Obesity and Elevated Blood Pressure following Repair of Coarctation of the Aorta Melissa Smith-Parrish, MD, Sunkyung Yu, MS, and Albert Rocchini, MD Objective To determine whether patients with coarctation of the aorta (COA) were more likely to develop obesity compared with the general population or others with isolated forms of congenital heart disease. Study design We conducted a cross-sectional study of 160 patients who underwent COA repair at our institution between 1974 and 2009. Body mass index (BMI) measurements were obtained from the most recent clinic visit and at 5, 10, 15, and 20 years of age from retrospective chart review. BMI values were compared against established normal data to obtain age-sex matched z-scores. We also compared the rates of developing obesity over time in adults with COA vs 96 adults with other isolated forms of congenital heart disease, including aortic valve stenosis, pulmonary valve stenosis, or atrial septal defect. Results After age 5 years, patients with COA had significantly greater BMI z-scores compared with age-sex matched normal data (P < .001). The proportion of obesity in patients with COA significantly increased over time (P < .001). Adults with repaired COA developed obesity at a greater rate than those with either aortic valve stenosis (P = .004) or with pulmonary valve stenosis or atrial septal defect (P < .001). Conclusions There is a greater incidence of obesity that progressively increases with age in patients with repaired COA. Adults with repaired COA developed obesity at a greater rate than those with other isolated forms of congenital heart disease. Further prospective trials are needed to confirm our observations and to elucidate the potential mechanism relating COA to obesity. (J Pediatr 2014;164:1074-8).
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hildhood obesity remains a major health concern, with the incidence dramatically increasing during the past 3 decades.1 In only a few studies have authors evaluated the prevalence of obesity in children with congenital heart disease. Pinto et al2 reported that 15.2% of patients diagnosed with congenital heart disease and followed in an outpatient pediatric cardiology clinic were obese. Unfortunately, childhood obesity has been shown to persist into adulthood, and with 35.7% of American adults currently meeting criteria for being obese, the number impacted by obesity is expected to increase.1,3 Just as obesity is associated with significant cardiovascular risk factors, coarctation of the aorta (COA) is also associated with an increased risk of early death and other life-long sequelae, including hypertension and premature coronary artery disease, even after successful repair.4-8 One postoperative follow-up study reports a mortality rate of 12% at a mean age of 32.5 years in patients 20 years after COA repair, with other follow-up series reporting comparable findings.6,7,9,10 One-third of deaths after COA repair are likely attributable to ischemic heart disease, with the most common cause of death being myocardial infarction.7 Because obesity is strongly associated with both hypertension and atherosclerotic vascular disease, conditions that occur at an accelerated rate after COA repair, the primary objective of this study was to determine whether individuals with repaired COA were more likely to develop obesity compared with either the general population or with others with isolated forms of congenital heart disease. We also attempted to determine whether obesity was associated with the development of hypertension after COA repair.
Methods All individuals with COA, with or without a ventricular septal defect, who underwent repair at the University of Michigan between 1974 and 2009 and were serially followed at the University of Michigan were included in this cross-sectional study with retrospective chart review as long as they were older than 4 years of age at their most recent clinic visit and had a clinic visit after 2003. Exclusion criteria included any chromosomal anomaly, complex congenital heart disease such as hypoplastic left heart
AS ASD BMI BMIz COA NHANES III PS SBP SBPz
Aortic valve stenosis Atrial septal defect Body mass index Body mass index z-score Coarctation of the aorta The Third National Health and Nutrition Examination Survey Pulmonary valve stenosis Systolic blood pressure Systolic blood pressure z-score
From the Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI The authors declare no conflicts of interest. Portions of the study were presented as a poster at the American Heart Association Scientific Sessions, in Orlando, FL, November 12-16, 2011. 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.01.043
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Vol. 164, No. 5 May 2014 syndrome or Taussig Bing anomaly, or congestive heart failure defined as an ejection fraction less than 35% on echocardiogram or requiring medical therapy such as diuretics or afterload reduction. The study was approved by the University of Michigan Institutional Review Board. Eligible patients were identified from the University of Michigan Congenital Heart Center database. To determine whether an increase in body mass index (BMI) was specific to COA or whether this also was observed in other individuals with congenital heart disease, patients with COA who were 20 years of age or older were compared with adult individuals with isolated aortic valve stenosis (AS), pulmonary valve stenosis (PS), or atrial septal defect (ASD), as long as they were serially followed at the University of Michigan with 3 or more visits at 5, 10, 15, and 20 years of age. Exclusion