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He F, Huang H, Xu W, Cui K, Ruan Y, Guo Y, Wang J, Bin J, Wang Y, Chen Y. Prognostic impact of malnutrition in patients with coronary artery disease: a systematic review and meta-analysis. Nutr Rev 2023:nuad108. [PMID: 37665731 DOI: 10.1093/nutrit/nuad108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023] Open
Abstract
CONTEXT Conflicting predictions of malnutrition for the long-term prognosis of coronary artery disease (CAD) exist. OBJECTIVE This study aimed to investigate the relationship between malnutrition and long-term prognosis of patients with CAD. DATA SOURCES Four databases were searched for articles from February 11, 1936, to September 10, 2022. DATA EXTRACTION Cohort studies adjusting for multiple cardiovascular risk factors with data on CAD and malnutrition were included. Malnutrition was measured and defined by different nutritional evaluation tools. The hazard ratios (HRs) and confidence intervals (CIs) for all-cause mortality and major adverse cardiovascular events (MACEs) were synthesized. Subgroup analyses were performed based on study design, assessment tools, ethnicity/race, follow-up, sample size, and types of CAD. Meta-regression was used to compare whether the effect sizes of the 2 subgroups were statistically significant. DATA ANALYSIS A total of 30 cohort studies were included, totaling 81 361 participants with CAD. Nutritional evaluation tools, including the Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status (CONUT), Nutritional Risk Screening 2002, Mini-Nutritional Assessment, and Prognostic Nutritional Index, were used. Malnutrition increased all-cause mortality (HR = 1.72; 95% CI: 1.53, 1.93) and MACEs (HR = 1.47; 95% CI: 1.35, 1.60) in patients with CAD. Subgroup analysis revealed the results were consistent across study design, ethnicity/race, follow-up, sample size, and types of CAD. Subgroup analyses and meta-regression revealed that malnutrition was associated with a higher risk of all-cause mortality (HR = 2.26; 95% CI: 1.91, 2.68) and MACEs (HR = 2.28; 95% CI: 1.69, 3.08) in patients with stable CAD than those with other types of CAD. Meta-regression revealed that the GNRI (HR = 2.20; 95% CI: 1.65, 2.93) was more effective than CONUT (HR = 1.47; 95% CI: 1.21, 1.78) in predicting all-cause mortality. CONCLUSION Malnutrition independently increased all-cause mortality by 72% and MACEs by 47% in patients with CAD, especially with stable CAD. The GNRI is a more effective nutritional evaluation tool than CONUT in predicting all-cause mortality.
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Affiliation(s)
- Fengling He
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation , Southern Medical University, Guangzhou, China
| | - Haoxiang Huang
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation , Southern Medical University, Guangzhou, China
| | - Wenlong Xu
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation , Southern Medical University, Guangzhou, China
| | - Kai Cui
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation , Southern Medical University, Guangzhou, China
| | - Yifei Ruan
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation , Southern Medical University, Guangzhou, China
| | - Yuetong Guo
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation , Southern Medical University, Guangzhou, China
| | - Junfen Wang
- Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jianping Bin
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation , Southern Medical University, Guangzhou, China
| | - Yuegang Wang
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation , Southern Medical University, Guangzhou, China
| | - Yanmei Chen
- Department of Cardiology, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Cardiac Function and Microcirculation , Southern Medical University, Guangzhou, China
- Department of Cardiology, Ganzhou People's Hospital, Guangzhou, China
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Lu J, Huang Z, Wang J, Zhao X, Yang Y, Wu B, Kang Y, Xiu J, Tu J, Pan Y, Chen W, Bao K, Chen L, Liu J, Liu Y, Chen S, Fang Y, Chen K. Prevalence and Prognostic Impact of Malnutrition in Critical Patients With Acute Myocardial Infarction: Results From Chinese CIN Cohort and American MIMIC-III Database. Front Nutr 2022; 9:890199. [PMID: 35782927 PMCID: PMC9240700 DOI: 10.3389/fnut.2022.890199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 05/12/2022] [Indexed: 11/24/2022] Open
Abstract
Background Malnutrition is associated with poor prognosis in patients with acute myocardial infarction (AMI). However, the prognostic impact of malnutrition in critical patients with AMI has not been well addressed. Methods We analyzed two critical AMI cohorts from Cardiorenal ImprovemeNt (CIN) in China and Medical Information Mark for Intensive Care-III (MIMIC-III) in the United States. The primary outcome was all-cause mortality. Cox proportional hazards models were constructed to examine the risk of malnutrition for mortality in critical patients with AMI. Results There were 2,075 critical patients with AMI (mean age, 62.5 ± 12.3 years, 20.00% were female) from the CIN cohort and 887 critical patients with AMI (mean age, 70.1 ± 12.9 years, 37.43% were female) from MIMIC-III included in this study. Based on the Controlling Nutritional Status (CONUT) score, of the Chinese patients with AMI, the prevalence was 47.5, 28.3, and 3.5% for mild, moderate, and severe malnutrition, respectively. The percentage of mild, moderate, and severe malnutrition was 41.60, 30.55, and 7.32% in the MIMIC-III cohort, respectively. Controlling for confounders, worse nutritional state was significantly associated with increased risk for all-cause mortality [an adjusted hazard ratio for mild, moderate, and severe malnutrition, respectively, 1.10 (95% confidence interval (CI): 0.76–1.59), 1.49 (95% CI: 1.02–2.19), and 1.70 (95% CI: 1.00–2.88) in the CIN cohort and 1.41 (95% CI: 0.95–2.09), 1.97 (95% CI: 1.32–2.95), and 2.70 (95% CI: 1.67–4.37) in the MIMIC-III cohort]. Conclusion Malnutrition was independently associated with an increased risk of all-cause mortality in critical patients with AMI after full adjustments. Further trials are needed to prospectively evaluate the efficacy of nutritional interventions in critical patients with AMI.
