International Journal of Cardiology Cardiovascular Risk and Prevention 23 (2024) 200331

Contents lists available at ScienceDirect

International Journal of Cardiology
Cardiovascular Risk and Prevention
journal homepage: www.journals.elsevier.com/international-journal-of-cardiology-
cardiovascular-risk-and-prevention

Review Article

Obesity and cardiovascular disease: Risk assessment, physical activity, and

management of complications
Francesco Perone a,* , Luigi Spadafora b, Alessandra Pratesi c , Giulia Nicolaio d , Barbara Pala e,
Giulia Franco f, Matteo Ruzzolini g , Marco Ambrosetti h
a
Cardiac Rehabilitation Unit, Rehabilitation Clinic "Villa delle Magnolie", 81020, Castel Morrone, Caserta, Italy
b
Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
c
Internal Medicine 1, San Jacopo Hospital, Pistoia, Italy
d
Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
e
Division of Cardiology, Department of Clinical and Molecular Medicine, University of Rome Sapienza, Sant’Andrea Hospital, 00189, Rome, Italy
f
Cardiac Rehabilitation Unit, Cardiovascular Department, University and Hospital of Trieste, 34122, Trieste, Italy
g
Cardiology Department, Isola Tiberina-Gemelli Isola Hospital, Rome, Italy
h
Cardiovascular Rehabilitation Unit, ASST Crema, Santa Marta Hospital, Rivolta D’Adda, Italy

A R T I C L E I N F O A B S T R A C T

Handling editor: D Levy The patient with obesity is at risk of developing cardiovascular disease and risk factors. Obesity negatively
impacts prognosis and increases cardiovascular morbidity and mortality. Therefore, a comprehensive risk
Keywords: assessment is needed to define the cardiovascular risk of the patient and, thus, a tailored management and
Obesity treatment. Chronic and successful management of these patients involves the evaluation of the various thera­
Cardiovascular disease
peutic strategies available (comprehensive lifestyle intervention, weight-loss medications, and bariatric surgery)
Physical activity
and the diagnosis and treatment of cardiovascular complications (coronary artery disease, heart failure, and
Cardiac rehabilitation
Atrial fibrillation atrial fibrillation). Cardiac rehabilitation in patients with obesity is showing beneficial effect and a positive
Heart failure impact on weight loss, cardiovascular risk factors, mental health, functional capacity, and adherence to lifestyle
Coronary artery disease interventions and pharmacological treatment. Long-term weight loss and maintenance represent a key objective
during the management of the patient with obesity to reduce the risk of future adverse events. Multidisciplinary
management and interventions are necessary to prevent and reduce overall cardiovascular risk and mortality.
The aim of our review is to propose a comprehensive, critical and updated overview regarding risk assessment,
physical activity, and the management of cardiovascular complications in patient with obesity.

1. Introduction mass and muscle mass [2,3]. Consequently, recent insights indicate the
existence of various obesity phenotypes, advocating for the integration
Obesity is deemed to be the pandemic of our times, surging to un­ to BMI of tools such as abdominal circumference assessment and visceral
precedented levels of prevalence, with estimates indicating a two-fold fat evaluation [2,3]. The complexity of obesity emerges from genetic,
increase compared to the mid-20th century [1]. This phenomenon is organic, socio-economic, and psycho-social factors, contributing to its
particularly pronounced in Western countries and the younger popula­ characterization as a multifactorial condition [2,4]. This intricate
tion, outlining a substantial challenge for public health [2]. Globally, it context becomes even more critical when considering the interplay be­
is estimated that 39%–49 % of the population is either overweight or tween obesity, dysmetabolism, and cardiovascular risk factor­
obese [2]. According to the World Health Organization (WHO), obesity s/complications [1]. The scientific community is increasingly focusing
is defined as an abnormal accumulation of adipose tissue, with diagnosis on enhancing outcomes and the quality of life for patients dealing with
based on the Body Mass Index (BMI) [2]. A BMI of 25 signifies over­ both obesity and cardiovascular comorbidities [2,5]. Recent de­
weight, while 30 characterizes obesity type 1, however, this BMI-centric velopments, exemplified by the SELECT [6] and STEP-HFpEF [7] trials
definition may prove limiting as it does not discriminate between fatty in 2023, underscore the utilization of Glucagon-like peptide 1 (GLP-1)

