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. 2022 Dec 19;28(2):e13022. doi: 10.1111/anec.13022

The obesity paradox in ST‐segment elevation myocardial infarction patients: A meta‐analysis

Si‐Han Liu 1, Ying‐Zi Lin 1, Shuo Han 1, Yuan‐Zhe Jin 1,✉
PMCID: PMC10023892  PMID: 36537052

Abstract

Objective

The aim of this study was to investigate whether there was a difference in survival after initial percutaneous coronary intervention (PCI) among ST‐segment elevation myocardial infarction (STEMI) patients with different body mass index (BMI).

Methods

Literature retrieval was conducted on PubMed, Web of Science, Embase, CNKI, and Wanfang databases to obtain the published studies on the survival of STEMI patients with different BMI after initial PCI from the establishment of the database to 2022. All statistical analyses were performed using STATA16.0.

Results

Two hundred thirty‐nine studies were retrieved, and 12 studies were eventually included. Meta‐analysis showed that overweight patients [OR = 0.66, 95% CI (0.58, 0.76), p < .001] and obese patients [OR = 0.60, 95% CI (0.51, 0.72), p < .001] had lower in‐hospital mortality than healthy‐weight patients. Overweight patients [OR = 0.66, 95% CI (0.58, 0.74), p < .001] and obese patients [OR = 0.62, 95% CI (0.53, 0.72), p < .001] had lower short‐term mortality than healthy‐weight patients. In addition, overweight patients [OR = 0.63, 95% CI (0.58, 0.69), p < .001] and obese patients [OR = 0.59, 95% CI (0.52, 0.66), p < .001] also had lower long‐term mortality than healthy‐weight patients. There was no significant difference in in‐hospital mortality [OR = 1.06, 95% CI (0.89, 1.27), p > .05], short‐term mortality [OR = 1.04, 95% CI (0.89, 1.22), p > .05], and long‐term mortality [OR = 1.07, 95% CI (0.95, 1.20), p > .05] between overweight and obese patients.

Conclusion

This meta‐analysis confirmed an obesity paradox in STEMI patients following PCI. The obesity paradox exists in in‐hospital, short‐term, and long‐term conditions.

Keywords: body mass index, meta‐analysis, obesity, percutaneous coronary intervention, ST‐segment elevation myocardial infarction

In this study, we systematically analyzed whether there were differences in survival after initial percutaneous coronary intervention (PCI) among ST‐segment elevation myocardial infarction (STEMI) patients with different body mass index by meta‐analysis. The database was first searched for studies published from the establishment of the database to 2022. A total of 243 articles were retrieved, and 12 articles were finally included. Meta‐analysis showed that there was an obesity paradox after PCI in STEMI patients. The obesity paradox exists in both in‐hospital, short‐term, and long‐term conditions.

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1. INTRODUCTION

Over the last few decades, the number of obese people has risen dramatically and has developed into a global threat. Obesity is detrimental to human health and is now the second leading cause of preventable death after tobacco (Lavie et al., 2018). Obesity is an independent risk factor for all types of heart disease, including heart failure, hypertension, coronary heart disease (CHD), and atrial fibrillation (Lavie et al., 2016, 2017; Sandhu et al., 2018). According to studies, every 1 kg/m2 increase in body mass index (BMI) results in a 5%–7% increase in heart failure (Carbone et al., 2018). Excess adipose tissue activates renin–angiotensin–aldosterone system activity and affects sodium and water retention, resulting in blood pressure increase (Parto & Lavie, 2017). Additionally, obesity increases plasma low‐density lipoprotein levels, which is a major risk factor among all leading causes of acute myocardial infarction (Wang et al., 2015). Moreover, Ellis et al. first found in 1996 that obese and overweight patients undergoing percutaneous coronary intervention (PCI) for CHD exhibit better clinical outcomes than those of normal weight. Since then, numerous studies have revealed that patients with high BMI in CHD treated with PCI achieved a better prognosis. They called this phenomenon the “obesity paradox” (Ellis et al., 1996). However, some studies refute this paradox (Akin et al., 2012; Iliodromiti et al., 2018). Therefore, we are interested in determining the “obesity paradox” that exists in the population of ST‐segment elevation myocardial infarction (STEMI) patients treated with PCI. Also, whether the outcome is time‐dependent requires further validation with additional research. This study analyzed the correlation between BMI and mortality in STEMI patients treated with PCI and explored whether a difference between long‐term and short‐term outcomes is observed.