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Affiliation(s)
- Jin Lu
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Zhidong Huang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Junjie Wang
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Xiaoli Zhao
- Department of Cardiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yanfang Yang
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Bo Wu
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Yu Kang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jiaming Xiu
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Jiabin Tu
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Yuxiong Pan
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Weihua Chen
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Kunming Bao
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Liling Chen
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
| | - Jin Liu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yong Liu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shiqun Chen
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shiqun Chen
| | - Yong Fang
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
- Yong Fang
| | - Kaihong Chen
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, China
- *Correspondence: Kaihong Chen
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Fan W, Liu Y, Zhang Y, Gao X, Shi F, Liuand J, Sun L. Prognostic value of a novel dNLR-PNI score in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Perfusion 2022:2676591221090620. [PMID: 35608438 DOI: 10.1177/02676591221090620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is currently limited information on the prognostic value of the dNLR-PNI (the combination of the derived neutrophil-to-lymphocyte ratio [dNLR] and prognostic nutritional index [PNI]) score for patients with acute coronary syndrome (ACS). We aimed to explore the predictive value of a dNLR-PNI score on the long-term prognosis of patients with ACS undergoing percutaneous coronary intervention (PCI). A total of 1773 patients with ACS who underwent PCI were consecutively enrolled from January 2016 to December 2018. The cutoff values of dNLR and PNI to predict major adverse cardiovascular events (MACE) were calculated using receiver operating characteristic curves. The patients were divided into three groups based on the dNLR-PNI score, and Kaplan-Meier curves and Cox regression models were used for survival analysis. The endpoints were MACE, including all-cause mortality and rehospitalisation for severe heart failure during follow-up. A total of 1542 patients with ACS who underwent PCI were included. Kaplan-Meier curves showed that a higher level of dNLR, PNI, or dNLR-PNI score was associated with a higher risk of MACE (allp < .001). In multivariate Cox regression models, the dNLR-PNI two score (hazard ratio 3.049, 95% confidence interval 1.503-6.184, p = .002) was found to be an independent predictor of all-cause mortality and rehospitalization for severe heart failure. A high dNLR-PNI score was independently associated with a higher risk of developing MACE in patients with ACS undergoing PCI. The dNLR-PNI score may be a useful prognostic parameter for identifying high-risk ACS patients after PCI.
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Affiliation(s)
- Wenjun Fan
- Department of Cardiology, The Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Yixiang Liu
- Department of Cardiology, The Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Ying Zhang
- Department of Cardiology, The Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Xiuxin Gao
- Department of Cardiology, The Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Fei Shi
- Department of Cardiology, The Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Jingyi Liuand
- Department of Cardiology, The Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Lixian Sun
- Department of Cardiology, The Affiliated Hospital of Chengde Medical University, Chengde, China
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Zengin A, Karataş MB, Çanga Y, Durmuş G, Güzelburç Ö, Durak F, Emre A. Prognostic performance of Controlling Nutritional Status score in patients with ST segment elevation myocardial infarction treated with primary percutaneous coronary intervention. Anatol J Cardiol 2022; 26:23-28. [PMID: 35191382 PMCID: PMC8878938 DOI: 10.5152/anatoljcardiol.2021.190] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 09/06/2023] Open
Abstract
OBJECTIVE The effect of malnutrition in patients with ST segment elevation myocardial infarction (STEMI) is not fully understood. In this study, we tried to investigate the prognostic consequence of the Controlling Nutritional Status (CONUT) score in patients with STEMI. METHODS In this study, we evaluated the CONUT scores of 1,028 patients with STEMI and examined its relationship with major adverse cardiovascular events (MACE) (all-cause mortality, myocardial reinfarction, and vessel revascularization) during a period of 19.9±10.3 months. Patients with CONUT score ≥5 were defined as severely malnourished. Predictors of MACE were assessed by Cox regression analysis, and p<0.05 was considered to indicate statistical significance. RESULTS MACE was observed in a total of 147 (14.3%) patients. MACE was more frequent in the group with a higher CONUT score (33.3% vs. 10.9%, p<0.001). CONUT score ≥5 was an independent predictor of MACE in the Cox regression analysis (hazard ratio=2.50, 95% confidence interval: 1.61-3.90, p<0.001). Low ejection fraction, Killip class ≥3 at presentation, thrombolysis in myocardial infarction flow grade <3 after intervention, left main artery involvement, and low hemoglobin levels were other independent predictors of MACE in the long-term follow-up. Kaplan-Meier curves showed decreased MACE free survival rates in the high CONUT score group at a mean 19.9±10.3 months' follow-up duration (log-rank p<0.01). CONCLUSION Malnutrition was strongly associated with poor outcomes in patients with STEMI treated using primary percutaneous coronary intervention.
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Affiliation(s)
- Ahmet Zengin
- Department of Cardiology, University of Health Scienses, Dr. Siyami Ersek Training and Research Hospital; İstanbul-Turkey
| | - Mehmet Baran Karataş
- Department of Cardiology, University of Health Scienses, Dr. Siyami Ersek Training and Research Hospital; İstanbul-Turkey
| | - Yiğit Çanga
- Department of Cardiology, University of Health Scienses, Dr. Siyami Ersek Training and Research Hospital; İstanbul-Turkey
| | - Gündüz Durmuş
- Department of Cardiology, University of Health Scienses, Dr. Siyami Ersek Training and Research Hospital; İstanbul-Turkey
| | - Özge Güzelburç
- Department of Cardiology, University of Health Scienses, Dr. Siyami Ersek Training and Research Hospital; İstanbul-Turkey
| | - Furkan Durak
- Department of Cardiology, University of Health Scienses, Dr. Siyami Ersek Training and Research Hospital; İstanbul-Turkey
| | - Ayşe Emre
- Department of Cardiology, University of Health Scienses, Dr. Siyami Ersek Training and Research Hospital; İstanbul-Turkey
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The prognostic significance of controlling nutritional status (CONUT) score for surgically treated renal cell cancer and upper urinary tract urothelial cancer: a systematic review and meta-analysis. Eur J Clin Nutr 2021; 76:801-810. [PMID: 34815539 DOI: 10.1038/s41430-021-01014-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 09/11/2021] [Accepted: 09/16/2021] [Indexed: 02/05/2023]
Abstract
In order to evaluate the predictive effect of the controlled nutritional status (CONUT) score on the prognosis of patients with renal cell carcinoma (RCC) and upper urinary tract urothelial carcinoma (UTUC), a meta-analysis was performed. This systematic review has been registered on PROSPERO, the registration ID is CRD42021251879. A systematic search of the published literature using PubMed, Web of Science, Cochrane Library, EMBASE, and MEDLINE was performed. The fields of "renal cell cancer," "upper tract urothelial cancer," and "controlling nutritional status" and other fields were used as search terms. STATA 16 software was used to carry out data merging and statistical analysis of binary variables, Q test and χ2 tests were used to verify the heterogeneity between the included works of studies. Subgroup analysis and sensitivity analysis were used to explain the sources of heterogeneity between studies. Begg's test was used to assess publication bias between studies. From the first 542 studies retrieved, through strict inclusion and exclusion criteria, 7 studies finally met the requirements and were included in the meta-analysis. Pooled results indicated that high CONUT indicates worse over survival (OS) [HR = 1.70, 95% CI (1.43-2.03), P = 0.02], cancer-specific survival (CSS) [HR = 1.84, 95% CI (1.52-2.23), P = 0.01], recurrence-free survival (RFS) [HR = 1.60, 95% CI (1.26-2.03), P = 0.116], and disease-free survival (DFS) [HR = 1.47, 95% CI (1.20-1.81), P = 0.03]. Based on cancer type, cutoff value, region, and sample size, a subgroup analysis was performed. The results showed that OS and CSS were not affected by the above factors, and the high CONUT score before surgery predicted worse OS and CSS. In conclusion, this meta-analysis revealed that the preoperative CONUT score is a potential independent predictor of the postoperative prognosis of RCC/UTUC patients. A high CONUT predicts worse OS/CSS/DFS and RFS in patients.
