A total of 4,437 patients with angiographically confirmed LM/3VD were followed for 10 years. Participants were categorized into obesity-metabolic phenotypes based on body mass index (BMI, with ≥28 kg/m² defining obesity) and metabolic health status (defined as the presence of two or more of the following: hypertension, dyslipidemia, or diabetes). The primary endpoint was the occurrence of major adverse cardiovascular events (MACE). Statistical analyses included Kaplan-Meier survival analysis with log-rank tests, Landmark analysis, and time-dependent as well as time-stratified Cox proportional hazards regression models to assess the associations between phenotypes and clinical outcomes.

Over 10 years, 1,960 major adverse cardiovascular events (MACE) occurred (44.2%). Event rates by obesity–metabolic phenotype were: metabolically healthy normal weight (MHN) 37.9%, metabolically healthy obese (MHO) 38.5%, metabolically unhealthy normal weight (MUN) 45.3%, and metabolically unhealthy obese (MUO) 47.6%.Kaplan–Meier analysis showed significant differences in event-free survival across phenotypes over the 10-year follow-up (log-rank P<0.05), with Landmark analysis showing disparities emerging only after 2 years. Time-dependent Cox regression identified metabolic abnormality as an independent risk factor for 10-year MACE [MUN: aHR (95%CI): 1.167 (1.014-1.344), P=0.023; MUO: 1.282 (1.088-1.510), P=0.003]. Time-stratified Cox regression confirmed that the risk was most prominent during 2–10 years [MUO: 1.324 (1.078-1.627), P=0.003].

Metabolic abnormality, especially metabolically unhealthy obesity, is an independent predictor of cardiovascular adverse events in LM/3VD patients, predominantly influencing long-term prognosis. Long-term metabolic disease management and active weight loss are crucial for improving outcomes in these high-risk patients.