of follow-up. Conclusions: Despite perceptions of higher risk and higher risk scores, increasingly obese patients had obstructive CAD less frequently than predicted and had fewer adverse clinical outcomes. There is a need for risk assessment tools and guidelines that account for obesity. Trial registration number: NCT01174550.

Original languageEnglish (US)
JournalHeart
DOIs
StateAccepted/In press - Jan 1 2019

Fingerprint

Body Mass Index
Ischemia
Coronary Artery Disease
Obesity
Sedentary Lifestyle
Physicians
Diamond
Needs Assessment
Unstable Angina
Hospitalization
Myocardial Infarction
Guidelines
Hypertension

Keywords

  • Angina
  • Chest pain
  • Coronary artery disease
  • Mortality
  • Obesity
  • Risk score

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Litwin, S. E., Coles, A., Hill, C. L., Alhanti, B., Pagidipati, N., Lee, K. L., ... Douglas, P. S. (Accepted/In press). Discordances between predicted and actual risk in obese patients with suspected cardiac ischaemia. Heart. https://doi.org/10.1136/heartjnl-2018-314503

Discordances between predicted and actual risk in obese patients with suspected cardiac ischaemia. / Litwin, Sheldon E.; Coles, Adrian; Hill, C. Larry; Alhanti, Brooke; Pagidipati, Neha; Lee, Kerry L.; Pellikka, Patricia A.; Mark, Daniel B.; Udelson, James E.; Cooper, Lawton; Tardif, Jean Claude; Hoffmann, Udo; Douglas, Pamela S.

In: Heart, 01.01.2019.

Research output: Contribution to journalArticle

Litwin, SE, Coles, A, Hill, CL, Alhanti, B, Pagidipati, N, Lee, KL, Pellikka, PA, Mark, DB, Udelson, JE, Cooper, L, Tardif, JC, Hoffmann, U & Douglas, PS 2019, 'Discordances between predicted and actual risk in obese patients with suspected cardiac ischaemia', Heart. https://doi.org/10.1136/heartjnl-2018-314503
Litwin, Sheldon E. ; Coles, Adrian ; Hill, C. Larry ; Alhanti, Brooke ; Pagidipati, Neha ; Lee, Kerry L. ; Pellikka, Patricia A. ; Mark, Daniel B. ; Udelson, James E. ; Cooper, Lawton ; Tardif, Jean Claude ; Hoffmann, Udo ; Douglas, Pamela S. / Discordances between predicted and actual risk in obese patients with suspected cardiac ischaemia. In: Heart. 2019.
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abstract = "Objectives: To test the relationship between increasing severity of obesity, calculated risk and observed outcomes. Methods: Patients with symptoms suggestive of coronary artery disease (CAD) (n=10 003) were stratified according to body mass index (BMI). We compared risk factors, pooled risk scores and physicians' perception of risk. Cox regression tested the association between BMI and (1) presence of obstructive CAD and (2) composite clinical endpoints (death, cardiovascular death, unstable angina hospitalisation and myocardial infarction). Results: BMI was ≥30 kg/m2 in 48{\%} of patients and ≥35 in 20{\%}. Increasingly obese patients were younger, female and non-smoking but with higher prevalence of hypertension, diabetes, black race and sedentary lifestyle. Pooled risk estimates of CAD were highest in those with mid-range BMI. In contrast, physicians' estimation of the likelihood of significant CAD based on clinical impression increased progressively with BMI. For a 10{\%} increase in the Diamond-Forrester probability of CAD, the adjusted OR for obstructive CAD was 1.5 (95{\%} CI 1.4 to 1.5) in patients with BMI <35, but only 1.2 (95{\%} CI 1.1 to 1.3) in those with BMI ≥35 (interaction p<0.001). Framingham Risk Score increased across increasing BMI categories. However, there was a strong and consistent inverse relationship between degree of obesity and all three composite clinical endpoints over a median 25 months of follow-up. Conclusions: Despite perceptions of higher risk and higher risk scores, increasingly obese patients had obstructive CAD less frequently than predicted and had fewer adverse clinical outcomes. There is a need for risk assessment tools and guidelines that account for obesity. Trial registration number: NCT01174550.",
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AU - Litwin, Sheldon E.

