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The Obesity Paradox in Patients with Peripheral Arterial Disease: The Influence of Chronic Obstructive Pulmonary Disease

^aDepartment of Anesthesiology, Erasmus MC, Rotterdam, the Netherlands. ^cDepartment of Surgery, Erasmus MC, Rotterdam, the Netherlands. ^fDepartment of Anesthesiology and Cardiology, Erasmus MC, Rotterdam, the Netherlands. ^bThe Heart and Lung Institute and The James Hogg iCAPTURE Center for Cardiovascular and Pulmonary Research, St. Paul's Hospital & University of British Columbia, Vancouver, Canada. ^dDepartment of Cardiology, Leiden Medical Centre, Leiden, The Netherlands. ^eDepartment of Anesthesiology, Tanta Faculty of Medicine, Tanta, Egypt

d.poldermans{at}erasmusmc.nl

Abstract

BackgroundCardiac events are the predominant cause of late mortality in patients with peripheral arterial disease (PAD). In these patients mortality decreases with increasing body mass index (BMI). Chronic obstructive pulmonary disease (COPD) is a recently identified cardiac risk factor, which preferentially affects underweight individuals. Whether or not COPD explains the obesity paradox in PAD patients is unknown.

MethodsWe studied 2,392 patients who underwent major vascular surgery at one teaching institution. Patients were divided according to COPD status and BMIs (underweight, normal, overweight, and obese) and determined the relationship between these variables and all-cause mortality using a Cox regression analysis. Median follow-up was 4.37 years (interquartile range 1.98-8.47 years).

ResultsOverall mortality among underweight, normal, overweight, and obese patients was 54%, 50%, 40%, and 31% respectively (P<0.001). The distribution of COPD severity classes showed increased prevalence of moderate to severe COPD in underweight patients. In the entire population BMI (continuous) was associated with increased mortality (hazard ratio, HR= 0.96; 95%CI: 0.94-0.98). In addition, patients classified as underweight were at increased risk for mortality (HR=1.42; 95% CI: 1.00-2.01). However after adjusting for COPD severity, the relationship was no longer significant (HR=1.29; 95%CI: 0.91-1.93).

ConclusionsThe excess mortality among underweight patients was largely explained by the over-representation of individuals with moderate to severe COPD. COPD may in part explain the "obesity paradox" in the PAD population.

Key Words: Body Mass Index • Peripheral arterial disease • Chronic obstructive pulmonary disease • Mortality