Impact of Metabolic Surgery on Cardiovascular Disease Outcomes

Obesity is strongly associated with a range of cardiovascular conditions, including coronary artery disease, heart failure, atrial fibrillation, and stroke. Metabolic surgery has emerged as one of the most effective interventions for individuals with severe obesity, not only by promoting substantial and durable weight loss but also by improving cardiovascular risk factors and outcomes. Cardiovascular benefits may also be mediated via weight-independent mechanisms involving insulin sensitivity, gastrointestinal hormones, bile acid dynamics, and gut microbiome. Long-term cohort studies have documented that metabolic surgery is associated with a reduction in all-cause mortality and major adverse cardiovascular events in this population. In this narrative review we examine the role of metabolic surgery in the prevention and management of cardiovascular disease associated with severe obesity. It provides an overview of the most common metabolic surgery procedures, including sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch, as well as newer procedures like single-anastomosis duodenal switch. We also evaluate the impact of these interventions on key cardiovascular risk factors, such as type 2 diabetes, hypertension, dyslipidemia, and obstructive sleep apnea, as well as their effects on cardiac structure and function. Metabolic surgery is associated with reductions in all-cause mortality and cardiovascular events, including myocardial infarction and heart failure, especially in individuals with obesity and pre-existing cardiovascular disease. The current evidence supporting the link between metabolic surgery and cardiovascular outcomes is reviewed. Notably, randomized trials specifically focusing on cardiovascular outcomes after metabolic surgery are lacking, which highlights an important knowledge gap and the crucial need for these studies. Addressing this gap is essential for guiding future clinical practice and optimizing patient care.