Original Article

Impact of Obesity in Hospitalized Patients with Heart Failure: A Nationwide Cohort Study

Authors: Rama Dilip Gajulapalli, MD, Amer Kadri, MD, Mohamed Gad, MD, Johnny Chahine, MD, Leen Nusairat, MD, Florian Rader, MD


Objectives: Obesity and cardiovascular disease remain significant burdens on the overall provision of health care in the United States. Obesity has been shown to be a direct risk factor for heart failure (HF). We conducted a nationwide cohort study to assess the short-term impact of obesity in hospitalized patients with HF.

Methods: We identified 1,520,871 encounters with a primary diagnosis of HF in the 2013–2014 Nationwide Readmission Database. We excluded patients younger than 18 years (n = 2755), hospitalized patients discharged in December (n = 126,137), patients with missing mortality information (n = 477), missing length of stay (LOS; n = 91), patients who were transferred to another hospital (n = 38,489), and patients with conflicting body weight information (n = 7757). Multivariable logistic regression was used to evaluate the association between baseline characteristics (including the presence of obesity) and in-hospital mortality, as well as 30-day readmission rates.

Results: The overall in-patient mortality rate was 2.8% (n = 37,927). Obese patients had numerically a lower mortality (1.8%) compared with the nonobese patients (3.1%); however, the difference in risk was not significant on multivariable analysis (hazard ratio 0.97, 95% confidence interval 0.94–1.01). In the overall cohort, 20.6% (n = 269,988) were readmitted within 30 days. The risk of 30-day readmission was significantly lower in obese patients (19.4%) compared with nonobese patients (20.9%) (odds ratio 0.85, 95% confidence interval 0.84–0.86). Obese patients had longer LOSs (median of 5 days [3–7] vs 4 days [2–6], P < 0.001) and higher costs of index admission (median of $27,206 [$16,027–$48,316] vs $23,339 [$13,698–$41,982], P < 0.001) compared with nonobese patients.

Conclusions: In this cross-sectional study of patients hospitalized for HF in the United States, obesity was not associated with a higher risk of inpatient mortality, but it was associated with a lower 30-day readmission rate. Obese patients with HF, however, had longer LOSs and higher costs of index admission. Our findings support the obesity paradox seen in patients with HF.
Posted in: Cardiovascular Disease15