2. MATERIALS AND METHOD

2.1. Literature search and study selection

PubMed, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), and Wanfang database were retrieved by computer to collect data from the data of database construction to 2022. All randomized controlled trials (RCTs) and observational studies of survival after PCI in STEMI patients with different BMI were included. The literature search was conducted taking “BMI or body mass index,” “ST‐segment elevation myocardial infarction or STEMI,” and “percutaneous coronary intervention or PCI” as search terms.

2.2. Inclusion and exclusion criteria

Inclusion criteria: (1) Population: STEMI patients undergoing PCI; (2) Intervention measures: The patients were divided into the overweight group, obesity group, and the healthy‐weight group. Not all studies utilized the traditional BMI classification system, which considers BMI at 18.5–24.9, 25.0–29.9, and >30 kg/m2 as normal, overweight, and obese, respectively. The BMI difference of 2 kg/m2 was considered acceptable. If obesity was described as “mild,” “moderate,” or “severe,” the results were only used “obesity” for analysis. (3) Outcome measures: in‐hospital mortality, short‐term mortality (30 days), long‐term mortality (≥1 year), one of the above indicators should be included. (4) Study design: RCTs and observational studies published in relevant medical journals at home and abroad were selected.

Exclusion criteria: (1) The study design or intervention measures are inconsistent; (2) The original study fails to provide the relevant data required for this meta‐analysis; (3) The studies are repeatedly published; (4) The diagnostic criteria or outcome measures are not clear.

2.3. Literature screening and data extraction

The obtained studies were imported into Endnote7.0 software, and the included studies were evaluated by the Newcastle–Ottawa Scale (NOS; Stang, 2010) and Cochrane systematic evaluator's manual 5.0.1 (Deeks et al., 2011). Two researchers (Sihan Liu and ShuoHan) independently screened studies and extracted relevant data. Any dispute shall be settled by a third party (Yingzi Lin) through consultation. We evaluated all the results according to systematic reviews and meta‐analyses (PRISMA; Moher et al., 2009). Relevant data include literature title, first author, study design, intervention, patient baseline information, BMI, etc.

2.4. Statistical analysis

All statistical analyses were performed using STATA (version 16.0, STATA Corporation). Odds ratio (OR) and 95% confidence intervals (CI) were used to represent counting data. The heterogeneities between studies were tested using the chi‐squared test and I 2 test (among which I 2 > 50% had apparent heterogeneity). When I 2 > 50% and p < .05, the random effect model was selected for results pooling, and when I 2 < 50% and p > .05, the fixed‐effect model was adopted. Also, Harbord and Peters' tests were involved in detecting publication bias. p < .05 was considered statistically significant.

3. RESULTS

3.1. Basic information of the included studies

We initially retrieved 243 references, and 57 duplicated articles were excluded. We excluded 148 articles after reviewing their titles and abstracts and 26 articles after reading the full text, including 18 articles irrelevant to our topic, three articles not found, and five articles of the conference. Finally, 12 (Baumann et al., 2016; Champagne‐Langabeer et al., 2017; Iakobishvili et al., 2006; Joyce et al., 2017; Kang et al., 2010; Kosuge et al., 2008; Lazzeri et al., 2013; Moscarella et al., 2017; Shabbar et al., 2021; Timoteo et al., 2011; Witassek et al., 2014; Wu et al., 2017) articles met the standards and were included in this meta‐analysis (Figure 1).

FIGURE 1.

FIGURE 1

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Flow chart of literature screening

A total of 54,397 patients were included in this meta‐analysis. The characteristics, quality valuation, BMI group, and demographics of the included studies are listed in Table 1.

TABLE 1.

