Effect of Obesity on Mortality in Pulmonary Hypertension—A Systematic Review and Meta-Analysis
Abstract
:1. Introduction
2. Methods
2.1. Study Design and Study Selection
2.2. Inclusion and Exclusion Criteria
2.3. Outcome Definitions
2.4. Data Extraction
2.5. Quality Assessment
2.6. Statistical Analysis
3. Results
4. Discussion
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Study Name (First Author and Year) | Study Design | Obesity Definition | Pulmonary Hypertension Definition | Study Groups and Patient Numbers | Mortality Hazard Ratio (95% CI*) | Follow-Up Duration | Limitations | Comments |
---|---|---|---|---|---|---|---|---|
Zafir 2013 | Single-center, prospective | BMI ≥ 30 kg/m2 | Pre-capillary PH defined as MPAP > 25 mm Hg, PCWP ≤ 15 mm Hg, and PVR ≥ 3 WU; post-capillary PH defined as MPAP > 25 mm Hg, PCWP > 15 mm Hg, PVR ≥ 3 WU. | Total = 105; BMI < 30, n = 62; BMI > 30, n = 43 | BMI > 30, HR 0.2 (0.1–0.6, p = 0.004) | 19 ± 13 months | Small sample size; single-center; inclusion of pre-capillary and post-capillary PH; no sub-group analysis of survival by class I–III obesity. | Higher mortality in low-BMI groups in both pre- and post-capillary PH; adjusted for functional class, pericardial effusion, BMI, moderate–severe TRV, right ventricular dysfunction, systolic blood pressure, MPAP, PVR, RAP, hemoglobin level. |
Poms 2013 | Multicenter, prospective (REVEAL registry) | BMI ≥ 30 kg/m2 | Pre-capillary PH defined as MPAP > 25 mm Hg at rest or more than 30 mm Hg with exercise, PCWP ≤ 15 mm Hg, and PVR ≥ 3 WU. | Total = 2959; BMI ≥ 30, n = 956 | BMI ≥ 30, HR 0.73 (0.61–0.86, p < 0.001) | 3 years | Obesity defined by BMI and not by adipose distribution pattern; no sub-group analysis of survival by class I–III obesity. | Adjusted for hypertension, clinical depression, DM, obesity, COPD, OSA, and thyroid disease; amongst obese patients, functional class III/IV was associated with increased HR 1.37 (1.14–1.65). |
Strange 2018 | Multicenter, Prospective (PHSANZ registry) | BMI ≥ 30 kg/m2 | Pre-capillary PH defined as MPAP ≥ 25 mm Hg and PCWP ≤ 15 mm Hg | Total = 220; obese BMI ≥ 30, n = 75 | BMI ≥ 30, HR 0.91 (0.87–0.97), p = 0.008) | 26 months | Data limited to idiopathic, heritable, and drug-induced PH; obesity defined by BMI and not by adipose distribution pattern; no sub-group analysis of survival by class I–III obesity. | Adjusted for sex and six-minute walk distance. |
Weathearald 2018 | Multicenter, Prospective (FHPR) | BMI ≥ 30 kg/m2; morbid obesity BMI ≥35 kg/m2 | Pre-capillary PH defined as MPAP ≥ 25 mm Hg, PCWP ≤ 15 mm Hg, and PVR ≥ 3 WU | Total = 1255; BMI < 30, n = 874; BMI ≥ 30, n = 381 | BMI < 18.5, n = 57, HR 1.76 (0.97–3.19, p = 0.06); BMI 18.5–24.9, n = 416, HR 1; BMI 25–29.9, n = 401, HR 0.85 (0.64–1.12, p = 0.24); BMI 30–34.9, n = 240, HR 0.98 (0.71–1.36, p = 0.92); BMI > 35, n = 141, HR 1.42 (0.95–2.14, p = 0.09); Obesity HR 1.16 (0.9–1.5, p = 0.26) | Average of 3 years | Data limited to idiopathic, heritable, and drug-induced PH; serial BMI not measured over time; obesity defined by BMI and not by adipose distribution pattern. | Adjusted for age, sex, etiology of pulmonary arterial hypertension, systemic hypertension, DM, smoking, New York Heart Association functional class, RAP, MPAP, and CI. Age < 65, morbidly obese patients had higher mortality HR 3 (1.56–5.79, p = 0.001). Among patients > 65 years, there was no significant association between higher BMI and mortality after adjusting for potential confounders, but there was an increase in mortality for patients who were underweight. |
