Effects of Left Ventricular Geometry and Obesity on Mortality in Women With Normal Ejection Fraction Dharmendrakumar A. Patel, MD, MPH a , Carl J. Lavie, MD b,c, *, Surya M. Artham, MD d , Richard V. Milani, MD b , Gustavo A. Cardenas, MD e , and Hector O. Ventura, MD b Left ventricular (LV) geometry is an independent predictor of cardiovascular morbidity and mortality. Although obesity is a known risk factor for cardiovascular diseases, studies have suggested a paradoxical relation between obesity and prognosis. We retrospectively assessed 26,126 female patients with normal LV ejection fraction to determine the impact of LV geometry, including normal structure, concentric remodeling, and eccentric or concentric LV hypertrophy, and obesity on mortality during an average follow-up of 1.7 years. Abnormal LV geometry occurred more commonly in obese (body mass index ‡30 kg/m 2 ,n [ 10,465) compared with nonobese (body mass index <30 kg/m 2 ,n [ 15,661) patients (56% vs 47%, respectively, p <0.0001). Overall mortality, however, was consider- ably less in obese compared with nonobese patients (5.6% vs 8.7%, respectively, p <0.0001). In both groups, progressive increases in mortality were observed from normal structure to concentric remodeling and then to eccentric and concentric LV hypertrophy (obese patients 2.9%, 6.5%, 6.7%, and 11.1%, respectively, and nonobese patients 5.3%, 10.6%, 11.4%, and 16.8%, respectively, p <0.0001 for trend). In conclusion, although an obesity paradox exists, in that obesity in women is associated with abnormal LV geometry but less mortality, our data demonstrate that abnormal LV geometric patterns are highly prevalent in both obese and nonobese female patients with normal ejection fraction and are associated with greater mortality. Ó 2014 Elsevier Inc. All rights reserved. (Am J Cardiol 2014;113:877e880) Obesity is a strong risk factor for the development of left ventricular (LV) hypertrophy. 1 Both obesity and LV hy- pertrophy has been independently shown to predict adverse cardiovascular (CV) outcomes. 2e5 However, obese patients with known CV diseases such as heart failure have been shown to have better prognosis compared with leaner pa- tients with similar disease processes, highlighting an “obesity paradox.” 2,6e10 In the present study, in 26,216 female patients with normal systolic function, we assessed the prevalence of abnormal LV geometric patterns in both obese and nonobese female patients, the impact of obesity on these individual geometric patterns, and the independent effects of LV geometry and obesity on all-cause mortality. Methods We obtained relevant clinical and echocardiographic data from Ochsner clinical echocardiography database (CVIS) of 26,126 studies that were recorded at Ochsner Clinic Foun- dation (New Orleans, Louisiana) from January 2004 to December 2006. Patients who were selected had normal LV ejection fraction (LVEF, defined as LVEF 50%) and absence of moderate or severe valvular heart disease. Pa- tients with missing clinical or echocardiographic informa- tion were also excluded from the study. Survival status for the entire cohort was obtained from the National Death In- dex during a mean follow-up of 1.7  1.0 years. The end point was death due to all causes. This study was approved by the Institutional Review Board of the Ochsner Clinic Foundation. Height and weight were measured to calculate body mass index (BMI ¼ weight in kilograms divided by the square of the height in meters). Obesity was defined as BMI 30 kg/m 2 . Echocardiographic examinations were performed using a standard protocol. The LV dimensions and wall thickness were measured and LV mass was calculated 11 as recommended by the American Society of Echocardiog- raphy. 12 Using LV mass indexed to body surface area (LV mass index), LV hypertrophy was considered present in women when the LV mass index was >95 g/m 2 . Relative wall thickness (RWT) was calculated as 2  (posterior wall thickness in diastole)/(LV internal diameter). Increased RWT was present when this ratio was >0.42. 12 Using the gender- specific criteria recommended by the American Society of Echocardiography, 12 the normal geometry was present when both LV mass index and RWT were normal (LV mass index 95 g/m 2 and RWT 0.42); increased RWT (>0.42) and normal LV mass index (95 g/m 2 ) was classified as concentric remodeling, increased LV mass index (>95 g/m 2 ) but normal RWT (0.42) identified eccentric LV hypertro- phy, and increase in both RWT (>0.42) and LV mass index (>95 g/m 2 ) represented concentric LV hypertrophy. 13 a UT Erlanger Cardiology, Erlanger Health System, Chattanooga, Ten- nessee; b Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School—The University of Queensland School of Medicine, New Orleans, Louisiana; c Department of Preventive Medicine, Pennington Biomedical Research Center, Louisiana State Uni- versity System, Baton Rouge, Louisiana; d Sanford Cardiology, Bismarck, North Dakota; and e Palm Beach Heart Associates and University of Miami- Miller School of Medicine, Atlantis, Florida. Manuscript received October 16, 2013; revised manuscript received and accepted November 14, 2013. See page 879 for disclosure information. *Corresponding author: Tel: (504) 842-5874; fax: (504) 842-5875. E-mail address: clavie@ochsner.org (C.J. Lavie). 0002-9149/14/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. www.ajconline.org http://dx.doi.org/10.1016/j.amjcard.2013.11.041