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Background <p>Obesity is prevalent in patients with heart failure with reduced ejection fraction (HFrEF). With the advent of glucagon-like peptide 1 analogues, understanding the relationship between body mass index (BMI) and clinical outcomes in HFrEF is crucial.</p> Objective <p>This study investigated whether a BMI &gt; 27&#xa0;kg/m<sup>2</sup> is associated with higher rates of all-cause mortality, cardiovascular mortality, and heart failure (HF) hospitalization in patients with HFrEF.</p> Methods <p>A total of 1017 clinically stable and medically optimized HFrEF patients from the NorthStar study (enrolled 2005–2009) were analyzed. Patients were followed until 2023 using Danish nationwide registries. The primary outcome was all-cause mortality, while secondary outcomes included cardiovascular mortality, HF hospitalization, and a composite of all-cause mortality or HF hospitalization. Cox proportional-hazards models adjusted for prognostic factors were used to assess associations. Interaction analyses for the primary outcome were conducted for BMI categories (&lt; 24, 24–27, &gt; 27&#xa0;kg/m<sup>2</sup>) and prognostic variables.</p> Results <p>Compared to patients with a BMI of 24–27&#xa0;kg/m<sup>2</sup>, those with a BMI &gt; 27 had a higher prevalence of diabetes (27.8% vs. 17.7%), similar HF etiology (ischemic: 57.5% vs. 58.7%), and lower NT-proBNP levels (median 776 vs. 1163&#xa0;pg/mL). Over a median follow-up of 8.8&#xa0;years, the primary outcome occurred in 235 patients (71.9%) with BMI 24–27, and 338 patients (71.8%) with BMI &gt; 27 (ref. BMI 24–27: Hazard ratios (HR) 1.11 [0.94 − 1.32]). 124 patients (37.9%) and 186 patients (39.5%) died from cardiovascular causes, respectively (HR 1.21 [0.96 − 1.53]). A first worsening HF event occurred in 214 patients (65.4%) and 317 patients (67.3%) (HR 1.12 [0.93 − 1.33]). A combined outcome of all-cause death and first worsening HF events occurred in 277 patients (84.7%) and 398 patients (84.5%) (HR 1.09 [0.93 − 1.27]). The subgroup analyses revealed a significantly higher mortality rate for BMI &gt; 27 vs 24–27 in patients with ischemic cardiomyopathy (HR 1.31 [1.05–1.64]), but not in patients with non-ischemic cardiomyopathy (HR 0.86 [0.66–1.12]).</p> Conclusion <p>In HFrEF patients, a BMI &gt; 27 was not associated with increased mortality, contradicting the “obesity-survival paradox.” In fact, patients with ischemic cardiomyopathy and a BMI &gt; 27 may be associated with a higher mortality rate.</p>

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Associations of body mass index on worsening of heart failure and mortality in patients with heart failure and reduced left ventricular ejection fraction: a 10-year follow-up study (a NorthStar substudy)

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  • 发表日期：

    2026年1月29日

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  • Morten Malmborg,
  • Mohamed El-Chouli,
  • Camilla Fuchs Andersen,
  • Mariam Elmegaard,
  • Caroline Garred,
  • Deewa Zahir,
  • Jawad H. Butt,
  • Daniel M. Christensen,
  • Nina Nouhravesh,
  • Emil Fosbøl,
  • Lars Videbæk,
  • Lars Køber,
  • Finn Gustafsson,
  • Morten Schou

摘要

Background

Obesity is prevalent in patients with heart failure with reduced ejection fraction (HFrEF). With the advent of glucagon-like peptide 1 analogues, understanding the relationship between body mass index (BMI) and clinical outcomes in HFrEF is crucial.

Objective

This study investigated whether a BMI > 27 kg/m2 is associated with higher rates of all-cause mortality, cardiovascular mortality, and heart failure (HF) hospitalization in patients with HFrEF.

Methods

A total of 1017 clinically stable and medically optimized HFrEF patients from the NorthStar study (enrolled 2005–2009) were analyzed. Patients were followed until 2023 using Danish nationwide registries. The primary outcome was all-cause mortality, while secondary outcomes included cardiovascular mortality, HF hospitalization, and a composite of all-cause mortality or HF hospitalization. Cox proportional-hazards models adjusted for prognostic factors were used to assess associations. Interaction analyses for the primary outcome were conducted for BMI categories (< 24, 24–27, > 27 kg/m2) and prognostic variables.

Results

Compared to patients with a BMI of 24–27 kg/m2, those with a BMI > 27 had a higher prevalence of diabetes (27.8% vs. 17.7%), similar HF etiology (ischemic: 57.5% vs. 58.7%), and lower NT-proBNP levels (median 776 vs. 1163 pg/mL). Over a median follow-up of 8.8 years, the primary outcome occurred in 235 patients (71.9%) with BMI 24–27, and 338 patients (71.8%) with BMI > 27 (ref. BMI 24–27: Hazard ratios (HR) 1.11 [0.94 − 1.32]). 124 patients (37.9%) and 186 patients (39.5%) died from cardiovascular causes, respectively (HR 1.21 [0.96 − 1.53]). A first worsening HF event occurred in 214 patients (65.4%) and 317 patients (67.3%) (HR 1.12 [0.93 − 1.33]). A combined outcome of all-cause death and first worsening HF events occurred in 277 patients (84.7%) and 398 patients (84.5%) (HR 1.09 [0.93 − 1.27]). The subgroup analyses revealed a significantly higher mortality rate for BMI > 27 vs 24–27 in patients with ischemic cardiomyopathy (HR 1.31 [1.05–1.64]), but not in patients with non-ischemic cardiomyopathy (HR 0.86 [0.66–1.12]).

Conclusion

In HFrEF patients, a BMI > 27 was not associated with increased mortality, contradicting the “obesity-survival paradox.” In fact, patients with ischemic cardiomyopathy and a BMI > 27 may be associated with a higher mortality rate.