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Fan Y, He L, Zhou Y, Man C. Predictive Value of Geriatric Nutritional Risk Index in Patients With Coronary Artery Disease: A Meta-Analysis. Front Nutr 2021; 8:736884. [PMID: 34660665 PMCID: PMC8511313 DOI: 10.3389/fnut.2021.736884] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/30/2021] [Indexed: 01/03/2023] Open
Abstract
Background: Low Geriatric Nutritional Risk Index has been identified as an index of impaired nutritional state. The objective of the meta-analysis was to assess the association of the Geriatric Nutritional Risk Index (GNRI) with adverse outcomes in patients with coronary artery disease (CAD). Methods: Relevant studies were identified by comprehensively searching PubMed and Embase databases in May 2021. Studies assessing the association of GNRI with all-cause mortality or major adverse cardiovascular events (MACEs) in patients with CAD were included. The predictive value of GNRI was summarized by pooling multivariable adjusted risk ratios (RR) with 95% confidence intervals (CI) per GNRI point decrease or the lowest vs. the highest GNRI group. Results: A total of eight studies involving 9277 patients with CAD were analyzed. Meta-analysis showed that the lowest GNRI was associated with a higher risk of all-cause mortality (RR 2.10; 95% CI 1.68–2.63) and MACEs (RR 2.84; 95% CI 1.56–5.16), respectively. Furthermore, per point decrease in GNRI was associated with 8 and 10% additional risk of all-cause mortality and MACEs. Subgroup analysis indicated that the value of low GNRI in predicting all-cause mortality was not affected by subtype of patients or follow-up duration. Conclusion: Low GNRI score at baseline was associated with a higher risk of all-cause mortality and cardiovascular events in patients with CAD. The nutritional state estimated by the GNRI score could provide important predictive information in patients with CAD.
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Affiliation(s)
- Yu Fan
- Institute of Molecular Biology and Translational Medicine, The Affiliated People's Hospital, Jiangsu University, Zhenjiang, China
| | - Lian He
- Institute of Molecular Biology and Translational Medicine, The Affiliated People's Hospital, Jiangsu University, Zhenjiang, China
| | - Yongjing Zhou
- Institute of Molecular Biology and Translational Medicine, The Affiliated People's Hospital, Jiangsu University, Zhenjiang, China
| | - Changfeng Man
- Institute of Molecular Biology and Translational Medicine, The Affiliated People's Hospital, Jiangsu University, Zhenjiang, China
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Tasbulak O, Guler A, Duran M, Sahin A, Bulut U, Avci Y, Demir AR, Kahraman S, Aydin U, Ertürk M. Association Between Nutritional Indices and Long-Term Outcomes in Patients Undergoing Isolated Coronary Artery Bypass Grafting. Cureus 2021; 13:e16567. [PMID: 34430169 PMCID: PMC8378304 DOI: 10.7759/cureus.16567] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2021] [Indexed: 12/19/2022] Open
Abstract
Background It is well known that approximately 20% of patients who undergo cardiac surgery experience weight loss in postoperative period. However, there is a lack of data on postoperative consequences of malnutrition. This study aimed to investigate the relationship between nutritional status and long-term outcomes in patients undergoing isolated coronary artery bypass grafting (CABG). Material and methods A total of 586 patients who underwent isolated CABG in our center between January 2015 and March 2016 were included in this study. The primary outcome was major adverse cardiac and cerebrovascular events (MACCE) defined as a composite of all-cause death, non-fatal myocardial infarction (MI), and stroke. Patients were divided into two groups based on their MACCE outcomes. Prognostic nutritional index (PNI), geriatric nutritional risk index (GNRI), and controlling nutritional status (CONUT) scores were used to show the nutritional status. Results The mean follow-up time of the whole study group was 38.08 ± 13.4 months. The follow-up time was 39 ± 13 months in patients with mortality, while it was 20 ± 15 months in those without mortality. The PNI and GNRI values were lower in patients with major adverse cardiac and cerebrovascular events (MACCE) compared to patients without MACCE. The median CONUT score was higher in patients with MACCE. Conclusion Our study showed that nutritional indices including PNI, CONUT, and GNRI were associated with long-term MACCE and mortality in patients who underwent isolated CABG. The use of these scores in order to predict prognosis in patients treated with CABG seems to be an applicable method in clinical practice.
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Affiliation(s)
- Omer Tasbulak
- Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, TUR
| | - Arda Guler
- Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, TUR
| | - Mustafa Duran
- Cardiology, University of Health Sciences, Konya Training and Research Hospital, Konya, TUR
| | - Anil Sahin
- Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, TUR
| | - Umit Bulut
- Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, TUR
| | - Yalcin Avci
- Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, TUR
| | - Ali R Demir
- Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, TUR
| | - Serkan Kahraman
- Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, TUR
| | - Unal Aydin
- Cardiovascular Surgery, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, TUR
| | - Mehmet Ertürk
- Cardiology, University of Health Sciences, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, TUR
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Yıldırım A, Kucukosmanoglu M, Koyunsever NY, Cekici Y, Belibagli MC, Kılıc S. Combined effects of nutritional status on long-term mortality in patients with non-st segment elevation myocardial infarction undergoing percutaneous coronary intervention. ACTA ACUST UNITED AC 2021; 67:235-242. [PMID: 34406247 DOI: 10.1590/1806-9282.67.02.20200610] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 12/10/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the performance of controlling nutritional status (CONUT) index, geriatric nutritional risk index (GNRI), and prognostic nutritional index (PNI) scores in predicting the long-term prognosis of patients with non-ST-elevated myocardial infarction (NSTEMI) who underwent percutaneous coronary intervention (PCI). METHODS A total of 915 patients with NSTEMI (female: 48.4%; mean age: 73.1±9.0 years) who underwent PCI at Adana Numune Training and Research Hospital, Cardiology Clinic between January 2014 and January 2015 were included in this cross-sectional and retrospective study. CONUT, GNRI, and PNI scores were calculated based on the admission data derived from samples of peripheral venous blood. The mean follow-up duration was 64.5±15.4 months. RESULTS During follow-up (mean 64.5±15.4 months), 179 patients (19.6%) died. The mean GNRI and PNI scores were significantly lower in the nonsurvivor group; however, the median CONUT score was significantly higher in the nonsurvivor group compared with the survivor group. The receiver operating characteristic (ROC) curve analyses have shown that GNRI score has similar performance to the CONUT score and has better performance than PNI score in predicting 5-year mortality. The Kaplan-Meier curve analysis has shown that patients with lower PNI or GNRI had higher cumulative mortality than the patients with higher PNI or GNRI. Also, the patients with higher CONUT scores had higher cumulative mortality compared with those with lower scores. The multivariate analyses have shown that GNRI (HR: 0.973), PNI (HR: 0.967), CONUT score (HR: 1.527), and body mass index (BMI) (HR: 0.818) were independent predictors of the 5-year mortality in patients with NSTEMI. CONCLUSION In this study, we have shown that CONUT score, GNRI, and PNI values were associated with the long-term mortality in patients with NSTEMI who underwent PCI, and GNRI yielded similar results to CONUT score but was better than PNI.
