Prognostic Impact of Obesity, Cardiometabolic Risk Factors, and Vascular Function Markers on Outcomes in Ischemic Cardiomyopathy

<b>Background/Objectives</b>: Ischemic cardiomyopathy is a major cause of morbidity and mortality. Obesity is paradoxically associated with better outcomes, while clustering of cardiometabolic risk factors (CMRFs)-diabetes mellitus, arterial hypertension, and hyperlipidemia-is associated with worse prognosis in heart failure (HF) patients. The interplay between vascular function, obesity and clustering of CMRFs in ischemic HF is not thoroughly investigated. <b>Methods</b>: In a prospective, single-center cohort study, 560 patients with ischemic cardiomyopathy were followed for a median of 43 months. Baseline BMI, CMRFs and markers of vascular function including flow-mediated dilation (FMD), and carotid-femoral pulse wave velocity (cf-PWV) were assessed. Major adverse cardiovascular events (MACE), including death, myocardial infarction, coronary revascularization, stroke, and hospitalization for heart failure or other cardiovascular causes, were recorded. Cox proportional hazards models and cubic spline analyses evaluated associations and nonlinear relationships. <b>Results</b>: Obesity was independently associated with a 50% lower risk of MACE (HR 0.50; 95% CI 0.32-0.981; <i>p</i> = 0.01) and improvement of FMD by 1% corresponded to a 7% reduction in MACE risk (HR 0.93; 95% CI 0.87-0.99; <i>p</i> = 0.03) after adjusting for multiple confounders. Clustering of all three CMRFs predicted greater MACE risk (HR 1.42; 95% CI 1.03-1.95; <i>p</i> = 0.03). No significant differences in FMD or cf-PWV were observed across BMI groups. cf-PWV values were impaired among patients with all 3 CMRFs but cf-PWV did not predict MACE. <b>Conclusions</b>: Higher BMI and FMD each independently predict improved outcomes in ischemic cardiomyopathy. The clustering of cardiometabolic risk factors is a strong predictor of adverse events.