The US Food and Drug Administra- tion s statement also includes a notation that the drug can increase heart rate and should not be used in those with unstable heart disease,245 and the sponsor is required to perform a long-term postmarketing study of cardiovascu- lar outcomes associated with the drug. Ephedra, which has been used for the purposes of athletic performance enhancement and weight loss, has been linked to a high rate of serious adverse outcomes, including LV systolic dysfunction, the development of and cardiac deaths, ultimately resulting in ban of this agent by the US Food and Drug Administration. There has also been concern about the use of sibutra- mine in HF because of reports of the development of cardiomyopathy, and this medication is contraindicated in patients with HF238 (Table 9). Bariatric Surgery in HF Obesity surgery, or bariatric surgery, is recommended for class 2 obesity or above (BMI 35 kg/m2 ) and possibly in individuals with a BMI of 30 to 34.9 kg/m2 when associ- ated with comorbid conditions such as diabetes mellitus, sleep apnea, and systemic hypertension, but the safety and efficacy of bariatric surgery in patients with HF have not been ascertained. 