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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Body mass index > 30 kg/m2

  • Increased left ventricular mass by imaging in the absence of hypertension or diabetes

  • Heart failure and cardiac arrhythmias common

GENERAL CONSIDERATIONS

  • Obesity is not only a risk factor for coronary artery disease, but can also cause left ventricular hypertrophy, heart failure, and arrhythmias independent of hypertension

  • Fatty infiltration of the conduction system and sleep apnea have been found in obese individuals; both can lead to arrhythmias

  • Eccentric left ventricular hypertrophy may be related to increased plasma volume and metabolic demands

  • Obesity is also part of the metabolic syndrome, which predisposes to atherosclerosis

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Dyspnea and fatigue are common

  • Chest pain and palpitations can occur

PHYSICAL EXAM FINDINGS

  • Increased body mass index:

    • – Obese > 30 kg/m2

  • Central (truncal or android) obesity (waist circumference > 102 cm men, > 88 cm women) is a risk factor for atherosclerosis

  • Lower body (gynecoid) obesity is not a risk factor for coronary artery disease

  • Systemic hypertension

  • Left ventricular lift or heave

  • Signs of heart failure may be present

  • S3 or S3 may be present

DIFFERENTIAL DIAGNOSIS

  • Coronary artery disease

  • Dilated cardiomyopathy

  • Hypertrophic cardiomyopathy

  • Diabetic cardiomyopathy

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Elevated lipids

  • Abnormal liver function tests from fatty accumulation

ELECTROCARDIOGRAPHY

  • Prolonged QTc

IMAGING STUDIES

  • CT and MRI: useful to confirm excess internal fat accumulation

  • Echocardiography:

    • – Shows left ventricular hypertrophy, usually eccentric but sometimes concentric

    • – Evidence of systolic or diastolic dysfunction may be present

DIAGNOSTIC PROCEDURES

  • Underwater weighing for determination of lean body mass

  • Skinfold thickness measures with calipers

  • Sleep study to detect sleep apnea

TREATMENT

CARDIOLOGY REFERRAL

  • Suspected cardiac disease

  • Difficult to control hypertension

HOSPITALIZATION CRITERIA

  • Heart failure

  • Respiratory failure

  • Planned procedure or surgery

MEDICATIONS

  • Weight loss through diet, exercise, and approved drugs

  • Assessment and treatment of comorbid conditions, such as hyperlipidemia, sleep apnea, and hypertension

  • Indicated treatment for heart failure or arrhythmias

SURGERY

  • Bariatric surgery in selected cases

MONITORING

  • ECG in hospital as appropriate

  • Daily weight

DIET AND ACTIVITY

  • Diet of 500–1000 kcal/day: 30% total fat, 7% saturated fat

  • Aerobic exercise for at least 30 minutes a day

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Resolution of problem

  • After successful surgery

FOLLOW-UP
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