* Corresponding author.
E-mail address: francescoperone1988@gmail.com (F. Perone).

https://doi.org/10.1016/j.ijcrp.2024.200331
Received 25 July 2024; Accepted 31 August 2024
Available online 5 September 2024
2772-4875/© 2024 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
F. Perone et al. International Journal of Cardiology Cardiovascular Risk and Prevention 23 (2024) 200331

receptor agonist antidiabetic drugs within the specific context of 2. Risk assessment in patient with obesity
obesity. This because obesity propels the development of numerous
cardiovascular risk factors, thereby facilitating the onset of A holistic approach to risk assessment in obese patients involves a
cardio-metabolic imbalance [2,3]. The link between obesity and car­ thorough examination of cardiovascular risk factors, consideration of
diovascular risk factors, for instance, it is acknowledged as a robust risk modifiers, psychological assessment, evaluation of inflammatory
independent risk factor for arterial hypertension. Indeed, weight loss is burden, cardiovascular imaging, and assessment of visceral fat (Fig. 1)
recommended as first-line treatment in hypertension management, as [8]. To effectively mitigate this risk, a comprehensive risk assessment is
emphasized by current guidelines [8]. Furthermore, obesity is correlated pivotal, encompassing various dimensions of the patient’s health [8].
with heart failure, particularly with preserved ejection fraction [2,9]. Integrating these components into clinical practice facilitates a more
Obesity can exert an impact on both diastolic and systolic function, with nuanced understanding of the cardiovascular risk profile in obese in­
the incidence of heart failure escalating in relation to BMI [2,10]. dividuals, paving the way for personalized and effective risk manage­
Noteworthy inflammatory burden, fibroadipose infiltration, and the ment strategies, as well as the multidisciplinary treatment and
activation of various systems are believed to contribute to the myocar­ management of cardiovascular complications (Fig. 2).
dial remodeling underlying the development of heart failure with pre­
served ejection fraction (HFpEF) and atrial fibrillation [11]. In addition 2.1. Control of cardiovascular risk factors
is getting clear and clearer the role of epicardial fat, acting as a producer
of inflammatory mediators in an autocrine/paracrine manner, influ­ Central to any risk assessment in obese patients is the meticulous
encing coronary microcirculation and myocardial cells, thereby pro­ control of cardiovascular risk factors. Elevated blood pressure, dyslipi­
moting the mechanisms that lead to HFpEF [11]. Another crucial aspect demia, and impaired glucose metabolism are common companions of
involves the interplay between dyslipidemia and obesity, given that high obesity [2,3]. The assessment must include a thorough examination of
rates of dyslipidemia are prevalent in obesity, as evidenced by studies these factors, employing a combination of lifestyle modifications and
reporting rates of 42.9 % in obese children and adolescents [12]. pharmacological interventions [2,3]. Lifestyle interventions encompass
Moreover, obese patients exhibit significantly elevated levels of total dietary changes, regular physical activity, and smoking cessation, aim­
cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides ing to address the modifiable risk factors directly linked to obesity [3].
compared to non-obese individuals [2]. Given this profound connection, However, it should be borne in mind that a basal cardiovascular
obesity can aptly be recognized as a cardio-metabolic disease. Therefore, assessment, involving electrocardiogram (ECG), echocardiogram and
the aim of this review is to provide a comprehensive and current over­ blood analysis (e.g. lipid profile) should be undertaken even in absence
view of cardiovascular assessment, physical activity, and the manage­ of cardiological red flags or symptoms in obese patients [2,8]. Blood
ment of cardiovascular complications, such as coronary artery disease, pressure values should be also taken into account, possibly through a
heart failure, and atrial fibrillation, in patients with obesity. home-monitoring approach [2,3]. Poor evidence regards stress-ECG,
given also the limited functional capacity affecting many obese pa­
tients [2].

Fig. 1. Domains to be considered in risk assessment for the obese patient.

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F. Perone et al. International Journal of Cardiology Cardiovascular Risk and Prevention 23 (2024) 200331

Fig. 2. Pathway and comprehensive management of the patient with obesity: risk assessment, treatment and cardiovascular complications.