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Affiliation(s)
- Arafat Yıldırım
- University of Health Sciences, Adana Health Practice and Research Center, Department of Cardiology - Adana, Turkey
| | - Mehmet Kucukosmanoglu
- University of Health Sciences, Adana Health Practice and Research Center, Department of Cardiology - Adana, Turkey
| | - Nermin Yıldız Koyunsever
- University of Health Sciences, Adana Health Practice and Research Center, Department of Cardiology - Adana, Turkey
| | - Yusuf Cekici
- University of Health Sciences, Mehmet Akif İnan Research and Training Hospital, Department of Cardiology - Sanlıurfa, Turkey
| | - Mehmet Cenk Belibagli
- University of Health Sciences, Adana Health Practice and Research Center, Department of Family Medicine - Adana, Turkey
| | - Salih Kılıc
- University of Health Sciences, Adana Health Practice and Research Center, Department of Cardiology - Adana, Turkey
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Mas-Peiro S, Hoffmann J, Seppelt PC, De Rosa R, Murray MI, Walther T, Zeiher AM, Fichtlscherer S, Vasa-Nicotera M. Value of prognostic nutritional index for survival prediction in trans-catheter aortic valve replacement compared to other common nutritional indexes. Acta Cardiol 2021; 76:615-622. [PMID: 32396499 DOI: 10.1080/00015385.2020.1757854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nutritional status predicts outcomes after TAVR. Predictive value of Prognostic Nutritional Index (PNI) was investigated in patients undergoing TAVR, and compared to other nutritional indexes. METHODS A cohort of 114 patients undergoing TAVR in a high-volume centre was studied. A prospective 1-year follow-up was completed. PNI was estimated as follows: (10 × serum albumin[g/dl])+(0.005 × total lymphocytes [1000/μl]). One-year survival was compared in patients with PNI above vs below median; Kaplan-Meier curves were created. A multivariate analysis was used to assess predictive value of PNI for 1-year mortality. ROC curves were used to assess discrimination by PNI, and to compare it with Geriatric Nutritional Risk Index (GNRI) and Body Mass Index (BMI). RESULTS Mean age was 82.2 years, 59.6% were male. Mean PNI was 46 ± 5. Pre-procedurally, no differences were found between patients with high vs. low PNI. One-year mortality was significantly higher in patients with low PNI values (19/57 vs. 4/57; p < .001). Complications did not differ. A higher PNI predicted 1-year survival, even after adjusting for clinical factors (model 1: HR 0.8, 95% CI 0.7-0.9, p < .0001) and laboratory parameters (NT-proBNP, IL-6, CRP, eGFR, cystatin C, haemoglobin) (model 2: HR 0.8, 95% CI 0.7-0.9, p < .05). ROC curves revealed a stronger predictive value for PNI (AUC 0.80) compared to GNRI (0.77) and BMI (0.6). The optimal cut-off for PNI was 45. CONCLUSION PNI is a useful and practical nutritional marker reflecting malnutrition and inflammation prior to the intervention, and strongly predicts 1-year survival. PNI seems to be a better prognostic marker than BMI or GNRI after TAVR.
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Affiliation(s)
- Silvia Mas-Peiro
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany
- German Centre for Cardiovascular Research, DZHK, Berlin, Germany
| | - Jedrzej Hoffmann
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany
- German Centre for Cardiovascular Research, DZHK, Berlin, Germany
| | - Philipp C. Seppelt
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany
- German Centre for Cardiovascular Research, DZHK, Berlin, Germany
| | - Roberta De Rosa
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany
| | - Marie-Isabel Murray
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany
| | - Thomas Walther
- German Centre for Cardiovascular Research, DZHK, Berlin, Germany
- Department of Cardiothoracic Surgery, University Hospital Frankfurt am Main, Frankfurt, Germany
| | - Andreas M. Zeiher
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany
- German Centre for Cardiovascular Research, DZHK, Berlin, Germany
| | - Stephan Fichtlscherer
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany
- German Centre for Cardiovascular Research, DZHK, Berlin, Germany
| | - Mariuca Vasa-Nicotera
- Department of Cardiology, University Hospital Frankfurt am Main, Frankfurt, Germany
- German Centre for Cardiovascular Research, DZHK, Berlin, Germany
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10
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Chen L, Huang Z, Lu J, Yang Y, Pan Y, Bao K, Wang J, Chen W, Liu J, Liu Y, Chen K, Li W, Chen S. Impact of the Malnutrition on Mortality in Elderly Patients Undergoing Percutaneous Coronary Intervention. Clin Interv Aging 2021; 16:1347-1356. [PMID: 34290497 PMCID: PMC8286965 DOI: 10.2147/cia.s308569] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 06/30/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Malnutrition has been shown to be related to adverse clinical outcomes in patients with heart failure, hypertension, atrial fibrillation and other cardiovascular diseases. However, in the patients with coronary artery disease (CAD) undergoing percutaneous coronary interventions (PCI), especially in the elderly, the association of nutritional state and all-cause mortality remains unknown. We aimed to investigate the association of malnutrition with all-cause mortality in the elder patients undergoing PCI. Patients and Methods Based on the largest retrospective and observational cohort study from January 2007 to December 2017, the Controlling Nutritional Status (CONUT) score was applied to 21,479 consecutive patients with age ≥60 who undergoing PCI for nutritional assessment. Participants were classified as absent, mild, moderate and severe malnutrition by CONUT score. The Kaplan-Meier method was used to compare all-cause mortality among the above four groups. Multivariable Cox proportional hazard regression analyses were performed to examine the association of malnutrition with all-cause mortality. Results According to the CONUT score, 48.19%, 15.08% and 0.94% patients were mildly, moderately and severely malnourished, respectively. During a median follow-up of 5.16 years (interquartile range: 3.02 to 7.89 years), 3173 (14.77%) patients died. Kaplan-Meier analysis showed that the risk of all-cause mortality was significantly higher in patients with a worse nutritional status. Compared with normal nutritional state, malnutrition was associated with significantly increased risk for all-cause mortality (adjusted hazard ratio for mild, moderate and severe degrees of malnutrition, respectively: 1.20 [95% confidence interval (CI): 1.09 to 1.33], 1.32 [95% CI: 1.17 to 1.49] and 1.76 [95% CI: 1.33 to 2.33]). Conclusion Malnutrition is prevalent among elderly patients with CAD undergoing PCI, and is strongly related to the all-cause mortality increasing. For elderly patients with CAD undergoing PCI, it is necessary to assess the status of nutrition, and evaluate the efficacy of nutritional interventions.
