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Falls Can be a Serious, Poorly Understood Threat to People with Heart Disease

Michael Merschel wrote . . . . . . . . .

Falls pose a major risk to people with heart problems, and health experts need to do more to understand and prevent the danger, a new report says.

“Falls are very common,” said Dr. Sarah Goodlin, senior author of the scientific statement from the American Heart Association. They are associated with serious injuries, and just the fear of falling can limit a person’s quality of life.

“And falls are particularly common in adults with cardiovascular disease,” said Goodlin, medical director of geriatrics and palliative medicine at the VA Portland Health Care System in Oregon. “Yet they’re very underrecognized.”

The report, published Thursday in the AHA journal Circulation: Cardiovascular Quality and Outcomes, said basic information is lacking on how often and why people with heart disease fall, as well as on how severely they are injured.

One 2018 study published in that same Circulation journal estimated that 60% faced a moderate to high risk of falling. That’s based on records from 2,456 people hospitalized with heart disease in one Minnesota county.

Overall, the potential harm from falls is clear, said report co-author Stephanie Turrise, a nurse-scientist at the University of North Carolina Wilmington. The Centers for Disease Control and Prevention says about 36 million falls are reported among older adults each year. About 3 million of those who fall will end up in an emergency room for treatment, and more than 32,000 will die.

“Falls, especially in older adults, can be absolutely devastating,” Turrise said.

Problems can persist even after someone has recovered and becomes afraid of falling again, Goodlin said. That can start a vicious cycle where older adults with cardiovascular problems become less active and more prone to problems, Turrise said. “To keep them healthy, they’ve got to be active.”

Heart problems can lead to falls both directly and indirectly.

A heart rhythm problem, for example, might cause blood pressure to dip, which could cause someone to lose consciousness. Fall risks also could be higher in someone with diabetes, who might have foot numbness from neuropathy, or in someone recovering from a stroke, who might have weakness on one side, Turrise said.

The report says people with heart failure, a condition in which the heart and circulation do not circulate blood adequately, and irregular heartbeats called arrhythmias might be at higher risk of falling than those without these conditions.

Medications to treat cardiovascular conditions can cause side effects such as dizziness, blurred vision, confusion or other problems, Turrise said.

“I can’t tell you how many older adults are on diuretics for heart failure or for blood pressure management,” she said, “and it increases their urinary frequency, and they get in such a hurry to make it to the bathroom that they fall.” Diuretics also can cause the person’s blood pressure to drop when they stand, making them lightheaded, Goodlin said.

Medical teams need to take note, Turrise said. “We need to be aware, and we need to act.”

People can be embarrassed to admit they fell, Goodlin said. So, a “really simple” first step for a health care team would be simply asking patients about falls. Health care professionals should also watch patients walk, and if they seem off balance, consider sending them to a physical therapist for a more in-depth evaluation.

“One of the fundamental things that we advocate is checking blood pressure when the person has been standing for three minutes,” Goodlin said. That can alert a care team to health problems or medications that might be causing worrisome dips.

Teams also need to think holistically, she said. A cardiologist who rules out a heart-related cause for a fall shouldn’t dismiss the problem, because “it’s still important to sort out why the person fell and to intervene to try to prevent the next fall.”

For patients, Goodlin said, the most important thing is to be honest with their doctors and nurses, even if they are embarrassed to bring it up, and to say they have fallen or that they’re afraid of falling when they walk.

“There are things that can be done to improve their situation,” she said. “Certain exercises can improve balance and safety, so working with a physical therapist can help.”

It’s essential for people who are given assistive devices to use them, Goodlin said. Some people don’t want to use a cane or a walker because they think it makes them look old. “You look a whole lot older in a hospital bed with a hip fracture than you look being safe,” she reminds her patients.

Turrise said people also can ask an expert, such as their doctor or pharmacist, to review their medications to see what might be contributing to falls.

