{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,23]],"date-time":"2026-04-23T16:02:41Z","timestamp":1776960161586,"version":"3.51.4"},"reference-count":38,"publisher":"Medknow","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["smedj"],"published-print":{"date-parts":[[2022,6]]},"abstract":"<jats:p>INTRODUCTION The obesity paradox, where obesity is associated with improved survival, has been described in patients undergoing haemodialysis and in those with heart failure. It was also demonstrated in patients undergoing valve replacement for aortic stenosis (AS). We explored this phenomenon in medically managed severe AS. METHODS 154 patients with medically managed severe AS (aortic valve area index [AVAi] &lt; 0.6 cm2\/m2; mean pressure gradient &gt; 40 mmHg and peak velocity &gt; 400 cm\/s) and preserved left ventricular ejection fraction (&gt; 50%) were categorised into the obese (body mass index [BMI] Asian cut-off \u2265 27.5 kg\/m2) and non-obese groups. Their clinical and echocardiographic profiles were compared. RESULTS 24 (15.6%) patients were obese. Obese patients were similar to non-obese patients in age (68.5 \u00b1 11.6 years vs. 68.9 \u00b1 13.1 years) but had higher prevalence of cardiovascular risk factors. Left atrial diameter (43.7 \u00b1 6.7 mm vs. 38.5 \u00b1 10.2 mm) was larger in obese patients, while left ventricular outflow tract diameter (19.5 \u00b1 1.7 mm vs. 20.4 \u00b1 2.1 mm) was smaller. Despite lower AVAi in obese patients (0.36 \u00b1 0.10 cm2\/m2 vs. 0.43 \u00b1 0.11 cm2\/m2), there was lower mortality (37.5% vs. 41.0%, log-rank 4.06, p = 0.045) on follow-up (8.0 \u00b1 5.7 years). After adjusting for age and AVAi, higher BMI \u2265 27.5 kg\/m2 remained protective for mortality (hazard ratio 0.38, 95% confidence interval 0.15 to 0.98, p = 0.046). CONCLUSION We demonstrated that obesity was associated with improved survival in severe AS despite lower AVAi and increased prevalence of cardiovascular risk factors.<\/jats:p>","DOI":"10.11622\/smedj.2020169","type":"journal-article","created":{"date-parts":[[2020,12,2]],"date-time":"2020-12-02T09:54:50Z","timestamp":1606902890000},"page":"330-334","source":"Crossref","is-referenced-by-count":6,"title":["The obesity paradox: association of obesity with improved survival in medically managed severe aortic stenosis"],"prefix":"10.4103","volume":"63","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3339-7281","authenticated-orcid":false,"given":"JN","family":"Ngiam","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"N","family":"Chew","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"BYQ","family":"Tan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"HW","family":"Sim","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2764-2869","authenticated-orcid":false,"given":"CH","family":"Sia","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7366-8966","authenticated-orcid":false,"given":"WKF","family":"Kong","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"TC","family":"Yeo","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3515-7924","authenticated-orcid":false,"given":"KK","family":"Poh","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2581","published-online":{"date-parts":[[2022,6]]},"reference":[{"key":"ref0","doi-asserted-by":"publisher","first-page":"2032","DOI":"10.1016\/S0140-6736(03)13640-9","article-title":"Obesity in general elective surgery","volume":"361","author":"Dindo","year":"2003","unstructured":"1. Dindo D, Muller MK, Weber M, Clavien PA. Obesity in general elective surgery. Lancet 2003; 361:2032-5.","journal-title":"Lancet"},{"key":"ref1","doi-asserted-by":"publisher","first-page":"1083","DOI":"10.1016\/S0140-6736(09)60318-4","article-title":"Body-mass index and cause-specific mortality in 900,000 adults: collaborative analyses of 57 prospective studies","volume":"373","author":"Studies Collaboration","year":"2009","unstructured":"2. Prospective Studies Collaboration, Whitlock G, Lewington S, et al. Body-mass index and cause-specific mortality in 900,000 adults: collaborative analyses of 57 prospective studies. Lancet 2009; 373:1083-96.","journal-title":"Lancet"},{"key":"ref2","unstructured":"3. Gruberg L, Weissman NJ, Waksman R, et al. The impact of obesity on the short-term and long-term outcomes after percutaneous coronary intervention: the obesity paradox? J Am Coll Cardiol 2002; 39:578-84."