Basic characteristics of included literature

Author Year Country Study period Number of people Study type Quality score
Zaza Iakobishvili et al. 2006 Isral 2002.1–2003.1 164 Non‐RCT 7
Won Yu Kang et al. 2009 Korea 2005.11–2007.11 3824 Non‐RCT 8
Ana Teresa et al. 2011 Portugal 2005.11–2008.12 539 Non‐RCT 8
Tiffanychampagne ‐Langabeer et al. 2017 America 2010.1–2015.12.31 8725 Non‐RCT 7
Emer Joyce et al. 2017 Netherlands 2004.2–2010.12 1604 Non‐RCT 6
Elisabetta Moscarella et al. 2017 Spain NA 1421 Non‐RCT 8
FabenneWitassek et al. 2017 Swiss 2005.1–2012.7 6938 Non‐RCT 8
Po‐Juiwu et al. 2017 China (Taiwan) 2009.10–2014.12 925 Non‐RCT 7
C.Lazzeri et al. 2012 Italy 2004.1.1–2010.12.31 1268 Non‐RCT 7
Stefan Baumann et al. 2015 German 2002.1–2013.12 529 Non‐RCT 7
Masami Kosuge et al. 2008 Japan 2001.1–2003.12 3076 Non‐RCT 8
Shabbar Jamaly et al. 2021 Switzerland 2011.1–2018.5.31 25,384 Non‐RCT 8
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3.2. Comparison of in‐hospital mortality after PCI

Among the studies included in this meta‐analysis, a total of seven studies compared in‐hospital mortality after PCI in overweight and healthy‐weight STEMI patients, seven studies compared in‐hospital mortality after PCI in obese and healthy‐weight STEMI patients, and seven studies compared in‐hospital mortality after PCI in overweight and obese STEMI patients. There was no significant heterogeneity among studies (overweight vs. healthy‐weight: I 2 = 40.9%, p = .118; obesity vs. healthy‐weight: I 2 = 0.0%, p = .718; overweight vs. obesity: I 2 = 0.7%, p = .419) and was analyzed using a fixed‐effect model. The results showed that the in‐hospital mortality of overweight patients was lower than that of healthy‐weight patients [OR = 0.66, 95% CI (0.58, 0.76), p < .001; Figure 2a], and the in‐hospital mortality of obese patients was lower than that of healthy‐weight patients [OR = 0.60, 95% CI (0.51, 0.72), p < .001; Figure 2b], but there was no significant difference in in‐hospital mortality between overweight and obese patients [OR = 1.06, 95% CI (0.89, 1.27), p > .05; Figure 2c].

FIGURE 2.

FIGURE 2

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Forest map to compare the in‐hospital mortality of patients with STEMI after PCI. (a) Forest map of in‐hospital mortality in overweight and healthy‐weight patients. (b) Forest map of in‐hospital mortality in obese and healthy‐weight patients. (c) Forest map of in‐hospital mortality in overweight and obese patients.

Further sensitivity analysis was conducted on the study results, and there was no significant difference between the results and the original results after each study was removed, indicating that the results of this study were relatively robust and reliable (Figure 3a–c). Then, bias analysis was conducted on the results of the study by funnel plot, and the scattered points were scattered on both sides of the funnel plot, suggesting that the possibility of publication bias in this study was low (Figure 4a–c).

FIGURE 3.

FIGURE 3

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Sensitivity analysis of in‐hospital mortality after PCI in STEMI patients. Sensitivity analysis of in‐hospital mortality in overweight and healthy‐weight patients (a); obese and healthy‐weight patients (b); and overweight and obese patients (c).

FIGURE 4.

FIGURE 4

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Funnel plot of in‐hospital mortality after PCI in STEMI patients. (a) Overweight and healthy‐weight patients; (b) obese and healthy‐weight patients; (c) overweight and obese patients

3.3. Comparison of short‐term mortality (30 days) and complication rate after PCI

Among the studies included in this meta‐analysis, a total of five studies compared short‐term mortality (30 days) after PCI in overweight and healthy‐weight STEMI patients, five studies compared in obese and healthy‐weight STEMI patients, and five studies in overweight and obese STEMI patients. There was no significant heterogeneity among studies (overweight vs. healthy‐weight: I 2 = 42.1%, p = .141; obesity vs. healthy‐weight: I 2 = 0.0%, p = .636; overweight vs. obesity: I 2 = 0.0%, p = .605) and was analyzed using a fixed‐effect model. The results showed that short‐term mortality of overweight patients was lower than that of healthy‐weight patients [OR = 0.66, 95% CI (0.58, 0.74), p < .001; Figure 5a], and the short‐term mortality of obese patients was lower than that of healthy‐weight patients [OR = 0.62, 95% CI (0.53, 0.72), p < .001; Figure 5b]; there was no significant difference in short‐term mortality between overweight and obese patients [OR = 1.04, 95% CI (0. 89, 1.22), p > .05; Figure 5c].

