Int J Heart Fail.  2022 Apr;4(2):95-109. 10.36628/ijhf.2022.0007.

Body Mass Index, Muscle Mass, and All-Cause Mortality in Patients With Acute Heart Failure: The Obesity Paradox Revisited

  • 1Department of Cardiology, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
  • 2Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
  • 3Cardiovascular Center and Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
  • 4Department of Cardiology, Internal Medicine, Chungnam National University Hospital, Daejeon, Korea


Background and Objectives
Lower body mass index (BMI) is considered a poor prognostic factor in patients with heart failure (HF). We aimed to investigate the clinical impact of BMI on the risk of mortality in patients with acute HF (AHF) across various phenotypes.
We retrospectively identified 4,146 registry patients with AHF and BMI data. The study population was categorized according to the WHO Asia-Pacific BMI classification: BMI <18.5 kg/m2 (underweight; n=418), BMI 18.5–23 kg/m2 (ideal; n=1,620), BMI 23–25 kg/m2 (overweight; n=828), BMI 25–30 kg/m2 (obesity I; n=1,047), and BMI ≥30 kg/m2(obesity II; n=233). The risk of all-cause mortality was compared between these 5 groups.
During a median follow-up of 32 months, 1,732 patients (41.8%) died. Compared to patients with obesity II, those with overweight, ideal BMI or underweight status had a higher risk of mortality (overweight: hazard ratio [HR], 1.606; 95% confidence interval [CI], 1.016– 2.539; p=0.042) (ideal BMI: HR, 1.744; 95% CI, 1.112–2.734; p=0.015) (underweight: HR, 2.729; 95% CI, 1.686–4.417; p<0.001). Higher risk of mortality among patients with lower BMI was observed regardless of age, sex, hypertension, diabetes, ischemic heart disease, atrial fibrillation, and HF phenotype. Furthermore, low muscle index (total muscle mass/ height 2 ), calculated using serum cystatin C data in a subset of 579 patients, was associated with higher mortality risk.
A lower BMI is associated with a higher risk of mortality in patients with AHF. This obesity paradox is observed in AHF regardless of comorbidities and HF phenotype.


Body mass index; Obesity; Sarcopenia; Heart failure; Mortality
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