Unmasking Risk Behind the Obesity-Paradox Signal: Prognostic Value of CONUT Score Combined with BMI

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Coronary artery disease (n=631). Intervention: Malnutrition combined with obesity (CONUT score ≥ 2 and BMI ≥ 25 kg/m2) vs. Non-malnourished, obese patients (CONUT score 0-1 and BMI ≥ 25 kg/m2). Primary outcome: Composite of all-cause death, non-fatal myocardial infarction, stent thrombosis, heart-failure hospitalization, major bleeding, stroke, and venous thromboembolism (HR 2.25, 95% CI 1.01-5.00, p=0.047).

Ran Sumida; Riku Arai; Yasunari Ebuchi; Keisuke Kojima; Michiaki Matsumoto; N Matsumoto; Tomoyuki Morikawa; Wataru Atsumi; Eizo Tachibana; Hironori Haruta; Takaaki Kogo; K Nomoto; Masaru Arai; Ken Arima; Takashi Mineki; Yutaka Koyama; Koji Oiwa; Yasuo Okumura; SAKURA PCI2 Antithrombotic Registry Investigators

doi:10.1536/ihj.25-603

Key result

Malnutrition combined with obesity significantly increased the risk of composite adverse events by 2.25-fold compared to non-malnourished obese patients undergoing percutaneous coronary intervention.

Why the study?

The obesity paradox suggests better outcomes in overweight cardiovascular patients, but the prognostic role of poor nutritional status remains unclear.

Does combining the CONUT score with BMI refine the prognostic interpretation of the obesity paradox in patients undergoing PCI?

Key Points

To evaluate whether combining body mass index with the Controlling Nutritional Status (CONUT) score refines risk stratification and clarifies the obesity-paradox signal in patients undergoing percutaneous coronary intervention.
Analyzed 631 patients with coronary artery disease undergoing percutaneous coronary intervention from the SAKURA PCI2 Registry enrolled between 2020 and 2022, with a median follow-up of 652 days (IQR 474-884).
Stratified patients on admission into four cohorts based on CONUT score (0-1 vs. 2-12) and body mass index (< 25 vs. ≥ 25 kg/m²): Group 1 (n = 146), Group 2 (n = 138), Group 3 (n = 241), and Group 4 (n = 106).
Composite adverse events occurred in 19.5% of patients overall; rates were lowest in non-malnourished obese patients (6.5%) compared with non-malnourished non-obese (16.4%, P = 0.009), malnourished obese (25.5%), and malnourished non-obese patients (26.1%, P = 0.90 vs. malnourished obese).
In multivariate Cox regression using non-malnourished obese patients as reference, malnutrition predicted worse outcomes in both non-obese (adjusted HR 2.18, 95% CI 1.03-4.59, P = 0.041) and obese patients (adjusted HR 2.26, 95% CI 1.02-5.01, P = 0.046), whereas non-malnourished non-obese status did not (adjusted HR 1.90, 95% CI 0.87-4.15, P = 0.11).

Study Design

Type

Observational (n=631)

Multicenter

Yes

Structured PICO

Does combining the CONUT score with BMI refine the prognostic interpretation of the obesity paradox in patients undergoing PCI?

P

Population

631 patients with coronary artery disease (CAD) undergoing percutaneous coronary intervention (PCI)

I

Intervention

Stratification by nutritional status (CONUT score ≥ 2) and obesity (BMI ≥ 25 kg/m2)

C

Comparator

Non-malnourished, obese patients (CONUT score 0-1 and BMI ≥ 25 kg/m2)

O

Outcome

Composite of adverse clinical events (all-cause death, non-fatal myocardial infarction, stent thrombosis, hospitalization for heart failure, BARC type 3 or 5 bleeding events, stroke, and venous thromboembolism)composite

Main Result

Effect estimate: HR 2.25 (95% CI 1.01-5.00)

Absolute Event Rate: 25.5% vs 6.5%

p-value: p=0.047

Limitations

Observational design conducted in a single country limits generalizability to other settings and populations.
BMI and CONUT were measured only at admission, failing to capture temporal changes during hospitalization or follow-up.
Lack of direct body composition assessments precluded a definitive diagnosis of sarcopenic obesity.
Limited assessment of inflammation (only total leukocyte count available) and potential unmeasured confounding.
Exclusion of patients with missing nutritional or BMI data may have introduced selection bias.

Implication

May warrant CONUT assessment with BMI in obese PCI patients for improved risk stratification; extends prognostic interpretation of the obesity paradox.[[1]](https://read.qxmd.com/read/41922281/unmasking-risk-behind-the-obesity-paradox-signal-prognostic-value-of-conut-score-combined-with-bmi)[[1]](https://read.qxmd.

Abstract

The "obesity paradox" suggests better outcomes in overweight cardiovascular patients, yet the prognostic role of poor nutritional status-even in obese individuals-remains unclear. We evaluated whether combining body mass index (BMI) with the Controlling Nutritional Status (CONUT) score refines interpretation of the obesity-paradox signal in patients undergoing percutaneous coronary intervention (PCI).

Discussion

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Cite This Study

Sumida et al. (2026) conducted an observational in Coronary artery disease (n=631). Malnutrition combined with obesity (CONUT score ≥ 2 and BMI ≥ 25 kg/m2) vs. Non-malnourished, obese patients (CONUT score 0-1 and BMI ≥ 25 kg/m2) was evaluated on Composite of all-cause death, non-fatal myocardial infarction, stent thrombosis, heart-failure hospitalization, major bleeding, stroke, and venous thromboembolism (HR 2.25, 95% CI 1.01-5.00, p=0.047). Malnutrition combined with obesity significantly increased the risk of composite adverse events by 2.25-fold compared to non-malnourished obese patients undergoing percutaneous coronary intervention.

synapsesocial.com/papers/69cd79bb5652765b073a694b https://doi.org/10.1536/ihj.25-603

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Unmasking Risk Behind the Obesity-Paradox Signal: Prognostic Value of CONUT Score Combined with BMI

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Unmasking Risk Behind the Obesity-Paradox Signal: Prognostic Value of CONUT Score Combined with BMI

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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