More research could lead to better ways to protect and treat people, the report says. Meanwhile, “there’s really a partnership between adults who have cardiovascular disease and their doctors and nurses,” Goodlin said. “Adults need to feel comfortable talking to doctors and nurses about falls and safety.”

Source: American Heart Association

Despite Hopes, Vitamin K2 Supplements Fail to Slow Calcium Buildup in Heart Valve

Laura Williamson wrote . . . . . . . . .

The progressive narrowing of the aortic heart valve in a group of older men could not be slowed during a recent clinical trial using vitamin K2 supplements, dampening hopes of finding a medical treatment for this common but serious condition.

The research, published in the American Heart Association journal Circulation, built upon earlier studies suggesting vitamin K2 supplements could slow the progression of aortic stenosis, a narrowing of the valve that controls blood flow from the heart to the rest of the body. But this randomized, double-blind, placebo-controlled trial – considered the gold standard of epidemiological studies – found vitamin K2 and vitamin D supplements did not slow the progression of calcium deposits on the aortic valves of older men once the process had begun.

“As previous animal studies, epidemiological studies and an open-label study did suggest a beneficial effect, we hoped for a positive trial,” said lead study author Dr. Axel Diederichsen, a professor in the department of cardiology at Odense University Hospital in Denmark. “Thus, we were surely disappointed.”

Aortic stenosis is the most common heart valve disease in high-income countries, according to the study, which estimates it affects about 2% to 5% of people older than 65. The number of people in the United States and Europe with aortic stenosis is expected to more than double by the year 2050, according to American Heart Association statistics that estimate 12.4% of people over 75 have the condition.

Symptoms may include chest pain, a fluttering heartbeat, trouble breathing, lightheadedness, fatigue, swollen ankles or feet and difficulty sleeping. There are no treatments when detected early, other than trying to control risk factors such as high blood pressure, high cholesterol, obesity, diabetes and gum disease. In the later stages, it is treated by replacing the heart valve. If not treated, aortic stenosis can progress and lead to heart failure and death.

“We haven’t had any medical therapies that slow the progression of stenosis,” said Dr. Brian Lindman, medical director of the Structural Heart and Valve Center and an associate professor of medicine at Vanderbilt University Medical Center in Nashville, Tennessee. “We anticipate when we see it in the earlier stages that it will eventually become severe, and you’ll have to have your valve replaced.”

Lindman, who was not involved in the research, said he was disappointed by the results because prior research suggested “this might be an effective intervention. I very much want to identify an effective medical therapy for these patients, so there’s an emotional component to it.”

In the study, 365 men with aortic stenosis from four Danish hospitals were randomly assigned to receive placebo or 720 micrograms of vitamin K2 and 25 micrograms of vitamin D for two years. All were 65 to 74 years old with aortic valve calcification scores of 300 AU or higher, a measure obtained with CT scans showing calcification had begun. The scores were measured again at the end of one year and at the end of the study. They also measured calcification levels in participants’ coronary arteries, which supply blood to the heart.

Researchers found no significant differences in valve calcification progression between the two groups, leading them to conclude the supplements were ineffective in slowing disease progression. However, there was some suggestion the group taking them experienced slower progression of calcification in their coronary arteries. Diederichsen said this needs to be explored in future studies. Researchers also said because the study only included men, the findings do not apply to women.

Research has suggested eating a diet high in vitamin K can benefit heart health. Vitamin K comes in two forms and is primarily found in leafy vegetables such as kale and spinach. Vitamin K2 is the less common form and is found in fermented foods, such as cheese. A study published last August in the Journal of the American Heart Association found eating a diet rich in vitamin K was associated with a lower risk for hospitalizations from cardiovascular disease related to plaque buildup in the arteries.

But Diederichsen said most foods contain insufficient levels of vitamin K2 to make an impact on heart health – with one exception. Natto, a traditional Japanese food made from fermented soybeans, is high in vitamin K2.