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Affiliation(s)
- Liling Chen
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, People's Republic of China
| | - Zhidong Huang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People's Republic of China
| | - Jin Lu
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, People's Republic of China
| | - Yanfang Yang
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, People's Republic of China
| | - Yuxiong Pan
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, People's Republic of China
| | - Kunming Bao
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, People's Republic of China
| | - Junjie Wang
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, People's Republic of China
| | - Weihua Chen
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, People's Republic of China
| | - Jin Liu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People's Republic of China
| | - Yong Liu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People's Republic of China
| | - Kaihong Chen
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, People's Republic of China
| | - Weiguo Li
- Department of Cardiology, Longyan First Affiliated Hospital of Fujian Medical University, Longyan, 364000, People's Republic of China
| | - Shiqun Chen
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People's Republic of China
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11
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Gürbak İ, Güner A, Güler A, Şahin AA, Çelik Ö, Uzun F, Onan B, Ertürk M. Prognostic influence of objective nutritional indexes on mortality after surgical aortic valve replacement in elderly patients with severe aortic stenosis (from the nutrition-SAVR trial). J Card Surg 2021; 36:1872-1881. [PMID: 33586213 DOI: 10.1111/jocs.15434] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/21/2021] [Accepted: 02/01/2021] [Indexed: 02/06/2023]
Abstract
AIM Several scoring systems, such as controlling nutritional status (CONUT) score, geriatric nutritional risk index (GNRI), and prognostic nutritional index (PNI), have been previously described to show nutritional status. In the present study, we aimed to investigate the value of these scoring systems in predicting in-hospital and long-term mortality in patients undergoing surgical aortic valve replacement (SAVR). METHODS PNI, GNRI, and CONUT were determined using the receiver operator characteristics curve analysis in 150 consecutive elderly patients (age: 70 (66-74) years, male: 78) who underwent SAVR due to degenerative severe aortic stenosis (AS). Patients were divided into two groups according to cutoff values from these indexes. RESULTS During the 50 ± 31 months follow-up period, a total of 36 (24%) patients died. 30-day mortality, 1-year mortality, and total mortality were significantly higher in lower PNI, lower GNRI, and higher CONUT groups. PNI cutoff value was 49.2, GNRI cutoff value was 102.5, and CONUT cutoff value was 1.5. PNI ≤ 49.2, GNRI ≤ 102.5, and CONUT > 1.5 values were found to be independent predictors of total mortality even after risk adjustment. In addition, in the mortality group, PNI (53.7 ± 5.9 vs. 47.4 ± 6.3; p < .001) and GNRI (108 ± 10 vs. 99 ± 6.3); p < .001) were significantly lower, while CONUT score (1 [0-2] vs. 2 [0.2-3]; p < .001) was significantly higher. CONCLUSION Objective nutritional indexes including CONUT score, PNI, and GNRI are important prognostic factors and those indexes should be part of frailty assessment in patients with severe AS.
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Affiliation(s)
- İsmail Gürbak
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ahmet Güner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Arda Güler
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ahmet A Şahin
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ömer Çelik
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Fatih Uzun
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Burak Onan
- Department of Cardiovascular Surgery, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Mehmet Ertürk
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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Abstract
OBJECTIVE The aim of this study is to evaluate the association between Nutritional Risk Index (NRI), a simple tool to assess nutritional status, and coronary artery disease severity and complexity in patients undergoing coronary angiography. METHODS This study is a retrospective analysis of 822 patients undergoing coronary angiography. Patients with previous revascularization were excluded. Gensini and SYNTAX scores were calculated according to the angiographic images to determine atherosclerosis severity. NRI was calculated as follows: NRI = [15.19 × serum albumin (g/dl)] + [41.7 × (body weight/ideal body weight)]. In patients ≥65 years of age, Geriatric NRI (GNRI) was used instead of NRI. GNRI was calculated as follows: GNRI = [14.89 × serum albumin (g/dl)] + [41.7 × (body weight/ideal body weight)]. Patients were then divided into three groups as previously reported: NRI < 92, NRI 92-98 and NRI > 98. Gensini and SYNTAX scores were compared between three groups. RESULTS The mean age of study population was 61.9 ± 11.1 years. NRI < 92, 92-98, and >98 was measured in 212, 321 and 289 patients, respectively. There was no difference regarding to sex, BMI, smoking, hypertension and diabetes mellitus between three groups. Patients with NRI < 92 had the highest mean Gensini score than the patients with NRI 92-98 and NRI > 98 (38.0 ± 40.6 vs. 31.17 ± 42.4 vs. 25.8 ± 38.4, P = 0.005). Also patients with NRI < 92 had the highest mean SYNTAX score than the patients with NRI 92-98 and NRI > 98 (11.8 ± 12.9 vs. 9.3 ± 12.4 vs. 7.7 ± 11.8, P = 0.001). Also, Gensini score of ≥20 and high SYNTAX score of ≥33 were associated with lower NRI (P < 0.001 and P < 0.001, respectively). CONCLUSION In our study, nutritional status evaluated by the NRI was associated with more extensive and complex coronary atherosclerosis in patients undergoing coronary angiography.
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13
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Donahue BS. Commentary: Preoperative nutritional status and mortality from cardiac surgery: Do we have your attention yet? J Thorac Cardiovasc Surg 2021; 164:1150-1151. [PMID: 34561101 DOI: 10.1016/j.jtcvs.2021.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 12/31/2020] [Accepted: 01/04/2021] [Indexed: 12/27/2022]
Affiliation(s)
- Brian S Donahue
- Division of Pediatric Cardiac Anesthesia, Departments of Anesthesiology and Pediatrics, Vanderbilt University Medical Center, Nashville, Tenn.
