The paradox of obesity in patients with heart failure.

PURPOSE: Heart failure (HF) patients often have comorbid conditions that confound management and adversely affect prognosis. The purpose of this study was to determine whether the obesity paradox is also present in hospitalized HF patients in an integrated healthcare system. DATA SOURCES: A cohort of 2707 patients with a primary diagnosis of HF was identified within an integrated, 20-hospital healthcare system. Patients were identified by ICD-9 codes or a left ventricular ejection fraction < or =40% dating back to 1995. Body mass index (BMI) was calculated using the first measured height and weight when hospitalized with HF. Survival rates were calculated using Kaplan Meier estimation. Hazard ratios for 3-year mortality with 95% confidence intervals were assessed using Cox regression, controlling for age, gender, and severity of illness at time of diagnosis. CONCLUSIONS: Three-year survival rates paradoxically improved for patients with increasing BMI. Survival rates for the larger three BMI quartiles were significantly better than for the lowest quartile after adjusting for severity of illness, age, and gender. IMPLICATIONS FOR PRACTICE: While obesity increases the risk of developing HF approximately twofold, reports involving stable outpatients suggest that obesity is associated with improved survival after the development of HF. This finding is paradoxical because obesity increases the risk and worsens the prognosis of other cardiovascular diseases.

Cardiac resynchronization therapy and automatic implantable cardiac defibrillators in the treatment of heart failure: a review article.

PURPOSE: To review the use of cardiac resynchronization therapy (CRT) and automatic implantable cardiac defibrillators (AICDs) in heart failure (HF) patients. DATA SOURCES: Selected scientific literature. CONCLUSIONS: New developments in device therapy for HF patients are helping to decrease morbidity and mortality in this challenging patient population. CRT improves left ventricular (LV) ejection fraction, quality of life, 6-min walk distances, and New York Heart Association scores in select patients. AICDs can prevent sudden cardiac death in those who have LV dysfunction and are at risk for ventricular arrhythmias. Cardiac devices are now becoming a standard of care for those with HF who meet certain criteria. IMPLICATIONS FOR PRACTICE: Despite advances in medical therapy for treating LV dysfunction, newly diagnosed patients face a 50% mortality rate in 5 years. The natural history of HF leads to continual deterioration of function unless adverse cardiac remodeling is reversed. Until recently, the only means for improving symptoms and cardiac function has been through the optimization of standard medicines that are indicated for LV dysfunction, such as angiotensin-converting enzyme inhibitors and beta-blockers. However, not all patients benefit from medical management alone. Cardiac devices may now be considered when significant symptoms persist after standard medicines are optimized. When practitioners use a multiple-modality approach, careful patient selection based on the inclusion criteria used in the trials outlined in this article will likely lead to improved management of those with LV dysfunction.