Guideline Video

Guideline Resources

  • Title: Management of Obesity in Adults With Heart Failure
  • Society: American College of Cardiology (ACC)
  • Publish Date: June 13, 2025
  • Guideline Summary
  • Full-text

Video Transcription

Just published June 13th, 2025 The American College of Cardiology’s newest scientific statement on the Management of Obesity in Adults With Heart Failure (HF).

This scientific statement: reviews the diagnosis, evaluation, and risk assessment of obesity in HF; describes HF-specific management strategies from lifestyle intervention to medications to surgery; and addresses evidence gaps and future directions in obesity-related HF.

There are 15 recommendations so let’s get started.

Starting with recommendations for the epidemiology of obesity in HF:

  • Avoidance of excess adiposity throughout the lifespan is key to the prevention of incident HF, particularly heart failure with preserved ejection fraction (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.

Now for the 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, direct assessment of excess adiposity with an anthropometric criterion or body composition assessment 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 HF

  • 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.

Now we’ll go over the management of obesity, starting with 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 risk of cardiovascular events, although weight loss is often unsustainable.
  • Exercise can improve functional status in individuals with HFpEF.

For pharmacologic interventions

  • The STEP-HFpEF program and SUMMIT trial show that, in people with BMI ≥30 and HF with (EF) ≥45% and EF ≥50%, 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, 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.

For 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.

And there you have it. Make sure to check out the full guideline from The American College of Cardiology and other related clinical decision support tools at guidelinecentral.com.

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