title: Obesity in patients with non-ST-segment elevation acute coronary syndromes: results from the SYNERGY trial.
abstract: BACKGROUND
  Obese patients are at increased risk of acute coronary syndromes (ACS). We evaluated the prevalence of obesity in a large ACS population, as well as the relationship between body mass index (BMI) and the use of cardiac medications and procedures, clinical outcomes, and treatment effects between enoxaparin and unfractionated heparin (UFH).
  
  
  METHODS
  Using the database of the SYNERGY trial, we identified 9978 patients in 12 countries who were randomly assigned to receive enoxaparin or UFH. Patient weight at baseline and 30-day follow-up was recorded. BMI information was available on 9837 patients. BMI was analyzed in clinically meaningful categories (<20, 20-25, 30-35, > or =35 kg/m(2)) and as a continuous variable.
  
  
  RESULTS
  Thirty-two percent of patients were obese (BMI> or =30), with a greater proportion of patients with obesity from North America (36%) compared with other regions. Enoxaparin was dosed as 1 mg/kg regardless of body weight without maximum. The first dose of enoxaparin was underdosed in 15% of patients assigned enoxaparin, and obese patients were more likely to be underdosed than non-obese patients. Obese patients were younger, less often white, had more diabetes, hypertension, hyperlipidemia, family history of coronary artery disease, and congestive heart failure but fewer strokes, less peripheral vascular disease, and less often smoked. After adjustment, increased BMI was not an independent predictor of bleeding outcomes or 30-day death/myocardial infarction (MI), but increased BMI was predictive of lower 1-year mortality in the subgroup of patients with BMI at baseline below approximately 30 kg/m(2). No statistical interaction term was observed between obesity and randomized therapy for the outcomes of death/MI at 30 days and 6 months; death at 30 days, 6 months, and 1 year; and GUSTO or TIMI bleeding.
  
  
  CONCLUSIONS
  Nearly one third of patients in SYNERGY were obese. Despite multiple comorbidities, obese patients had better unadjusted short- and long-term outcomes. After adjustment, higher BMI was not an independent predictor of in-hospital bleeding events or 30-day death/MI, but increased BMI was an independent predictor of 1-year mortality in patients with lower BMI but not in heavier patients. No interaction between the randomized treatment and obesity for efficacy and safety outcomes was observed across the range of BMI in this dataset. Standard dosing of enoxaparin should be used in patients without extreme obesity due to limited outcome data in these patients.
authors.affiliation: Duke Clinical Research Institute, Durham, NC 27715, USA. mahaf002@mc.duke.edu
authors.forename: Kenneth W
authors.initials: KW
authors.lastname: Mahaffey
authors.forename: Simon T
authors.initials: ST
authors.lastname: Tonev
authors.forename: Sarah A
authors.initials: SA
authors.lastname: Spinler
authors.forename: Glenn N
authors.initials: GN
authors.lastname: Levine
authors.forename: Richard
authors.initials: R
authors.lastname: Gallo
authors.forename: John
authors.initials: J
authors.lastname: Ducas
authors.forename: Shaun G
authors.initials: SG
authors.lastname: Goodman
authors.forename: Elliott M
authors.initials: EM
authors.lastname: Antman
authors.forename: Richard C
authors.initials: RC
authors.lastname: Becker
authors.forename: Anatoly
authors.initials: A
authors.lastname: Langer
authors.forename: Harvey D
authors.initials: HD
authors.lastname: White
authors.forename: Philip E
authors.initials: PE
authors.lastname: Aylward
authors.forename: Jacques J
authors.initials: JJ
authors.lastname: Col
authors.forename: James J
authors.initials: JJ
authors.lastname: Ferguson
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality*; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D015992:Body Mass Index; D015897:Comorbidity; D016208:Databases, Factual; D004562:Electrocardiography; D017984:Enoxaparin / Q000008:administration & dosage* / Q000009:adverse effects; D005260:Female; D006470:Hemorrhage / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic / Q000706:statistics & numerical data; D009204:Myocardial Revascularization / Q000706:statistics & numerical data; D009765:Obesity / Q000401:mortality*; D017063:Outcome Assessment, Health Care; D011237:Predictive Value of Tests; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data; D012307:Risk Factors
chemical_list: D000925:Anticoagulants; D017984:Enoxaparin