Obesity paradox has been described in various populations of coronary artery disease, mainly asymptomatic subjects. However, relationship between obesity and coronary artery calcification detected by cardiac CT in symptomatic patients has rarely been demonstrated. This study seeks to investigate whether the paradoxical relationship between obesity and coronary artery calcification exists in patients with acute chest pain. A final cohort of 1030 chest pain patients presenting at our emergency department who underwent coronary evaluation by multidetector cardiac CT were examined. With absent-to-mild coronary calcification (CAC score < 100) as a referent, multivariable analysis showed that presence of obesity (OR 0.564; 95% CI 0.395, 0.806; 0.002), body mass index (OR 0.945; 95% CI 0.920, 0.971; ), body weight (OR 0.987; 95% CI 0.979, 0.995; 0.001), and body surface area (OR 0.582; 95% CI 0.369, 0.920; 0.020) were inversely associated with moderate-to-severe coronary calcification (CAC score ≥ 100). This study extends the concept of obesity paradox to symptomatic patients undergoing coronary artery calcium score assessment. However, biological explanation(s) of this paradox remains unanswered. 1. Introduction Obesity has been believed to be one of the major risk factors and adverse prognosticators, associated with increased mortality risk, for atherosclerotic diseases, especially coronary artery disease (CAD) [1, 2]. Extensive studies have shown that obesity is an independent predictor for CAD and cardiovascular death in multiple populations including a large-scale epidemiological study and a systemic review [3, 4]. Obesity is not only associated with prevalence and death in CAD itself but also related to its major risk factors including hypertension, diabetes mellitus, and dyslipidemia [5]. Body mass index (BMI) which is the index most commonly used in majority of the studies to define obesity has also been shown to be positively associated with increased risk of CAD even in the normal weight range [6]. Pathophysiology of obesity and cardiovascular diseases is complicated and it involves several pathways particularly cardiovascular hemodynamics, systemic inflammation, and leptin metabolism [5]. Given its complexity of interaction and arguable robustness of BMI in defining obesity, it is not surprising that evidences of ability of obesity to be a risk factor and a poor prognosticator are inconsistent among studies. There have been multiple studies describing “obesity paradox,” a protective effect of obesity, with various clinical surrogates and outcomes in
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