criteria were as stated previously and also included subaortic stenosis and mitral valve stenosis. Individuals with AS were of particular interest, given that both COA and AS have a male predominance, most patients with COA also have aortic valve abnormalities, and both COA and AS may share a common genetic basis. PS and ASD were chosen as these are isolated lesions that still require follow-up into adulthood. Data collected from the most recent clinic visit included sex, race/ethnicity, age at intervention, height, weight, BMI, arm systolic blood pressures (SBPs) for all subjects, and leg SBPs and development of recoarctation for the subjects with COA. When available in the medical record, height, weight, BMI, and blood pressure measurements also were obtained at 5, 10, 15, and 20 years of age. Centers for Disease Control and Prevention data were used to define overweight and obesity with overweight defined as a BMI $85th and
C
hildhood obesity remains a major health concern, with the incidence dramatically increasing during the past 3 decades.1 In only a few studies have authors evaluated the prevalence of obesity in children with congenital heart disease. Pinto et al2 reported that 15.2% of patients diagnosed with congenital heart disease and followed in an outpatient pediatric cardiology clinic were obese. Unfortunately, childhood obesity has been shown to persist into adulthood, and with 35.7% of American adults currently meeting criteria for being obese, the number impacted by obesity is expected to increase.1,3 Just as obesity is associated with significant cardiovascular risk factors, coarctation of the aorta (COA) is also associated with an increased risk of early death and other life-long sequelae, including hypertension and premature coronary artery disease, even after successful repair.4-8 One postoperative follow-up study reports a mortality rate of 12% at a mean age of 32.5 years in patients 20 years after COA repair, with other follow-up series reporting comparable findings.6,7,9,10 One-third of deaths after COA repair are likely attributable to ischemic heart disease, with the most common cause of death being myocardial infarction.7 Because obesity is strongly associated with both hypertension and atherosclerotic vascular disease, conditions that occur at an accelerated rate after COA repair, the primary objective of this study was to determine whether individuals with repaired COA were more likely to develop obesity compared with either the general population or with others with isolated forms of congenital heart disease. We also attempted to determine whether obesity was associated with the development of hypertension after COA repair.
Methods All individuals with COA, with or without a ventricular septal defect, who underwent repair at the University of Michigan between 1974 and 2009 and were serially followed at the University of Michigan were included in this cross-sectional study with retrospective chart review as long as they were older than 4 years of age at their most recent clinic visit and had a clinic visit after 2003. Exclusion criteria included any chromosomal anomaly, complex congenital heart disease such as hypoplastic left heart
AS ASD BMI BMIz COA NHANES III PS SBP SBPz
Aortic valve stenosis Atrial septal defect Body mass index Body mass index z-score Coarctation of the aorta The Third National Health and Nutrition Examination Survey Pulmonary valve stenosis Systolic blood pressure Systolic blood pressure z-score
From the Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI The authors declare no conflicts of interest. Portions of the study were presented as a poster at the American Heart Association Scientific Sessions, in Orlando, FL, November 12-16, 2011. 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.01.043
1074
Vol. 164, No. 5 May 2014 syndrome or Taussig Bing anomaly, or congestive heart failure defined as an ejection fraction less than 35% on echocardiogram or requiring medical therapy such as diuretics or afterload reduction. The study was approved by the University of Michigan Institutional Review Board. Eligible patients were identified from the University of Michigan Congenital Heart Center database. To determine whether an increase in body mass index (BMI) was specific to COA or whether this also was observed in other individuals with congenital heart disease, patients with COA who were 20 years of age or older were compared with adult individuals with isolated aortic valve stenosis (AS), pulmonary valve stenosis (PS), or atrial septal defect (ASD), as long as they were serially followed at the University of Michigan with 3 or more visits at 5, 10, 15, and 20 years of age. Exclusion criteria were as stated previously and also included subaortic stenosis and mitral valve stenosis. Individuals with AS were of particular interest, given that both COA and AS have a male predominance, most patients with COA also have aortic valve abnormalities, and both COA and AS may share a common genetic basis. PS and ASD were chosen as these are isolated lesions that still require follow-up into adulthood. Data collected from the most recent clinic visit included sex, race/ethnicity, age at intervention, height, weight, BMI, arm systolic blood pressures (SBPs) for all subjects, and leg SBPs and development of recoarctation for the subjects with COA. When available in the medical record, height, weight, BMI, and blood pressure measurements also were obtained at 5, 10, 15, and 20 years of age. Centers for Disease Control and Prevention data were used to define overweight and obesity with overweight defined as a BMI $85th and