},{"key":"ref3","doi-asserted-by":"publisher","first-page":"1485","DOI":"10.1016\/j.amjcard.2007.01.018","article-title":"Relation of body mass index to outcome in patients with known or suspected coronary artery disease","volume":"99","author":"Galal","year":"2007","unstructured":"4. Galal W, van Domburg RT, Feringa HH, et al. Relation of body mass index to outcome in patients with known or suspected coronary artery disease. Am J Cardiol 2007; 99:1485-90.","journal-title":"Am J Cardiol"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"1767","DOI":"10.1016\/j.amjcard.2011.09.010","article-title":"Effect of body mass index on survival in patients having aortic valve replacement for aortic stenosis with or without concomitant coronary artery bypass grafting","volume":"108","author":"Roberts","year":"2011","unstructured":"5. Roberts WC, Roberts CC, Vowels TJ, et al. Effect of body mass index on survival in patients having aortic valve replacement for aortic stenosis with or without concomitant coronary artery bypass grafting. Am J Cardiol 2011; 108:1767-71.","journal-title":"Am J Cardiol"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"127","DOI":"10.1002\/ccd.26394","article-title":"Impact of body mass index on the outcomes following transcatheter aortic valve implantation","volume":"88","author":"Abramowitz","year":"2016","unstructured":"6. Abramowitz Y, Chakravarty T, Jilaihawi H, et al. Impact of body mass index on the outcomes following transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2016; 88:127-34.","journal-title":"Catheter Cardiovasc Interv"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"1016","DOI":"10.1136\/heartjnl-2013-305314","article-title":"Predictive factors of early mortality after transcatheter aortic valve implantation: individual risk assessment using a simple score","volume":"100","author":"Iung","year":"2014","unstructured":"7. Iung B, Laou\u00e9nan C, Himbert D, et al; FRANCE 2 Investigators. Predictive factors of early mortality after transcatheter aortic valve implantation: individual risk assessment using a simple score. Heart 2014; 100:1016-23.","journal-title":"Heart"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"117","DOI":"10.2147\/RMHP.S34587","article-title":"Clinical and economic outcomes after surgical aortic valve replacement in Medicare patients","volume":"5","author":"Clark","year":"2012","unstructured":"8. Clark MA, Duhay FG, Thompson AK, et al. Clinical and economic outcomes after surgical aortic valve replacement in Medicare patients. Risk Manag Healthc Policy 2012; 5:117-26.","journal-title":"Risk Manag Healthc Policy"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"57","DOI":"10.1159\/000095319","article-title":"Obesity paradox in patients on maintenance dialysis","volume":"151","author":"Kalantar-Zadeh K","year":"2006","unstructured":"9. Kalantar-Zadeh K, Kopple JD. Obesity paradox in patients on maintenance dialysis. Contrib Nephrol 2006; 151:57-69.","journal-title":"Contrib Nephrol"},{"key":"ref9","unstructured":"10. Oga EA, Eseyin OR. The obesity paradox and heart failure: a systematic review of a decade of evidence. J Obes 2016; 2016:9040248."},{"key":"ref10","doi-asserted-by":"publisher","first-page":"1597","DOI":"10.1056\/NEJMoa1008232","article-title":"Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery","volume":"363","author":"MB","year":"2010","unstructured":"11. Leon MB, Smith CR, Mack M, et al; PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010; 363:1597-607.","journal-title":"N Engl J Med"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"2187","DOI":"10.1056\/NEJMoa1103510","article-title":"Transcatheter versus surgical aortic-valve replacement in high-risk patients","volume":"364","author":"CR","year":"2011","unstructured":"12. Smith CR, Leon MB, Mack MJ, et al; PARTNER Trial Investigators. