Cardiology
Kevin Willmann
A scientific statement published on June 13, 2025, in the Journal of the American College of Cardiology reveals the challenges that remain in treating patients with obesity and heart failure. These include the question of whether BMI is an optimal metric to measure obesity, as well as the safety profile of medications such as semaglutide and tirzepatide and their overall impact on weight loss.
In fact, the expanding therapeutic landscape of safe and effective anti-obesity medications with evidence of added benefit in obesity-related comorbidities, including CVD, obstructive sleep apnea, and metabolic dysfunction–associated steatotic liver disease, motivated the American College of Cardiology report, said Michelle M. Kittleson, MD, from Smidt Heart Institute at Cedars-Sinai California Heart Center in Los Angeles, and chair of the writing committee.
“Insufficient evidence exists to date to confidently conclude that semaglutide and tirzepatide reduce [heart failure] events in individuals with [HFpEF] and obesity, with stronger evidence for tirzepatide,” Kittleson said. She did note that some exploratory research has shown favorable changes in biomarkers and imaging parameters in patients using the drugs, which suggests potential advantages for them besides weight loss.
The report authors noted that while BMI has been the key metric for identifying obesity both in research and clinical practice, significant limitations exist in the detection of excess adiposity, the location of adiposity, and its applicability to diverse populations.
The authors recommend direct assessment of excess adiposity with an anthropometric criterion—examples include waist circumference, waist-to-hip ratio, or waist-to-height ratio—or a body composition assessment using DEXA, when available.
For strategies to manage obesity for patients with heart failure, Kittleson said behavioral and lifestyle changes for weight loss are appropriate because even modest changes in body weight can result in improvements in cardiovascular risk events. Exercise can improve functional status in individuals with HFpEF as well.
The report noted that, where behavioral changes resulted in an average 5% to 10% weight loss in patients, the percentage of weight loss went up to 10% to 20% with the use of medications and 10% to 30% with surgery. Additionally, where weight could be regained with cessation of anti-obesity medications, weight loss was often sustained over years with surgery.
The authors also cautioned clinicians to be aware that obesity remains a stigmatized condition for many patients.
Takeaways for pharmacists
During the early-phase gradual dose escalation of semaglutide or tirzepatide, which occurs every 4 weeks, Kittleson recommended the treating physician monitor the kidney function and electrolytes of patients taking the medication, with adjustment of diuretics, antihypertensive agents, and antihyperglycemic agents as indicated, particularly if GI adverse effects are prominent.
“Cardiometabolic clinics may improve care delivery to individuals with obesity,” Kittleson said. “These could serve as a dedicated, multidisciplinary platform for the early detection, prevention, and comprehensive management of obesity and related comorbidities, such as diabetes, hypertension, dyslipidemia, and obesity.”
She said physicians, advanced practice professionals, pharmacists, and registered dieticians would be involved in the integration of the patient’s cardiology, endocrinology, nutrition, and behavioral therapy. This would optimize their metabolic risk factors, personalize treatment strategies and metabolic procedures, as well as provide structured follow up to improve long-term outcomes.
Kittleson also noted that it is essential for clinicians to consider anti-obesity interventions—such as behavioral modifications, medication, or surgery—as just one component of care for individuals with obesity. Cardiometabolic clinics could provide a multifaceted approach for long-term success for patients.
Challenges to care
Variations in clinical infrastructure, the need for standardized protocols, reimbursement limitations, and gaps in evidence guiding best practices for integration into heart failure care all remain challenges to cardiometabolic care, said Kittleson.
“Until such multidisciplinary systems are established, it’s essential for clinicians to provide ongoing longitudinal care that targets not just anti-obesity medication titration and tolerance, but also optimization of the related comorbidities including obesity, diabetes, dyslipidemia, metabolic dysfunction–associated steatotic liver disease, and chronic kidney disease,” Kittleson said. ■