The following are key points to remember from this review on challenges in cardiovascular evaluation and management of obese patients:

1. Obesity is a heterogeneous condition frequently seen in patients at risk for, or with cardiovascular disease (CVD). A multidisciplinary approach is warranted for the management of overweight and obesity.
2. Obesity is typically defined based on body mass index (BMI); however, anthropometric measures (e.g., waist-hip ratio, waist circumference), when performed accurately, may provide a better assessment of CV risk.
3. Pathologic changes observed in obesity can include increased left ventricular (LV) stroke volume, increased wall stress, LV and right ventricular (RV) hypertrophy and enlargement, sleep apnea, and pulmonary artery hypertension. These pathophysiologic changes can lead to both LV and RV failure.
4. Diagnostic testing frequently performed in CV medicine can be challenging in obese individuals. Excess weight can lead to changes in QRS voltage and axis. Poor acoustic windows in the setting of larger body habitus can limit echocardiography. Stress testing may be limited by exercise capacity, treadmill, and electrocardiography limitations. Many institutions now recommend positron emission tomography stress testing for patients with a BMI >40 kg/m² to reduce the impact of adiposity on image interpretation.
5. Obesity impacts the management of CV risk and CVD. Obesity can impact the pharmacokinetics of CV medications through the deposition of medications in adipose tissue and impact the volume of distribution, metabolism, and clearance rates. For hydrophobic drugs, most are best calculated using ideal body weight. Dosing of anticoagulants can also present a challenge, with concerns regarding the use of direct oral anticoagulants among patients with a BMI >40 kg/m².
6. For invasive management, challenges related to access and hemostasis may be present in obese patients. Studies suggest a higher risk for stent thrombosis with obesity, while for computed tomography surgical revascularization, higher rates of atrial fibrillation and long-term mortality have been observed. In addition, higher rates of wound complications are present among obese patients.
7. Elevated BMI increases the risk of rejection for patients considered for heart transplantation. The 2016 International Society of Heart Lung Transplantation recommends weight loss for patients with a BMI of ≥35 kg/m² before heart transplantation.
8. It is well known that lifestyle modifications for weight loss can be challenging. Limitations to physical activity can include osteoarthritis, lung disease, including sleep apnea, or asthma. In addition, obese patients have higher rates of depression, which can impact their ability to modify their lifestyle. Similarly, dietary changes can be difficult, particularly among patients with CVD. Beta-blockers can also affect weight loss success.
9. Weight loss interventions may be beneficial for cardiac patients. Bariatric surgery is associated with reduced CV risk factors and a lower incidence of major CVD events. Weight loss surgery for patients at higher risk for CVD is best completed at specialized centers with the co-management of multidisciplinary teams.
10. The obesity paradox has been observed in numerous studies, with an inverse association between obesity and CVD events, including heart failure, heart events, and atrial fibrillation. It is important to note that this paradox does not indicate causality but rather suggests that obese patients present with heart disease at a younger age. Furthermore, weight loss has been associated with a lower risk for CV risk factors and CVD events, including mortality. Thus, maintenance of a healthy weight is strongly recommended.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Heart Transplant, Pulmonary Hypertension, Interventions and Imaging, Interventions and Vascular Medicine, Exercise, Hypertension, Sleep Apnea

Keywords: Adiposity, Anticoagulants, Asthma, Atrial Fibrillation, Bariatric Surgery, Body Mass Index, Cardiovascular Diseases, Depression, Diagnostic Imaging, Electrocardiography, Exercise, Heart Failure, Heart Transplantation, Hypertension, Pulmonary, Hypertrophy, Life Style, Lung Diseases, Obesity, Osteoarthritis, Overweight, Patient Care Team, Primary Prevention, Risk Factors, Sleep Apnea Syndromes, Stents, Thrombosis, Waist Circumference, Weight Loss

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