| PART 1.Association of Lean Body Mass and Fat Mass with 1-Year Mortality among Patients Hospitalized for Heart FailureBackground:Prior studies have found an unexplained inverse or U-shaped relationship between body mass index(BMI)and mortality in heart failure(HF)patients.However,little is known about the independent effects of each body component,i.e.,lean body mass(LBM)and fat mass(FM),on prognosis.Aims:We aimed to evaluate the effect of LBM and FM on prognosis in acute HF.Methods:We used data from the China Patient-centered Evaluative Assessment of Cardiac Events-Prospective Heart Failure Study.LBM and FM were calculated using equations developed from the National Health and Nutrition Examination Survey.LBM index(LBMI)and FM index(FMI),calculated by dividing LBM or FM in kilograms by the square of height in meters,were used for analysis.All enrolled patients were followed up for lyear,and the clinical outcomes in this study were allcause death,HF readmission,the composite end-point events(cardiovascular death or HF readmission).(1)Cox proportional hazards frailty models or competing risk models were used to examine the association of LBMI and FMI(both as continuous variables and category variables)with all-cause mortality,HF readmission and the composite end-point events risk.(2)We used restricted cubic spline(RCS)to explore the non-linear association between LBMI,FMI(as continuous variables)and clinical outcomes.Results:(1)Among 4305 patients,median(interquartile range,IQR)age was 67(57-75)years,37.3%were women.During the 1-year follow-up,691 patients died,1399 patients had HF readmission,1610 patients had composite end-point events.(2)In the Cox models,higher BMI was associated with decreased death risk(HR 0.95,95%CI 0.93-0.97),decreased HF readmission risk(HR 0.99,95%CI 0.97-1.00)and decreased composite end-point events risk(HR 0.98,95%CI 0.97-0.99).(3)In the Cox models,higher LBMI was associated with decreased death risk(HR 0.77,95%CI 0.67-0.88),decreased readmission risk(HR 0.90,95%CI 0.82-0.99)and decreased composite end-point events risk(HR 0.89,95%CI 0.82-0.97).When we assessed the association between the LBMI quartiles and prognosis,the results are consistent with the results above.In addition,in the RCS analysis,LB MI was associated with prognosis in a linear way,the death risk,readmission risk and composite end-point events risk decreased consistently with increasing LBMI(Poverall association<0.05;P-non-linearity>0.05).(4)In the Cox models,FMI was not associated with clinical outcomes(all-cause death:HR 0.95,95%CI 0.83-1.09;HF readmission:HR 1.06,95%CI 0.99-1.14;the composite end-point events risk:HR 1.03,95%CI 0.96-1.11).When we assessed the association between the FMI quartiles and prognosis,the results are consistent with the results above.In addition,in the RCS analysis,it shows no association between FMI and clinical outcomes(P-overall association>0.05;P-non-linearity>0.05).Conclusions:In a national Chinese cohort of patients hospitalized for HF,higher LBMI was associated with decreased risk of all-cause death,HF readmission and composite end-point events.While no association between FMI and clinical outcomes was observed.PART 2.The Impact of BMI on the Prognostic Value of N-Terminal Pro-Brain Natriuretic Peptide among Patients Hospitalized for Heart FailureBackground:Although the inverse relationship between body mass index(BMI)and N-terminal pro-B-type natriuretic peptide(NT-proBNP)level is well known,the impact of obesity on the prognostic performance of NT-proBNP in acute heart failure(HF)remains uncertain.Aims:We aimed to evaluate the impact of obesity on the prognostic value of NTproBNP in acute HF.Methods:We used data from the China Patient-centered Evaluative Assessment of Cardiac Events-Prospective Heart Failure Study.Patients were classified as underweight(BMI<18.5 kg/m2),normal weight(BMI 18.5-24.9 kg/m2),overweight(BMI 25-29.9 kg/m2),and obese(BMI≥30 kg/m2).All enrolled patients were followed up for 1 year,and the clinical outcomes in this study were all-cause death,HF readmission,cardiovascular death or HF readmission.We evaluated the prognostic value of admission NT-proBNP across BMI categories,using Cox proportional hazards frailty models or competing risk models.Results:(1)Among 4375 patients,median(IQR)age was 67(57-75)years,37.3%were women.Most patients were normal weight(53.0%),followed by overweight(30.6%),obese(9.3%),and underweight(7.1%).During 1-year follow up,705 patients died,1417 patients had HF readmission,1635 patients had composite end-point events.