Min 2020 | Multicenter, prospective (PHAR) | BMI ≥ 30 kg/m2 | Pre-capillary PH defined as MPAP ≥ 25 mm Hg, PCWP ≤ 15 mm Hg and PVR ≥ 3 WU | Total = 767; BMI 18.5–24.9, n = 204; BMI 25–29.9, n = 259; BMI > 30, n = 304 | BMI ≥ 30, HR 0.43 (0.23–0.78, p = 0.006); BMI 25–29.9, HR 0.48 (0.25–0.89, p = 0.002) | Median 512–557 days | Underweight patients were excluded; 7% of patients were lost to follow-up; obesity defined by BMI and not by adipose distribution pattern; comorbidities associated with obesity such as OSA and DM were not available; no sub-group analysis of survival by class I–III obesity. | Adjusted for age, sex, race/ethnicity, PAH etiology, cardiac index, RAP, combination therapy, parenteral prostacyclin analog use, use of supplemental oxygen, and lung transplantation; overweight subjects and obese subjects had worse HQROL compared with normal-weight patients (p = 0.001 and p = 0.01, respectively). |
Frank 2020 | Single-center, prospective | BMI ≥ 30 kg/m2 | PH defined as MPAP ≥ 20 mm Hg; pre-capillary PH defined as MPAP ≥ 20 mm Hg, PCWP ≤ 15 mm Hg and TPG ≥ 12 mm Hg | Total = 8940; BMI ≥ 30, n = 3428 | Obesity PH BMI ≥ 30, HR 0.77 (0.69–0.85, p < 0.001); obesity pre-capillary PH BMI ≥ 30, HR 0.57, (0.47–0.70, p < 0.001) | 5.5 years | Referral bias and confounding by indication; single-center; obesity defined by BMI and not by adipose distribution pattern. | Multivariable model adjusted for age, sex, heart rate, hypertension, DM, OSA, chronic kidney disease, previous myocardial infarction, and heart failure. |
Study (Author and Year) | Selection | Comparability | Outcome | AHRQ Standards (Good, Fair, and Poor) | |||||
---|---|---|---|---|---|---|---|---|---|
Representativeness of the Exposed Cohort | Selection of the Non-exposed Cohort | Ascertainment of Exposure | Demonstration that Outcome of Interest Was not Present at Start of Study | Comparability of Cohorts Based on the Design or Analysis Controlled for Confounders | Assessment of Outcome | Was Follow-Up Long Enough for Outcomes to Occur | Adequacy of Follow-Up for Cohorts | ||
Zafir 2013 | * | * | * | * | * | * | * | Poor | |
Poms 2013 | * | * | * | * | * | * | Poor | ||
Strange 2018 | * | * | * | * | * | * | * | Fair | |
Weatherald 2018 | * | * | * | * | * | * | * | * | Good |
Frank 2020 | * | * | * | * | * | * | * | * | Good |
Min 2020 | * | * | * | * | * | * | * | * | Good |
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Reddy, R.; Kalra, S.S.; Alzghoul, B.; Khan, A.; Zayed, Y. Effect of Obesity on Mortality in Pulmonary Hypertension—A Systematic Review and Meta-Analysis. J. Cardiovasc. Dev. Dis. 2023, 10, 419. https://doi.org/10.3390/jcdd10100419
Reddy R, Kalra SS, Alzghoul B, Khan A, Zayed Y. Effect of Obesity on Mortality in Pulmonary Hypertension—A Systematic Review and Meta-Analysis. Journal of Cardiovascular Development and Disease. 2023; 10(10):419. https://doi.org/10.3390/jcdd10100419
Chicago/Turabian StyleReddy, Raju, Saminder Singh Kalra, Bashar Alzghoul, Akram Khan, and Yazan Zayed. 2023. "Effect of Obesity on Mortality in Pulmonary Hypertension—A Systematic Review and Meta-Analysis" Journal of Cardiovascular Development and Disease 10, no. 10: 419. https://doi.org/10.3390/jcdd10100419