Obesity and Subtypes of Incident Cardiovascular Disease

Abstract

Background: Obesity is a risk factor for various subtypes of cardiovascular disease (CVD), including coronary heart disease (CHD), heart failure (HF), and stroke. Nevertheless, there are limited comparisons of the associations of obesity with each of these CVD subtypes, particularly regarding the extent to which they are unexplained by traditional CVD mediators.

Methods and results: We followed 13 730 participants in the Atherosclerosis Risk in Communities (ARIC) study who had a body mass index ≥18.5 and no CVD at baseline (visit 1, 1987-1989). We compared the association of higher body mass index with incident HF, CHD, and stroke before and after adjusting for traditional CVD mediators (including systolic blood pressure, diabetes mellitus, and lipid measures). Over a median follow-up of 23 years, there were 2235 HF events, 1653 CHD events, and 986 strokes. After adjustment for demographics, smoking, physical activity, and alcohol intake, higher body mass index had the strongest association with incident HF among CVD subtypes, with hazard ratios for severe obesity (body mass index ≥35 versus normal weight) of 3.74 (95% CI 3.24-4.31) for HF, 2.00 (95% CI 1.67-2.40) for CHD, and 1.75 (95% CI 1.40-2.20) for stroke (P<0.0001 for comparisons of HF versus CHD or stroke). Further adjustment for traditional mediators fully explained the association of higher body mass index with CHD and stroke but not with HF (hazard ratio 2.27, 95% CI 1.94-2.64).

Conclusions: The link between obesity and HF was stronger than those for other CVD subtypes and was uniquely unexplained by traditional risk factors. Weight management is likely critical for optimal HF prevention, and nontraditional pathways linking obesity to HF need to be elucidated.

Keywords: coronary heart disease; epidemiology; heart failure; obesity; stroke.

Figure 1

Association of BMI categories with adjusted incidence rates for different CVD subtypes. Incidence rates were calculated at mean levels of age, sex, race, smoking status, alcohol use, education level, occupation, and physical activity within the study population. BMI indicates body mass index; CVD, cardiovascular disease; PY, person‐year.

Figure 2

Relationship of continuous BMI with incident cardiovascular disease subtypes in linear spline models after multivariable adjustment. Linear spline with knots at the BMI values of 25, 30, 35, 40, and 45 and reference at BMI of 22. Adjusted for age, race, sex, alcohol use, smoking status, occupation, education level, physical activity, diabetes mellitus, systolic blood pressure, antihypertensive medication use, HDL‐C and LDL‐C, and estimated glomerular filtration rate. BMI indicates body mass index; CHD, coronary heart disease; HDL‐C, high‐density lipoprotein cholesterol; HF, heart failure; LDL‐C, low‐density lipoprotein cholesterol.

Figure 3

Association of higher BMI categories with incident heart failure after multivariable adjustment within demographic subgroups. Adjusted for age, race, sex, alcohol use, smoking status, occupation, education level, physical activity, diabetes mellitus, systolic blood pressure, antihypertensive medication use, HDL‐C and LDL‐C, triglycerides, and estimated glomerular filtration rate. BMI indicates body mass index; HDL‐C, high‐density lipoprotein cholesterol; HR, hazard ratio; ; LDL‐C, low‐density lipoprotein cholesterol; Ref, reference.