To the editor

We have read with great interest the results of the retrospective analysis by Kozieł et al,1 showing that the relative frequency of central obesity significantly increased among patients with established coronary artery disease (CAD) over an observation period of 20 years. Notably, as the researchers state, the results were significant only for male participants, while the impact of dysglycemia was also greater over time.1 As obesity represents an independent, strong cardiovascular risk factor, with increasing prevalence, especially in the Western world, it is undoubted that we need appropriate treatment options, besides lifestyle modification, including pharmacologic intervention and bariatric surgery in more severe cases.2

It seems that, especially as the prevalence of dysglycemia is high among obese patients with concomitant CAD, novel antidiabetic agents, namely glucagon-like peptide-1 receptor agonists (GLP-1RAs) and sodium-glucose co-transporter-2 (SGLT-2) inhibitors can play a catalytic role in the management of such patients, for the reduction of body weight and visceral adiposity, along with the optimal control of several other cardiovascular risk factors. Both drug classes are associated with significant decrease in the risk for myocardial infarction and cardiovascular death, as demonstrated in a recent meta-analysis of the first hallmark cardiovascular outcome trials in the field.3 Therefore, novel antidiabetic agents could be the ideal pharmacologic intervention for obese patients with concomitant CAD, even in the absence of diabetes mellitus, as more recent randomized controlled trials have established their cardiovascular efficacy also in nondiabetic individuals.

Bariatric surgery is indicated for patients with body mass index (BMI) greater than 40 kg/m2, or 35 kg/m2 for those with comorbidities. A question that arises is whether such an intervention is safe for patients with cardiovascular comorbidities and if the expected result can alter the overall prognosis. Recently published real-world data are really promising. Bariatric surgery in patients with severe obesity and concomitant type 2 diabetes mellitus in the absence of pre-existing CAD has been shown to reduce the 5-year risk for incident CAD, macrovascular composite outcome and all-cause death compared with the nonsurgical group.4 In a more recent retrospective cohort study, also enrolling subjects with type 2 diabetes mellitus and morbid obesity (including, however, participants with pre-existing CAD), it was demonstrated that metabolic surgery is associated with a significant decrease in the 8-year risk for the primary composite cardiovascular outcome and for CAD events, as well, compared with nonsurgical management.5

Collectively, it seems that we have, for the first time, treatment options for optimal management of obese patients with concomitant CAD, in order to decrease cardiovascular morbidity and mortality and all-cause mortality. It would be interesting to document prospectively in surveys similar to that conducted by Kozieł et al1 whether current knowledge affects physicians’ treatment preferences and the impact of such interventions on the quality of life and outcomes of specific interest of affected patients. In addition, it would be valuable to know whether there is a gender-specific phenotype and the effect of applied treatment on disease course and overall prognosis.