2.2. Risk modifiers aids in tailoring interventions to address the inflammatory component of
cardiovascular risk. Anti-inflammatory therapies, such as colchicine,
Risk modifiers are an important domain to be assessed when can now be administered in secondary prevention when traditional risk
exploring a patients’ cardiovascular risk, as clarified by 2021 European factors are poorly tamed despite optimal medical therapy: this paradigm
Society of Cardiology (ESC) guidelines on cardiovascular disease pre­ may hold particular importance in obese patients, given the great in­
vention [8]. Risk modifiers are more frequent in the obese population flammatory burden in this setting [2,3].
than in the non-obese population [2,3]. Factors such as genetic predis­
position, socio-economic status, and ethnicity can modify the cardio­ 2.5. Cardiovascular imaging
vascular risk associated with obesity [8]. Furthermore, it is essential to
take into consideration comorbidities such as endocrinological and Advancements in imaging technologies have revolutionized the
nephrological ones, chronic inflammatory diseases and also the possible assessment of cardiovascular risk, with particular regard to obesity [2].
presence of obstructive sleep apnea [3]. Tailoring risk assessment to Non-invasive imaging modalities as computed tomography (CT) angi­
account for these modifiers ensures a personalized approach to patient ography and magnetic resonance imaging (MRI) provide detailed in­
care, acknowledging the diverse nature of cardiovascular risk among sights into the structural and functional aspects of the cardiovascular
obese individuals [2,3]. system in obese patients, especially for the fact that their acoustic
windows are quite often suboptimal [2]. These imaging techniques aid
2.3. Psychological assessment in the early detection of atherosclerotic plaques, cardiac remodeling,
and other cardiovascular abnormalities, allowing for a more precise risk
The intricate interplay between mental health and cardiovascular assessment and targeted intervention in obese patients [2,3]. Last but
risk cannot be overstated [8]. Obesity often coexists with psychological not least, as highlighted previously, great importance is given nowadays
factors such as stress, depression, and anxiety, which can significantly to the evaluation of epicardial and pericardial adipose tissue [2].
impact cardiovascular health [13]. A comprehensive risk assessment
should, therefore, integrate a psychological evaluation, recognizing and 2.6. Assessment of visceral fat
addressing mental health aspects that may contribute to the overall
cardiovascular risk profile [13]. Visceral fat is a key player in the pathophysiology of obesity-related
cardiovascular complications [3]. Its close association with insulin
2.4. Evaluation of inflammatory burden resistance and dyslipidemia makes it a crucial parameter for cardio­
vascular risk assessment [2]. Goossens [14] highlighted the significance
Obesity is characterized by a chronic low-grade inflammatory state, of body fat distribution and adipose tissue function in metabolic health,
and assessing the inflammatory burden becomes pivotal in under­ noting that metabolically healthy obese individuals exhibit improved
standing cardiovascular risk. Elevated levels of inflammatory markers, adipose tissue function. Other authors have emphasized the existence of
such as C-reactive protein, may serve as indicators of heightened car­ normal-weight individuals with metabolic disorders, emphasizing the
diovascular risk in obese patients [4]. A thorough evaluation of in­ necessity for a deeper understanding of these obesity phenotypes [15].
flammatory status provides valuable insights for risk stratification and For instance, some specific serum biomarkers such as glutamine and

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F. Perone et al. International Journal of Cardiology Cardiovascular Risk and Prevention 23 (2024) 200331

