{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,10]],"date-time":"2025-12-10T08:50:05Z","timestamp":1765356605744,"version":"3.44.0"},"reference-count":27,"publisher":"BMJ","issue":"4","funder":[{"DOI":"10.13039\/100000050","name":"National Heart, Lung, and Blood Institute","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000050","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Heart"],"accepted":{"date-parts":[[2019,7,30]]},"published-print":{"date-parts":[[2020,2]]},"abstract":"<jats:sec>\n                  <jats:title>Objectives<\/jats:title>\n                  <jats:p>To test the relationship between increasing severity of obesity, calculated risk and observed outcomes.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Patients with symptoms suggestive of coronary artery disease (CAD) (n=10 003) were stratified according to body mass index (BMI). We compared risk factors, pooled risk scores and physicians\u2019 perception of risk. Cox regression tested the association between BMI and (1) presence of obstructive CAD and (2) composite clinical endpoints (death, cardiovascular death, unstable angina hospitalisation and myocardial infarction).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>BMI was \u226530 kg\/m<jats:sup>2<\/jats:sup> in 48% of patients and \u226535 in 20%. Increasingly obese patients were younger, female and non-smoking but with higher prevalence of hypertension, diabetes, black race and sedentary lifestyle. Pooled risk estimates of CAD were highest in those with mid-range BMI. In contrast, physicians\u2019 estimation of the likelihood of significant CAD based on clinical impression increased progressively with BMI. For a 10% increase in the Diamond-Forrester probability of CAD, the adjusted OR for obstructive CAD was 1.5 (95% CI 1.4 to 1.5) in patients with BMI &lt;35, but only 1.2 (95% CI 1.1 to 1.3) in those with BMI \u226535 (interaction p&lt;0.001). Framingham Risk Score increased across increasing BMI categories. However, there was a strong and consistent inverse relationship between degree of obesity and all three composite clinical endpoints over a median 25 months of follow-up.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Despite perceptions of higher risk and higher risk scores, increasingly obese patients had obstructive CAD less frequently than predicted and had fewer adverse clinical outcomes. There is a need for risk assessment tools and guidelines that account for obesity.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Trial registration number<\/jats:title>\n                  <jats:p>\n                     <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"clintrialgov\" xlink:href=\"NCT01174550\">NCT01174550<\/jats:ext-link>.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/heartjnl-2018-314503","type":"journal-article","created":{"date-parts":[[2019,10,10]],"date-time":"2019-10-10T17:24:17Z","timestamp":1570728257000},"page":"273-279","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":10,"title":["Discordances between predicted and actual risk in obese patients with suspected cardiac ischaemia"],"prefix":"10.1136","volume":"106","clinical-trial-number":[{"clinical-trial-number":"nct01174550","registry":"10.18810\/clinical-trials-gov"}],"author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5887-8161","authenticated-orcid":false,"given":"Sheldon E","family":"Litwin","sequence":"first","affiliation":[{"name":"Division of Cardiology, Department of Medicine, Ralph H Johnson VA Medical Center, Charleston, South Carolina, USA"},{"name":"Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Adrian","family":"Coles","sequence":"additional","affiliation":[{"name":"Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"C Larry","family":"Hill","sequence":"additional","affiliation":[{"name":"Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brooke","family":"Alhanti","sequence":"additional","affiliation":[{"name":"Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Neha","family":"Pagidipati","sequence":"additional","affiliation":[{"name":"Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kerry L","family":"Lee","sequence":"additional","affiliation":[{"name":"Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patricia A","family":"Pellikka","sequence":"additional","affiliation":[{"name":"Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel B","family":"Mark","sequence":"additional","affiliation":[{"name":"Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"James E","family":"Udelson","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Tufts University Medical Center, Tufts University School of Medicine, Boston, MA, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lawton","family":"Cooper","sequence":"additional","affiliation":[{"name":"National Heart, Lung and Blood institute, Bethesda, MD, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jean-Claude","family":"Tardif","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Montreal Heart Institute, Universit\u00e9 de Montr\u00e9al, Montreal, Quebec, Canada"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Udo","family":"Hoffmann","sequence":"additional","affiliation":[{"name":"Department of Radiology, Massachusetts General Hospital, Boston, MA, United States"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pamela S","family":"Douglas","sequence":"additional","affiliation":[{"name":"Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, 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