June 26, 2023
Exploring Medications for Preventative Cardiology: Treating Cardiovascular Health in Patients with Obesity
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Cardiovascular disease is the leading cause of death worldwide, and the medical community has endlessly worked to advance our knowledge of prevention, diagnosis, and timely treatment of heart disease.1 The most notable modifiable heart disease risk factors include smoking, diabetes, hypertension, hypercholesterolemia, and obesity. 2
Obesity is a unique risk factor, often the driver for all the above factors except smoking. Some might say it is the umbrella problem wherein controlling obesity helps improve all the other metabolic derangements. We know patients with obesity have high levels of systemic inflammation 3, which increases rates of plaque formation in the coronary arteries and heightens the risk of a heart attack. Systemic inflammation of obesity also increases the risk of thromboembolism, which can lead to acute heart failure in severe cases. Due to fat mass disease, many patients with obesity struggle with obstructive sleep apnea, which worsens hypertension and can cause congestive heart failure if left untreated. These are only a few examples of how obesity contributes to the pathophysiology of many cardiovascular diseases, making it an imperative risk factor to modify.
In addition, women with obesity who go on to bear children frequently experience pregnancy complications such as gestational hypertension and/or gestational diabetes. 4 Heart disease risk is considerably higher in women with these pregnancy complications. Working on weight loss before conception helps improve pregnancy outcomes for the mother and the baby and protects the mother years later.
When I discuss with my patients their reasons and motivation for weight loss, disease prevention, and longevity undeniably are at the top of their list. Some are already struggling with coronary artery disease or arrhythmias, such as Atrial Fibrillation, which is common in patients with obesity. Others have seen loved ones suffer from congestive heart failure or other heart diseases related to obesity. We work to lower blood pressure and improve cholesterol and blood glucose. When successful, we find we can reduce doses of blood pressure medication or discontinue one or more medications altogether. We often see triglycerides (a type of bad cholesterol) decrease and HDL cholesterol (a type of good cholesterol) increase with successful weight loss. It is thrilling to see patients with insulin resistance or prediabetes be able to reverse disease and regain normal glucose metabolism- crossing hyperglycemia off their risk factor list for heart disease.
The most common medication associated with preventative cardiology falls into the anti-hypertensive, cholesterol-lowering, and blood glucose-lowering classes. There are many medications to improve the above parameters; however, some conversely promote weight gain. A common weight-promoting medication class is beta-blockers. Although beta blockers are critical in certain diseases, they can cause a worsening in insulin resistance; therefore, they should be avoided in patients with obesity for the treatment of hypertension alone. Certainly, an exception should be made in patients with specific indications for a beta-blocker, such as coronary artery disease or arrhythmia. In recent years, newer cardiovascular agents-GLP1 agonists and SGLT2 inhibitors have been game changers in helping patients lose weight, improve blood glucose control, reduce rates of major adverse cardiac events, and improve heart failure control. If a patient has known heart disease, insulin resistance, and obesity, I urge clinicians to treat the insulin resistance early, both with lifestyle modification and medications. According to the AACE guidelines from June 2023- any patient with overweight and prediabetes should be started on anti-obesity medication. Patients with obesity develop coronary artery disease earlier than those without obesity; therefore, clinicians should be aggressive in lowering cholesterol with statin medications in this patient population.
Clinicians increasingly recognize that treating obesity first should be everyone’s priority, especially within preventative cardiology. When we diagnose obesity for our patients, we partner with them to provide comprehensive and individualized care, including lifestyle modification, medication, and, at times, bariatric surgery to prevent and treat cardiovascular disease. Continued research and clinical advancements will further enhance our understanding and utilization of medications to combat the cardiovascular consequences of obesity.
Medications have emerged as valuable tools in the realm of preventative cardiology for patients with obesity. By effectively addressing key cardiovascular risk factors, such as hypertension and inflammation, these medications play a crucial role in reducing the burden of cardiovascular disease in individuals with obesity. However, a comprehensive and individualized approach and lifestyle modifications remain essential in managing cardiovascular health effectively. Continued research and clinical advancements will further enhance our understanding and utilization of medications to combat the cardiovascular consequences of obesity.
For more information on medications for preventative cardiology in patients with obesity, the OMA Obesity Algorithm has an excellent section on medications that can contribute to weight gain. It would be prudent for a clinician in preventative cardiology to review these medications.
1 Centers for Disease Control and Prevention. (2023, May 15). Heart disease facts. Centers for Disease Control and Prevention. https://www.cdc.gov/heartdisease/facts.htm#:~:text=Heart%20disease%20is%20the%20leading,groups%20in%20the%20United%20States.&text=One%20person%20dies%20every%2033,United%20States%20from%20cardiovascular%20disease 2 Cover Story | Obesity and Cardiovascular Disease Risk - American College of Cardiology. (2018). American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2018/07/06/12/42/cover-story-obesity-and-cardiovascular-disease-risk 3 Ellulu, M. S., Patimah, I., Khaza’ai, H., Rahmat, A., & Abed, Y. (2017). Obesity and inflammation: the linking mechanism and the complications. Archives of Medical Science, 13(4), 851–863. https://doi.org/10.5114/aoms.2016.58928 4 Kim, J., & Ayabe, A. (2021). Obesity In Pregnancy. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK572113/
Article written by:
Alina Elperin, MD, DABOM
Alina Elperin, MD, DABOM, is an Internist and Obesity Medicine specialist in Evanston, Illinois. She is a Clinical Assistant Professor at the University of Chicago Pritzker School of Medicine and frequently teaches residents and students. She strives to improve access for patients with obesity to get the compassionate and comprehensive care they need. Dr. Elperin's philosophy of patient care aims to empower patients to take control of their physical and mental health. She loves the longitudinal relationships she builds with her patients. She partners with her patients to change their mindset and improve their lifestyles gradually and sustainably to reach their health goals. She lives by the motto, "An ounce of prevention is worth a pound of cure". When not helping patients meet their health goals or teaching residents, Dr. Elperin is enjoying time with her husband and three children and maybe even planning her next travel destination.