FIGURE 5.

FIGURE 5

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Forest map to compare the short‐term mortality of patients with STEMI after PCI. (a) Forest map of short‐term mortality in overweight and healthy‐weight patients; (b) forest map of short‐term mortality in obese and healthy‐weight patients; (c) forest map of short‐term mortality in overweight and obese patients.

Further sensitivity analysis was conducted on the study results, and there was no significant difference between the results and the original results after each study was removed, indicating that the results of this study were relatively robust and reliable (Figure 6a–c). Then, bias analysis was conducted on the results of the study by funnel plot, and the scattered points were scattered on both sides of the funnel plot, suggesting that the possibility of publication bias in this study was low (Figure 7a–c).

FIGURE 6.

FIGURE 6

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Sensitivity analysis of short‐term mortality after PCI in STEMI patients. (a) Overweight and healthy‐weight patients; (b) obese and healthy‐weight patients; (c) overweight and obese patients.

FIGURE 7.

FIGURE 7

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Funnel plot of short‐term mortality after PCI in STEMI patients. (a) Overweight and healthy‐weight patients; (b) obese and healthy‐weight patients; (c) overweight and obese patients.

3.4. Comparison of long‐term mortality (≥1 year) after PCI

Among the studies included in this meta‐analysis, a total of six studies compared long‐term mortality (≥1 year) after PCI in overweight and healthy‐weight STEMI patients, six studies compared long‐term mortality after PCI in obese and healthy‐weight STEMI patients, and six studies compared long‐term mortality after PCI in overweight and obese STEMI patients. There was no significant heterogeneity among studies (overweight vs. healthy‐weight: I 2 = 6.3%, p = .377; obesity vs. healthy‐weight: I 2 = 0.0%, p = .955; overweight vs. obesity: I 2 = 0.0%, p = .762) and was analyzed using a fixed‐effect model. The results showed that the long‐term mortality of overweight patients was lower than that of healthy‐weight patients [OR = 0.63, 95% CI (0.58, 0.69), p < .001; Figure 8a], and the long‐term mortality of obese patients was lower than that of healthy‐weight patients [OR = 0.59, 95% CI (0.52, 0.66), p < .001; Figure 8b]; there was no significant difference in long‐term mortality between overweight and obese patients [OR = 1.07, 95% CI (0.95, 1.20), p > .05; Figure 8c].

FIGURE 8.

FIGURE 8

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Results of a meta‐analysis of long‐term mortality after PCI in two groups of STEMI patients. (a–c) Forest map of long‐term mortality in (a) overweight and healthy‐weight patients, (b) obese and healthy‐weight patients, and (c) overweight and obese patients. (d–f) Sensitivity analysis of long‐term mortality in (d) overweight and healthy‐weight patients, (e) obese and healthy‐weight patients, and (f) overweight and obese patients. (g–i) Funnel plot of long‐term mortality in (g) overweight and healthy‐weight patients, (h) obese and healthy‐weight patients, and (i) overweight and obese patients.

Further sensitivity analysis was conducted on the study results, and there was no significant difference between the results and the original results after each study was removed, indicating that the results of this study were relatively robust and reliable (Figure 8d–f). Then, bias analysis was conducted on the results of the study by funnel plot, and the scattered points were scattered on both sides of the funnel plot, suggesting that the possibility of publication bias in this study was low (Figure 8g–i).

4. DISCUSSION

The prevalence and increasing death rate of obesity has become a global public health concern. In addition, obesity significantly increases the risk of type 2 diabetes and heart disease. It is debatable if there is a clinical necessity for CHD patients to lose weight in light of the “obesity paradox.” The necessity of weight loss in CHD guidelines is also controversial. In this study, a total of 12 cohort studies were included, and each study was rated at least seven points based on quality. All the 12 articles in this meta‐analysis were non‐RCT studies. There was no evidence that the RCT study is superior to the non‐RCT one (Abraham et al., 2010). The main findings of this meta‐analysis illustrate that the in‐hospital and long‐term mortality rates of overweight and obese patients were lower than those of normal‐weight patients. This finding supports the existence of the “obesity paradox.” Another important finding is that obesity compared with overweight does not predict an increased or decreased risk of death in a population of patients undergoing PCI for STEMI. This illustrates that obese and overweight patients exhibit the same possibility of death regardless of the time. Our results reveal that the “obesity paradox” exists in the population of STEMI patients treated with PCI. Also, high BMI exhibits a protective effect on in‐hospital and long‐term prognosis, consistent with the results from previous large clinical studies and their meta‐analyses (Angeras et al., 2013; Azimi et al., 2013; Das et al., 2011; Romero‐Corral et al., 2006). However, the causes and mechanisms of the obesity paradox remain unclear. Kang et al. (2010), Timóteo et al. (2011, Baumann et al. (2016), Champagne‐Langabeer et al. (2017), Witassek et al. (2014) and Shabbar et al. (2021) indicate that patients with high BMI were younger at the time of STEMI, which may have a beneficial impact on their prognosis.

