“Obesity and survival in patients with heart failure and preserved systolic function: A U-shaped relationship (Am Heart J 2010;159:75-80).

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Dear Editor:

We read with interest the article “Obesity and survival in patients with heart failure and preserved systolic function: A U-shaped relationship” by Kapoor and Heidenreich (Am Heart J 2010;159:75-80). The authors concluded that there is a U-shaped relationship between body mass index (BMI) and survival. This result is similar to previous studies.¹, ²

However, we found that the baseline characteristics of patients enrolled in this study were significantly different to previous studies¹, ²; for example, the level of serum creatinine was higher than 1.5 mg/dL in almost half of patients, and about 20% of patients had nonsinus rhythm. This may increase risk of death.³ The most important issue was the high proportion of malignant tumors in patients at baseline. Moreover, when the BMI index increased, the rate of death declined (41% in the group of BMI <20 kg/m²; 13% in the group of BMI >45 kg/m²). Therefore, this group of patients with heart failure had more severe illness. Furthermore, in the 1-year follow-up, the mortality was much higher compared with previous researches.¹, ² According to the “Clinical cancer advances 2007” from the American Society of Clinical Oncology, the 5-year survival rate of all kinds of malignancy was 66% from 1996 to 2002; but the rates significantly varied in different cancers (eg, 5% for pancreas cancer, 100% for prostate cancer).⁴ Thus, malignancy could seriously affect the mortality as a confounding factor. Under such condition, the relationship of BMI and mortality must be considered carefully. In addition, there is no adequate theoretical basis for this clinical phenomenon until now. We cannot get convinced of the conclusion until some well-designed studies with large sample can provide further evidences.

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References 

1. 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
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2. Davos CH, Doehner W, Rauchhaus M, et al. Body mass and survival in patients with chronic heart failure without cachexia: the importance of obesity. J Card Fail. 2003;9:29–35
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3. Kearney MT, Fox KAA, Lee AJ, et al. Predicting death due to progressive heart failure in patients with mild-to-moderate chronic heart failure. J Am Coll Cardiol. 2002;40:1801–1808
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4. Gralow J, Ozols RF, Bajorin DF, et al. Clinical cancer advances 2007: major research advances in cancer treatment, prevention, and screening—a report from the American Society of Clinical Oncology. J Clin Oncol 26:313-325.
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