Obesity and Beyond: Lifestyle Patterns and Cardiometabolic Burden in High-Risk Patients with Coronary Artery Disease—Moving Toward Personalized Prevention

Background: Obesity substantially increases cardiovascular risk and contributes to the accumulation of cardiometabolic risk factors. Achieving optimal control of body weight and guideline-recommended targets is essential in high-risk patients, particularly in secondary prevention following acute coronary events. This study aimed to evaluate treatment strategies and lifestyle modifications undertaken by patients with obesity during long-term follow-up. Methods: This analysis included patients enrolled 6–18 months after acute coronary syndrome or coronary revascularization within the multicentre POLASPIRE II study. Standardized EUROASPIRE methodology was applied to collect clinical, anthropometric, and lifestyle-related data. Results: A total of 788 patients (mean age 65.4 ± 8.9 years; 25.8% women) were included, of whom 40.6% had obesity. No significant association between sex and BMI was observed (β = −0.48; 95% CI −1.30 to 0.31; p = 0.20). Increasing age was associated with lower BMI (β = −0.05; 95% CI −0.09 to −0.0001; p = 0.044), and higher education correlated with lower BMI (β = −1.10; 95% CI −2.00 to −0.22; p = 0.015). With advancing age (OR 1.02; 95% CI 1.002–1.033; p = 0.023) and increasing BMI (OR 1.11; 95% CI 1.076–1.138; p = 0.001), the number of risk factors and comorbidities increased. Higher BMI was associated with poorer control of medical risk factors (OR 1.06; 95% CI 1.03–1.10; p < 0.001), whereas patients with higher BMI demonstrated better control of lifestyle-related risk factors (OR 0.95; 95% CI 0.919–0.983; p = 0.003). Conclusions: Obesity is highly prevalent among high-risk cardiovascular patients and is associated with a greater burden of comorbidities and poorer control of medical risk factors. These findings support the need for strengthened, risk-stratified secondary prevention strategies and more personalized therapeutic approaches in patients with obesity.