In addition, our study revealed that regardless of the duration for STEMI patients, no difference in mortality was observed between the obese and overweight groups treated with PCI. This indicated that a higher BMI does not provide a lower mortality rate. Consequently, there may be a nonlinear relationship between BMI and mortality. It might have presented as a J or U curve. This is different from the meta‐analysis of Wang et al. (2016) proved that compared with overweight patients, obese patients exhibit the same all‐cause mortality, regardless of BMI. In addition, our results were corroborated in recent studies. Sinjini Biswas et al. (Braekkan et al., 2016) selected 25,413 patients undergoing PCI therapy for CHD to follow for 4.4 years. The results demonstrate that after adjusting multiple factors such as age and complication, BMI in different classifications and long‐term mortality hazard ratio (HR) correlation was observed as J type, namely overweight (BMI 25–29.9 kg/m2), (HR: 0.85) slightly obese (BMI 30–34.9 kg/m2), (HR: 0.85) moderately obese (BMI 35–39.9 kg/m2), (HR: 0.95), and severely obese (BMI ≥ 40 kg/m2) (HR: 1.33). The result achieved by Timóteo et al. (2011) indicates a bi‐model (U‐shaped) relation between BMI and mortality among STEMI patients undergoing PCI, consistent with the outcome from Sinjini. The same results also exist in our analysis. It was proved that the BMI index has a protective effect on all‐cause mortality to a certain degree. This outcome might be attributed to the adverse effects of severe obesity offsetting its protective effect on prognosis. These results may guide the clinical management of the weight of STEMI patients undergoing PCI. However, the mechanisms underlying this observation remain unclear, requiring additional epidemiological studies.

There may be some inevitable bias in this meta‐analysis. Although we assessed the quality of the NOS scale to reduce possible selection bias, some potential limitations remain. For instance, the survival bias could be eliminated, but it would be impossible to include patients who already died before admission to the hospital. Secondly, for the included articles, BMI was only measured at the time of admission without alterations over time. However, some studies indicate that little weight changes among acute myocardial infarction patients after 1‐year long‐term follow‐up (Fadl et al., 2007). Thirdly, since acute myocardial infarction is a cardiovascular disease, the cardiogenic mortality employed for meta‐analysis needs to be more representative. However, only a few of the included articles reported a relationship between BMI and cardiogenic mortality, requiring additional research.

5. CONCLUSIONS

This meta‐analysis reported the obesity paradox in STEMI patients following primary PCI. The obesity paradox exists in in‐hospital, short‐term, and long‐term outcomes. However, obesity was not a prognostic factor.

AUTHOR CONTRIBUTIONS

Si‐Han Liu and Yuan‐Zhe Jin involved in the conception and design. Ying‐Zi Lin and Shuo Han involved in the collection and assembly of data and data analysis and interpretation. All authors involved in manuscript writing and final approval of the manuscript.

CONFLICT OF INTEREST

The authors declare that they have no competing interests.

ETHICAL APPROVAL

This article does not contain any studies with human participants or animals performed by any of the authors.

ACKNOWLEDGMENT

We would like to express our gratitude to all those who helped us during the writing of this manuscript.

Liu, S.‐H. , Lin, Y.‐Z. , Han, S. , & Jin, Y.‐Z. (2023). The obesity paradox in ST‐segment elevation myocardial infarction patients: A meta‐analysis. Annals of Noninvasive Electrocardiology, 28, e13022. 10.1111/anec.13022

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Articles from Annals of Noninvasive Electrocardiology are provided here courtesy of International Society for Holter and Noninvasive Electrocardiology, Inc. and Wiley Periodicals, Inc.

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