Cardiovascular outcomes are improved and the use of medications for diabetes and cardiovascular disease are reduced, along with the weight loss achieved through metabolic surgery, in patients with diabetes and obesity. These are among the findings of a study presented Sept. 2 by Ali Aminian, MD, at ESC Congress 2019 and simultaneously published in the Journal of the American Medical Association.

The retrospective study matched 2,287 patients who had metabolic surgery in the Cleveland Clinic System in the U.S. between 1998 and 2017 at a 1:5 ratio with nonsurgical patients with diabetes and obesity (body mass index [BMI] ≥30) (nonsurgical group, n=11,435). Follow-up continued until December 2018. About two-thirds of the surgical and nonsurgical groups were women (65.5 percent and 64.2 percent) and the median age was 52.5 and 54.8 years.

In the surgery group, compared with the nonsurgery group, the patients had higher body weight (126.5 vs. 120.2 kg), higher BMI (45.1 vs. 42.6) and higher rates of dyslipidemia (74 percent vs. 65 percent). The nonsurgical group was older (54.8 vs. 52.5 years) and had more patients who were black (25 percent vs. 19 percent), current smokers (14 percent vs. 7 percent) and had a higher rate of aspirin use (40 percent vs. 32 percent).

At eight years, the mean reduction in body weight was 29.1 kg and 8.7 kg in the surgical and nonsurgical groups, and the mean difference from baseline in HbA1c was 1.1 percent (p<0.001).

The six-component primary endpoint – the first occurrence of all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy and atrial fibrillation – was 39 percent lower in the surgical group compared with the nonsurgical group. The cumulative incidence of the primary endpoint at the eight-year follow-up was 30.8 percent and 47.7 percent, respectively (p<0.001).

Patients who had metabolic surgery, vs. those who did not, also fared better when assessing the secondary endpoints of a three-component MACE (myocardial infarction, ischemic stroke and mortality), with a cumulative incidence at eight years of 17 percent vs. 27.6 percent (hazard ratio [HR], 0.62), as well as the individual components of the primary endpoint. All-cause mortality was also lower with metabolic surgery (112 patients vs. 1,111 patients in the nonsurgical group; adjusted HR, 0.59).

"We speculate that the lower rate of MACE after metabolic surgery observed in this study may be related to substantial and sustained weight loss with subsequent improvement in metabolic, structural, hemodynamic, and neurohormonal abnormalities," wrote the investigators. Their hypothesis, they state, is supported by the observed significant reductions in body weight, HbA1c levels and use of medications to treat diabetes and cardiovascular diseases.

While noting the absence of randomized controlled trials but that a few other observational studies have also reported an association between metabolic surgery and a reduction in MACE, the authors write their data are hypothesis-generating and require confirmation.

Clinical Topics: Diabetes and Cardiometabolic Disease, Prevention, Stable Ischemic Heart Disease, Chronic Angina

Keywords: ESC 19, ESC Congress, Diabetes Mellitus, Type 2, Obesity, Primary Prevention, Metabolic Syndrome, Angina, Stable

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