Roux-en-Y Bypass Favors Higher-Risk Patients with Lower Long-Term Incidence of Major Cardiovascular Events

Lewis KH, Argetsinger S, LeCates RF, et al. Risk of Incident Cardiovascular Events Following Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy: A Claims-based Retrospective Cohort Study. Ann Surg. March 2026.

Using commercial claims (2010–2021), the authors created matched, weighted cohorts of 13,545 sleeve gastrectomy (SG) and 13,545 Roux-en-Y gastric bypass (RYGB) patients and followed them for up to 5 years for incident cardiovascular events. 

In the overall cohort, there was no difference in the primary composite outcome of major adverse cardiovascular event (MACE) plus arrhythmia (aHR 1.01 for RYGB vs SG, 95% CI 0.90–1.12); results were also similar in older adults (aHR 0.97, 95% CI 0.85–1.10). Event rates were modest at 5 years (about 9% to 10% for MACE plus arrhythmia), and individual components did not differ meaningfully between procedures in the overall cohort. 

The clinically actionable signal is in higher-risk patients. Among those with type 2 diabetes, RYGB was associated with lower MACE risk when arrhythmia was excluded (aHR 0.78, 95% CI 0.66–0.92). A similar relative benefit was seen in patients with pre-existing cardiovascular disease or elevated baseline morbidity (aHR 0.81, 95% CI 0.70–0.93 for MACE excluding arrhythmia).

For surgeons counseling procedure choice, these data support a risk-stratified approach. For many patients, SG and RYGB appear comparable for medium-term cardiovascular event risk, while patients with diabetes or established cardiovascular risk may derive incremental cardiovascular benefit from RYGB that can be weighed against its higher procedural and follow-up complexity.