Association Between Bariatric Surgery and Macrovascular Disease Outcomes in Patients With Type 2 Diabetes and Severe Obesity

Abstract

IMPORTANCE Macrovascular disease is a leading cause of morbidity and mortality for patients with type 2 diabetes, and medical management, including lifestyle changes, may not be successful at lowering risk. OBJECTIVE To investigate the relationship between bariatric surgery and incident macrovascular (coronary artery disease and cerebrovascular diseases) events in patients with severe obesity and type 2 diabetes. DESIGN, SETTING, AND PARTICIPANTS In this retrospective, matched cohort study, patients with severe obesity (body mass index Ն35) aged 19 to 79 years with diabetes who underwent bariatric surgery from 2005 to 2011 in 4 integrated health systems in the United States (n = 5301) were matched to 14 934 control patients on site, age, sex, body mass index, hemoglobin A 1c , insulin use, observed diabetes duration, and prior health care utilization, with follow-up through September 2015. EXPOSURES Bariatric procedures (76% Roux-en-Y gastric bypass, 17% sleeve gastrectomy, and 7% adjustable gastric banding) were compared with usual care for diabetes. MAIN OUTCOMES AND MEASURES Multivariable-adjusted Cox regression analysis investigated time to incident macrovascular disease (defined as first occurrence of coronary artery disease [acute myocardial infarction, unstable angina, percutaneous coronary intervention, or coronary artery bypass grafting] or cerebrovascular events [ischemic stroke, hemorrhagic stroke, carotid stenting, or carotid endarterectomy]). Secondary outcomes included coronary artery disease and cerebrovascular outcomes separately. RESULTS Among a combined 20 235 surgical and nonsurgical patients, the mean (SD) age was 50 (10) years; 76% of the surgical and 75% of the nonsurgical patients were female; and the baseline mean (SD) body mass index was 44.7 (6.9) and 43.8 (6.7) in the surgical and nonsurgical groups, respectively. At the end of the study period, there were 106 macrovascular events in surgical patients (including 37 cerebrovascular and 78 coronary artery events over a median of 4.7 years; interquartile range, 3.2-6.2 years) and 596 events in the matched control patients (including 227 cerebrovascular and 398 coronary artery events over a median of 4.6 years; interquartile range, 3.1-6.1 years). Bariatric surgery was associated with a lower composite incidence of macrovascular events at 5 years (2.1% in the surgical group vs 4.3% in the nonsurgical group; hazard ratio, 0.60 [95% CI, 0.42-0.86]), as well as a lower incidence of coronary artery disease (1.6% in the surgical group vs 2.8% in the nonsurgical group; hazard ratio, 0.64 [95% CI, 0.42-0.99]). The incidence of cerebrovascular disease was not significantly different between groups at 5 years (0.7% in the surgical group vs 1.7% in the nonsurgical group; hazard ratio, 0.69 [95% CI, 0.38-1.25]). CONCLUSIONS AND RELEVANCE In this observational study of patients with type 2 diabetes and severe obesity who underwent surgery, compared with those who did not undergo surgery, bariatric surgery was associated with a lower risk of macrovascul...

Impact of bariatric surgery on cardiovascular outcomes and mortality: a population-based cohort study

“…Most previous studies analysing the impact of bariatric surgery in patients with T2DM focused on weight loss and glycaemic control, and had small sample sizes. A recent retrospective study from the USA found a lower risk of composite cardiovascular outcome in participants with diabetes undergoing bariatric surgery. After analysing the outcomes separately, these authors found a reduction in coronary artery disease, but a non‐significant difference in CVD, as in the present study.…”

“…A recent retrospective study from the USA found a lower risk of composite cardiovascular outcome in participants with diabetes undergoing bariatric surgery. After analysing the outcomes separately, these authors found a reduction in coronary artery disease, but a non‐significant difference in CVD, as in the present study. A meta‐analysis including five cohort studies found a 48 per cent reduction in macrovascular complications during follow‐up of 5–15 years, but no data were presented for individual components of macrovascular complications.…”

“…Several studies (including RCTs) have established that bariatric surgery is associated with a reduction in CVD risk factors, but the impact on CVD is limited to a few observational studies. In the UK, patients with a BMI of 35 kg/m 2 or above and obesity‐related complications, a BMI of 40 kg/m 2 or above without obesity‐related complications, or a BMI of 30–35 kg/m 2 with recent‐onset T2DM can be offered bariatric surgery according to National Institute for Health and Care Excellence guideline CG189.…”

Novel mediation analysis of human plasma proteome and metabolome reveals mediators of improved glycemia after gastric bypass surgery

“…Significance for this and other omics analyses was defined as FDR<0. 15. In plots of individual analytes with standard error of the mean (SEM), ordinary (i.e.…”

“…Improved glycemic control occurs days after RYGB, before substantial weight loss, supporting that weight loss-independent mechanisms drive metabolic improvements (11)(12)(13). Moreover, recent observational studies indicate that bariatric surgery is associated with fewer microvascular and macrovascular complications of diabetes and reduced mortality (14)(15)(16). Identifying molecular mechanisms responsible for improved systemic metabolism could allow development of novel nonsurgical approaches for T2D treatment.…”