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med 2011; 364:2187-98.","journal-title":"N Engl J Med"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"1683","DOI":"10.1016\/j.jacc.2013.04.081","article-title":"Effect of overweight and obesity on cardiovascular events in asymptomatic aortic stenosis: a SEAS substudy (Simvastatin Ezetimibe in Aortic Stenosis)","volume":"62","author":"Rogge","year":"2013","unstructured":"13. Rogge BP, Cramariuc D, L\u00f8nnebakken MT, et al. Effect of overweight and obesity on cardiovascular events in asymptomatic aortic stenosis: a SEAS substudy (Simvastatin Ezetimibe in Aortic Stenosis). J Am Coll Cardiol 2013; 62:1683-90.","journal-title":"J Am Coll Cardiol"},{"key":"ref13","unstructured":"14. WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 2014; 363:157-63."},{"key":"ref14","doi-asserted-by":"publisher","first-page":"254","DOI":"10.1093\/ehjci\/jew335","article-title":"Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography","volume":"18","author":"Baumgartner","year":"2017","unstructured":"15. Baumgartner H, Hung J, Bermejo J, et al. Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2017; 18:254-75.","journal-title":"Eur Heart J Cardiovasc Imaging"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"233","DOI":"10.1093\/ehjci\/jev014","article-title":"Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging","volume":"16","author":"Lang","year":"2015","unstructured":"16. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2015; 16:233-70.","journal-title":"Eur Heart J Cardiovasc Imaging"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"734","DOI":"10.1093\/ejcts\/ezs043","article-title":"EuroSCORE II","volume":"41","author":"Nashef","year":"2012","unstructured":"17. Nashef SA, Roques F, Sharples LD, et al. EuroSCORE II. Eur J Cardiothorac Surg 2012; 41:734-45.","journal-title":"Eur J Cardiothorac Surg"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"9","DOI":"10.1016\/S1010-7940(99)00134-7","article-title":"European system for cardiac preoperative risk evaluation (EuroSCORE)","volume":"16","author":"Nashef","year":"1999","unstructured":"18. Nashef SA, Roques F, Michel P, et al. European system for cardiac preoperative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999; 16:9-13.","journal-title":"Eur J Cardiothorac Surg"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"231","DOI":"10.1016\/j.amjcard.2012.09.022","article-title":"Effect of body mass index on short- and long-term outcomes after transcatheter aortic valve implantation","volume":"111","author":"der Boon RM","year":"2013","unstructured":"19. van der Boon RM, Chieffo A, Dumonteil N, et al; PRAGMATIC-Plus Researchers. Effect of body mass index on short- and long-term outcomes after transcatheter aortic valve implantation. Am J Cardiol 2013; 111:231-6.","journal-title":"Am J Cardiol"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"1932","DOI":"10.1016\/j.amjcard.2013.08.022","article-title":"Effect of body mass index on 30- and 365-day complication and survival rates of transcatheter aortic valve implantation (from the FRench Aortic National CoreValve and Edwards 2 [FRANCE 2] registry)","volume":"112","author":"Yamamoto","year":"2013","unstructured":"20. Yamamoto M, Mouillet G, Oguri A, et al; FRANCE 2 Registry Investigators. Effect of body mass index on 30- and 365-day complication and survival rates of transcatheter aortic valve implantation (from the FRench Aortic National CoreValve and Edwards 2 [FRANCE 2] registry). Am J Cardiol 2013; 112:1932-7.","journal-title":"Am J Cardiol"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"66","DOI":"10.1016\/j.athoracsur.2004.06.047","article-title":"Body mass index and outcomes after left ventricular assist device placement","volume":"79","author":"Butler","year":"2005","unstructured":"21. Butler J, Howser R, Portner PM, Pierson RN 3rd. Body mass index and outcomes after left ventricular assist device placement. Ann Thorac Surg 2005; 