Cardiovascular Impact of Metabolic Surgery Across Patient and Surgery Subgroups: A Systematic Review and...

Previous meta-analyses have shown that metabolic surgery reduces mortality as well as major adverse cardiovascular events. However, it remains underutilized as a cardiovascular intervention. This study aims to identify patient subgroups most likely to benefit as well as compare outcomes from different metabolic surgery procedures. We systematically searched online databases for comparative cohorts (surgery vs no surgery) with ≥4-year follow-up and >200 participants. The primary outcome was all-cause mortality; secondary outcomes were cardiovascular mortality, myocardial infarction, heart failure (HF), stroke, and new atrial fibrillation (AF). Only unadjusted hazard ratios (HR) were extracted using random-effects models, and meta-regression was performed to identify any significant predictors. We included 25 studies (n = 659,517). MS was associated with lower risk of mortality (18 studies; HR 0.55 (95% CI [0.45, 0.67], p < 0.001), cardiovascular mortality (4; 0.36, [0.18, 0.72], p = 0.004), myocardial infarction (6; 0.61 [0.41, 0.90], p = 0.01), new HF (7; 0.55 [0.47, 0.65], p < 0.001), stroke (6, 0.80 [0.66 to 0.96], p = 0.02), and AF (3, 0.70 [0.55 to 0.89], p = 0.003). There were no specific study-level predictors that modified all-cause mortality. Associations were seen for cardiovascular mortality (ischemic heart disease, HF, and smoking) and AF (younger age, smoking). Benefits across all end points were consistent regardless of procedure subtypes. In conclusion, MS confers broad cardiovascular benefit with minimal effect modification from specific patient factors. Individual patient-level analyses and comparisons with modern incretin therapies are warranted.