The American College of Cardiology (ACC) recently released a new scientific statement on the Management of Obesity in Adults with Heart Failure. The new report details six recommendation categories that were generated following a confidential meeting of the ACC writing committee and additional ACC staff. The resulting recommendations are the product of internal ACC discourse and remain uninfluenced by commercial entities. ACC member involvement was all voluntary.  

The ACC volunteer committee achieved consensus recommendations, outlined below in six different sections. These recommendations focus on the epidemiology of obesity in heart failure, diagnosing obesity, and the management of obesity. 

Refer to the full-text version of the guideline update for the most thorough explanation of these and other recommendations.

Epidemiology of Obesity in Heart Failure:
  • Avoidance of excess adiposity throughout the lifespan is key to the prevention of incident HF, particularly HFpEF.
  • The “HF obesity survival paradox” in part represents the negative implications of unintentional weight loss.
  • Obesity treatments offer opportunities for improved HF symptom burden, functional capacity, quality of life, and hospitalizations.

Diagnosis of Obesity:

  • Although BMI is an inexpensive, easily acquired, and readily reproducible metric that is strongly embedded in research and clinical practice, significant limitations exist in the detection of excess adiposity, the location of adiposity, and applicability to diverse populations.
  • To determine a diagnosis of clinical obesity in individuals with BMI <35 kg/m2, direct assessment of excess adiposity with an anthropometric criterion (eg, waist circumference [the most readily obtainable], waist-to-hip ratio, or waist-to-height ratio) or body composition assessment (eg, dual X-ray absorptiometry, when available) may be used.
  • Clinicians should be aware that obesity remains a stigmatized condition and that some individuals may experience discomfort with being weighed, abdominally measured, or talking about weight during a medical visit.

Risk Assessment and Evaluation of Obesity and Heart Failure:

  • Because individuals with obesity have lower natriuretic peptide concentrations, lower thresholds are used in those who have obesity and exertional dyspnea to avoid underdiagnosis of HF in this population, although specific thresholds are not currently established.
  • For individuals with HF and obesity, monitoring for T2DM, hypertension, atrial fibrillation, sleep-disordered breathing, and objective evidence of exercise intolerance can identify the need for targeted interventions.

Management of Obesity in Heart Failure: Lifestyle and Behavioral Interventions:

  • Behavioral changes aimed at intentional weight loss are appropriate to attempt for individuals with obesity because even modest changes in body weight can result in improvements in the risk of cardiovascular events, although weight loss is often unsustainable.
  • Exercise can improve functional status in individuals with HFpEF.

Management of Obesity in Heart Failure: Pharmacologic Interventions:

  • The STEP-HFpEF program and SUMMIT trial show that, in people with BMI ≥30 kg/m2 and HF with EF ≥45% (semaglutide) and EF ≥50% (tirzepatide), weight loss is associated with improvements in symptoms and functional capacity.
  • Insufficient evidence exist to date to confidently conclude that semaglutide and tirzepatide reduce HF events in individuals with HFpEF and obesity (with stronger evidence for tirzepatide), although exploratory analysis indicates favorable changes in biomarkers and imaging parameters suggesting potential distinct mechanistic advantages outside of weight loss.
  • During early-phase gradual dose escalation of semaglutide or tirzepatide, which occurs every 4 weeks, monitor kidney function and electrolytes with adjustment of diuretics, antihypertensive agents, and antihyperglycemic agents as indicated, particularly if gastrointestinal adverse effects are prominent.

Management of Obesity in Heart Failure: Invasive Interventions

  • For individuals with HF and obesity, metabolic and bariatric surgery appears effective for intentional weight loss and potentially to reduce risk of HF events, including hospitalization for HF and death, although these possibilities are based only on data from observational studies.
  • Individuals with HF who are undergoing metabolic and bariatric surgery have an increased risk of postoperative cardiovascular morbidity and death, suggesting the need for preoperative optimization and perioperative care by clinicians with expertise in HF management.
  • BMI = body mass index; EF = ejection fraction; HF = heart failure; HFpEF = heart failure with preserved ejection fraction; STEP-HFpEF = Semaglutide Treatment Effect in People with Obesity and HFpEF; SUMMIT = A Study of Tirzepatide [LY3298176] in Participants With Heart Failure With Preserved Ejection Fraction [HFpEF] and Obesity; T2DM = type 2 diabetes mellitus.

At the end of these new recommendations, the ACC reiterates that a future priority is helping ensure people living with obesity and heart failure have an equitable ability to bypass social drivers of health and have access to anti-obesity medication to avoid further exacerbating their health. 

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