Nutritional status of geriatric outpatients with systolic heart failure and its prognostic value regarding death or hospitalization, biomarkers and quality of life

Natriuretic peptides and C-reactive protein in in heart failure and malnutrition: a systematic review and meta-analysis

BACKGROUND

Heart failure (HF) and malnutrition exhibit overlapping risk factors, characterized by increased levels of natriuretic peptides and an inflammatory profile. The aim of this study was to compare the differences in plasma brain natriuretic peptide (BNP), N-terminal-pro B-type natriuretic peptide (NT-proBNP), and C-reactive protein (CRP) in patients with HF and malnutrition versus normal nutrition.

METHODS

From inception until July 2023, the databases, PubMed, Scopus, Web of Science, and Cochrane Library were searched. To examine the association among malnutrition [controlling nutritional status (CONUT) score ≥2; Geriatric Nutritional Risk Index (GNRI) score <92] with BNP, NT-proBNP and CRP in patients with HF, a meta-analysis using a random-effects model was conducted (CRD42023445076).

RESULTS

A significant association of GNRI with increased levels of BNP were demonstrated [mean difference (MD): 204.99, 95% confidence interval (CI) (101.02, 308.96, I2 = 88%, P < 0.01)], albeit no statistically significant findings were shown using CONUT [MD: 158.51, 95% CI (-1.78 to 318.79, I2 = 92%, P = 0.05)]. GNRI [MD: 1885.14, 95% CI (1428.76-2341.52, I2 = 0%, P < 0.01)] and CONUT [MD: 1160.05, 95% CI (701.04-1619.07, I2 = 0%, P < 0.01)] were associated with significantly higher levels of NT-proBNP. Patients with normal GNRI scores had significantly lower levels of CRP [MD: 0.50, 95% CI (0.12-0.88, I2 = 87%, P = 0.01)] whereas significantly higher levels of CRP were observed in those with higher CONUT [MD: 0.40, 95% CI (0.08-0.72, I2 = 88%, P = 0.01)]. Employing meta-regression, age was deemed a potential moderator between CRP and GNRI.

CONCLUSIONS

Normal nutrition scores in patients with HF are linked to lower BNP, NT-proBNP, and CRP levels compared with malnourished counterparts. Despite the significant link between CRP and malnutrition, their relationship may be influenced in older groups considering the sensitivity of GNRI due to ageing factors.

Association between isolated or combined malnutrition and sarcopenia and quality of life in heart failure outpatients: A cross-sectional study

BACKGROUND

Heart failure (HF) is a chronic condition with symptoms linked to worse quality of life. Malnutrition and sarcopenia are conditions frequently found in patients with HF. This study aims to evaluate the association between isolated or combined malnutrition and sarcopenia and quality of life in outpatients with HF.

METHODS

This is a cross-sectional study with a sample of outpatients with HF aged ≥18 years. Malnutrition was assessed according to the criteria of the Global Leadership Initiative on Malnutrition, and sarcopenia was evaluated by the European Working Group on Sarcopenia in Older People. Quality of life was assessed using the Minnesota Living with HF questionnaire (MLHFQ). Clinical and sociodemographic data were collected.

RESULTS

One hundred and fifty-one patients were included in this study, with a median (interquartile range) age of 58 (48-65) years, 58.9% were adults, and 68.9% were male. A total of 29.5% of the patients were malnourished, and 28.5% and 2.6% were identified with probable sarcopenia and sarcopenia, respectively. Of the total, 15.9% of patients were identified with both conditions. Sarcopenia was associated with higher odds of increase in the MLHFQ total score, indicating worse quality of life (odds ratio [OR] = 3.61; 95% CI, 1.65-7.89). The same was found in the presence of two conditions (OR 3.97; 95% CI, 1.32-11.54), whereas isolated malnutrition was not related to life quality (OR = 1.62; 95% CI, 0.73-3.60).

CONCLUSION

The presence of malnutrition and sarcopenia simultaneously were associated with worse quality of life scores when compared with these isolated conditions.

Sex differences in the nutritional status and its association with long-term prognosis in patients with heart failure with reduced ejection fraction: a prospective cohort study

AIMS

Many studies show the association between malnutrition and poor prognosis in heart failure (HF) patients. Our research aimed to analyse sex differences in patients with HF with reduced ejection fraction (HFrEF), emphasizing nutritional status and the influence of selected parameters on the prognosis.

