Bariatric surgery for obesity from age 65: a cardiovascular win

• The study found a lower risk of death, heart failure, myocardial infarction and stroke.

Bariatric surgery is associated with a significantly reduced risk of mortality and adverse cardiovascular events in patients with obesity, including those aged 65 to 75, a population often considered unsuitable for this important weight-loss strategy, according to a Cleveland Clinic -led observational study of nearly 190,000 Medicare beneficiaries with obesity followed for a median of four years. The study was published in the Journal of the American College of Cardiology.

“Our findings on the cardiovascular benefits of bariatric surgery in older patients with obesity were significant, including a reduction of more than half in the risk of new-onset heart failure,” says the study’s corresponding author, Amgad Mentias, M.D., a Cleveland Clinic cardiologist. “The benefits were evident in both men and women, at all ages within our cohort, and regardless of whether or not patients had diabetes.”

Lingering unknowns about the extent of the benefits

Despite evidence that bariatric surgery is the most effective available treatment for severe obesity, its role in reducing long-term cardiovascular risk has not been well studied in a real-world national cohort in the United States, especially among patients over 65 and those without diabetes.

This large study, using a Medicare database and advanced statistical methods, was designed to address these gaps.

Study design and results

The Medicare Provider Analysis and Review (MedPAR) database, which contains records of all Medicare beneficiaries using inpatient services, was examined for patients diagnosed with obesity from 2013 to 2019. Those with an urgent admission or discharged to any destination other than home were excluded, as were patients over 75 or with established heart failure.

The resulting study cohort consisted of 94,885 Medicare beneficiaries who underwent bariatric surgery during that period. Almost two-thirds underwent sleeve gastrectomy, a third gastric bypass and 1.3% gastric banding. The control group consisted of the same number of patients with obesity who did not undergo bariatric surgery, matched 1:1 with the bariatric surgery group by exact age, sex, race, body mass index and propensity score using 87 other clinical variables.

Both groups were 70% female and had a similar mean age (62.3 ± 10.6 years) and body mass index (44.7 kg/m2 ± 7.3; range, 30-70 kg/m2).

After a median follow-up of 4.0 years (interquartile range, 2.4-5.7), the bariatric surgery group was found to have a reduced risk of the following adverse outcomes relative to controls:

• All-cause mortality (incidence of 9.2 vs. 14.7/1,000 person-years; hazard ratio [HR] = 0.63; 95% CI, 0.60-0.66)
• New-onset heart failure (incidence of 13.3 vs. 27.0/1,000 person-years; HR = 0.46; 95% CI, 0.44-0.49)
• Myocardial infarction (incidence of 6.1 vs. 9.5/1,000 person-years; HR = 0.63; 95% CI, 0.59-0.68)
• Ischaemic stroke (incidence of 3.5 vs. 4.6/1,000 person-years; HR = 0.71; 95% CI, 0.65-0.79)

These factors did not differ significantly in men versus women or by the presence or absence of diabetes at baseline.

Instrumental variable analysis, a statistical method that mimics randomised clinical trials, was then used to adjust for potential confounders. With this technique, the risk reductions in the bariatric surgery group were 60% for all-cause mortality, 79% for new-onset heart failure and 80% for myocardial infarction compared with the control group. No significant differences were found for stroke incidence.

The combined incidence of in-hospital and 30-day mortality was below 0.3% in patients who underwent bariatric surgery.

Strengthening the evidence base for bariatric surgery

The results of this study are consistent with those of smaller studies showing the cardiovascular benefit of bariatric surgery. The authors point to the following key findings this study adds to the evidence base:

• Older patients benefit. Although bariatric surgery is mainly performed in younger patients, this study demonstrated safety, as well as a significant reduction in mortality and cardiovascular risk, in patients who had surgery between the ages of 65 and 75.
• Risk reduction was evident across all major clinical cardiovascular endpoints, regardless of diabetes status. Propensity score matching showed bariatric surgery is associated with a 37% lower risk of mortality, a 54% lower risk of new-onset heart failure, a 37% lower risk of myocardial infarction and a 29% lower risk of stroke.
• The number needed to treat to prevent one major adverse cardiovascular event over three years was 15.

“Despite the substantial benefits of bariatric surgery, it is used in less than 1% of patients who are potential candidates,” notes the study’s senior author, Milind Desai, M.D., MBA, Director of Clinical Operations in the Department of Cardiovascular Medicine at Cleveland Clinic’s Heart, Vascular and Thoracic Institute. “Doctors should discuss this option when appropriate, including with their older patients.”

“With the availability of new weight-loss medications such as glucagon-like peptide-1 analogues, their efficacy and cardiovascular benefits should be compared with bariatric surgery in future studies,” adds Dr. Mentias.

About Cleveland Clinic

Cleveland Clinic – now in its centennial year – is a nonprofit multispecialty academic medical centre that integrates clinical and hospital care with research and education. Located in Cleveland, Ohio, it was founded in 1921 by four renowned physicians with a vision of providing outstanding patient care based on the principles of cooperation, compassion and innovation. Cleveland Clinic has pioneered many medical breakthroughs, including coronary artery bypass surgery and the first face transplant in the United States.

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