When we think about heart failure, heart attacks are what most commonly jump to mind.  Is it possible that obesity can cause heart failure…. and could it be going undetected in many people?


First, a quick primer on heart failure.  There are two kinds of heart failure:

  • Heart failure with reduced ejection fraction (HFrEF) – when the heart is not able to contract properly, after having sustained damage (eg after a heart attack)
  • Heart failure with preserved ejection fraction (HFpEF) – when the heart can contract properly, but cannot relax properly, because it has become thick and rigid. This is the type of heart failure that is more closely associated with obesity


The vast majority (75-85%) of people with HFpEF heart failure have overweight or obesity.  There are many reasons for the strong link between obesity and HFpEF.  Obesity promotes inflammation, hypertension (high blood pressure), insulin resistance, and impairs cardiac (heart), arterial, skeletal muscle, and physical function.  Intra-abdominal fat (the metabolically unhealthy belly fat) in particular is a strong, independent negative predictor of physical function in HFpEF patients.


To make matters worse, HFpEF often goes undiagnosed.  It is somewhat insidious in nature, not having an ‘event’ in particular that sets it off.  It creeps up over time, and often, symptoms are often ‘written off’ by doctors to other causes.

Some signals of concern can include:

  • swelling of the ankles (often attributed by health care providers to obesity with poor lymphatic drainage)
  • shortness of breath on exertion (sadly, patients often being told they are simply ‘out of shape’)
  • sleeping poorly at night (Should sleep apnea be tested? Absolutely! But – has HFpEF been considered?)


HFpEF heart failure needs to be higher on the radar of health care professionals, particularly if there are symptoms such as the above. 



What can we do to treat HFpEF?

Well, there is evidence that weight loss can be of benefit in people with obesity and HFpEF. In a study published in JAMA, people with obesity and HFpEF  were randomized to dietary management, exercise, both, or neither.  They found that peak VO2 (a measure of exercise capacity) improved similarly with exercise and diet, and doing both together provided an additive benefit (greater than either alone).  Weight loss was associated with improvement in the symptom severity (NYHA class) of heart failure in this study.


Currently there are no available medications that have been proven to be of benefit in people with HFpEF.  However, the EMPEROR-preserved study, conducted in people with HFpEF with or without type 2 diabetes, released high level results recently, stating that empagliflozin (trade name Jardiance) reduced the risk of cardiovascular death or hospitalization for heart failure.  The data will be released at the end of this month (August 2021).  The SGLT2 inhibitor dapagliflozin is also under study in HFpEF patients with or without type 2 diabetes.


Semaglutide at a dose of 2.4mg weekly, now approved for weight management in USA (trade name Wegovy) is also currently under study in people with HFpEF heart failure and obesity (without, or with, type 2 diabetes)

Tirzepatide, a dual GLP1 and GIP agonist and up-and-coming potential treatment of diabetes and obesity, is also currently under study in people with HFpEF heart failure and obesity (with or without type 2 diabetes).

We await these data with great anticipation!


Disclaimer:  I receive honoraria as a continuing medical education speaker and consultant from the makers of empagliflozin (Boehringer Ingelheim/Eli Lilly), dapagliflozin (Astra Zeneca), semaglutide (Novo Nordisk), and tirzepatide (Eli Lilly). I have been involved as an investigator in clinical trials of semaglutide and tirzepatide.


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