METHODS AND RESULTS

We enrolled 276 consecutive patients diagnosed with HFrEF. Nutritional status was assessed using Mini Nutritional Assessment (MNA), geriatric nutritional risk index (GNRI), and body mass index (BMI). The mean follow-up period was 564.4 ± 346.3 days. The analysed group included 81.2% of men. The median age was 58, interquartile range (IQR) 49-64 years. Among all patients, almost 60% were classified as NYHA III or IV. Half of the participants were at risk of malnutrition, and 2.9% were malnourished. During follow-up, 72 (26.1%) patients died. The female sex was not associated with a higher occurrence of malnutrition (P = 0.99) or nutritional risk (P = 0.85), according to MNA. Coherently, GNRI scores did not differ significantly between the sexes (P = 0.29). In contrast, BMI was significantly higher in males (29.4 ± 5.3 vs. 25.9 ± 4.7; P < 0.001). Impaired nutritional status assessed with any method (MNA, GNRI, BMI) was not significantly associated with a worse prognosis. In multivariable analysis, NYHA class, lower estimated glomerular filtration rate, higher B-type natriuretic peptide (BNP), higher N-terminal fragment of proBNP, and higher uric acid were independent of sex and age predictors of all-cause mortality.

CONCLUSION

There were no sex differences in the nutritional status in the HFrEF patients, apart from lower BMI in females. Impaired nutritional status was not associated with mortality in both men and women.

The impact of geriatric nutritional risk index on one-year outcomes in hospitalized elderly patients with heart failure

Background

Strategies that accurately predict outcomes in elderly heart failure (HF) patients have not been sufficiently established. In previous reports, nutritional status, ability to perform activities of daily living (ADL), and lower limb muscle strength are known prognostic factors associated with cardiac rehabilitation (CR). In the present study, we investigated which CR factors can accurately predict one-year outcomes in elderly patients with HF among the above factors.

Methods

Hospitalized patients with HF over 65 years of age from January 2016 to January 2022 were retrospectively enrolled in the Yamaguchi Prefectural Grand Medical (YPGM) Center. They were consequently recruited to this single-center retrospective cohort study. Nutritional status, ADL, and lower limb muscle strength were assessed by geriatric nutritional risk index (GNRI), Barthel index (BI), and short physical performance battery (SPPB) at discharge, respectively. One year after discharge, the primary and secondary outcomes were evaluated by all-cause death or HF readmission and major adverse cardiac and cerebrovascular events (MACCE), respectively.

Results

Overall, 1,078 HF patients were admitted to YPGM Center. Of those, 839 (median age 84.0, 52% female) met the study criteria. During the follow-up of 228.0 days, 72 patients reached all-cause death (8%), 215 experienced HF readmission (23%), and 267 reached MACCE (30%: 25 HF death, six cardiac death, and 13 strokes). A multivariate Cox proportional hazard regression analysis revealed that the GNRI predicted the primary outcome (Hazard ratio [HR]: 0.957; 95% confidence interval [CI]: 0.934-0.980; p < 0.001) and the secondary outcome (HR: 0.963; 95%CI: 0.940-0.986; p = 0.002). Furthermore, a multiple logistic regression model using the GNRI most accurately predicted the primary and secondary outcomes compared to those with the SPPB or BI models.

Conclusion

A nutrition status model using GNRI provided a better predictive value than ADL ability or lower limb muscle strength. It should be recognized that HF patients with a low GNRI at discharge may have a poor prognosis at one year.

Prediction of all-cause mortality with malnutrition assessed by nutritional screening and assessment tools in patients with heart failure：a systematic review

BACKGROUND AND AIMS

In the absence of a gold standard or scientific consensus regarding the nutritional evaluation of heart failure (HF) patients, this study aimed to summarize and systematically evaluate the prognostic value of nutritional screening and assessment tools used for all-cause mortality in HF patients.

METHODS AND RESULTS

Relevant studies were retrieved from major databases (PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang Data, and China Biology Medicine disc (CMB)) and searched from the earliest available date until July 2021. If three or more studies used the same tool, meta-analysis using RevMan 5.3 was performed. This systematic review was registered at PROSPERO (number CRD42021275575). A total of 36 articles involving 25,141 HF patients were included for qualitative analysis and 31 studies for quantitative analysis. Meta-analysis of these studies indicated, poor nutritional status evaluated by using 5 nutritional screening tools (Prognostic Nutritional Index (PNI), Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status Score (CONUT), Nutritional Risk Index (NRI), and Short Form Mini Nutritional Assessment (MNA-SF)) or 2 nutritional assessment tools (the Mini Nutritional Assessment (MNA) and Generated Subjective Global Assessment (SGA)) predicted all-cause mortality in HF patients. Of all tools analyzed, MNA had the maximum HR for mortality [HR = 2.62, 95%CI 1.11-6.20, P = 0.03] and MNA-SF [HR = 1.94, 95%CI 1.40-2.70, P＜0.001] was the best nutritional screening tools.

