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A 48-year-old man with nonischemic cardiomyopathy (left ventricular ejection fraction [LVEF] 20%) presents for subspecialty heart failure evaluation. He has a history of multiple decompensated heart failure hospitalizations (4 within the past year), episodes of ventricular tachycardia, hypertension, hyperlipidemia, hypothyroidism, a thromboembolic stroke with no residual neurological deficit, atrial fibrillation, sleep apnea, and deep vein thrombosis. His weight at the time of evaluation is 162 kg (358 lb); he is volume overloaded in clinic, but after inpatient diuresis his dry weight is established at 156 kg, giving a body mass index (BMI) of 46.8 kg/m2. He is receiving full doses of guideline-directed medial therapy and is anticoagulated. What is the potential impact of obesity on his clinical cardiovascular course and what recommendations should the clinician make regarding weight management for this patient?


Obesity is a key determinant of health status and has the potential to affect multiple organ systems (Figure 4-1). The overweight and obese states are commonly defined by BMI, with overweightness diagnosed in the BMI range of 25 to 30 kg/m2 and obesity ≥30 kg/m2 (Table 4-1). The prevalence of obesity has grown rapidly since the 1960s, with over one-third of adults and 17% of youth in the United States now classified as obese.1 Obesity has long been known to pose a major threat to cardiovascular population health.2 Higher BMI, and other anthropometric measures of obesity such as waist circumference, are independent risk factors for the development of coronary heart disease and heart failure (HF),3,4 particularly heart failure with preserved ejection fraction (HFpEF),5 as well as for cardiovascular death.6 There are probably contributions from multiple pathways including the development of hyperlipidemia, insulin resistance, low-level inflammation, and left ventricular hypertrophy, with a potential pathogenic role for the adipokine and gut hormone signaling to the myocardium.

Figure 4-1

The impact of obesity on the body. (Reproduced, with permission, from Cleveland Clinic Center for Medical Art & Photography © 2005-2017. All rights reserved.)

Table 4-1Body Mass Index Chart

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