79:66-73.","journal-title":"Ann Thorac Surg"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"428","DOI":"10.1016\/j.healun.2008.12.020","article-title":"Body mass index is a useful predictor of prognosis after left ventricular assist system implantation","volume":"28","author":"Mano","year":"2009","unstructured":"22. Mano A, Fujita K, Uenomachi K, et al. Body mass index is a useful predictor of prognosis after left ventricular assist system implantation. J Heart Lung Transplant 2009; 28:428-33.","journal-title":"J Heart Lung Transplant"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"118","DOI":"10.1002\/ccd.26377","article-title":"Body mass index association with survival in severe aortic stenosis patients undergoing transcatheter aortic valve replacement","volume":"88","author":"Koifman","year":"2016","unstructured":"23. Koifman E, Kiramijyan S, Negi SI, et al. Body mass index association with survival in severe aortic stenosis patients undergoing transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2016; 88:118-24.","journal-title":"Catheter Cardiovasc Interv"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"909","DOI":"10.1016\/j.ijcard.2016.06.155","article-title":"Transcatheter aortic valve implantation in obese patients: overcoming technical challenges and maintaining adequate hemodynamic performance using new generation prostheses","volume":"220","author":"Kische","year":"2016","unstructured":"24. Kische S, D'Ancona G, Agma HU, et al. Transcatheter aortic valve implantation in obese patients: overcoming technical challenges and maintaining adequate hemodynamic performance using new generation prostheses. Int J Cardiol 2016; 220:909-13.","journal-title":"Int J Cardiol"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"1139","DOI":"10.1093\/ejcts\/ezw218","article-title":"Early and mid-term outcomes of 1904 patients undergoing transcatheter balloon-expandable valve implantation in Italy: results from the Italian Transcatheter Balloon-Expandable Valve Implantation Registry (ITER)","volume":"50","author":"Salizzoni","year":"2016","unstructured":"25. Salizzoni S, D'Onofrio A, Agrifoglio M, et al; TAVI Team. Early and mid-term outcomes of 1904 patients undergoing transcatheter balloon-expandable valve implantation in Italy: results from the Italian Transcatheter Balloon-Expandable Valve Implantation Registry (ITER). Eur J Cardiothorac Surg 2016; 50:1139-48.","journal-title":"Eur J Cardiothorac Surg"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"633","DOI":"10.1093\/icvts\/ivx191","article-title":"The 'obesity paradox' does exist in patients undergoing transcatheter aortic valve implantation for aortic stenosis: a systematic review and meta-analysis","volume":"25","author":"Lv","year":"2017","unstructured":"26. Lv W, Li S, Liao Y, et al. The 'obesity paradox' does exist in patients undergoing transcatheter aortic valve implantation for aortic stenosis: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2017; 25:633-42.","journal-title":"Interact Cardiovasc Thorac Surg"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"851","DOI":"10.1016\/j.jcin.2011.03.019","article-title":"Transfemoral aortic valve implantation new criteria to predict vascular complications","volume":"4","author":"Hayashida","year":"2011","unstructured":"27. Hayashida K, Lef\u00e8vre T, Chevalier B, et al. Transfemoral aortic valve implantation new criteria to predict vascular complications. JACC Cardiovasc Interv 2011; 4:851-8.","journal-title":"JACC Cardiovasc Interv"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"1867","DOI":"10.1001\/archinte.162.16.1867","article-title":"Overweight and obesity as determinants of cardiovascular risk: the Framingham experience","volume":"162","author":"Wilson","year":"2002","unstructured":"28. Wilson PW, D'Agostino RB, Sullivan L, Parise H, Kannel WB. Overweight and obesity as determinants of cardiovascular risk: the Framingham experience. Arch Intern Med 2002; 162:1867-72.","journal-title":"Arch Intern Med"},{"key":"ref28","unstructured":"29. Li S, Wang Z, Huang J, et al. Systematic review of prognostic roles of body mass index for patients undergoing lung cancer surgery: does the 'obesity paradox' really exist? Eur J Cardiothorac Surg 2017; 51:817-28."