CONCLUSION

Poor nutritional status predicted all-cause mortality in HF patients. MNA may be the best nutritional assessment tool, and MNA-SF is most recommended for HF patient nutritional screening. The application value of MNA, especially in patients with reduced left ventricular ejection fraction (LVEF), needs to be further confirmed. The clinical application value of Mini-Nutrition Assessment Special for Heart Failure (MNA-HF) and Global Leadership Initiative on Malnutrition (GLIM) in HF patients needs to be confirmed.

Appetite and Nutritional Status as Potential Management Targets in Patients with Heart Failure with Reduced Ejection Fraction-The Relationship between Echocardiographic and Biochemical Parameters and Appetite

This study aimed to investigate the role of appetite loss and malnutrition in patients with heart failure with reduced ejection fraction (HFrEF). In this prospective, observational, single-center study, we enrolled 120 consecutive adults with HFrEF. We analyzed the selected clinical, echocardiographic, and biochemical parameters. Appetite loss and malnutrition were assessed by CNAQ (Council on Nutrition Appetite Questionnaire) and MNA (Mini Nutritional Assessment)/GNRI (Geriatric Nutritional Risk Index) questionnaires, respectively.Most patients were men (81.7%), mean age was 55.1 ± 11.3 years, and mean left ventricular ejection fraction was 23.9 ± 8.0%. The mean CNAQ score was 28.8 ± 3.9, mean MNA-23.1 ± 2.6, and mean GNRI-113.0 ± 12.3. Based on ROC curves, we showed that a sodium concentration <138 mmol/L had the greatest discriminating power for diagnosing impaired nutritional status (MNA ≤ 23.5) with a sensitivity of 54.5% and specificity of 77.8%. The threshold of HDL <0.97 mmol/L characterized 40.7% sensitivity and 86% specificity, B-type natriuretic peptide >738.6 pg/dL had 48.5% sensitivity and 80.8% specificity, high-sensitivity C-reactive protein >1.8 mg/L had 94.9% sensitivity and 42.9% specificity, and bilirubin >15 µmol/L had 78.2% sensitivity and 56.9% specificity. Nutritional status and appetite assessed by MNA/GNRI and CNAQ questionnaires showed poor correlations with other findings in HFrEF patients.

Tools for the Assessment of the Malnutrition Status and Possible Interventions in Elderly with Cardiovascular Diseases

Malnutrition represents a common and important feature in elderly people affected by cardiovascular diseases. Several studies have investigated its prevalence and prognostic role in most clinical settings, including cardiovascular disease. However, in daily practice it usually remains unrecognized and consequently untreated. The present review was ideated to answer the main questions about nutritional status assessment in patients with cardiovascular disease: why, when, where, how to evaluate it, and what to do to improve it. The three main cardiovascular diseases, namely aortic stenosis, ischaemic heart disease, and heart failure were considered. First, the main evidence supporting the prognostic role of malnutrition are summarized and analyzed. Second, the main tools for the assessment of malnutrition in the hospital and outpatient setting are reported for each condition. Finally, the possible strategies and interventions to address malnutrition are discussed.

＜Editors' Choice＞ Prognostic utility of multipoint nutritional screening for hospitalized patients with acute decompensated heart failure

This study aimed to evaluate the impact of serial changes in nutritional status on 1-year events including all-cause mortality or rehospitalization owing to heart failure (HF) among hospitalized patients with acute decompensated HF (ADHF). The study subjects comprised 253 hospitalized patients with ADHF. The controlling nutritional status (CONUT) score was assessed both at hospital admission and discharge. The subjects were divided into three groups according to nutritional status using CONUT score: normal (0 and 1), mild risk (2-4), and moderate to severe risk defined as malnutrition (5-12). We observed nutritional status was improved or not. The incidence of malnutrition was 30.4% at hospital admission and 23.7% at discharge, respectively. Malnutrition was independently associated with 1-year events among hospitalized patients with ADHF. Presence or absence of improvement in nutritional status was significantly associated with 1-year events (P < 0.05), that was independent of percentage change in plasma volume in multivariate Cox regression analyses. We determined a reference model, including gender and estimated glomerular filtration rate, using multivariate logistic regression analysis (P < 0.05). Adding the absence of improvement in nutritional status during hospitalization to the reference model significantly improved both NRI and IDI (0.563, P < 0.001 and 0.039, P = 0.001). Furthermore, malnutrition at hospital discharge significantly improved NRI (0.256, P = 0.036) In conclusion, serial changes in the nutritional status evaluated on the basis of multiple measurements may provide more useful information to predict 1-year events than single measurement at hospital admission or discharge in hospitalized patients with ADHF.

