Cardiovascular outcomes and mortality of bariatric surgery versus glucagon-like peptide-1 receptor agonists: a systematic review and meta-analysis.

BACKGROUND: Bariatric surgery (BS) and glucagon-like peptide-1- receptor agonists (GLP-1RAs) are established treatments for obesity and cardiovascular risk, but their comparative impact on clinical outcomes remains unclear. OBJECTIVES: To compare long-term outcomes of BS versus GLP-1RA therapy in adults with obesity, focusing on mortality, major adverse cardiovascular events (MACE), and heart failure. SETTING: Multicenter observational studies using national and institutional databases. METHODS: PubMed, Embase, and Cochrane CENTRAL were searched for studies comparing bariatric surgery and GLP-1RAs reporting adjusted hazard ratios for mortality, MACE, or heart failure. Two reviewers independently performed screening and data extraction. Risk of bias was assessed with ROBINS-I, and random-effects meta-analysis was used. Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessed certainty of evidence. RESULTS: Five cohort studies (N = 39,569) were included. BS was associated with a 43% lower risk of mortality (hazard ratio [HR] .57, 95% CI .34-.95), 35% lower MACE risk (HR .65, 95% CI .51-.83), and 55% lower risk of heart failure (HR .45, 95% CI .39-.51). Per 1000 patients treated, absolute reductions were 25 deaths, 25 cardiovascular events, and 23 heart failure cases. Certainty ranged from low (MACE) to moderate (heart failure). CONCLUSIONS: In this meta-analysis of observational studies, bariatric surgery was associated with lower risks of mortality and cardiovascular outcomes compared to GLP-1RA therapy in adults with obesity. These findings suggest potential differences in long-term effectiveness between treatment strategies, warranting further investigation in randomized controlled trials. Residual confounding and selection bias cannot be fully eliminated given the observational design of the included cohorts.