Abstract: Background Obesity is closely related to the occurrence and development of dilated cardiomyopathy (DCM). Differences in clinical characteristics of dilated cardiomyopathy patients with distinct weight status and the prognostic value of weight management have not been clarified. Objective To explore the baseline clinical characteristics of DCM patients with different weight statuses, and to analyze the impact of weight management on their prognosis. Methods This was a single center prospective cohort study. DCM patients were assigned into the normal group (BMI<24 kg/m2 ), overweight group (24 kg/m2≤BMI<28 kg/m2) and obese group (BMI ≥ 28 kg/m2 ) according to the body mass index (BMI). Baseline characteristics were collected. They were followed up for 12 months on telephone or outpatient visits. The incidence of major adverse cardiovascular events (MACEs) was recorded. According to the weight change during the 12-month weight management, they were divided into weight change <5%, 5% ≤ weight change <10% and ≥ 10% weight change groups. Plots of MACEs among the three groups and Kaplan-Meier survival curves were plots. Univariate and multivariate Cox regression and subgroup analyses were conducted to identify influlencing factors for MACEs in DCM patients. Results A total of 322 obese patients with DCM admitted to the Affiliated Hospital of Jiangsu University from January 2022 to June 2024 were prospectively collected. They were divided into the normal group (84 cases), overweight group (132 cases) and obese group (106 cases) according to baseline BMI. There were significant differences in age, systolic blood pressure, diastolic blood pressure, left ventricular end-systolic diameter (LVSd), comorbidities (hypertension, diabetes, coronary atherosclerosis), lifestyle (smoking history), and drug use[ orlistat, glucagon-like peptide-1(GLP-1) agonists, soluble guanylate cyclase(GC)] agonists] among the three groups (all P<0.05) . There were significant differences in admission body weight, follow-up brain natriuretic peptide (BNP), follow-up left ventricular ejection fraction (LVEF), follow-up cardiac function, follow-up MACEs and GLP-1 agonist use among the weight change <5%, 5% ≤ weight change<10% and ≥ 10% weight change groups (P<0.05). The range of weight change during the 12-month follow-up was linearly related to follow-up BNP (r=-0.158, P=0.004) and LVEF (r=0.229, P<0.001). The Kaplan-Meier survival curve showed a significant difference in the incidence of MACEs among the weight change <5%, 5% ≤ weight change<10% and ≥ 10% weight change groups (χ2 =16.83, P<0.001). Univariate Cox proportional hazards regression model analysis showed that follow-up BNP, LVEF, follow-up cardiac function, weight change, and the use of GLP-1 receptor agonists, mineralocorticoid receptor antagonist (MRA), and sodium-glucose cotransporter-2 inhibitor (SGLT2i) were independent influencing factors for MACEs in DCM patients (P<0.05). After adjusting for gender, diabetes, smoking history, drinking history, and drug use, MACEs was the dependent variable and weight change was the independent variable. Multivariate Cox proportional hazards regression model showed that weight change was independently related to the occurrence of MACEs in DCM patients (P<0.05). Subgroup analysis results showed that increased weight change was significantly associated with a reduced risk of MACEs (HRoverall=0.89, 95%CI=0.81-0.98, P=0.018). The interaction analysis showed the increase in weight change was consistent with the risk of MACEs in DCM patients stratified by gender, age, diabetes, and use of SGLT2i, MRA or GLP-1 receptor agonists (Pinteraction>0.05), all showing a protective effect. The association between weight change and the risk of MACEs in DCM patients was significantly different among patients who used β-blockers or not (Pinteraction =0.004). Conclusion DCM patients with a BMI ≥ 24 kg/m2 are younger and more likely to have metabolic disorders like hypertension and diabetes. After 12 months of weight management, DCM patients with a weight loss of ≥ 10% have the most significant improvement in cardiac function, manifesting as significantly decreased BNP and increased LVEF at follow-up, and the lowest incidence of MACEs. Structured weight management with the goal of weight loss ≥ 10% is therefore recommended to be included in the comprehensive treatment of overweight/obese DCM patients to improve their cardiac function and clinical prognosis.