While vitamin K2 supplements showed no promise for treating aortic stenosis, Lindman remains hopeful researchers will find another way to slow the progression of the disease. “There are a number of potential drugs and pathways that still need to be tested.”

Source: American Heart Association

Read also at The Heart and Vascular Centre:

What is Aortic Stenosis . . . . .

About 1 in 4 Adults Has an Often-missed Liver Disorder Linked to Higher Heart Disease Risk

It is estimated that about one in four adults worldwide has a liver condition that is a risk factor for heart disease, according to a new American Heart Association scientific statement published today in the Association’s peer-reviewed journal Arteriosclerosis, Thrombosis, and Vascular Biology. The condition, called nonalcoholic fatty liver disease (NAFLD), occurs when abnormally elevated amounts of fat are deposited in the liver, sometimes resulting in inflammation and scarring. The prevalence of NAFLD is an estimate, given the challenges in diagnosing the condition, which are detailed in the statement.

An American Heart Association scientific statement is an expert analysis of current research and may inform future guidelines. Professional organizations specializing in gastroenterology have previously published statements on the condition, however, they focus on liver toxicity (including scarring, cirrhosis and liver cancer) rather than heart disease risk. This is the Association’s first statement about NAFLD.

“Nonalcoholic fatty liver disease (NAFLD) is a common condition that is often hidden or missed in routine medical care. It is important to know about the condition and treat it early because it is a risk factor for chronic liver damage and cardiovascular disease,” said P. Barton Duell, M.D., FAHA, chair of the statement writing committee and professor of medicine in the Knight Cardiovascular Institute and Division of Endocrinology, Diabetes and Clinical Nutrition at Oregon Health & Science University in Portland, Oregon.

There are two types of NAFLD: one when only fat is present in the liver (called non-alcoholic fatty liver), and the other when inflammation and scarring are also present (called non-alcoholic steatohepatitis, or NASH). Excess alcohol intake can cause similar fat deposits and liver dysfunction, so the term NAFLD is used to differentiate between disease caused by excess alcohol intake vs. disease without alcohol as the underlying cause.

NAFLD may go undiagnosed for years, thus, the statement emphasizes the need for awareness and monitoring for NAFLD, access to improved screening tools and treatment and highlights the lifestyle changes to help prevent and treat the disorder.

NAFLD raises heart disease risk

Heart disease is the leading cause of death in people with NAFLD. The diseases share many of the same risk factors, including metabolic syndrome (elevated blood sugar and blood triglycerides, increased abdominal fat and high blood pressure); Type 2 diabetes; impaired glucose tolerance (prediabetes); and obesity. However, people with NAFLD are at higher risk of heart disease than people who have the same heart disease risk factors without the liver condition.

NAFLD may sometimes be prevented

NAFLD is often preventable by maintaining a healthy body weight, exercising regularly, eating a heart-healthy foods diet and managing conditions such as Type 2 diabetes and elevated triglycerides (a type of fat) in the blood. Genetic factors also play a role in whether a person develops NAFLD and whether it leads to NASH, cirrhosis or liver cancer.

“Although healthy living can help avert NAFLD in many individuals, some may develop NAFLD despite their best efforts,” Duell said. “At the other end of the spectrum, some individuals may have a genetic makeup that protects them from developing NAFLD despite having obesity, Type 2 diabetes, metabolic syndrome, unhealthy dietary habits or being sedentary.”

NAFLD can go undiagnosed for years

Most people with NAFLD are undiagnosed, creating a barrier to optimal medical management, according to the statement. The initial stages of NAFLD generally have no symptoms and people feel well, and routine blood tests may not show liver abnormalities. Often, elevated liver enzymes in blood, a possible sign of NAFLD, may be misattributed to a side effect of medication or to recent alcohol consumption. In addition, the absence of elevated liver enzyme levels does not rule out NAFLD or NASH.