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14
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Demir AR, Celik O, Uygur B, Somuncu MU, Bayram M, Yilmaz E, Avci Y, Sevinc S, Tasbulak O, Bulut U, Ersoy B, Erturk M. Malnutrition provides important long-term prognostic information in patients undergoing endovascular abdominal aortic aneurysm repair. Vascular 2020; 29:330-339. [PMID: 32998666 DOI: 10.1177/1708538120960859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Malnutrition has been shown to be associated with survival in a variety of diseases. Our aim is to evaluate the prognostic value of objective nutritional indexes indicating malnutrition, in patients underwent endovascular aortic replacement. METHODS We retrospectively evaluated 149 consecutive patients who underwent technically successful endovascular aortic replacement operation between October 2010 and August 2019. Objective nutritional indexes, prognostic nutritional index, geriatric nutritional risk index and controlling nutritional status, scores were calculated using the preoperative data. Optimal cut-off values were obtained by receiver operating characteristic analysis. According to the cut-off values, we investigated the relationship between indexes and the long-term all-cause mortality. RESULTS During mean 48.0 ± 30.3 months follow-up duration, in 47 of patients (31.5%), all-cause mortality were documented. In mortality group, prognostic nutritional index (42.8 ± 7.1 vs 51.3 ± 5.2, p < 0.001) and geriatric nutritional risk index (100.7 ± 10.1 vs 107.6 ± 9.2, p < 0.001) were significantly lower, controlling nutritional status score (2.0 (1.0-4.0) vs 1.0 (0.0-2.0), p < 0.001) was higher when compared to survivor group. Kaplan-Meier curves presented higher mortality incidence in malnutrition patients evaluated with objective nutritional indexes (Log-rang test, for all three indexes p < 0.001). Besides Cox-proportional hazard analysis showed all three nutritional indexes may be a predictive marker for all-cause mortality, prognostic nutritional index introduced more valuable data than other two indexes. CONCLUSIONS Malnutrition is associated with significant increase in postoperative long-term mortality in endovascular aortic replacement patients. Preoperatively calculated objective nutritional indexes especially prognostic nutritional index can be used as an important prognostic tool.
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Affiliation(s)
- Ali Riza Demir
- Cardiology Department, University of Health Science, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Omer Celik
- Cardiology Department, University of Health Science, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Begum Uygur
- Cardiology Department, University of Health Science, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Umut Somuncu
- Cardiology Department, Faculty of Medicine, Zonguldak Bülent Ecevit University, Zonguldak, Turkey
| | - Muhammed Bayram
- Cardiovascular Surgery Department, University of Health Science, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Emre Yilmaz
- Cardiology Department, Görele Op. Dr. Ergun Ozdemir State Hospital, Giresun, Turkey
| | - Yalcin Avci
- Cardiology Department, University of Health Science, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Samet Sevinc
- Cardiology Department, University of Health Science, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Omer Tasbulak
- Cardiology Department, University of Health Science, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Umit Bulut
- Cardiology Department, University of Health Science, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Burak Ersoy
- Cardiovascular Surgery Department, University of Health Science, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Erturk
- Cardiology Department, University of Health Science, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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15
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Test-retest reliability of the Mini Nutritional Assessment-Short Form (MNA-SF) in older patients undergoing cardiac rehabilitation. J Geriatr Cardiol 2020; 17:574-579. [PMID: 33117422 PMCID: PMC7568041 DOI: 10.11909/j.issn.1671-5411.2020.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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16
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Deng X, Zhang S, Shen S, Deng L, Shen L, Qian J, Ge J. Association of Controlling Nutritional Status Score With 2-Year Clinical Outcomes in Patients With ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention. Heart Lung Circ 2020; 29:1758-1765. [PMID: 32622915 DOI: 10.1016/j.hlc.2020.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 01/31/2020] [Accepted: 02/29/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND This study evaluated whether the Controlling Nutritional Status (CONUT) score could predict clinical outcomes in ST elevation myocardial infarction (STEMI) patients. METHODS We performed a retrospective cohort study of STEMI patients after primary percutaneous coronary intervention (pPCI). The endpoint was major adverse cardiac event (MACE). Information was obtained from medical records and via telephone calls. Patients were divided into three groups: normal (CONUT score 0-1; n=278), mild-moderate (score 2-4; n=418), and severe (score ≥5; n=55) groups. RESULTS During the 24.6±12 months follow-up, MACEs were observed in 65 (8.7%) patients. The incidence of MACEs was 6.1%, 5.5%, and 45.5% in the normal, mild-moderate, and severe group, respectively (p<0.001). Kaplan-Meier curves revealed that patients with a CONUT score ≥5 had the significantly highest rate of MACE, myocardial re-infarction, and vessel revascularisation. In three Cox proportional hazard models, the CONUT scores were unexceptionally associated with MACE, even after adjusting all other variables (hazard ratio, 12.09; 95% confidence interval [CI], 5.09-28.7; p<0.001). The C-statistic of the CONUT score for the prediction of MACE was 0.692 (95% CI, 0.613-0.771; p<0.001), which is close to that of Global Registry of Acute Coronary Events. CONCLUSIONS The nutritional status evaluated by the CONUT score can independently predict clinical outcomes in STEMI patients, which suggests that active nutritional management is meaningful for these patients after PCI.
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Affiliation(s)
- Xin Deng
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Cardiovascular Medical Center, Shanghai Institute of Cardiovascular Diseases; Institute of Pan-vascular Medicine, Fudan University, Shanghai, China
| | - Shuning Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Cardiovascular Medical Center, Shanghai Institute of Cardiovascular Diseases; Institute of Pan-vascular Medicine, Fudan University, Shanghai, China
| | - Shutong Shen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Cardiovascular Medical Center, Shanghai Institute of Cardiovascular Diseases; Institute of Pan-vascular Medicine, Fudan University, Shanghai, China
| | - Liyu Deng
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Cardiovascular Medical Center, Shanghai Institute of Cardiovascular Diseases; Institute of Pan-vascular Medicine, Fudan University, Shanghai, China
| | - Li Shen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Cardiovascular Medical Center, Shanghai Institute of Cardiovascular Diseases; Institute of Pan-vascular Medicine, Fudan University, Shanghai, China
| | - Juying Qian
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Cardiovascular Medical Center, Shanghai Institute of Cardiovascular Diseases; Institute of Pan-vascular Medicine, Fudan University, Shanghai, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Cardiovascular Medical Center, Shanghai Institute of Cardiovascular Diseases; Institute of Pan-vascular Medicine, Fudan University, Shanghai, China.
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17
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Yang QY, Li XF, Lin MQ, Xu JH, Yan H, Zhang ZM, Wang SY, Chen HC, Chen XN, Lin KY, Guo YS. Association between red blood cell distribution width and long-term mortality among patients undergoing percutaneous coronary intervention with previous history of cancer. Biomarkers 2020; 25:260-267. [PMID: 32141338 DOI: 10.1080/1354750x.2020.1734860] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background: The number of patients suffering from coronary heart disease with cancer is rising. There is scarce evidence concerning the biomarkers related to prognosis among patients undergoing percutaneous coronary intervention (PCI) with cancer. Thus, the aim of this study was to investigate the association between red blood cell distribution width (RDW) and prognosis in this population.Methods: A total of 172 patients undergoing PCI with previous history of cancer were enrolled in this retrospective study. The endpoint was long-term all-cause mortality. According to tertiles of RDW, the patients were classified into three groups: Tertile 1 (RDW <12.8%), Tertile 2 (RDW ≥12.8% and <13.5%) and Tertile 3 (RDW ≥13.5%).Results: During an average follow-up period of 33.3 months, 29 deaths occurred. Compared with Tertile 3, mortality of Tertile 1 and Tertile 2 was significantly lower in the Kaplan-Meier analysis. In multivariate Cox regression analysis, RDW remained an independent risk factor of mortality (HR: 1.938, 95% CI: 1.295-2.655, p < 0.001). The all-cause mortality in Tertile 3 was significantly higher than that in Tertile 1 (HR: 5.766; 95% CI: 1.426-23.310, p = 0.014).Conclusions: An elevated RDW level (≥13.5%) was associated with long-term all-cause mortality among patients undergoing PCI with previous history of cancer.