Key words: Overweight, Obesity, Body weight changes, Weight management, Qbesity paradox, Dilated cardiomyopathy, Prognosis

摘要： 背景 肥胖与扩张型心肌病（DCM）的发生、发展密切相关，但不同体重状态扩心病患者的临床特征差异及体重管理的预后价值尚未明确。目的 探讨不同体重状态DCM患者的基线临床特征，并分析体重管理对其预后的影响。方法 本研究为单中心前瞻性队列研究，依据BMI将患者分为正常组（BMI<24 kg/m2）、超重组（24 kg/m2≤BMI<28 kg/m2）及肥胖组（BMI≥28 kg/m2），收集患者的基本临床资料，出院后通过门诊或电话进行12个月的随访，记录患者主要不良心血管事件（MACE）事件发生情况。依据12个月体重管理幅度将患者分为体重变化幅度<5%组、5%≤体重变化幅度<10%组、体重变化幅度≥10%组，绘制3组患者MACE及生存时间的Kaplan Meier生存曲线，采用单因素、多因素Cox比例风险回归模型及亚组分析评估体重管理对DCM患者MACE发生风险的影响。结果 前瞻性收集江苏大学附属医院2022年1月—2024年6月收治的肥胖合并DCM患者322例，根据基线BMI分为正常组（84例）、超重组（132例）和肥胖组（106例），3组患者年龄、收缩压、舒张压、左心室收缩末内径（LVSd），高血压、糖尿病、冠状动脉粥样硬化、吸烟史比例，以及可溶性鸟苷酸环化酶（sGC）激动剂、奥利司他、胰高血糖素样肽-1（GLP-1）受体激动剂使用情况比较，差异均有统计学意义（P<0.05）。不同体重变化幅度的3组DCM患者入院体重、随访B型钠尿肽（BNP）、随访左心室射血分数（LVEF）、随访心功能、随访期间MACE及GLP-1受体激动剂使用情况比较，差异有统计学意义（P<0.05）。随访12个月的体重变化幅度与随访BNP（r=-0.158，P=0.004）、LVEF（r=0.229，P<0.001）呈线性关系。Kaplan Meier生存曲线显示，不同体重变化幅度的3组DCM患者MACE发生率比较，差异有统计学意义（χ2 =16.83，P<0.001）。单因素Cox比例风险回归模型分析显示：随访BNP、LVEF、随访心功能、体重变化幅度及使用GLP-1受体激动剂、醛固酮受体拮抗剂（MRA）、钠-葡萄糖协同转运蛋白2抑制剂（SGLT2i）是DCM患者发生MACE的独立影响因素（P<0.05）。在调整性别、糖尿病、吸烟史、饮酒史、药物使用后，以MACE为因变量，体重变化幅度为自变量，多因素Cox比例风险回归模型调整协变量分析结果显示，体重变化幅度与DCM患者的MACE发生独立相关（P<0.05）。亚组分析结果显示，体重变化幅度的增加与MACE风险降低相关（HR总体 =0.89，95%CI=0.81~0.98，P=0.018）。交互作用显示，在不同性别、年龄、是否合并糖尿病，以及是否使用SGLT2i、MRA或GLP 1受体激动剂的患者群体中，体重变化幅度的增加与DCM患者MACE发生风险关系一致（P交互>0.05），均呈现保护效应；体重变化幅度与DCM患者MACE发生风险的关系在是否使用β受体阻滞剂的患者中存在显著差异（P交互 =0.004）。结论 BMI≥24 kg/m2的扩张型心肌病患者临床特征更年轻，且合并高血压、糖尿病等代谢紊乱的比例更高。实施为期12个月的体重管理后，体重减轻幅度≥10%的患者心功能改善最为显著，表现为随访BNP显著下降、随访LVEF明显提升，且主要不良心血管事件发生率最低。因此，建议将以减轻体重≥10%为目标的结构化体重管理纳入超重/肥胖DCM患者的综合治疗，以改善其心功能与临床预后。

关键词: 超重, 肥胖症, 体重变化, 体重管理, 肥胖悖论, 扩张型心肌病, 预后