According to the statement, a specialized ultrasound that measures liver elasticity, fat and stiffness (a result of scarring) in the liver can detect NAFLD. This type of liver scan is a noninvasive way to help diagnose and monitor treatment in NAFLD and NASH, yet it is underused. Liver biopsy is the definitive test for the diagnosis of more advanced stages of NAFLD, however, it is invasive and expensive.

“The lack of awareness of the high prevalence of NAFLD contributes to underdiagnosis,” said Duell. “Individuals with risk factors for NAFLD warrant more careful screening.”

If diagnosed in time, liver damage may be reversible

“Part of the good news about managing NAFLD is that healthy eating, regular exercise and weight loss or avoiding weight gain are all valuable interventions to improve health in most of us, regardless of whether we have NAFLD,” said Duell.

Lifestyle changes are the cornerstone of treatment for early NAFLD. Dietary recommendations include reducing fat intake, limiting the consumption of simple sugars and choosing more fiber-rich vegetables and whole grains. A Mediterranean-style diet is the only specific dietary pattern recommended by a consortium of professional groups for the treatment of NAFLD and NASH. Avoiding alcohol is encouraged since even light alcohol intake can aggravate NAFLD and interfere with the liver’s ability to heal.

Consultation with a dietitian may help people with NAFLD plan and maintain a healthful diet and lose weight, if needed. The statement cites research showing that losing 10% of body weight dramatically reduced liver fat and improved fibrosis, with lower levels of improvement with at least a 5% loss in body weight. Research also supports 20-30 minutes of physical activity per day to decrease liver fat and improve insulin sensitivity even in the absence of weight loss.

Medications may be needed to treat Type 2 diabetes, lower cholesterol or reduce weight. Weight loss surgery may be appropriate for some people because the resulting, marked weight loss can be an effective intervention for NAFLD. Optimal care may also involve consulting with a lipid specialist, endocrinologist or gastroenterologist.

Source: American Heart Association

Heart Disease and Sleepless Nights Often Go Together

Insomnia is widespread in heart disease patients and significantly boosts the risk of heart attack, stroke or other major heart event, a new study says.

The findings show the need to check for and treat sleep problems in heart disease patients, according to researchers.

“Our study indicates that insomnia is common in heart disease patients and is linked with subsequent cardiovascular problems regardless of risk factors, coexisting health conditions and symptoms of mental health,” said lead author Lars Frojd, a medical student at the University of Oslo in Norway.

The new study included more than 1,000 heart disease patients (average age: 62). They participated for an average 16 months after a heart attack and/or a procedure to open blocked arteries — either bypass surgery or stent implantation.

At the start, 45% said they had insomnia and 24% said had used sleep medication in the previous week.

During an average 4.2-year follow-up, 225 patients had 364 major heart events. They included hospitalization for heart attack, restoring blocked blood flow, stroke, heart failure and cardiovascular death.

Insomnia accounted for 16% of repeat heart events, ranking it third in importance after smoking (27%) and inactivity (21%), according to findings presented Thursday at a virtual meeting of the European Society of Cardiology. The study was also published in the journal Sleep Advances.

“This means that 16% of recurrent major adverse cardiovascular events might have been avoided if none of the participants had insomnia,” Frojd said in a meeting news release.

He noted more research is needed to learn whether insomnia treatments such as cognitive behavioral therapy and digital applications would help heart patients.

Source: HealthDay

Undiagnosed Heart Disease May be Common in People with Heart Attacks Not Caused by Clots

Laura Williamson wrote . . . . . . . . .

More than two-thirds of people who have a type of heart attack not caused by a blood clot also may have undiagnosed heart disease, according to a small study from Scotland.

The study, published in the American Heart Association journal Circulation, focused on people who had what’s known as Type 2 heart attacks, which result from strain caused by an illness such as infections or fast heart rates that can lower blood pressure or oxygen in the blood. But when researchers conducted advanced heart imaging, they discovered study participants also had conditions such as narrowed arteries or weakened heart muscles that were frequently undiagnosed. Fewer than a third of those patients were being treated for heart disease.