lactate are being tested, distinguishing between normal-weight and implement primary and secondary prevention strategies. It is well
obese individuals and among different obesity types [16]. Utilizing known that obesity tends to mostly interest poor populations and lower
imaging techniques, such as dual-energy X-ray absorptiometry (DEXA) socio-economic adults living in high-income countries with a low cul­
or abdominal CT scans, may allow an accurate quantification of visceral tural level [26], affecting nowadays more women than men [27].
fat, enabling a more comprehensive evaluation of the patient’s cardio­ Indeed, obesity is a common disease in women who experience biolog­
vascular risk [17]. The assessment of visceral fat is not yet routine in ical and lifestyle changes at midlife and menopause period [28]. It is
clinical practice; however, it is undoubted that, due to the analyzed estimated that midlife women gain weight at an average of approxi­
physiopathological pathways, it can be of great assistance in the mately 1.5 pounds per year [29]. The change in the hormonal profile
approach to cardiovascular risk in this setting. which occurs progressively from the age of 40 onwards determines a
redistribution of body fat from the subcutaneous to the visceral areas,
3. Obesity, physical activity, and cardiac rehabilitation with a consequent increase in pro-inflammatory and atherogenic adi­
pose tissue, and therefore in cardiovascular risk [28,30]. However, it
Physical activity is a key intervention in patients with obesity to should be remembered that obesity was found to be the most important
reduce cardiovascular risk and promote long-term weight loss (Fig. 3) modifiable risk factor for hypertension and pre-hypertension even in
[5]. A systematic review and meta-analysis of randomized controlled reproductive age [31]. Also in women, obesity increases the risk of
trials (RCTs) demonstrated that lifestyle interventions prevented cu­ metabolic disorders (diabetes mellitus, dyslipidemia, polycystic ovary
mulative weight gain among non-obese adults and physical activity is syndrome, and fatty liver disease), cardiovascular diseases (arterial
considered a cornerstone of public health programs in prevention hypertension, coronary artery disease, heart failure, and stroke) and
perspective [18,19]. European Guidelines suggest to perform at least cancers (endometrium, ovary, and breast) [28]. The Framingham Heart
150 min per week of moderate-intensity endurance exercise training Study revealed that the excess risk of cardiovascular disease attributed
combined with three sessions of resistance exercise per week in in­ to obesity was 64 % in women and 46 % in men [32].
dividuals with obesity [20]. In addition to weight reducing, the bene­ In approaching obesity, it is crucial hot to measure the excess of
ficial effect of this intervention has a wide-ranging action by improving weight and the distribution of adiposity, to better profile the real car­
glucose tolerance, insulin sensitivity, lipid level, and general well-being diovascular burden (Table 1). However, a very large study, who
and reducing blood pressure, chronic inflammation, intra-abdominal fat recruited more than 500000 patients, showed that higher waist
mass, depression, and anxiety [8]. circumference and waist-to-hip ratio, that are measures of central
Cardiac rehabilitation in patients with obesity is showing interesting adiposity, are associated to a greater risk of myocardial infarction in
and emerging data on the beneficial effect both before (defined as women [33]. Even more, the waist-to-hip ratio seems to relate stronger
“prehabilitation”) [21] and after acute events, heart failure or invasive with myocardial infarction than BMI in both sexes, especially in women
interventions [5]. The aim of rehabilitation program is to improve [33]. In conclusion, obesity is a prevalent syndrome in women, leading
weight loss, adherence to a healthy diet, cardiovascular risk factors, to chronic and life-threatening diseases. Considering this, the Women’s
psychological well-being, and functional capacity. Several programs Preventive Services Initiative, a United States coalition of more than 21
have been suggested [22–25] but further studies are needed to stan­ health professional organizations and patient representatives, devel­
dardize exercise training and better characterize the prognostic role. oped some recommendations with the aim to reduce the burden of
Resistance training should be performed with exercises involving the obesity and its complications [34]. Among those, there is counseling for
main muscle groups, from 1 to 3 sets of 8–12 repetitions at a load equal midlife women aged 40–60 years with normal BMI, with the aim to
to 60–80 % (10–15 repetitions at 40–50 % for elderly subjects) of the investigate diet and exercise habits, but also chronic stress, trauma and
single repetition maximum for at least 2 days per week. Cardiac reha­ socioeconomic conditions, and then to tailor specific interventions [34].
bilitation program improves baseline metabolic equivalents, cardiore­ Outpatient prevention clinics and cardiac rehabilitation may be optimal
spiratory fitness, and exercise tolerance in this setting [5]. settings to implement these strategies, intercepting obese women or
with normal weight but at high cardiovascular risk. Further research is
4. Obesity, gender, and cardiovascular disease needed to identify optimal and more sustainable behavioral and phar­
macological interventions. Promising data derived from studies on lir­
The contribution of gender medicine, that is the branch of medicine aglutide and semaglutide, in which the gender gap is inverted in favor of
that studies how biological (defined by sex) and socioeconomic and women, that are more represented in the main trials of these drugs [35,
cultural (defined by gender) differences influence people’s health, in the 36].
field of obesity is undoubtedly crucial. Even starting from the mere
epidemiological observation of the distribution of the obesity pandemic 5. Management of cardiovascular complications
in time and space, we could identify possible areas of intervention to
5.1. Coronary artery disease

