Underweight Is Associated with Poor Prognosis in Heart Failure with Preserved Ejection Fraction
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Updated: Oct 19, 2025
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Published on: February 13, 2021
Yutaka Matsuhiro1, Masami Nishino1, Kohei Ukita1
1Division of Cardiology, Osaka Rosai Hospital.
Insights
Underweight patients with heart failure with preserved ejection fraction (HFpEF) in Asia face a significantly higher mortality risk. This finding challenges the obesity paradox in this specific population, highlighting underweight as a critical prognostic factor.
Area of Science:
- Cardiology
- Clinical Research
- Public Health
Background:
- The obesity paradox suggests better outcomes for overweight individuals with heart failure with preserved ejection fraction (HFpEF).
- Previous studies on underweight patients with HFpEF have yielded inconclusive results, often due to limited sample sizes.
- Underweight is disproportionately prevalent in Asian populations with HFpEF compared to Western populations.
Purpose of the Study:
- To investigate the prognostic significance of underweight in Asian patients diagnosed with HFpEF.
- To determine if underweight is associated with increased all-cause mortality in this demographic.
Main Methods:
- Analysis of 846 consecutive patients from the PURSUIT-HFpEF registry.
- Classification of patients into underweight (BMI < 18.5 kg/m²), normal weight (18.5 ≤ BMI < 23), and overweight (23 ≤ BMI) groups.
- Multivariable Cox regression analysis was performed to assess mortality risk, adjusting for clinical factors.
Main Results:
- The underweight group comprised 187 patients (22% of the cohort).
- Over a mean follow-up of 407 days, 105 deaths occurred.
- Underweight status was significantly associated with a higher risk of all-cause mortality (HR: 2.33 for normal weight, HR: 3.54 for overweight) after adjustment.
Conclusions:
- Underweight is a significant predictor of poor prognosis in Asian patients with HFpEF.
- The findings suggest that underweight status should be carefully considered in risk stratification for HFpEF patients in Asian populations.
- This study underscores the need for further research into the specific mechanisms driving higher mortality in underweight HFpEF patients in Asia.
Abstract:
The obesity paradox states higher body mass index (BMI) is associated with better outcomes than normal weight in patients with heart failure with preserved ejection fraction (HFpEF). However, underweight was defined by BMI < 18.5 kg/m2, and results have been inconclusive, in part due to small number of participants. The number of underweight patients with HFpEF is higher in Asian than in Western countries. In this study, we aim to determine the prognostic impact of underweight in patients with HFpEF in Asian population.We enrolled 846 consecutive patients from the PURSUIT-HFpEF registry. We then divided them into three groups by BMI, namely, underweight (BMI < 18.5 kg/m2), normal weight (18.5 ≤ BMI < 23), and overweight (23 ≤ BMI). The underweight group consisted of 187 patients (22%). Over a mean follow-up of 407 days, 105 deaths were reported as all-cause mortality. On multivariable Cox analysis, the underweight group was determined to be significantly associated with higher risk of all-cause mortality than the normal and overweight groups (Hazard ratios [HR]: 2.33; 95% confidence intervals [CI]: 1.45-3.75, P < 0.001; HR: 3.54; 95% CI: 1.99-6.29, P < 0.001, respectively), after adjustment for age, sex, vital signs, and comorbidities.Underweight is a useful predictor of poor prognosis in patients with HFpEF in Asian population.
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