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BMI above 45 with obesity-related heart failure or severe sleep apnea Patient has failed multiple prior weight-loss attempts Cardiovascular risk of continued obesity exceeds cardiovascular risk of combination therapy Close monitoring (weekly BP and HR checks) is feasible Phentermine is used short-term (4-8 weeks) to accelerate initial weight loss while tirzepatide builds effect Scenario 2: Tirzepatide plateau with excellent cardiovascular health