(2)NT-proBNP inversely correlated with BMI(P<0.01).In risk-adjusted analyses,higher admission NT-proBNP level was associated with increased death risk in underweight(HR 1.31,95%CI 1.06-1.62),normal weight(HR 1.52,95%CI 1.381.68)and overweight patients(HR 1.60,95%CI 1.37-1.87),but not in obese patients(HR 1.28,95%CI 0.93-1.77)(P for interaction=0.04).In terms of HF readmission,higher admission NT-proBNP level was associated with increased readmission risk in normal weight patients(HR 1.19,95%CI 1.121.28),while not associated with readmission in underweight,overweight and obese patients.The test for interaction was not significant(P for interaction=0.43).In terms of composite end-point events risk,higher admission NT-proBNP level was associated with increased risk in underweight(HR 1.22,95%CI 1.06-1.40),normal weight(HR 1.30,95%CI 1.21-1.39)and overweight(HR 1.15,95%CI 1.061.24)patients,while not associated with the composite end-point events risk in obese patients(HR 1.03,95%CI 0.88-1.20)(P for interaction=0.02).Conclusions:In a national Chinese cohort of patients hospitalized for HF,BMI modify the association between NT-proBNP and prognosis(the death risk,composite end-point events risk).Higher NT-proBNP level is associated with poor prognosis in non-obese patients,while the association is compromised in obese patients.PART 3.Effect of Spironolactone in Patients with Heart Failure and Preserved Ejection Fraction:Effect Modification by ObesityBackground:Obesity is common in heart failure with preserved ejection fraction(HFpEF).Whether obesity modifies the response to spironolactone in patients with HFpEF remains unclear.Aims:we investigated if the clinical response to spironolactone in HFpEF patients varied by obesity status.Methods:We used data from the China Patient-centered Evaluative Assessment of Cardiac Events-Prospective Heart Failure Study,we selected HFpEF patients for this analysis.Patients were classified as non-obesity(BMI<30 kg/m2)and obesity(BMI≥30 kg/m2).And the abdominal obesity was classified as waist circumference ≥102 cm in men and≥88 cm in women.All enrolled patients were followed up for lyear,and the clinical outcomes in this study were all-cause death,HF readmission,cardiovascular death or HF readmission.(1)We evaluated the effect of spironolactone on clinical outcomes across BMI categories,using Cox proportional hazards models or competing risk models.(2)We also evaluated the effect of spironolactone on clinical outcomes across WC categories.Results:(1)Among 1446 HFpEF patients,median(IQR)age was 71(63-79)years,50.2%were women.During 1-year follow up,189 patients died,408 patients had HF readmission,458 patients had composite end-point events.(2)Obesity modify the association between the use of spironolactone and mortality(P for interaction=0.02).Among obese patients,those with the use of spironolactone tended to have reduced risk of death,but did not achieve statistical significance(HR 0.15,95%CI 0.02-1.22,P=0.08).While in non-obese patients,the use of spironolactone was not associated with mortality.There was no interaction between obesity and the use of spironolactone on HF readmission and composite end-point event risk.(3)Abdominal obesity modify the association between the use of spironolactone and mortality(P for interaction=0.03).In the multivariable Cox models,a significant benefit of spironolactone for mortality was noted in obese patients(HR 0.43,95%CI 0.19-0.95),while in non-obese patients,the use of spironolactone was not associated with mortality.In addition,there was no interaction between abdominal obesity and the use of spironolactone on HF readmission and composite end-point event risk.Conclusion:Obesity modify the association between the use of spironolactone and mortality.Obese patients with HFpEF might benefit from the use of spironolactone.This result requires further study and verification in large-scale studies. |
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