Online Data

Online Figure 1: Flow diagram of study cohort

BMI, body mass index in kg/m2

*Obesity-related comorbidity included (% of patients): hypertension only (49%), diabetes only (4%), hypertension and diabetes (39%), other (i.e. obstructive sleep apnea, hyperlipidemia, gastrointestinal or respiratory disease, 8%).

Online Table 1: Patients Meeting Clinical Endpoint*

Outcome Events (n) Annualized Event Rate** (%)

Total composite clinical endpoint 135 3.3 Death 72 1.7 Hospitalization for nonfatal myocardial infarction 43 1.0 Hospitalization for heart failure 52 1.2*Median (Q1-Q3) follow-up time was 5.6 (3.9-7.1) years. Time to first event was analyzed. **Annualized event rates were calculated using Poisson regression.

2

Online Figure 2: Cumulative Hazard of Adverse Cardiovascular Events in the Overall Cohort

3

Online Table 2: Baseline Characteristics of Obese Cohort by Bariatric Surgery Eligibility

Characteristic Obese (N=398)

Bariatric Surgery Eligible p value*

Yes (n=233) No (n=165)

DemographicsAge, y (Q1-Q3) 59.6 (51.2, 66.6) 58.2 (49.1, 65.1) 61.2 (53.5, 72.2) <0.01Female sex, % 298 (74.9%) 176 (75.5%) 122 (73.9%) 0.72White race, % 193 (48.5%) 118 (50.6%) 75 (45.5%) 0.31Body mass index, kg/m2 36.3 (32.7, 42.7) 41.2 (37.4, 47.2) 32.3 (31.1, 33.3) <0.01Medical HistoryHypertension, % 345 (86.7%) 205 (88.0%) 140 (84.8%) 0.36Dyslipidemia, % 239 (60.1%) 139 (59.7%) 100 (60.6%) 0.85Diabetes, % 179 (45.0%) 118 (50.6%) 61 (37.0%) <0.01Peripheral vascular disease, % 10 (2.5%) 4 (1.7%) 6 (3.6%) 0.23Stroke, % 13 (3.3%) 5 (2.1%) 8 (4.8%) 0.14Chronic obstructive pulmonary disease, %

46 (11.6%) 30 (12.9%) 16 (9.7%) 0.33

Atrial fibrillation, % 15 (3.8%) 9 (3.9%) 6 (3.6%) 0.91Tobacco use, % 36 (9.0%) 24 (10.3%) 12 (7.3%) 0.30MedicationsAspirin, % 198 (49.7%) 115 (49.4%) 83 (50.3%) 0.85β-blocker, % 181 (45.5%) 101 (43.3%) 80 (48.5%) 0.31RAS blocker, % 145 (36.4%) 89 (38.2%) 56 (33.9%) 0.38Statin, % 207 (52.0%) 121 (51.9%) 86 (52.1%) 0.97Insulin, % 68 (17.1%) 41 (17.6%) 27 (16.4%) 0.75Nitrate, % 23 (5.8%) 14 (6.0%) 9 (5.5%) 0.82Laboratory valuesSerum creatinine, mg/dL 0.8 (0.7, 0.9) 0.8 (0.7, 0.9) 0.8 (0.7, 1.0) 0.74eGFR, mL/min/1.73m² 87.5 (70.9, 99.7) 88.6 (71.7, 100.7) 86.3 (70.9, 98.1) 0.23Noninvasive imaging parametersLeft ventricular ejection fraction, % 62.0 (57.0, 68.0) 62.0 (56.0, 68.0) 62.0 (57.0, 68.0) 0.48Rest myocardial blood flow, ml/min/g 1.0 (0.8, 1.3) 0.9 (0.7, 1.2) 1.0 (0.8, 1.3) <0.01Stress myocardial blood flow, ml/min/g 2.0 (1.5, 2.6) 1.9 (1.3, 2.4) 2.2 (1.8, 2.7) <0.01

Stress coronary vascular resistance** mm Hg/ (mL/min/g)

45.4 (35.3, 61.7) 50.8 (36.5, 70.4) 40.5 (33.9, 51.0) <0.01

Coronary flow reserve 2.0 (1.5, 2.5) 2.0 (1.5, 2.4) 2.1 (1.7-2.6) 0.01*p value is for the comparison between bariatric surgery eligible groups, and is based on the χ2 test for categorical variables and the Wilcoxon rank-sum test for continuous variables. Continuous variables are presented as medians (Q1-Q3) and categorical variables as frequencies (%)

4