},{"key":"ref29","doi-asserted-by":"publisher","first-page":"689","DOI":"10.1016\/j.jacc.2017.06.024","article-title":"Frailty in older adults undergoing aortic valve replacement: the FRAILTY-AVR study","volume":"70","author":"Afilalo","year":"2017","unstructured":"30. Afilalo J, Lauck S, Kim DH, et al. Frailty in older adults undergoing aortic valve replacement: the FRAILTY-AVR study. J Am Coll Cardiol 2017; 70:689-700.","journal-title":"J Am Coll Cardiol"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"660","DOI":"10.1016\/j.jcin.2010.03.018","article-title":"Is there an obesity paradox after percutaneous coronary intervention in the contemporary era? An analysis from a multicenter Australian registry","volume":"3","author":"Lancefield","year":"2010","unstructured":"31. Lancefield T, Clark DJ, Andrianopoulos N, et al; MIG (Melbourne Interventional Group) Registry. Is there an obesity paradox after percutaneous coronary intervention in the contemporary era? An analysis from a multicenter Australian registry. JACC Cardiovasc Interv 2010; 3:660-8.","journal-title":"JACC Cardiovasc Interv"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"789","DOI":"10.1016\/S0735-1097(01)01448-6","article-title":"The relationship between obesity and mortality in patients with heart failure","volume":"38","author":"Horwich","year":"2001","unstructured":"32. Horwich TB, Fonarow GC, Hamilton MA, et al. The relationship between obesity and mortality in patients with heart failure. J Am Coll Cardiol 2001; 38:789-95.","journal-title":"J Am Coll Cardiol"},{"key":"ref32","doi-asserted-by":"crossref","unstructured":"33. Mohamed-Ali V, Goodrick S, Bulmer K, et al. Production of soluble tumor necrosis factor receptors by human subcutaneous adipose tissue in vivo. Am J Physiol 1999; 277:E971-5.","DOI":"10.1152\/ajpendo.1999.277.6.E971"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"1441","DOI":"10.1016\/j.ijcard.2014.08.037","article-title":"Protective effect of body mass index independently of age, disease severity, treatment modality and non-cardiac comorbidities","volume":"176","author":"Rossi","year":"2014","unstructured":"34. Rossi A, Gaibazzi N, Bellelli G, et al. Obesity paradox in patients with aortic valve stenosis. Protective effect of body mass index independently of age, disease severity, treatment modality and non-cardiac comorbidities. Int J Cardiol 2014; 176:1441-3.","journal-title":"Int J Cardiol"},{"key":"ref34","unstructured":"35. Yadav PK, Eng MH. Size does matter but is there an obesity paradox in TAVR? Catheter Cardiovasc Interv 2016; 88:125-6."},{"key":"ref35","doi-asserted-by":"publisher","first-page":"638","DOI":"10.1111\/echo.13525","article-title":"Comparing characteristics and clinical and echocardiographic outcomes in low-flow vs normal-flow severe aortic stenosis with preserved ejection fraction in an Asian population","volume":"34","author":"Ngiam","year":"2017","unstructured":"36. Ngiam JN, Tan BY, Sia CH, et al. Comparing characteristics and clinical and echocardiographic outcomes in low-flow vs normal-flow severe aortic stenosis with preserved ejection fraction in an Asian population. Echocardiography 2017; 34:638-48.","journal-title":"Echocardiography"},{"key":"ref36","unstructured":"37. Muhammad N, Yap SE, Seet D, Chia BL, Poh KK. Does Oral calcium intake or body habitus relate to the degree of valvular calcification and adverse events in patients with severe aortic stenosis? Int J Cardiol 2015; 180:74-75."},{"key":"ref37","doi-asserted-by":"publisher","first-page":"452","DOI":"10.11622\/smedj.2018103","article-title":"Management of severe aortic stenosis: the Singapore and Asian perspective","volume":"59","author":"Tay","year":"2018","unstructured":"38. Tay ELW, Ngiam JN, Kong WKF, Poh KK. Management of severe aortic stenosis: the Singapore and Asian perspective. 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