Association Between Adiposity and Lean Mass With Long‐Term Cardiovascular Events in Patients With Coronary Artery Disease: No Paradox

BACKGROUND: Prognosis based on body fat percentage (BF%) in patients with coronary artery disease has not been extensively studied. We tested the hypothesis that patients with coronary artery disease and increased BF% have a higher risk for major adverse cardiovascular events (MACEs) and that fat‐free mass is associated with better prognosis. METHODS AND RESULTS: We included 717 patients referred to cardiac rehabilitation after coronary artery disease events or procedures who underwent air displacement plethysmography to assess BF%; 75% were men, with a mean age 61.4±11.4 years and a mean body mass index of 30±5.4 kg/m(2). Follow‐up was performed using a record linkage system. Patients were classified in sex‐specific quartiles of BF% and fat‐free mass index. The composite outcome of MACEs included acute coronary syndromes, coronary revascularization, stroke, or death from any cause. After a median follow‐up of 3.9 years, 201 patients had a MACE. After adjusting for covariates, body mass index was not associated with MACEs (P=0.12). However, the risk of MACEs for those in the highest BF% quartile was nearly double when compared with those in the lowest quartile (hazard ratio, 1.89; 95% confidence interval, 1.30–2.77; P=0.0008). In contrast, fat‐free mass was inversely associated with MACEs. The risk of MACEs for those in the fourth fat‐free mass quartile was lower (adjusted hazard ratio, 0.53; 95% confidence interval, 0.35–0.82; P=0.004), when compared with those in the first quartile. CONCLUSIONS: In patients with coronary artery disease, there is no obesity paradox when measuring BF% instead of body mass index. BF% is associated with a higher risk of MACEs, whereas fat‐free mass is associated with a lower risk of MACEs. Body mass index was not associated with MACEs.