Near-universal prevalence of central adiposity in heart failure with preserved ejection fraction: the PARAGON-HF trial.

Summary

In PARAGON-HF, 96% of HFpEF patients had central adiposity (WHtR ≥0.5) and WHtR, more than BMI, showed a linear association with adverse HF outcomes without an obesity survival paradox. WHtR identified more high-risk patients and challenges BMI reliance in HFpEF characterization and risk stratification.

Key Findings

• Central adiposity (WHtR ≥0.5) was present in 96% of HFpEF patients; 37% of non-obese (BMI <30 kg/m2) had marked central adiposity (WHtR ≥0.6).
• WHtR showed a linear association with total HF hospitalizations and identified a larger high-risk fraction than BMI.
• The obesity survival paradox seen with BMI in unadjusted analyses was not observed with WHtR.

Clinical Implications

In HFpEF clinics, incorporate waist-to-height ratio to refine risk stratification and counseling; consider targeting central adiposity in lifestyle and therapeutic strategies rather than BMI alone.

Limitations

• Post hoc analysis; potential residual confounding and selection inherent to trial enrollment.
• Anthropometric measures limited to BMI and WHtR; no imaging-based adiposity quantification.

Future Directions

Prospective validation of WHtR-guided risk stratification and trials targeting central adiposity (e.g., exercise, nutrition, pharmacologic weight reduction) in HFpEF.