“This is the first evidence from a study to demonstrate underlying heart artery disease and heart weakness is common in this condition,” said the study’s senior author Dr. Andrew Chapman of the BHF Centre for Cardiovascular Science at the University of Edinburgh in Scotland.

In the more commonly recognized type of heart attack, called Type 1 myocardial infarction, blood supply to the heart is disrupted, usually by a blood clot, causing heart muscle in that area to die. A Type 2 myocardial infarction occurs when heart muscle is damaged from the strain of not getting enough oxygen through impaired blood supply.

In recent years, highly sensitive blood tests that detect levels of troponin, a protein released into the blood when heart muscle is damaged, have made it easier to quickly diagnose heart attacks. Up to half of all people with elevated troponin levels are believed to have experienced Type 2 heart attacks. Yet less than one-third of these patients are managed by cardiologists and fewer than 20% are examined for underlying cardiovascular disease, according to a 2020 study published in Circulation: Cardiovascular Quality and Outcomes.

The new study included 93 people, averaging 66 years old, who had been diagnosed with a Type 2 heart attack. Advanced heart imaging tests showed 68% had signs of coronary artery disease – a buildup of plaque in the arteries. Among them, 3 in 5 had been undiagnosed. And 34% of the full group had left ventricular systolic dysfunction, a weakening of the heart muscle that can lead to heart failure or sudden death. This condition had been undiagnosed in 84% of the patients who had it. Only 10 patients had normal heart images.

Failing to diagnose these conditions are likely contributing to the high death rates experienced by people with Type 2 heart attacks, Chapman said.

Studies show these people “have very poor long-term outcomes,” he said. “We know 1 in 6 patients have a (subsequent) typical heart attack that results from a blockage in the artery or death from a cardiovascular cause within a year, and only a third of patients are alive five years later.”

One reason Type 2 heart attacks are so difficult to diagnose – or treat – is because they can be caused by so many different illnesses and conditions, including arrhythmias, hemorrhage or sepsis, said Dr. Jason Wasfy, a cardiologist at Massachusetts General Hospital and an associate professor of medicine at Harvard Medical School in Boston.

And because these conditions are so different, it’s difficult to set up or conduct trials that explore treatment options, he said.

“Traditional treatments may be effective in this population, but that has not been validated,” said Wasfy, who was not involved in the study. “There’s not a single treatment strategy that has been validated in this population. Not one. The fact that this is so common and so deadly and there’s not a single randomized control trial showing us how to treat this is an enormous gap in the literature.”

Anti-platelet therapies or anticoagulants, typically used with stents inserted into an artery to improve blood flow after Type 1 heart attacks, could be problematic for people who had a Type 2 heart attack because they can cause hemorrhaging, Wasfy said. “This could make things worse, but even that we don’t know.”

Previously, there’s been a lack of evidence to guide decisions for investigation or treatment, Chapman said. But the new findings show underlying heart disease may be common. So, he said, it emphasizes the need to involve cardiologists in how these patients are cared for.

“Patients with this condition are managed throughout the hospital in medical wards, surgical wards and often in critical care,” Chapman said. “The primary illness is often not the heart, but the heart is damaged as a result. It is often appropriate that these patients are managed elsewhere, but cardiologists could become involved if there is a suggestion of underlying heart disease.”

Source: American Heart Association

AI Can Identify Heart Disease from an Eye Scan

Scientists have developed an artificial intelligence system that can analyse eye scans taken during a routine visit to an optician or eye clinic and identify patients at a high risk of a heart attack.

Doctors have recognised that changes to the tiny blood vessels in the retina are indicators of broader vascular disease, including problems with the heart.

In the research, led by the University of Leeds, deep learning techniques were used to train an AI system to automatically read retinal scans and identify those people who, over the following year, were likely to have a heart attack.

Deep learning is a complex series of algorithms that enable computers to identify patterns in data and to make predictions.