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Affiliation(s)
- Qing-Yong Yang
- Department of Internal Medicine, Jinshan Branch of Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fuzhou, China.,Clinical Medical College of Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China
| | - Xiu-Feng Li
- Clinical Medical College of Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China.,Department of Cardiology, Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fuzhou, China
| | - Mao-Qiang Lin
- Clinical Medical College of Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China.,Department of Cardiology, Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fuzhou, China
| | - Jia-Hao Xu
- Clinical Medical College of Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China.,Department of Cardiology, Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fuzhou, China
| | - Han Yan
- Clinical Medical College of Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China.,Department of Cardiology, Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fuzhou, China
| | - Zhi-Ming Zhang
- Clinical Medical College of Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China.,Department of Cardiology, Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fuzhou, China
| | - Sun-Ying Wang
- Clinical Medical College of Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China.,Department of Cardiology, Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fuzhou, China
| | - Han-Chuan Chen
- Clinical Medical College of Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China.,Department of Cardiology, Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fuzhou, China
| | - Xi-Nan Chen
- Clinical Medical College of Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China.,Department of Cardiology, Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fuzhou, China
| | - Kai-Yang Lin
- Clinical Medical College of Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China.,Department of Cardiology, Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fuzhou, China
| | - Yan-Song Guo
- Clinical Medical College of Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China.,Department of Cardiology, Fujian Provincial Hospital, Fujian Cardiovascular Institute, Fuzhou, China
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18
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Sumida H, Yasunaga Y, Takasawa K, Tanaka A, Ida S, Saito T, Sugiyama S, Matsui K, Nakao K, Tsujita K, Tohya Y. Cognitive function in post-cardiac intensive care: patient characteristics and impact of multidisciplinary cardiac rehabilitation. Heart Vessels 2020; 35:946-956. [PMID: 32052162 DOI: 10.1007/s00380-020-01566-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 01/24/2020] [Indexed: 01/18/2023]
Abstract
New/worsening cognitive and physical impairments following critical care pose significant problems. Multidisciplinary cardiac rehabilitation (CR) can improve physical function after cardiac intensive care (CIC). This observational study aimed to evaluate cognitive function in patients participating in multidisciplinary CR and to identify correlates of impaired cognitive function after CIC. We analyzed 111 consecutive patients admitted to our comprehensive care ward at least 7 days after CIC and assessed factors associated with cognitive function using the Functional Independence Measure (FIM). Patients were stratified into two groups based on the median FIM-Cognitive scores: impaired (n = 56) and preserved cognition (n = 55) groups. Multiple logistic regression analysis identified age [odds ratio (OR) 1.06; 95% confidence interval (CI) 1.00-1.13; p = 0.042], Mini-Nutrition Assessment-Short Form (MNA-SF; OR 0.73; 95% CI 0.56-0.95; p = 0.017), and FIM-Physical scores (OR: 0.94; 95% CI 0.90-0.99; p = 0.012) as significant and independent factors associated with impaired cognition. The median length of hospital stay was 28 (interquartile range: 18, 43) days. The FIM-Cognitive and FIM-Physical scores significantly increased from admission to discharge [32.0 (27.0, 35.0) vs. 34.0 (29.0, 35.0) points; p < 0.001; 67.0 (53.0, 75.0) vs. 85.0 (73.5, 89.0) points; p < 0.001, respectively]. On subgroup analysis within the impaired cognition group, increased FIM-Cognitive scores positively and significantly correlated with increased FIM-Physical scores (ρ = 0.450; p = 0.001). Multiple linear regression analysis identified atrial fibrillation (AF; β = - 0.29; p = 0.016), ln(glycated hemoglobin; HbA1c) (β = 0.29; p = 0.018), and ln(high-sensitivity C-reactive protein; hs-CRP) (β = - 0.26; p = 0.034) as significant and independent factors correlated with increased FIM-Cognitive scores. In conclusion, advanced age, low MNA-SF score, and FIM-Physical score were independent factors associated with impaired cognition in post-CIC patients. Multidisciplinary CR improved both physical and cognitive functions, and AF, HbA1c, and hs-CRP were independent factors correlated with increased FIM-Cognitive score.
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Affiliation(s)
- Hitoshi Sumida
- Division of Cardiology, Heisei Tohya Hospital, 8-2-15, Idenakama Minami-ku, Kumamoto, 862-0963, Japan.
| | - Yuichi Yasunaga
- Division of Cardiology, Heisei Tohya Hospital, 8-2-15, Idenakama Minami-ku, Kumamoto, 862-0963, Japan
| | - Kensei Takasawa
- Division of Cardiology, Heisei Tohya Hospital, 8-2-15, Idenakama Minami-ku, Kumamoto, 862-0963, Japan
| | - Aya Tanaka
- Division of Cardiology, Heisei Tohya Hospital, 8-2-15, Idenakama Minami-ku, Kumamoto, 862-0963, Japan
| | - Seiko Ida
- Division of Cardiology, Heisei Tohya Hospital, 8-2-15, Idenakama Minami-ku, Kumamoto, 862-0963, Japan
| | - Tadaoki Saito
- Division of Cardiology, Heisei Tohya Hospital, 8-2-15, Idenakama Minami-ku, Kumamoto, 862-0963, Japan
| | - Seigo Sugiyama
- Division of Cardiology, Jinnouchi Hospital, 6-2-3, Kuhonji Chuo-ku, Kumamoto, 862-0976, Japan
| | - Kunihiko Matsui
- Department of Community, Family, and General Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-ku, Kumamoto, 862-8556, Japan
| | - Koichi Nakao
- Department of Cardiovascular Medicine, Saiseikai Kumamoto Hospital, 5-3-1, Chikami Minami-ku, Kumamoto, 862-4116, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, 1-1-1, Honjo Chuo-ku, Kumamoto, 862-8556, Japan
| | - Yuji Tohya
- Division of Cardiology, Heisei Tohya Hospital, 8-2-15, Idenakama Minami-ku, Kumamoto, 862-0963, Japan
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19
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Predictive value of the geriatric nutritional risk index in percutaneous coronary intervention with rotational atherectomy. Heart Vessels 2020; 35:887-893. [PMID: 31970508 DOI: 10.1007/s00380-020-01558-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 01/10/2020] [Indexed: 10/25/2022]
Abstract
The prognostic value of the geriatric nutritional risk index (GNRI) in patients undergoing percutaneous coronary intervention (PCI) with rotational atherectomy (RA) remains unknown. Therefore, we aimed to clarify whether the GNRI could predict major adverse cardiac events (MACE) in patients undergoing PCI with RA. A total of 206 patients who underwent PCI with RA from January 2009 to December 2017 were retrospectively tracked. The patients were divided into 2 groups based on the GNRI value on admission. MACE comprised all-cause death, target lesion revascularization (TLR), target vessel revascularization (TVR), and myocardial infarction. One year of follow up was completed in 95.6% of patients. During this period, 50 cases of MACE were observed (all-cause death, 32 cases; TLR, 21 cases; and TVR, 2 cases). Patients with a low GNRI (< 98) had a significantly higher incidence of MACE than did patients with a high GNRI (≥ 98) (37.9% vs. 15.5%, log-rank p < 0.05). The GNRI was an independent predictor of MACE (hazard ratio, 0.94; 95% confidence interval [CI], 0.92-0.97). Furthermore, the GNRI had better predictive power than did its components alone (i.e. body mass index and serum albumin level) (net-reclassification improvement, 0.39; 95% CI, 0.07-0.71; p = 0.01; integrated discrimination improvement, 0.02; 95% CI, - 0.01-0.04; p = 0.07). The GNRI on admission is a predictor of MACE after PCI with RA. Further studies are required to determine whether intensive medical therapy could improve clinical events, particularly cardiovascular death and revascularization, in this population.