Obese patients with coronary artery disease represent a common and

Table 1
Optimal cut-off values for anthropometric measures of obesity in screening for
cardiometabolic disorders in adults, according to sex.
Parameter Male Female

WHR 0.96 0.85

WHtR 0.57 0.54
WC 100 87
BMI 28.1 27.5

BMI, body mass index; WC, waist circumference; WHR, waist-to-hip ratio;
WHtR, waist-to-height ratio.
Modified from: Macek et al. [37]. Optimal cut-off values for anthropometric
Fig. 3. Beneficial effects of physical activity and cardiac rehabilitation in pa­ measures of obesity in screening for cardiometabolic disorders in adults. Sci
tient with obesity. Rep. 2020 Jul 9; 10(1):11253, https://doi.org/10.1038/s41598-020-68265-y.

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F. Perone et al. International Journal of Cardiology Cardiovascular Risk and Prevention 23 (2024) 200331

challenge profile to manage. Obesity is associated with elevated risk of especially aerobic and concurrent interventions, in overweight
incident coronary artery disease [2,38], involving not only epicardial middle-aged and elderly patients is effective to promote
vessels but also the coronary microvasculature [39,40]. Cardiovascular anti-inflammatory responses [53]. Regarding pharmacological treat­
outcome in individual post-percutaneous coronary intervention is ment, beta-blockers can lead to tiredness and reduced exercise tolerance
characterized by a lower mortality rates in overweight individuals at 6 and are associated with weight gain in individuals with overweight or
months but, at 5- and 10-year intervals, severe obesity and high-risk obesity [50]. Sodium glucose cotransporter-2 inhibitors (SGLT2i) are
coronary anatomy were associated with higher mortality [41,42]. This recommended to reduce the risk of heart failure hospitalization and
paradox might be due in part to earlier cardiovascular disease diagnosis cardiovascular death, and also reduce body weight and blood pressure
and treatment in overweight or obese individuals, and it may be more and improve physical function and quality of life [10,54]. Long-term
relevant to focus on low body fat percentage and low BMI as predictors adherence is required to achieve therapeutic goals and improve
of adverse cardiovascular disease outcomes [2]. On the other side, the healthy weight control, quality of life, exercise capacity, and prognosis.
relationship between obesity and mortality (in-hospital and long-term) Motivated patients continue with a structured and specific follow-up
after coronary artery bypass grafting remains inconclusive [2]. Pa­ and home exercises with the benefit of mobile device-based healthcare
tients with obesity face a higher risk of post-operative deep sternal delivery or telehealth to evaluate and support patients over long time
wound infections, attributable to factors such as poorly vascularized periods [10].
adipose tissue and a higher incidence of dysglycemia [43,44]. Obesity
can lead to increased platelet activation, potentially reducing the 5.3. Atrial fibrillation
effectiveness of antiplatelet drugs, linked to factors like endothelial
dysfunction, chronic inflammation, and bioactive substances produced Obesity is among risk factors for atrial fibrillation development and
by adipose tissue [44]. This phenomenon has been observed with progression [55]. Indeed, weight gain is related to the risk of incident
aspirin, clopidogrel, and prasugrel, with prasugrel showing potential atrial fibrillation and for every 5-unit increase in BMI this risk is 29 %
advantages in platelet reactivity [45]. In patients with obesity and greater [56]. The management of atrial fibrillation in obese patients
coronary artery disease, a comprehensive risk assessment and multi­ involves several important aspects to consider regarding car­
disciplinary management are required to treat this major comorbidity. diometabolic risk factors and lifestyle changes, anticoagulants, and
Behavior modifications, healthy diet, and increased physical activity are rhythm control [57]. Compelling evidence supports the benefits of
strongly recommended. Weight management and intentional loss are weight loss in individuals with atrial fibrillation, emphasizing the im­
critical to significantly reduce the risk of future adverse clinical events in pactful role of adiposity [58]. Intensive weight loss and comprehensive
these type of patients [46]. Adopting lifestyle changes with weight loss management of cardiometabolic risk factors lead to more significant
has shown promise in addressing metabolic syndrome and related issues reduction in atrial fibrillation duration, symptom severity, and intensity
such as inflammation and endothelial dysfunction [2]. Medical weight [59]. Weight loss ≥10 % and long-term sustained loss are associated
