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Association of Metabolic Surgery With Major Adverse Cardiovascular Outcomes in Patients With Type 2 Diabetes and Obesity
Open accessAbstract
IMPORTANCE: Although metabolic surgery (defined as procedures that influence metabolism by inducing weight loss and altering gastrointestinal physiology) significantly improves cardiometabolic risk factors, the effect on cardiovascular outcomes has been less well characterized. OBJECTIVE: To investigate the relationship between metabolic surgery and incident major adverse cardiovascular events (MACE) in patients with type 2 diabetes and obesity. DESIGN, SETTING, AND PARTICIPANTS: Of 287 438 adult patients with diabetes in the Cleveland Clinic Health System in the United States between 1998 and 2017, 2287 patients underwent metabolic surgery. In this retrospective cohort study, these patients were matched 1:5 to nonsurgical patients with diabetes and obesity (body mass index [BMI] ≥30), resulting in 11 435 control patients, with follow-up through December 2018. EXPOSURES: Metabolic gastrointestinal surgical procedures vs usual care for type 2 diabetes and obesity. MAIN OUTCOMES AND MEASURES: The primary outcome was the incidence of extended MACE (composite of 6 outcomes), defined as first occurrence of all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation. Secondary end points included 3-component MACE (myocardial infarction, ischemic stroke, and mortality) and the 6 individual components of the primary end point. RESULTS: Among the 13 722 study participants, the distribution of baseline covariates was balanced between the surgical group and the nonsurgical group, including female sex (65.5% vs 64.2%), median age (52.5 vs 54.8 years), BMI (45.1 vs 42.6), and glycated hemoglobin level (7.1% vs 7.1%). The overall median follow-up duration was 3.9 years (interquartile range, 1.9-6.1 years). At the end of the study period, 385 patients in the surgical group and 3243 patients in the nonsurgical group experienced a primary end point (cumulative incidence at 8-years, 30.8% [95% CI, 27.6%-34.0%] in the surgical group and 47.7% [95% CI, 46.1%-49.2%] in the nonsurgical group [P < .001]; absolute 8-year risk difference [ARD], 16.9% [95% CI, 13.1%-20.4%]; adjusted hazard ratio [HR], 0.61 [95% CI, 0.55-0.69]). All 7 prespecified secondary outcomes showed statistically significant differences in favor of metabolic surgery, including mortality. All-cause mortality occurred in 112 patients in the metabolic surgery group and 1111 patients in the nonsurgical group (cumulative incidence at 8 years, 10.0% [95% CI, 7.8%-12.2%] and 17.8% [95% CI, 16.6%-19.0%]; ARD, 7.8% [95% CI, 5.1%-10.2%]; adjusted HR, 0.59 [95% CI, 0.48-0.72]). CONCLUSIONS AND RELEVANCE: Among patients with type 2 diabetes and obesity, metabolic surgery, compared with nonsurgical management, was associated with a significantly lower risk of incident MACE. The findings from this observational study must be confirmed in randomized clinical trials. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03955952.
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“After surgery, the significant improvement of metabolic disease, as well as the decrease in overall mortality, has been reported in multiple studies further supporting the importance of this treatment modality [15–19].”
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“After surgery, the significant improvement of metabolic disease, as well as the decrease in overall mortality, has been reported in multiple studies further supporting the importance of this treatment modality [15–19].”
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“Indeed, marked weight loss achieved through bariatric surgery is associated with improvements in glucose levels and cardiac structure and function in patients with obesity and T2DM.14, 15, 16”
From The cardioprotective effects of semaglutide exceed those of dietary weight loss in mice with HFpEF (2023) · cites this paper as [14]
In the citing paper
“In a recently published retrospective cohort study, a substantial reduction in all-cause mortality and incident cases of major adverse cardiovascular events such as coronary artery events, cerebrovascular events, nephropathy, heart failure and atrial fibrillation was noted in those who had bariatric surgery [62].”
From Bariatric surgery: remission of inflammation, cardiometabolic benefits, and common adverse effects (2020) · cites this paper as [62]
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Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 5-Year Outcomes
Schauer, P. R., Bhatt, D. L., Kirwan, J. P., Wolski, K., Aminian, A., Brethauer, S. A., Navaneethan, S. D., Singh, R. P., Pothier, C. E., Nissen, S. E., et al. (2017) · New England Journal of Medicine · doi:10.1056/nejmoa1600869 · Cited by 2,934
Self-citationCardiovascular effects of intensive lifestyle intervention in type 2 diabetes
The Look AHEAD Research Group (2013) · New England Journal of Medicine · doi:10.1056/nejmoa1212914 · Cited by 2,908
Long-term mortality after gastric bypass surgery
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Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association
Tsao, C. W., Aday, A. W., Almarzooq, Z. I., Alonso, A., Beaton, A. Z., Bittencourt, M. S., Boehme, A. K., Buxton, A. E., Carson, A. P., Commodore-Mensah, Y., et al. (2022) · Circulation · doi:10.1161/cir.0000000000001052 · Cited by 5,987
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Virani, S. S., Alonso, A., Aparicio, H. J., Benjamin, E. J., Bittencourt, M. S., Callaway, C. W., Carson, A. P., Chamberlain, A. M., Cheng, S., Delling, F. N., et al. (2021) · Circulation · doi:10.1161/cir.0000000000000950 · Cited by 5,784
Sheka, A. C., Adeyi, O. A., Thompson, J., Hameed, B., Crawford, P. A., & Ikramuddin, S. (2020) · JAMA · doi:10.1001/jama.2020.2298 · Cited by 1,432
Benefits and Risks of Bariatric Surgery in Adults: A Review
Arterburn, D. E., Telem, D. A., Kushner, R. F., & Courcoulas, A. P. (2020) · JAMA · doi:10.1001/jama.2020.12567 · Cited by 1,251
Self-citationCusi, K., Isaacs, S., Barb, D., Basu, R., Caprio, S., Garvey, W. T., Kashyap, S., Mechanick, J. I., Mouzaki, M., Nadolsky, K., et al. (2022) · Endocrine Practice · doi:10.1016/j.eprac.2022.03.010 · Cited by 1,021
Metadata
- Authors
- Aminian, A., Zajichek, A., Arterburn, D. E., Wolski, K. E., Brethauer, S. A., Schauer, P. R., Kattan, M. W., & Nissen, S. E.
- Affiliations
- Cleveland Clinic (US)
- Kaiser Permanente Washington Health Research Institute (US)
- Corresponding author
- Nissen, Steven E.
- ORCID
- Venue
- JAMA
- Publisher
- American Medical Association (AMA)
- Published
- 2019-10-01
- Volume
- 322
- Issue
- 13
- Pages
- 1271
- ISSN
- 0002-9955 (ISSN-L)
- 0098-7484
- PMC
- PMC6724187
- OpenAlex
- W2970007463
- Cited by
- 505
- References
- 32
- Citations by year
- 2026: 61 · 2025: 71 · 2024: 68 · 2023: 73 · 2022: 66 · 2021: 83 · 2020: 73 · 2019: 9
- FWCI
- 55.12
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Surgery › Bariatric Surgery and Outcomes
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac, Anesthesia and Surgical Outcomes
- Keywords
- metabolic surgery, type 2 diabetes, obesity, major adverse cardiovascular events, cardiovascular outcomes, bariatric surgery, weight loss, myocardial infarction, ischemic stroke, heart failure, atrial fibrillation, kidney disease, mortality, cardiometabolic risk factors
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