Writing in the journal Nature Machine Intelligence, the researchers report in their paper – Predicting Infarction through your retinal scans and minimal personal Information – that the AI system had an accuracy of between 70% and 80% and could be used as a second referral mechanism for in-depth cardiovascular examination.

The use of deep learning in the analysis of retinal scans could revolutionise the way patients are regularly screened for signs of heart disease.

Earlier identification of heart disease

Professor Alex Frangi, who holds the Diamond Jubilee Chair in Computational Medicine in the School of Computing at the University of Leeds and is a Turing Fellow at the Alan Turing Institute, supervised the research. He said: “Cardiovascular diseases, including heart attacks, are the leading cause of early death worldwide and the second-largest killer in the UK. This causes chronic ill-health and misery worldwide.

“This technique opens-up the possibility of revolutionising the screening of cardiac disease. Retinal scans are comparatively cheap and routinely used in many optician practices. As a result of automated screening, patients who are at high risk of becoming ill could be referred for specialist cardiac services.

“The system could also be used to track early signs of heart disease.”

The study involved a worldwide collaboration of scientists, engineers and clinicians from the University of Leeds; Leeds Teaching Hospitals’ NHS Trust; the University of York; the Cixi Institute of Biomedical Imaging in Ningbo, part of the Chinese Academy of Sciences; the University of Cote d’Azur, France; the National Centre for Biotechnology Information and the National Eye Institute, both part of the National Institutes for Health in the US; and KU Leuven in Belgium.

The UK Biobank provided data for the study.

Chris Gale, Professor of Cardiovascular Medicine at the University of Leeds and a Consultant Cardiologist at Leeds Teaching Hospitals NHS Trust, was one of the authors of the research paper.

He said: “The AI system has the potential to identify individuals attending routine eye screening who are at higher future risk of cardiovascular disease, whereby preventative treatments could be started earlier to prevent premature cardiovascular disease.”

Deep learning

During the deep learning process, the AI system analysed the retinal scans and cardiac scans from more than 5,000 people. The AI system identified associations between pathology in the retina and changes in the patient’s heart.

Once the image patterns were learned, the AI system could estimate the size and pumping efficiency of the left ventricle, one of the heart’s four chambers, from retinal scans alone. An enlarged ventricle is linked with an increased risk of heart disease.

With information on the estimated size of the left ventricle and its pumping efficiency combined with basic demographic data about the patient, their age and sex, the AI system could make a prediction about their risk of a heart attack over the subsequent 12 months.

Currently, details about the size and pumping efficiency of a patient’s left ventricle can only be determined if they have diagnostic tests such as echocardiography or magnetic resonance imaging of the heart. Those diagnostic tests can be expensive and often only available in a hospital setting, making them inaccessible for people in countries with less well-resourced healthcare systems – or unnecessarily increasing healthcare costs and waiting times in developed countries.

Sven Plein, British Heart Foundation Professor of Cardiovascular Imaging at the University of Leeds and one of the authors of the research paper, said: “The AI system is an excellent tool for unravelling the complex patterns that exist in nature, and that is what we have found – the intricate pattern of changes in the retina linked to changes in the heart.”

Source: University of Leeds

Cataracts Tied to Higher Odds of Death From Heart Disease

Robert Preidt and Ernie Mundell wrote . . . . . . . . .

Cataracts, a common eye disorder that often comes with age, may also be linked to a heightened risk of death from heart disease, new research shows.

Experts stressed that the finding doesn’t mean that cataracts somehow cause heart trouble, and the study wasn’t designed to prove cause and effect.

“A variety of medical conditions like [high blood pressure], diabetes or smoking have been associated with increased cataracts and these diseases are also associated with vascular mortality, which may explain the relationship,” said Dr. Matthew Gorski, an ophthalmologist at Northwell Health in Great Neck, N.Y. He believes cataracts may be an important signal of underlying health, however.