loss interventions are suggested to supplement lifestyle modifications with reduced atrial fibrillation burden and maintenance of
and maintenance of weight loss over time, however clinical trials have arrhythmia-free survival [58]. Lifestyle changes are protective for atrial
not consistently showed the reduction of coronary artery disease rates fibrillation and reduce its recurrence [60,61]. Physical activity has a
[47]. Bariatric surgery has consistently reduced major cardiovascular central role in addition to weight loss. Indeed, improved cardiorespi­
events, particularly coronary artery disease, compared to non-surgical ratory fitness (≥2 metabolic equivalents) reduces atrial fibrillation
weight management, likely due to substantial weight loss and its recurrence and enhances the beneficial effect of weight loss [62]. Bar­
impact on long-term obesity [48]. iatric surgery reduces the risk of new-onset atrial fibrillation [63] and is
associated with a significant reversal of the type [64]. In terms of
5.2. Heart failure thromboembolism risk management, obese patients may require higher
doses of vitamin K oral anticoagulants (VKAs) and extended treatment
Obesity predisposes to heart failure due to the development of sub­ initiation periods to achieve therapeutic INR levels [65]. Instead,
clinical cardiac damage over time. This consists of atrioventricular regarding non-vitamin K oral anticoagulants (NOACs), measurement of
remodeling, increased filling and pulmonary pressures, and left ven­ serum levels may be necessary in certain situations such as severely
tricular systolic and diastolic dysfunction [3]. Indeed, the latest Guide­ obese patients with a BMI exceeding 35 or a weight exceeding 120 kg
lines [9] indicate obesity as a risk factor for heart failure and suggest a [66]. However, this approach is discouraged for the majority of patients
prompt counseling to prevent and delay its onset. Pathophysiological due to insufficient outcome data [67].
processes affecting the myocardium and vascular system are associated For rhythm control in these patients, success following electrical
with the development of HFpEF [9,49]. Obese patients with HFpEF are cardioversion may be decreased due to the expansion of epicardial ad­
characterized by greater right ventricular dilatation and dysfunction, ipose tissue, promoting atrial fibrillation recurrence [68]. Routine use of
left ventricular remodeling, epicardial fat thickness and volume, and adhesive patches at 200 J is inadequate in obesity, and more effective
lower exercise capacity [2]. Weight loss is a key intervention in these strategies include the use of paddles, Manual Pressure Augmentation,
patients due to its multiple beneficial effects [50]. A recent systematic and escalating to 360 J [69]. Obese patients with a management of
review and meta-analysis [51] documented that weight loss improves weight loss and risk factors result in an enhanced arrhythmia-free sur­
long-term rehospitalization (>3 months), quality of life, cardiac func­ vival after atrial fibrillation ablation [60,70].
tion, and exercise capacity, and bariatric surgery reduces mortality in
overweight and obese heart failure patients. The optimal way of weight 6. Conclusions
loss should be selected based on the patient’s condition to acquire the
best prognosis. Furthermore, a healthy diet and physical activity are also Obesity is linked to the development of cardiovascular disease and
suggested as a corrective action for the heart failure or as a preventive risk factors and increases the risk of mortality. Patients with obesity are
strategy to avoid its development [10]. Indeed, in obese patients with a common profile in clinical practice and appropriate chronic manage­
HFpEF, caloric restriction and aerobic exercise training significantly ment is necessary to improve their quality of life and prognosis. A ho­
improve exercise capacity by increasing peak VO2 [52]. Exercise in­ listic risk assessment is the first step to evaluate the category and level of
terventions in patients with heart failure lead to a reduction in adipose risk in patients with obesity. This stratification is key to defining tailored
tissue, increased blood flow to the respiratory and skeletal muscles, and management and multidisciplinary treatment for each patient. Cardiac
improved pulmonary function, functional capacity, left ventricular rehabilitation in these patients is an intervention with multiple benefits,
ejection fraction and mitochondrial function. Exercise training, in addition to improving functional capacity. Finally, a comprehensive

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F. Perone et al. International Journal of Cardiology Cardiovascular Risk and Prevention 23 (2024) 200331

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