title: Exercise tolerance can explain the obesity paradox in patients with systolic heart failure: data from the MECKI Score Research Group.
abstract: Obesity has been found to be protective in heart failure (HF), a finding leading to the concept of an obesity paradox. We hypothesized that a preserved cardiorespiratory fitness in obese HF patients may affect the relationship between survival and body mass index (BMI) and explain the obesity paradox in HF.
  
  
  
  A total of 4623 systolic HF patients (LVEF 31.5 ± 9.5%, BMI 26.2 ± 3.6 kg/m(2) ) were recruited and prospectively followed in 24 Italian HF centres belonging to the MECKI Score Research Group. Besides full clinical examination, patients underwent maximal cardiopulmonary exercise test at study enrolment. Median follow-up was 1113 (553-1803) days. The study population was divided according to BMI (<25, 25-30, >30 to ≤35 kg/m(2) ) and predicted peak oxygen consumption (peak VO2 , <50%, 50-80%, >80%). Study endpoints were all-cause and cardiovascular deaths including urgent cardiac transplant. All-cause and cardiovascular deaths occurred in 951 (28.6%, 57.4 per person-years) and 802 cases (17.4%, 48.4 per 1000 person-years), respectively. In the high BMI groups, several prognostic parameters presented better values [LVEF, peak VO2 , ventilation/carbon dioxide slope, renal function, and haemoglobin (P < 0.01)] compared with the lower BMI groups. Both BMI and peak VO2 were significant positive predictors of longer survival: both higher BMI and peak VO2 groups showed lower mortality (P < 0.001). At multivariable analysis and using a matching procedure (age, gender, LVEF, and peak VO2 ), the protective role of BMI disappeared.
  
  
  
  Exercise tolerance affects the relationship between BMI and survival. Cardiorespiratory fitness mitigates the obesity paradox observed in HF patients.
authors.affiliation: Heart Failure Unit, Cardiology Department, G da Saliceto Hospital, Piacenza, Italy.
authors.forename: Massimo F
authors.initials: MF
authors.lastname: Piepoli
authors.affiliation: Divisione di Cardiologia Riabilitativa, Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Veruno, Italy.
authors.forename: Ugo
authors.initials: U
authors.lastname: Corrà
authors.affiliation: Centro Cardiologico Monzino, IRCCS, Milano, Italy.
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Veglia
authors.affiliation: Centro Cardiologico Monzino, IRCCS, Milano, Italy.
authors.forename: Alice
authors.initials: A
authors.lastname: Bonomi
authors.affiliation: Centro Cardiologico Monzino, IRCCS, Milano, Italy.
authors.forename: Elisabetta
authors.initials: E
authors.lastname: Salvioni
authors.affiliation: Centro Cardiologico Monzino, IRCCS, Milano, Italy.|Unità Operativa Cardiologia Riabilitativa, Ospedale S.Giuseppe, Multimedica Spa, IRCCS, Milano, Italy.
authors.forename: Gaia
authors.initials: G
authors.lastname: Cattadori
authors.affiliation: Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Metra
authors.affiliation: Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy.
authors.forename: Carlo
authors.initials: C
authors.lastname: Lombardi
authors.affiliation: Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, Italy.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Sinagra
authors.affiliation: Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Napoli, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Limongelli
authors.affiliation: Salvatore Maugeri Foundation, IRCCS, Istituto Scientifico di Tradate, Dipartimento di Medicina e Riabilitazione Cardiorespiratoria Unità Operativa di Cardiologia Riabilitativa, Tradate, Italy.
authors.forename: Rosa
authors.initials: R
authors.lastname: Raimondo
authors.affiliation: Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, St.Camillo-Forlanini Hospital, Roma, Italy.
authors.forename: Federica
authors.initials: F
authors.lastname: Re
authors.affiliation: Department of Clinical and Molecular Medicine, La Sapienza University, Roma, Italy.
authors.forename: Damiano
authors.initials: D
authors.lastname: Magrì
authors.affiliation: Cardiologia Riabilitativa, Azienda Ospedali Riuniti, Ancona, Italy.
authors.forename: Romualdo
authors.initials: R
authors.lastname: Belardinelli
authors.affiliation: Department of Health Science, University of Milano Bicocca and Department of Cardiology, S.Luca Hospital, Istituto Auxologico Italiano, Milano, Italy.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Parati
authors.affiliation: ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies), Palermo, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Minà
authors.affiliation: UOC Cardiologia Ospedale S. Spirito, Roma, Italy.
authors.forename: Angela B
authors.initials: AB
authors.lastname: Scardovi
authors.affiliation: Department of Medical Sciences, Cardiology, IRCCS San Donato Hospital, University of Milan, San Donato Milanese, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Guazzi
authors.affiliation: Section of Cardiology, Department of Medicine, University of Verona, Italy.
authors.forename: Mariantonietta
authors.initials: M
authors.lastname: Cicoira
authors.affiliation: Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Institute of Cassano Murge, Bari, Italy.
authors.forename: Domenico
authors.initials: D
authors.lastname: Scrutinio
authors.affiliation: Cardiovascular Center, Health Authority no. 1, Trieste, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Di Lenarda
authors.affiliation: Division of Cardiology, Salvatore Maugeri Foundation, IRCCS, Institute of Milan, Milan, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Bussotti
authors.affiliation: Cardiologic Department 'A. De Gasperis', Ospedale Cà Granda-A.O. Niguarda, Milano, Italy.
authors.forename: Maria
authors.initials: M
authors.lastname: Frigerio
authors.affiliation: Department of Cardiology, University of Foggia, Foggia, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Correale
authors.affiliation: Heart Failure Unit, Cardiology Department, G da Saliceto Hospital, Piacenza, Italy.
authors.forename: Giovanni Quinto
authors.initials: GQ
authors.lastname: Villani
authors.affiliation: IRCCS SDN Istituto di Ricerca, Napoli, Italy.
authors.forename: Stefania
authors.initials: S
authors.lastname: Paolillo
authors.affiliation: Centro Cardiologico Monzino, IRCCS, Milano, Italy.|Gabriele Monasterio Foundation, CNR-Regione Toscana, Pisa, Italy.|Scuola Superiore S. Anna, Pisa, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Passino
authors.affiliation: Centro Cardiologico Monzino, IRCCS, Milano, Italy.|Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milano, Italy.
authors.forename: Piergiuseppe
authors.initials: P
authors.lastname: Agostoni
mesh_terms: D000368:Aged; D000072599:Cardiorespiratory Fitness; D002423:Cause of Death; D015331:Cohort Studies; D005080:Exercise Test; D017079:Exercise Tolerance; D005260:Female; D054143:Heart Failure, Systolic / Q000453:epidemiology / Q000401:mortality / Q000503:physiopathology* / Q000601:surgery; D016027:Heart Transplantation; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009765:Obesity / Q000453:epidemiology / Q000503:physiopathology*; D010101:Oxygen Consumption; D011379:Prognosis; D065840:Protective Factors
keywords: Cardiopulmonary exercise testing; Exercise tolerance; Heart failure; MECKI score; Matching analysis; Prognosis