Anabolism to Catabolism: Serologic Clues to Nutritional Status in Heart Failure

PURPOSE OF REVIEW

Malnutrition, sarcopenia, and cachexia are areas of increasing interest in the management of patients with heart failure (HF). This review aims to examine the serological markers useful in guiding the physician in identification of these patients.

RECENT FINDINGS

Traditional nutritional biomarkers including albumin/prealbumin, iron, and vitamin D deficiencies predict poor prognosis in malnutrition and HF. Novel biomarkers including ghrelin, myostatin, C-terminal agrin fragment, and adiponectin have been identified as possible substrates and/or therapeutic targets in cardiac patients with sarcopenia and cachexia, though clinical trial data is limited to date. Increased focus on nutritional deficiency syndromes in heart failure has led to the use of established markers of malnutrition as well as the identification of novel biomarkers in the management of these patients, though to date, their usage has been confined to the academic domain and further research is required to establish their role in the clinical setting.

Quality of life, physical performance and nutritional status in older patients hospitalized in a cardiology department

OBJECTIVES

Quality of life (QoL) is a priority outcome in older adults suffering from cardiovascular diseases. Frailty and poor nutritional status may affect the QoL through mobility disorders and exhaustion. The objective of this study was to determine if physical frailty and nutritional status were associated with QoL, in older cardiology patients.

METHODS

Cross sectional, observational study conducted in a cardiology department from a university hospital. Participants (n = 100) were aged 70 and older. Collected data included age, sex, cardiac diseases, New York Heart Association (NYHA) classification, comorbidities (Charlson Index) and disability. A Short Physical Performance Battery (SPPB), including walking speed assessment was performed; handgrip strength were measured as well as Fried's frailty phenotype. Nutritional status was assessed using the Mini Nutritional Assessment (MNA) and Body Mass Index (BMI), inflammation by C-reactive protein (CRP). QoL was assessed using the EORTC-QLQ questionnaire. Univariate and multivariate analyses were performed to study the associations between all recorded parameters and QoL.

RESULTS

In participants (mean age: 79.3 ± 6.7 years; male: 59%), Charlson index, arrhythmia, heart failure, NYHA classⅢ-Ⅳ, MNA, disability, walking speed, SPPB score, frailty and CRP were significantly associated with QoL in univariate analysis. Multivariate analysis showed that NYHA classⅢ-Ⅳ (P < 0.001), lower MNA score (P = 0.03), frailty (P < 0.0001), and higher CRP (P < 0.001) were independently associated with decreased QoL.

CONCLUSIONS

Frailty, nutritional status and inflammation were independently associated with poor QoL. Further studies are needed to assess the efficacy of nutritional and physical interventions on QoL in this population.

Geriatric Nutritional Risk Index Is Associated With Prognosis in Patients With Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension

Background: The Geriatric Nutritional Risk Index (GNRI) is a simple tool for assessing nutritional risk that predicts prognosis in patients with heart failure. This study evaluated associations between the GNRI at first hospitalization and prognosis in patients with pulmonary artery hypertension (PAH) and those with chronic thromboembolic pulmonary hypertension (CTEPH). Methods and Results: This retrospective investigation included 104 patients with either PAH or CTEPH who were treated at Kagoshima University Hospital in Japan. Patients were divided into a high (≥92) and low (<92) GNRI groups. Body mass index and serum albumin levels were significantly lower in the low GNRI group (P<0.001). Over a median follow-up period of 24 months, the incidence of pulmonary hypertension rehospitalization was higher in the low GNRI group (P=0.04). Kaplan-Meier analysis revealed that the cumulative event-free rate was significantly lower in the low GNRI group (P=0.002). Low GNRI was significantly associated with a poorer outcome after adjusting for different sets of confounding factors, including: age and sex (P=0.004); age, sex, and PAH (P=0.043); and age, sex, and mean pulmonary artery pressure (P=0.003). Conclusions: The GNRI at first hospitalization is useful for predicting prognosis in PAH and CTEPH patients.

Malnutrition among elderly patients with severe aortic stenosis

BACKGROUND

Most patients with aortic stenosis (AS) are elderly. To achieve favorable outcomes after interventional treatments, careful management including adequate nutritional support is required. However, there has been a lack of knowledge about the prevalence of malnutrition and factors related to it.

