Key takeaways:
- The ACC issued a scientific assertion on the administration of weight problems for sufferers with coronary heart failure.
- The doc consists of concerns for life-style, pharmacologic and invasive weight-loss interventions.
Life-style remedy might not be sufficient to enhance outcomes for sufferers with HF and weight problems, however cautious threat analysis and understanding sufferers’ private targets can information the selection of medical vs. invasive weight-loss remedy, authors wrote.
The American Faculty of Cardiology issued a scientific assertion highlighting vital concerns for the prognosis, threat evaluation and remedy of weight problems for sufferers with HF with preserved ejection fraction. The doc was printed within the Journal of the American Faculty of Cardiology.
“What’s been so thrilling over the previous few years is that this transformation of the therapeutic panorama of weight problems administration. It’s astonishing that we’ve reached the purpose now the place there are drugs, specifically semaglutide (Wegovy, Novo Nordisk) and tirzepatide (Zepbound, Eli Lilly), that aren’t solely efficient at weight reduction, but in addition secure and with proof of further advantages past weight administration,” Michelle M. Kittleson, MD, PhD, director of postgraduate medical training in coronary heart failure and transplantation and professor of medication at Smidt Coronary heart Institute at Cedars-Sinai, informed Healio. “This rising proof in addition to a number of the ongoing challenges of who can profit, who ought to have these drugs, how can we outline weight problems and the way can we handle weight problems is what motivated this assertion — to assist clinicians optimize the care of their sufferers with HFpEF and weight problems.”
Analysis of weight problems for sufferers with HF
Step one within the administration of weight problems for sufferers with HF is the prognosis of weight problems, for which BMI shouldn’t be solely relied upon, in keeping with the assertion.
Kittleson mentioned a BMI of 35 kg/m2 or extra is cheap sufficient to diagnose weight problems, however people within the “indeterminate grey zone” of 25 kg/m2 to 30 kg/m2 in an Asian inhabitants or 30 kg/m2 to 35 kg/m2 in a white inhabitants might require measurement of different anthropometric criterion. This consists of waist circumference, waist-to-hip ratio, waist-to-height ratio or physique composition evaluation by way of twin X-ray absorptiometry.
“The aim right here is for clinicians to concentrate on the restrictions of BMI. It’s a essential measure, however to not prohibit their analysis of weight problems solely to BMI,” Kittleson informed Healio. “However we additionally should do not forget that weight problems is sadly societally a stigmatized situation. We have to be delicate that some sufferers might not need to be weighed, abdominally measured or speak about their weight. Meet the affected person the place they’re and really feel out these conversations as you enter these relationships with sufferers.”
Medical and invasive weight-loss methods
If shared decision-making leads the sufferers and their care crew to a weight administration intervention, behavioral interventions are all the time all proper to strive, Kittleson informed Healio.
Behavioral interventions geared toward intentional weight reduction can enhance threat for CV occasions along with practical standing in HFpEF; nevertheless, weight problems administration this manner is usually unsustainable, in keeping with the doc.
“Telling your affected person that in the event you simply ate much less and exercised extra, all of your issues can be solved, just isn’t an efficient or sustainable observe for weight administration,” Kittleson mentioned. “That’s to not say these interventions aren’t useful, as a result of even modest modifications in physique weight related to good consuming practices and train can result in enchancment within the threat for CV occasions. Particularly, in HFpEF, these interventions can enhance practical standing and high quality of life, however it does the affected person a disservice to imagine that not working laborious sufficient at train and dietary modifications is the explanation why they’re unable to shed some pounds.”
For sufferers who’re advisable for pharmacologic or invasive weight problems interventions, the assertion supplied a number of key concerns.
Earlier research, such because the STEP-HFpEF and SUMMIT trials, evaluated the impression of semaglutide and tirzepatide, respectively, in sufferers with HFpEF.
As Healio beforehand reported, in STEP-HFpEF, semaglutide was related to vital enchancment in HF signs, practical standing and weight reduction in grownup sufferers with HFpEF and weight problems vs. placebo.
In SUMMIT, tirzepatide was related to decrease threat for CV loss of life or worsening HF vs. placebo, and enchancment in well being standing and train tolerance in sufferers with weight problems and HFpEF.
Regardless of these trials, there’s a paucity of knowledge to conclude that semaglutide and tirzepatide lowered HF occasions; nevertheless, exploratory analyses have been favorable, in keeping with the assertion.
For sufferers with HF and weight problems who need pharmacologic weight administration, the authors of the doc advisable gradual dose escalation each 4 weeks, whereas monitoring kidney perform and electrolytes with adjustment of diuretic, antihypertensive and antihyperglycemic brokers as indicated.
“There’s little doubt that semaglutide and tirzepatide are efficient. You’ll obtain weight reduction on the order of 10% to fifteen% of physique weight within the first 12 months with these drugs. That being mentioned, metabolic bariatric surgical procedure, which contains each endoscopic interventions in addition to surgical interventions, are simpler,” Kittleson informed Healio. “You’ll be able to have a weight reduction as much as 30% at 1 12 months with a Roux-en-Y gastric bypass, and nearly all of people may have sustainable weight reduction as much as even 10 years later. There’s no query these interventions are efficient. Sufferers with HF who bear a lot of these surgical procedure have a future decreased threat for CV occasions. Talking particularly of the HFpEF inhabitants, we take into account these interventions to be secure so long as sufferers are appropriately managed and risk-stratified.”
Metabolic and bariatric surgical procedure seems efficient for intentional weight reduction and will decrease threat for HF occasions on this inhabitants, however the authors famous the shortage of randomized knowledge supporting this hypotheses, solely observational research.
Furthermore, sufferers with HFpEF and weight problems who bear metabolic and bariatric surgical procedure have elevated threat for adversarial postoperative outcomes, together with elevated threat for CV morbidity and loss of life. Sufferers might have preoperative optimization and perioperative care from HF physicians to expertise optimum outcomes, in keeping with the assertion.
“There are some sufferers who might say, ‘I don’t need to be on one more remedy for the remainder of my life. Let me have a process and intervention that enables me to higher and successfully incorporate these dietary modifications into my life.’ One other affected person would possibly say, ‘Wow, I don’t ever need to be lower open if I don’t need to. If there’s a capsule or injection that … will get me on the street to weight reduction, I’m offered,’” Kittleson informed Healio. “It’s a matter of giving the affected person the info: These are the advantages, these are the dangers, and the place does your private threat profit calculus once you get these info?”
Please see the doc for full particulars on the ACC assertion on administration of weight problems in sufferers with HFpEF.
Sources/Disclosures
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Disclosures:
Kittleson experiences no related monetary disclosures. Please see the scientific assertion for all different authors’ related monetary disclosures.
