title: Cardiovascular risk in relation to body mass index and use of evidence-based preventive medications in patients with or at risk of atherothrombosis.
abstract: OBJECTIVE
  Explore the relation between body mass index (BMI) and cardiovascular disease, and the influence of optimal medical therapy (OMT) on this relationship.
  
  
  RESULTS
  Patients from the REACH cohort, an international, prospective cohort of patients with or at high risk of atherosclerosis with documentation of potential confounders, including treatments and risk factors, were followed up to 4 years (n = 54 285). Patients were categorized according to baseline BMI (ranging from underweight to Grade III obesity). Optimal medical therapy was defined as the use of the four cardioprotective medication classes (statins, ACE inhibitors/angiotensin II receptor blockers, β-blockers, and antiplatelet agents). The main outcomes were all-cause mortality, cardiovascular (CV) mortality, and CV events. In primary and secondary prevention, a reverse J-shaped curve best described the relationship between BMI categories and the incidence of the various outcomes. In secondary prevention, the highest adjusted risks were observed for underweight patients (1.97, P < 0.01, and 1.29, P = 0.03, for CV mortality and CV events) and the lowest HRs were observed, respectively, in Grade II and Grade III obese patients (0.73, P < 0.01 and 0.80, P < 0.01). The proportion of patients on OMT increased with BMI from 10.1 to 36% (P < 0.001). The apparent CV protection conferred by obesity persisted in patients receiving OMT.
  
  
  CONCLUSIONS
  An obesity paradox was observed in both primary and secondary CV prevention patients. The intensity of use of evidence-based preventive medications does not account for the paradoxical CV protection associated with obesity. At extremes of BMI, further interventions beyond OMT may be needed to reduce CV risk.
authors.affiliation: Département d'Endocrinologie, Diabétologie et Nutrition, DHU-FIRE, HUPNVS, AP-HP, Paris, France Université Paris Diderot-Sorbonne Paris Cité, Paris, France Centre de Recherche des Cordeliers, INSERM, U-1138, Paris, France boris.hansel@bch.aphp.fr.
authors.forename: Boris
authors.initials: B
authors.lastname: Hansel
authors.affiliation: Département d'Endocrinologie, Diabétologie et Nutrition, DHU-FIRE, HUPNVS, AP-HP, Paris, France Université Paris Diderot-Sorbonne Paris Cité, Paris, France Centre de Recherche des Cordeliers, INSERM, U-1138, Paris, France.
authors.forename: Ronan
authors.initials: R
authors.lastname: Roussel
authors.affiliation: FACT, DHU FIRE, LVTS INSERM U-1148, Hôpital Bichat, HUPNVS, AP-HP, 46 Rue Henri Huchard, 75018 Paris, France NHLI, Imperial College, Royal Brompton Hospital, London, UK.
authors.forename: Yedid
authors.initials: Y
authors.lastname: Elbez
authors.affiliation: Département d'Endocrinologie, Diabétologie et Nutrition, DHU-FIRE, HUPNVS, AP-HP, Paris, France Université Paris Diderot-Sorbonne Paris Cité, Paris, France Centre de Recherche des Cordeliers, INSERM, U-1138, Paris, France.
authors.forename: Michel
authors.initials: M
authors.lastname: Marre
authors.affiliation: Clinique d'Endocrinologie, Maladies Métaboliques, Nutrition, Hôpital Laennec, Nantes, France.
authors.forename: Michel
authors.initials: M
authors.lastname: Krempf
authors.affiliation: Graduate School of Advanced Science and Engineering, Waseda University, Tokyo, Japan.
authors.forename: Yasuo
authors.initials: Y
authors.lastname: Ikeda
authors.affiliation: University of Michigan Health System, Ann Arbor, MI, USA.
authors.forename: Kim A
authors.initials: KA
authors.lastname: Eagle
authors.affiliation: Department of Internal Medicine, University Hospital of Ioannina, Ioannina, Greece.
authors.forename: Moses
authors.initials: M
authors.lastname: Elisaf
authors.affiliation: Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA.
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.affiliation: Université Paris Diderot-Sorbonne Paris Cité, Paris, France FACT, DHU FIRE, LVTS INSERM U-1148, Hôpital Bichat, HUPNVS, AP-HP, 46 Rue Henri Huchard, 75018 Paris, France NHLI, Imperial College, Royal Brompton Hospital, London, UK.
authors.forename: Ph Gabriel
authors.initials: PG
authors.lastname: Steg
mesh_terms: D017677:Age Distribution; D000368:Aged; D050197:Atherosclerosis / Q000517:prevention & control; D015992:Body Mass Index; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000517:prevention & control*; D019317:Evidence-Based Medicine; D005260:Female; D014943:Global Health; D006801:Humans; D008297:Male; D008875:Middle Aged; D000067329:Obesity, Metabolically Benign / Q000150:complications; D011446:Prospective Studies; D012307:Risk Factors; D013927:Thrombosis / Q000517:prevention & control; D016896:Treatment Outcome
chemical_list: D002317:Cardiovascular Agents
keywords: Cardiovascular disease; Epidemiology; Obesity; Optimal therapy; Paradox