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1. Hales CM, Carroll MD, Fryar CD, et al. Prevalence of obesity among adults and youth: United States, 2015-2016. NCHS Data Brief 2017;(288):1–8. 2. Finkelstein EA, Trogdon JG, Cohen JW, et al. Annual medical spending attributable to obesity: payer-and service-specific estimates. Health Aff (Millwood) 2009;28:w822–w831. 3. Kim DD, Basu A. Estimating the medical care costs of obesity in the United States: systematic review, meta-analysis, and empirical analysis. Value Heal J Int Soc Pharmacoecon Outcomes Res 2016;19:602–613. 4. Ritchey MD, Wall HK, Owens PL, et al. Vital signs: state-level variation in nonfatal and fatal cardiovascular events targeted for prevention by Million Hearts 2022. MMWR Morb Mortal Wkly Rep 2018;67:974–982. 5. Frieden TR, Berwick DM. The “Million Hearts” initiative–preventing heart attacks and strokes. N Engl J Med 2011;365:e27. 6. Ebong IA, Goff DCJ, Rodriguez CJ, et al. The relationship between measures of obesity and incident heart failure: the multi-ethnic study of atherosclerosis. Obesity (Silver Spring) 2013;21:1915–1922. 7. Loehr LR, Rosamond WD, Poole C, et al. Association of multiple anthropometrics of overweight and obesity with incident heart failure: the Atherosclerosis Risk in Communities study. Circ Heart Fail 2009;2:18–24. 8. Wang TJ, Parise H, Levy D, et al. Obesity and the risk of new-onset atrial fibrillation. JAMA 2004;292:2471–2477. 9. Elagizi A, Kachur S, Lavie CJ, et al. An overview and update on obesity and the obesity paradox in cardiovascular diseases. Prog Cardiovasc Dis 2018;61:142–150. 10. Healthcare Cost and Utilization Project. NRD overview. https://www.hcupus.ahrq.gov/nrdoverview.jsp. Accessed September 15, 2020. 11. Agency for Healthcare Research and Quality. Clinical Classifications Software (CCS) for ICD-9-CM. https://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp. Accessed July 7, 2010. 12. Lee DS, Donovan L, Austin PC, et al. Comparison of coding of heart failure and comorbidities in administrative and clinical data for use in outcomes research. Med Care 2005;43:182–188. 13. Blecker S, Paul M, Taksler G, et al. Heart failure-associated hospitalizations in the United States. J Am Coll Cardiol 2013;61:1259–1267. 14. Kenchaiah S, Evans JC, Levy D, et al. Obesity and the risk of heart failure. N Engl J Med 2002;347:305–313. 15. Lavie CJ, Alpert MA, Arena R, et al. Impact of obesity and the obesity paradox on prevalence and prognosis in heart failure. JACC Heart Fail 2013;1:93–102. 16. Horwich TB, Fonarow GC, Clark AL. Obesity and the obesity paradox in heart failure. Prog Cardiovasc Dis 2018;61:151–156. 17. Horwich TB, Fonarow GC, Hamilton MA, et al. The relationship between obesity and mortality in patients with heart failure. J Am Coll Cardiol 2001;38:789–795. 18. De Schutter A, Lavie CJ, Kachur S, et al. Body composition and mortality in a large cohort with preserved ejection fraction: untangling the obesity paradox. Mayo Clin Proc 2014;89:1072–1079. 19. Cicoira M, Maggioni AP, Latini R, et al. Body mass index, prognosis and mode of death in chronic heart failure: results from the Valsartan Heart Failure Trial. Eur J Heart Fail 2007;9:397–402. 20. Fonarow GC, Srikanthan P, Costanzo MR, et al. An obesity paradox in acute heart failure: analysis of body mass index and inhospital mortality for 108,927 patients in the Acute Decompensated Heart Failure National Registry. Am Heart J 2007;153:74–81. 21. Kenchaiah S, Pocock SJ, Wang D, et al. Body mass index and prognosis in patients with chronic heart failure: insights from the Candesartan in Heart Failure: assessment of Reduction in Mortality and Morbidity (CHARM) program. Circulation 2007;116:627–636. 22. Zhang J, Begley A, Jackson R, et al. Body mass index and all-cause mortality in heart failure patients with normal and reduced ventricular ejection fraction: a dose-response meta-analysis. Clin Res Cardiol 2019;108:119–132. 23. Padwal R, McAlister FA, McMurray JJ, et al. The obesity paradox in heart failure patients with preserved versus reduced ejection fraction: a meta-analysis of individual patient data. Int J Obes (Lond) 2014;38: 1110–1114. 24. Springer J, Filippatos G, Akashi YJ, et al. Prognosis and therapy approaches of cardiac cachexia. Curr Opin Cardiol 2006;21:229–233. 25. Anker SD, Negassa A, Coats AJS, et al. Prognostic importance of weight loss in chronic heart failure and the effect of treatment with angiotensinconverting-enzyme inhibitors: an observational study. Lancet 2003;361:1077–1083. 26. Pocock SJ, Wang D, Pfeffer MA, et al. Predictors of mortality and morbidity in patients with chronic heart failure. Eur Heart J 2006;27:65–75. 27. Rawshani A, Rawshani A, Franzen S, et al. Risk factors, mortality, and cardiovascular outcomes in patients with type 2 diabetes. N Engl J Med 2018;379:633–644. 28. Yu X-Y, Song P, Zou M-H. Obesity paradox and smoking gun: a mystery of statistical confounding? Circ Res 2018;122:1642–1644. 29. Stokes A, Preston SH. Smoking and reverse causation create an obesity paradox in cardiovascular disease. Obesity (Silver Spring) 2015;23: 2485–2490. 30. Dupre ME, Gu D, Xu H, et al. Racial and ethnic differences in trajectories of hospitalization in US men and women with heart failure. J Am Heart Assoc 2017;6:e006290. 31. Durstenfeld MS, Ogedegbe O, Katz SD, et al. Racial and ethnic differences in heart failure readmissions and mortality in a large municipal healthcare system. JACC Heart Fail 2016;4:885–893. 32. American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Obesity Expert Panel, 2013. Executive summary: guidelines (2013) for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society published by the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Based on a systematic review from the Obesity Society Expert Panel, 2013. Obesity (Silver Spring) 2014;22(suppl 2):S5–S39. 33. Biener AI, Decker SL. Medical care use and expenditures associated with adult obesity in the United States. JAMA 2018;319:218. 34. Adabag S, Huxley RR, Lopez FL, et al. Obesity related risk of sudden cardiac death in the Atherosclerosis Risk in Communities study. Heart 2015;101:215–221. 35. Aune D, Schlesinger S, Norat T, et al. Body mass index, abdominal fatness, and the risk of sudden cardiac death: a systematic review and dose-response meta-analysis of prospective studies. Eur J Epidemiol 2018;33:711–722. 36. Flegal KM, Kit BK, Orpana H, et al. Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis. JAMA 2013;309:71–82. 37. Mongraw-Chaffin M, Foster MC, Anderson CAM, et al. Metabolically healthy obesity, transition to metabolic syndrome, and cardiovascular risk. J Am Coll Cardiol 2018;71:1857–1865.