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20
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Ando T, Yoshihisa A, Kimishima Y, Kiko T, Shimizu T, Yamaki T, Kunii H, Nakazato K, Takeishi Y. Prognostic impacts of nutritional status on long-term outcome in patients with acute myocardial infarction. Eur J Prev Cardiol 2019; 27:2229-2231. [PMID: 31610705 DOI: 10.1177/2047487319883723] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Takuya Ando
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Yusuke Kimishima
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Takatoyo Kiko
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Takeshi Shimizu
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Takayoshi Yamaki
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Hiroyuki Kunii
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Kazuhiko Nakazato
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Japan
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21
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Cheng N, Dang A, Lv N, He Y, Wang X. Malnutrition status in patients of very advanced age with nonvalvular atrial fibrillation and its impact on clinical outcomes. Nutr Metab Cardiovasc Dis 2019; 29:1101-1109. [PMID: 31383499 DOI: 10.1016/j.numecd.2019.06.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 06/26/2019] [Accepted: 06/26/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Malnutrition is associated with adverse outcomes in patients with chronic disease. We screened malnutrition among patients of very advanced age with nonvalvular atrial fibrillation (AF) by malnutrition scores and investigated the associations between malnutrition and clinical outcomes. METHODS AND RESULTS This retrospective observational study included 461 patients aged ≥80 years with nonvalvular AF. Malnutrition was screened using the Controlling Nutritional Status (CONUT), Prognostic Nutritional Index (PNI), and Geriatric Nutritional Risk Index (GNRI) scores. The primary endpoints were composite events, including thromboembolic events and all-cause death. Malnutrition was present in 62.9%, 5.0%, and 21.9% of patients according to the CONUT, PNI, and GNRI scores, respectively. During a median 27-month follow-up, 130 (28.2%) patients had composite events. Kaplan-Meier curves revealed that patients with moderate to severe malnutrition had the worst clinical outcomes (log-rank P < 0.05 for all scores). Multivariate Cox proportional hazards analysis showed that moderate to severe malnutrition was an independent predictor of composite events [hazard ratio (HR): 2.051, 95% confidence interval (95%CI): 1.143-3.679, P = 0.016 for CONUT score; HR: 3.374, 95%CI: 1.898-5.998, P < 0.001 for PNI score; HR: 2.254, 95%CI: 1.381-3.679, P = 0.001 for GNRI score]. Addition of the CONUT or GNRI score to a baseline prediction model for composite events significantly improved the net reclassification improvement and integrated discrimination improvement (all P < 0.05). CONCLUSION Moderate to severe malnutrition was an independent predictor of adverse outcomes among patients of very advanced age with nonvalvular AF. Screening for malnutrition might provide useful information regarding prognosis and risk stratification.
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Affiliation(s)
- Nan Cheng
- Department of Special Care Center, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Aimin Dang
- Department of Special Care Center, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
| | - Naqiang Lv
- Department of Special Care Center, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yanru He
- Department of Special Care Center, Fuwai Hospital, National Clinical Research Center for Cardiovascular Diseases, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiao Wang
- Department of Cardiology, Fuwai Central China Cardiovascular Hospital, Zhengzhou, China
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22
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Boban M, Bulj N, Kolačević Zeljković M, Radeljić V, Krcmar T, Trbusic M, Delić-Brkljačić D, Alebic T, Vcev A. Nutritional Considerations of Cardiovascular Diseases and Treatments. Nutr Metab Insights 2019; 12:1178638819833705. [PMID: 30923440 PMCID: PMC6431763 DOI: 10.1177/1178638819833705] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 01/28/2019] [Indexed: 12/16/2022] Open
Abstract
Nutritional considerations of many chronic diseases are not fully understood or taken into consideration in everyday clinical practice. Therefore, it is not surprising that high proportion of hospitalized patients with cardiovascular diseases remains underdiagnosed with malnutrition. Malnourished patients have increased risk of poor clinical outcomes, complications rate, prolonged hospital stay, more frequent rehospitalizations, and lower quality of life. The purpose of this review is to recapitulate recent data on nutritional considerations in cardiovascular medicine.
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Affiliation(s)
- Marko Boban
- Department of Cardiology, University Hospital Centre "Sestre Milosrdnice," Zagreb, Croatia.,Department of Rehabilitation and Sports Medicine, Faculty of Medicine, University of Rijeka, Rijeka, Croatia.,Department of Internal Medicine, Medical Faculty, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia.,Department of Internal Medicine and Physiology, Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Nikola Bulj
- Department of Cardiology, University Hospital Centre "Sestre Milosrdnice," Zagreb, Croatia.,Department of Internal Medicine, School of Medicine, University of Zagreb, Zagreb, Croatia
| | | | - Vjekoslav Radeljić
- Department of Cardiology, University Hospital Centre "Sestre Milosrdnice," Zagreb, Croatia
| | - Tomislav Krcmar
- Department of Cardiology, University Hospital Centre "Sestre Milosrdnice," Zagreb, Croatia
| | - Matias Trbusic
- Department of Cardiology, University Hospital Centre "Sestre Milosrdnice," Zagreb, Croatia
| | - Diana Delić-Brkljačić
- Department of Cardiology, University Hospital Centre "Sestre Milosrdnice," Zagreb, Croatia.,Department of Internal Medicine, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Tamara Alebic
- Department of Internal Medicine, Medical Faculty, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Aleksandar Vcev
- Department of Internal Medicine, Medical Faculty, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia.,Department of Internal Medicine and Physiology, Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
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