Bariatric surgery versus GLP-1RAs: which delivers better CV outcomes in obesity?

People with obesity and type 2 diabetes have a 96% higher cardiovascular (CV) mortality risk than those with normal weight and no diabetes.¹ Both bariatric surgery (BS) and GLP-1 receptor agonists (GLP-1RAs) reduce CV events in this population,^2,3 but head-to-head evidence is thin.

This network meta-analysis combines direct and indirect comparisons to ask which approach is associated with the larger reduction in CV risk.⁴

Study design

• 43 studies involving 932,380 patients, published between January 2000 and September 2024, were included. 321,374 patients received BS or a GLP-1RA and 611,006 were controls (placebo or usual care).

• 830,215 patients came from BS versus control comparisons, 83,285 from GLP-1RA versus control comparisons and 18,880 from the four cohort studies comparing BS directly with GLP-1RAs.

• The BS evidence is entirely observational cohort data. The GLP-1RA evidence comes from randomised controlled trials, mostly of first-generation agents.

Results

The results are split by CV outcome: major adverse cardiovascular events (MACEs), heart failure and myocardial infarction.

• MACE: across models, BS was associated with a 27.4 to 34% reduction in MACE risk, compared with 12.6 to 15% for GLP-1RAs.

• Heart failure events: BS showed the most substantial reduction in HF events (52 to 55% by HR; up to 60% by RR). The 11% reduction with GLP-1RAs was significant only in the fixed-effects HR model.

• Myocardial infarction: BS was associated with a 47 to 62% reduction in MI risk; the GLP-1RA effect was not significant in random-effects models. None of the four head-to-head cohort studies reported MI, so the BS versus GLP-1RA comparison for this outcome rests on indirect evidence alone and its consistency could not be tested. The authors flag this as limiting the precision of the MI estimates.

Conclusion

Across all three outcomes, BS was associated with larger and more consistent reductions in CV risk than GLP-1RAs.

The authors conclude that the findings support BS as the more effective intervention for CV risk reduction in patients with obesity, with GLP-1RAs remaining an evidence-based alternative for patients who are not surgical candidates.

Note the BS evidence is observational and the GLP-1RA trials are largely first-generation agents, so the comparison does not reflect newer, higher-efficacy therapies.

The authors call for head-to-head trials and subgroup analyses by procedure type, agent, diabetes status and baseline CV risk before comparative efficacy can be settled.

These findings complement a previous Medicine Central breakdown: GLP-1 receptor agonists vs bariatric surgery: what the evidence actually shows.

Intended for UK healthcare professionals only. This article reports on published clinical data and does not constitute prescribing advice.

References

1. Koirala S, Sunnaa M, Bernier T, Oktay AA. The role of obesity as a cardiac disease risk factor in patients with type 2 diabetes. Curr Cardiol Rep. 2024;26(11):1309-1320.

2. Van Veldhuisen SL, Gorter TM, van Woerden G, et al. Bariatric surgery and cardiovascular disease: a systematic review and meta-analysis. Eur Heart J. 2022;43(20):1955-1969.

3. Sattar N, Lee MMY, Kristensen SL, et al. Cardiovascular, mortality, and kidney outcomes with GLP-1 receptor agonists in patients with type 2 diabetes: a systematic review and meta-analysis of randomised trials. Lancet Diabetes Endocrinol. 2021;9(10):653-662.

4. Shirmohammadi E, Ghasemloo N, Ebrahimi N, et al. Comparative cardiovascular outcomes of GLP-1 receptor agonists versus bariatric surgery: a systematic review and network meta-analysis. Endocrinol Diabetes Metab. 2026;9:e70311. https://doi.org/10.1002/edm2.70311