“Patients should use the results of this study as a reminder of the importance of having regular eye exams with your eye doctor, especially as you get older or if you have certain medical conditions,” said Gorski, who wasn’t involved in the new study.

The research was conducted in Australia, and was led by Dr. Mingguang He of the Centre for Eye Research Australia at the University of Melbourne. His team analyzed data obtained between 1999 and 2008 on nearly 15,000 American patients, aged 40 and older. More than 2,000 (9.6%) of them said they’d undergone a cataract surgery.

Over a median follow-up of nearly 11 years, close to 4,000 (19%) of the participants died.

After accounting for a number of health and socioeconomic factors, the researchers found that the risk of death from any cause was 13% higher and the risk of death from heart disease was 36% higher in people who’d had a cataract surgery.

Oxidative stress (an imbalance in natural oxidation processes affecting cells) and depression may be common factors that could impact the formation of cataracts and also raise a person’s risk of death from heart disease, He’s team said in their study.

The study authors pointed to prior research, which has shown that DNA damage caused by oxidative stress contributes to cataract formation while also spurring an unhealthy narrowing of the arteries.

According to the Australian team, people with cataracts are also more likely to develop depression than those without the eye condition, even after they’ve had cataract surgery, and people with depression have an increased risk of heart disease.

Overall, the study “found significant associations of self-reported cataract surgery” with a raised risk of death from any cause, and from heart-related causes in particular, the authors said.

Dr. Mark Fromer is an ophthalmologist at Lenox Hill Hospital in New York City. Reading over the findings, he said that “it is certainly not a surprise to expect cataract patients to have other underlying illnesses as most cataract patients are elderly.”

Fromer noted that people are typically having cataracts surgically removed at an earlier age than they might have a few decades ago. “This has led to patients living for a longer time after their surgery than was reported just decades ago,” he said. “Seeing better following surgery also leads to a better quality of life and may prevent accidents which can lead to death and injury due to poor sight.”

The study was published in the British Journal of Ophthalmology.

Source : HealthDay

More Belly Weight Increases Danger of Heart Disease Even If BMI Does Not Indicate Obesity

People with abdominal obesity and excess fat around the body’s mid-section and organs have an increased risk of heart disease even if their body mass index (BMI) measurement is within a healthy weight range, according to a new Scientific Statement from the American Heart Association published today in the Association’s flagship journal, Circulation.

“This scientific statement provides the most recent research and information on the relationship between obesity and obesity treatment in coronary heart disease, heart failure and arrhythmias,” said Tiffany M. Powell-Wiley, M.D., M.P.H., FAHA, chair of the writing committee and a Stadtman Tenure-Track Investigator and chief of the Social Determinants of Obesity and Cardiovascular Risk Laboratory in the Division of Intramural Research at the National Heart, Lung, and Blood Institute at the National Institutes of Health in Bethesda, Maryland. “The timing of this information is important because the obesity epidemic contributes significantly to the global burden of cardiovascular disease and numerous chronic health conditions that also impact heart disease.”

A greater understanding of obesity and its impact on cardiovascular health highlights abdominal obesity, sometimes referred to as visceral adipose tissue, or VAT, as a cardiovascular disease risk marker. VAT is commonly determined by waist circumference, the ratio of waist circumference to height (taking body size into account) or waist-to-hip ratio, which has been shown to predict cardiovascular death independent of BMI.

Experts recommend both abdominal measurement and BMI be assessed during regular health care visits because a high waist circumference or low waist-to-hip ratio, even in healthy weight individuals, could mean an increased risk of heart disease. Abdominal obesity is also linked to fat accumulation around the liver that often leads to non-alcoholic fatty liver disease, which adds to cardiovascular disease risk.

“Studies that have examined the relationship between abdominal fat and cardiovascular outcomes confirm that visceral fat is a clear health hazard,” said Powell-Wiley.

