# Impact of global work index on obesity paradox in heart failure with advanced left ventricle remodeling

## TL;DR

The study finds that in heart failure patients with advanced left ventricular remodeling, higher BMI is linked to better outcomes only when myocardial work is high.

## Contribution

The study introduces the global work index as a key modifier of the obesity paradox in heart failure patients with advanced left ventricular remodeling.

## Key findings

- Obesity (BMI ≥28 kg/m²) was associated with lower MACE risk in patients with advanced left ventricular remodeling.
- The obesity paradox was observed only in patients with higher global work index (GWI > 900 mmHg).
- No significant association between BMI and MACE was found in patients with lower GWI.

## Abstract

This study aimed to examine the role of myocardial work in the obesity paradox among heart patients with heart failure and advanced left ventricular remodeling.

In this post hoc analysis, 515 consecutive patients with LVEF ≤ 50% who were hospitalized between May 2016 and December 2020 were included and followed for a median of 37.4 months. Left ventricular mass index (LVMI) was used to define advanced left ventricular remodeling. The primary endpoint was major adverse cardiovascular events (MACE). We assessed the prognostic impact of obesity at different levels of the global work index (GWI) in patients with advanced left ventricular remodeling.

Of the 515 patients, 330 were classified as having advanced left ventricular remodeling based on LVMI thresholds (men ≥110 g/m2, women ≥120 g/m2). In this subgroup, a BMI ≥ 28 kg/m2 was associated with a lower risk of MACE. These 330 patients were further stratified into higher GWI (n = 139) and lower GWI (n = 191) subgroups. In the higher GWI subgroup, both BMI ≥ 28 kg/m2 and continuous BMI values were associated with a reduced risk of MACE. No such association was observed in the lower GWI subgroup.

Myocardial work index modifies the relationship between BMI and prognosis in heart failure. GWI should be considered when evaluating the obesity paradox in patients with left ventricular systolic dysfunction, particularly those with advanced left ventricular remodeling.

This figure illustrates the relationship between obesity, myocardial work, and major adverse cardiovascular events (MACE) in patients with systolic heart failure (HF) and advanced left ventricular remodeling (LVR). The left panel shows the comparison between HF patients with and without LVR. We use left ventricular mass index (LVMI) to quantitively depict LVR, as it is associated with LV wall thickening and LV chamber enlargement. The Kaplan-Meier analysis shows that male with LVMI ≥ 110 g/m2 and female with LVMI ≥ 120 g/m2 are at higher risks for MACE. The upper middle panel presents the survival analysis for patients with HF and advanced LVR, highlighting the association of obesity (defined as BMI ≥ 28 kg/m2) with lower risks for MACE. The upper right panel shows the assessment of global work index (GWI), by incorporating global longitudinal strain (GLS) and non-invasive systolic blood pressure. The bottom right panel distinguishes between obesity in higher and lower levels of GWI (grouped according to whether GWI is greater than 900 mmHg), demonstrating that the obesity paradox is only observed in patients with higher GWI, as indicated by the survival curves for patients with higher GWI (p = 0.019) and lower GWI (p = 0.094).Infographic summarizes a study on heart failure with advanced left ventricle remodeling, illustrating that obesity is linked to lower major adverse cardiac events only in patients with higher global work index, supported by diagrams of heart anatomy, survival curves, and myocardial work images.

This figure illustrates the relationship between obesity, myocardial work, and major adverse cardiovascular events (MACE) in patients with systolic heart failure (HF) and advanced left ventricular remodeling (LVR). The left panel shows the comparison between HF patients with and without LVR. We use left ventricular mass index (LVMI) to quantitively depict LVR, as it is associated with LV wall thickening and LV chamber enlargement. The Kaplan-Meier analysis shows that male with LVMI ≥ 110 g/m2 and female with LVMI ≥ 120 g/m2 are at higher risks for MACE. The upper middle panel presents the survival analysis for patients with HF and advanced LVR, highlighting the association of obesity (defined as BMI ≥ 28 kg/m2) with lower risks for MACE. The upper right panel shows the assessment of global work index (GWI), by incorporating global longitudinal strain (GLS) and non-invasive systolic blood pressure. The bottom right panel distinguishes between obesity in higher and lower levels of GWI (grouped according to whether GWI is greater than 900 mmHg), demonstrating that the obesity paradox is only observed in patients with higher GWI, as indicated by the survival curves for patients with higher GWI (p = 0.019) and lower GWI (p = 0.094).