Metabolic health modifies SYNTAX II–Based revascularization risk beyond body mass index

Background Body mass index (BMI) is widely used for cardiovascular risk stratification, yet it fails to capture underlying cardiometabolic heterogeneity. Whether metabolic–obesity phenotypes are associated with differences in coronary disease complexity and revascularization risk remains incompletely defined. Objectives To evaluate the association between metabolic–obesity phenotypes and SYNTAX I, SYNTAX II scores, and predicted revascularization-related mortality. Methods In this retrospective single-center cohort study, 270 patients undergoing coronary angiography were classified into four metabolic–obesity phenotypes based on BMI (<30 or ≥30 kg/m²) and the presence of hypertension, diabetes mellitus, or dyslipidemia: metabolically healthy non-obese (MHNO), metabolically unhealthy non-obese (MUNO), metabolically healthy obese (MHO), and metabolically unhealthy obese (MUO). Anatomical disease complexity (SYNTAX I), clinically integrated risk assessment (SYNTAX II for PCI and CABG), and predicted 4-year mortality were compared across phenotypes using ANOVA with Tukey-adjusted post-hoc testing. Results Anatomical disease complexity assessed by SYNTAX I did not differ significantly among phenotypes (p=0.13). In contrast, SYNTAX II scores differed significantly for both PCI (p=0.013) and CABG (p=0.043). Predicted 4-year mortality following CABG also varied significantly across metabolic phenotypes (p=0.030), whereas EuroSCORE values were comparable (p=0.44). Tukey-adjusted pairwise analyses demonstrated that MUNO patients exhibited significantly higher SYNTAX II PCI scores and higher predicted PCI- and CABG-related 4-year mortality compared with MHNO patients, while no significant differences were observed among other phenotype pairs. Conclusions Metabolic health status, rather than BMI alone, is a key determinant of clinically integrated revascularization risk. Metabolically unhealthy non-obese patients represent a high-risk phenotype that may be underrecognized by BMI-based stratification. Incorporation of simple comorbidity-defined metabolic status may enhance Heart Team risk assessment and guide revascularization decision-making.