The risk-inducing power of abdominal obesity is so strong that in people who are overweight or have obesity based on BMI, low levels of fat tissue around their midsection and organs could still indicate lower cardiovascular disease risks. This concept, referred to as “metabolically healthy obesity,” seems to differ depending on race/ethnicity and sex.

Worldwide, around 3 billion people are overweight (BMI = 25 to 29.9 kg/m2) or have obesity obese(BMI ≥30 kg/m2). Obesity is a complex disease related to many factors, including biologic, psychological, environmental and societal aspects, all of which may contribute to a person’s risk for obesity. Obesity is associated with greater risk of coronary artery disease and death due to cardiovascular disease and contributes to many cardiovascular risk factors and other health conditions, including dyslipidemia (high cholesterol), type 2 diabetes, high blood pressure and sleep disorders.

For this statement, experts evaluated research on managing and treating obesity, particularly abdominal obesity. The writing group reports that reducing calories can reduce abdominal fat, and the most beneficial physical activity to reduce abdominal obesity is aerobic exercise. Their analysis found that meeting the current recommendations of 150 min/week of physical activity may be sufficient to reduce abdominal fat, with no additional loss from longer activity times. Exercise or a combination of dietary change and physical activity has been shown in some instances to reduce abdominal obesity even without weight loss.

Lifestyle changes and subsequent weight loss improve blood sugar, blood pressure, triglyceride and cholesterol levels – a cluster of factors referred to as metabolic syndrome – and reduce inflammation, improve blood vessel function and treat non-alcoholic fatty liver disease. However, studies of lifestyle change programs have not shown a reduction in coronary artery disease events (such as heart attack or chest pain).

In contrast, bariatric surgery for weight loss treatment is associated with a reduction in coronary artery disease risk compared to non-surgical weight loss. This difference may be attributed to the larger amount of weight loss and the resultant changes in metabolism that are typical after bariatric surgery.

“Additional work is needed to identify effective interventions for patients with obesity that improve cardiovascular disease outcomes and reduce cardiovascular disease mortality, as is seen with bariatric surgery,” said Powell-Wiley.

The statement also addresses the “obesity paradox,” which is sometimes observed in research, particularly in populations that have overweight or have Class I obesity (BMI = 30 to 34.9 kg/m2). The paradox suggests that even though overweight and obesity are strong risk factors for the development of cardiovascular disease, they are not always a risk factor for negative cardiovascular outcomes. The writing group notes that people with overweight or obesity are often screened earlier for cardiovascular disease than people with healthy weight, thus resulting in earlier diagnoses and treatment.

“The underlying mechanisms for the obesity paradox remain unclear,” said Powell-Wiley. “Despite the existence of the paradox for short-term cardiovascular disease outcomes, the data show that patients with overweight or obesity suffer from cardiovascular disease events at an earlier age, live with cardiovascular disease for more of their lives and have a shorter average lifespan than patients with normal weight.”

In reviewing the effects of obesity on a common heart rhythm disorder, the writing group reports there is now “convincing data” that obesity may cause atrial fibrillation, a quivering or irregular heartbeat. Estimates suggest obesity may account for one-fifth of all atrial fibrillation cases and 60% of recently documented increases in people with atrial fibrillation. Research has demonstrated people with atrial fibrillation who had intense weight loss experienced a significant reduction in cumulative time spent in atrial fibrillation.

“The research provides strong evidence that weight management be included as an essential aspect of managing atrial fibrillation, in addition to the standard treatments to control heart rate, rhythm and clotting risk,” said Powell-Wiley.

The statement identifies areas of future research, including a call for further study of lifestyle interventions that may be most effective in decreasing visceral adiposity and improving cardiovascular outcomes. Powell-Wiley said, “It’s important to understand how nutrition can be personalized based on genetics or other markers for cardiovascular disease risk.

She added, “as overweight and obesity prevalence increases among adolescents worldwide, it is critical to address how best to develop upstream primary prevention interventions and better treatment strategies, particularly for young patients with severe obesity.”

Source: American Heart Association