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

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PubMed1 Apr 2026·Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery● 7/10i

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

Cordova F, Málaga N

Bariatric surgery reduced mortality by 43%, major cardiovascular events by 35%, and heart failure by 55% compared to GLP-1 receptor agonists in adults with obesity. Meta-analysis of 5 observational cohorts, 39,569 patients. This provides the first head-to-head comparison of these major obesity treatments on hard cardiovascular outcomes, showing substantial advantages for surgery. Observational design limits causal inference due to potential confounding and selection bias.

Strategic signal

This data creates a medical affairs challenge for Novo Nordisk and Eli Lilly as bariatric surgery advocates will use these mortality and MACE reductions to question GLP-1RA positioning as first-line therapy for severe obesity. US payers may tighten prior authorization requirements for expensive GLP-1RAs, demanding failed surgery candidacy before coverage. The findings mirror early SGLT2 versus insulin debates where observational data preceded definitive RCTs, forcing companies to invest in head-to-head surgical comparisons to defend their cardiovascular claims.

GLP-1CardiovascularWeight lossNovo Nordisk Eli Lilly

Original Abstract

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.

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