Abdominal Obesity and Increased Mortality in HFpEF

Study Questions:

What is the association between abdominal obesity and risk of all-cause mortality in patients with heart failure with preserved ejection fraction (HFpEF)?


The study investigators used data from the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) trial. They defined abdominal obesity as a waist circumference of ≥102 cm in men and ≥88 cm in women. The primary outcome was all-cause mortality. The investigators further analyzed primary outcome according to clinically relevant subgroups: age (<70 or ≥70 years), sex (male or female), obesity (nonobesity or obesity), diabetes (nondiabetes or diabetes), ischemic heart disease (no history or history of ischemic heart disease), atrial fibrillation (no history or history of atrial fibrillation), spironolactone (not taking or taking spironolactone), and New York Heart Association (NYHA) functional class (I and/or II or III and/or IV). Secondary outcomes included cardiovascular and noncardiovascular outcomes. Cardiovascular mortality included death from myocardial infarction, stroke, sudden death, pump failure, pulmonary embolism, and cardiovascular procedure-related events. Noncardiovascular mortality included death from noncardiovascular events, such as infection and malignancy. They analyzed and compared the hazard ratios (HRs) in patients with abdominal obesity and those without abdominal obesity (in propensity score-matched patients) using multivariable Cox proportional hazard models.


The study cohort was comprised of 3,310 HFpEF patients: 897 without abdominal obesity and 2,413 patients with abdominal obesity. The mean follow-up was 3.4 ± 1.7 years. During follow-up, 500 patients died. All-cause mortality rates in patients with and without abdominal obesity were 46.1 and 40.7 events per 1,000 person-years, respectively. After multivariable adjustment, the investigators found that the risk of all-cause mortality was significantly higher in patients with abdominal obesity than in those without (adjusted HR, 1.52; 95% confidence interval [CI], 1.16-1.99; p = 0.002). The risk of cardiovascular and noncardiovascular mortality was also significantly higher in patients with abdominal obesity than in those without (adjusted HR, 1.50; 95% CI, 1.08-2.08; p = 0.01 and adjusted HR, 1.58; 95% CI, 1.00-2.51; p = 0.04, respectively). Competing risk regression analyses for cardiovascular and noncardiovascular mortality showed similar results (HR, 1.43; 95% CI, 1.04-1.96; p = 0.02 and HR, 1.51; 95% CI, 0.96-2.36; p = 0.07, respectively).


The risk of all-cause mortality was significantly higher in patients with HFpEF with abdominal obesity than in those without abdominal obesity.


This post hoc analysis suggests that therapeutic approaches in nonobese patients probably should be different from those with abdominal obesity. Prospective studies are now needed to validate the findings of this report. As the authors discuss, it would be interesting to know whether sleep apnea is a confounder in those with abdominal obesity.

Clinical Topics: Arrhythmias and Clinical EP, Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Sleep Apnea

Keywords: Atrial Fibrillation, Death, Sudden, Diabetes Mellitus, Geriatrics, Heart Failure, Myocardial Infarction, Myocardial Ischemia, Obesity, Obesity, Abdominal, Primary Prevention, Pulmonary Embolism, Risk, Sleep Apnea Syndromes, Spironolactone, Stroke, Stroke Volume, Waist Circumference

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