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Background Obesity is closely related to the occurrence and development of dilated cardiomyopathy (DCM). Differences in clinical characteristics of dilated cardiomyopathy patients with distinct weight status and the prognostic value of weight management have not been clarified. Objective To explore the baseline clinical characteristics of DCM patients with different weight statuses, and to analyze the impact of weight management on their prognosis. Methods This was a single-center prospective cohort study. A total of 322 obese patients with DCM admitted to the Affiliated Hospital of Jiangsu University from January 2022 to June 2024 were prospectively collected. DCM patients were assigned into the normal group (BMI<24 kg/m2), overweight group (24 kg/m2≤BMI<28 kg/m2) and obese group (BMI≥28 kg/m2) according to the BMI. Baseline characteristics were collected. They were followed up for 12 months on telephone or outpatient visits. The incidence of major adverse cardiovascular events (MACEs) was recorded. According to the weight change during the 12-month weight management, they were divided into weight change <5%, 5%≤weight change <10% and≥10% weight change groups. Plots of MACEs among the three groups and Kaplan-Meier survival curves were plots. Univariate and multivariate Cox regression and subgroup analyses were conducted to identify influlencing factors for MACEs in DCM patients. Results DCM patients were divided into the normal group (84 cases), overweight group (132 cases) and obese group (106 cases) according to baseline BMI. There were significant differences in age, systolic blood pressure, diastolic blood pressure, left ventricular end-systolic diameter (LVSd), comorbidities (hypertension, diabetes, coronary atherosclerosis), lifestyle (smoking history), and drug use [orlistat, glucagon-like peptide 1 (GLP-1) agonists, soluble guanylate cyclase (GC) agonists] among the three groups (all P<0.05). Based on the magnitude of body weight change over 12 months, participants were categorized into three groups: weight change <5% (n=115), 5%≤weight change <10% (n=157), and ≥10% weight change (n=50) groups. There were significant differences in admission body weight, follow-up brain natriuretic peptide (BNP), follow-up left ventricular ejection fraction (LVEF), follow-up cardiac function, follow-up MACEs and GLP-1 agonist use among the weight change <5%, 5%≤weight change<10% and≥10% weight change groups (P<0.05). The range of weight change during the 12-month follow-up was linearly related to follow-up BNP (rs=-0.158, P=0.004) and LVEF (rs=0.229, P<0.001). The Kaplan-Meier survival curve showed a significant difference in the incidence of MACEs among the weight change <5%, 5%≤weight change <10% and≥10% weight change groups (χ2=16.83, P<0.001). Univariate Cox proportional hazards regression model analysis showed that follow-up BNP, LVEF, follow-up cardiac function, weight change, and the use of GLP-1 receptor agonists, mineralocorticoid receptor antagonist (MRA), and sodium-glucose cotransporter-2 inhibitor (SGLT2i) were independent influencing factors for MACEs in DCM patients (P<0.05). After adjusting for gender, diabetes, smoking history, drinking history, and drug use, MACEs was the dependent variable and weight change was the independent variable. Multivariate Cox proportional hazards regression model showed that weight change was independently related to the occurrence of MACEs in DCM patients (P<0.05). Subgroup analysis results showed that increased weight change was significantly associated with a reduced risk of MACEs (HRoverall=0.89, 95%CI=0.81-0.98, P=0.018). The interaction analysis showed the increase in weight change was consistent with the risk of MACEs in DCM patients stratified by gender, age, diabetes, and use of SGLT2i, MRA or GLP-1 receptor agonists (Pinteraction>0.05), all showing a protective effect. The association between weight change and the risk of MACEs in DCM patients was significantly different among patients who used β-blockers or not (Pinteraction =0.004). Conclusion DCM patients with a BMI≥24 kg/m2 are younger and more likely to have metabolic disorders like hypertension and diabetes. After 12 months of weight management, DCM patients with a weight loss of≥10% have the most significant improvement in cardiac function, manifesting as significantly decreased BNP and increased LVEF at follow-up, and the lowest incidence of MACEs. Structured weight management with the goal of weight loss ≥10% is therefore recommended to be included in the comprehensive treatment of overweight/obese DCM patients to improve their cardiac function and clinical prognosis.