Contents lists available at ScienceDirect Atherosclerosis journal homepage: www.elsevier.com/locate/atherosclerosis Association between body mass index and clinical outcomes after new- generation drug-eluting stent implantation: Korean multi-center registry data Byung Gyu Kim a,b,1 , Sung-Jin Hong a,1 , Byeong-Keuk Kim a,* , Chul-Min Ahn a , Dong-Ho Shin a , Jung-Sun Kim a , Young-Guk Ko a , Donghoon Choi a , Myeong-Ki Hong a , Yangsoo Jang a a Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea b Division of Cardiology, Department of Internal Medicine, Seoul Paik Hospital, Inje University College of Medicine, Seoul, South Korea HIGHLIGHTS • Lower BMI was linked to worse outcomes after new-generation DES implantation. • This result was driven by not only mortality but also ischemic adverse events. • A BMI below 24 kg/m 2 was an independent predictor of MACCEs. • Patients with low BMI might have more atherosclerotic burden than those with high BMI. • Physicians should identify other risk factors and comorbidities in patients with low BMI. ARTICLE INFO Keywords: Body mass index Obesity Percutaneous coronary intervention Drug-eluting stent ABSTRACT Background and aims: It is unclear whether the obesity paradox is still apparent in the new-generation drug- eluting stent (DES) era. Therefore, we assessed the impact of body mass index (BMI) on clinical outcome after percutaneous coronary intervention (PCI) with new-generation DESs. Methods: A total of 5264 consecutive patients from 4 new-generation DES registries were divided into 4 cate- gories according to BMI: 1) underweight (BMI < 18.5 kg/m 2 , n = 130), 2) normal weight (18.5 ≤ BMI < 25 kg/ m 2 , n = 2943), 3) overweight (25 ≤ BMI < 30 kg/m 2 , n = 1932), and 4) obese (BMI≥30 kg/m 2 , n = 259). The primary endpoint was the occurrence of major adverse cardiac and cerebrovascular event (MACCE) at 12 months, including all-cause mortality, nonfatal myocardial infarction, stroke, and target-vessel revasculariza- tion. Results: The 12-month MACCE rates decreased according to increasing BMI categories. (underweight, 13.1%; normal, 6.0%; overweight, 4.8%; obese, 4.2%; p < 0.001). After adjustment for other confounders, the un- derweight group had significantly higher MACCE rates than the normal-weight (hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.33–0.99; p = 0.049), overweight (HR, 0.49; 95% CI, 0.27–0.88; p = 0.017), and obese (HR, 0.41; 95% CI, 0.18–0.98; p = 0.044) groups. These differences were mainly driven by all-cause mortality and target-vessel revascularization. When BMI was treated as a continuous variable, BMI per 1 kg/m 2 was also an independent predictor for MACCE (HR, 0.95; 95% CI, 0.91–0.99; p = 0.008) and a MACE increase began below a BMI of 24 kg/m 2 . Conclusions: Lower BMI was significantly associated with higher rates of MACCE and all-cause mortality after PCI. The obesity paradox is manifested in Korean patients in the new-generation DES era. https://doi.org/10.1016/j.atherosclerosis.2018.08.047 Received 21 June 2018; Received in revised form 29 July 2018; Accepted 30 August 2018 * Corresponding author. Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, 120Seoul, South Korea. 1 These authors contributed equally to this work. E-mail address: kimbk@yuhs.ac (B.-K. Kim). Atherosclerosis 277 (2018) 155–162 Available online 31 August 2018 0021-9150/ © 2018 Elsevier B.V. All rights reserved. T