AU - Coles, Adrian

AU - Hill, C. Larry

AU - Alhanti, Brooke

AU - Pagidipati, Neha

AU - Lee, Kerry L.

AU - Pellikka, Patricia A.

AU - Mark, Daniel B.

AU - Udelson, James E.

AU - Cooper, Lawton

AU - Tardif, Jean Claude

AU - Hoffmann, Udo

AU - Douglas, Pamela S.

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N2 - Objectives: To test the relationship between increasing severity of obesity, calculated risk and observed outcomes. Methods: Patients with symptoms suggestive of coronary artery disease (CAD) (n=10 003) were stratified according to body mass index (BMI). We compared risk factors, pooled risk scores and physicians' perception of risk. Cox regression tested the association between BMI and (1) presence of obstructive CAD and (2) composite clinical endpoints (death, cardiovascular death, unstable angina hospitalisation and myocardial infarction). Results: BMI was ≥30 kg/m2 in 48% of patients and ≥35 in 20%. Increasingly obese patients were younger, female and non-smoking but with higher prevalence of hypertension, diabetes, black race and sedentary lifestyle. Pooled risk estimates of CAD were highest in those with mid-range BMI. In contrast, physicians' estimation of the likelihood of significant CAD based on clinical impression increased progressively with BMI. For a 10% increase in the Diamond-Forrester probability of CAD, the adjusted OR for obstructive CAD was 1.5 (95% CI 1.4 to 1.5) in patients with BMI <35, but only 1.2 (95% CI 1.1 to 1.3) in those with BMI ≥35 (interaction p<0.001). Framingham Risk Score increased across increasing BMI categories. However, there was a strong and consistent inverse relationship between degree of obesity and all three composite clinical endpoints over a median 25 months of follow-up. Conclusions: Despite perceptions of higher risk and higher risk scores, increasingly obese patients had obstructive CAD less frequently than predicted and had fewer adverse clinical outcomes. There is a need for risk assessment tools and guidelines that account for obesity. Trial registration number: NCT01174550.

AB - Objectives: To test the relationship between increasing severity of obesity, calculated risk and observed outcomes. Methods: Patients with symptoms suggestive of coronary artery disease (CAD) (n=10 003) were stratified according to body mass index (BMI). We compared risk factors, pooled risk scores and physicians' perception of risk. Cox regression tested the association between BMI and (1) presence of obstructive CAD and (2) composite clinical endpoints (death, cardiovascular death, unstable angina hospitalisation and myocardial infarction). Results: BMI was ≥30 kg/m2 in 48% of patients and ≥35 in 20%. Increasingly obese patients were younger, female and non-smoking but with higher prevalence of hypertension, diabetes, black race and sedentary lifestyle. Pooled risk estimates of CAD were highest in those with mid-range BMI. In contrast, physicians' estimation of the likelihood of significant CAD based on clinical impression increased progressively with BMI. For a 10% increase in the Diamond-Forrester probability of CAD, the adjusted OR for obstructive CAD was 1.5 (95% CI 1.4 to 1.5) in patients with BMI <35, but only 1.2 (95% CI 1.1 to 1.3) in those with BMI ≥35 (interaction p<0.001). Framingham Risk Score increased across increasing BMI categories. However, there was a strong and consistent inverse relationship between degree of obesity and all three composite clinical endpoints over a median 25 months of follow-up. Conclusions: Despite perceptions of higher risk and higher risk scores, increasingly obese patients had obstructive CAD less frequently than predicted and had fewer adverse clinical outcomes. There is a need for risk assessment tools and guidelines that account for obesity. Trial registration number: NCT01174550.

KW - Angina

KW - Chest pain

KW - Coronary artery disease

KW - Mortality

KW - Obesity

KW - Risk score

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