Semaglutide vs Metabolic and Bariatric Surgery and Cardiovascular Outcomes in Obesity.

OBJECTIVES

To compare cardiovascular outcomes associated with metabolic and bariatric surgery (MBS) vs semaglutide therapy among adults with obesity, stratified by type 2 diabetes mellitus (T2DM) status.

METHODS

This retrospective cohort study used the US Collaborative Network within TriNetX. Adults with obesity who initiated semaglutide therapy or underwent sleeve gastrectomy or Roux-en-Y gastric bypass between January 2018 and January 2025 were propensity score matched separately according to T2DM history. The primary outcome was a composite of coronary events, cerebrovascular events, heart failure, and cardiac arrest during follow-up of up to 5 years. Sensitivity analyses varied the follow-up horizon, postindex encounter requirements, semaglutide refill requirements, and the start of follow-up.

RESULTS

After matching, each treatment group included 11 466 patients without T2DM and 7327 patients with T2DM. MBS was associated with a lower risk of the composite cardiovascular outcome than semaglutide therapy among patients without T2DM (4.4% vs 6.6%; hazard ratio [HR], 0.402; 95% CI, 0.356-0.454) and with T2DM (9.0% vs 14.6%; HR, 0.421; 95% CI, 0.381-0.465). MBS was also associated with lower risks of coronary events, cerebrovascular events, and heart failure in both strata. The relative differences were greatest for heart failure (HR, 0.293 without a history of T2DM; HR, 0.346 with a history of T2DM). Findings remained directionally consistent across subgroup and sensitivity analyses.

CONCLUSIONS

Among adults with obesity, MBS was associated with lower cardiovascular risk than semaglutide therapy, regardless of T2DM history. These findings provide real-world comparative evidence to inform individualized discussions of surgical and pharmacologic obesity treatment options.