AIMS

To explore the prevalence of malnutrition and its related factors in patients with severe AS.

METHODS

This was a single-institution, cross-sectional study. A total of 300 consecutive older patients (mean age, 83.8 ± 0.5 years) with AS were prospectively enrolled. Nutritional status was evaluated with the Mini Nutritional Assessment-Short Form (MNA-SF). Cardiac, kidney, physical, cognitive functions, instrumental activities of daily living (IADL) as measured with the Frenchay Activities Index (FAI), medical history, and comorbidities were evaluated as potentially related factors. Multiple logistic regression analysis was performed to identify factors that were significantly associated with the MNA-SF.

RESULTS

The mean (SD) score of the MNA-SF was 10.9 (2.5). 34 patients (11.3%) and 127 patients (42.3%) met the criteria for malnutrition and at risk of malnutrition, respectively. On multiple logistic regression analysis, female sex (OR 3.455, 95% CI 1.045-11.42, P = 0.042), NYHA class (OR 3.625, 95% CI 1.627-8.074, P = 0.002), left ventricular ejection fraction (/10%) (OR 0.961, 95% CI 0.932-0.991, P = 0.010), and FAI score (/10 points) (OR 0.911, 95% CI 0.864-0.961, P < 0.001) were significantly related to malnutrition.

CONCLUSIONS

The prevalence of malnutrition was high among older persons with severe AS, and female sex, poor cardiac function, and lower IADL were independently related to it.

Mini Nutritional Assessment Short Form is a morbi-mortality predictor in outpatients with heart failure and mid-range left ventricular ejection fraction

BACKGROUND & AIMS

Nutritional status is an important prognostic factor in patients with heart failure (HF). In a pilot study we previously observed that the Mini Nutritional Assessment Short Form tool (MNA-SF) was the best approach for the screening of nutritional status in HF outpatients over other screening tools. The current study aimed to determine whether the MNA-SF has prognostic value in outpatients with HF and whether the impact of malnutrition differs depending on left ventricular ejection fraction (LVEF).

METHODS

Prospective study performed in outpatients attending a HF clinic at a university hospital. All subjects completed the MNA-SF at study entry. The primary endpoint was all-cause mortality. Secondary end-points were the number of recurrent HF-related hospitalizations and the composite end-point of all-cause death or HF-related hospitalizations. Patients with malnutrition and at risk of malnutrition were merged and considered as having abnormal nutritional status for statistical analysis.

RESULTS

From October 2016 to November 2017, 555 patients were included (age 69 ± 11.5 years, 71% male, LVEF 44.6 ± 13.2). Abnormal nutritional status was identified in 103 (18.6%) subjects. HF patients with preserved LVEF had a higher proportion of abnormal nutritional status (23%) than patients with HF and mid-range LVEF (HFmrEF) (16.4%) or those with HF with reduced LVEF (HFrEF) (15.9%.). During a mean follow-up of 23.8 ± 6.6 months, 99 patients died (17.8%), 74 were hospitalized due to HF (13.3%) and the composite end-point was observed in 181 (32.6%). In the univariate analysis, abnormal nutritional status was significantly associated with all-cause mortality (p = 0.02) and the composite end-point (p = 0.02) in the total cohort. However, in the multivariate analysis including age, sex, NYHA functional class, BMI, ischemic aetiology, diabetes, hypertension and HF duration, abnormal nutritional status remained significantly associated with all-cause mortality (HR 3.32 [95%CI 1.47-7.52], p = 0.004), and the composite end-point (HR 2.53 [95%CI 1.30-4.94], p = 0.006) only in HFmrEF patients. Patients with abnormal nutritional status suffered double the crude number of recurrent HF-related hospitalizations (16.4 vs. 8.4 per 100 patients-years, p < 0.001).

CONCLUSIONS

The implementation of MNA-SF as a routine screening tool allowed the detection of abnormal nutritional status in almost one out of five ambulatory HF patients. Nutritional status assessed by the MNA-SF was an independent predictor of all-cause death and the composite end-point of all-cause death or HF-related hospitalization in outpatients with HFmrEF. Furthermore, abnormal nutritional status was significantly related to recurrent hospitalizations across the HF spectrum.

The relationship between physical activity and appetite in patients with heart failure: A prospective observational study

INTRODUCTION

Physical activity and appetite are important components for maintaining health. Yet, the association between physical activity and appetite in heart failure (HF) populations is not completely understood. The aim of the present study was to investigate the relationship between physical activity, functional capacity, and appetite in patients with HF.

METHODS

This was a prospective observational study. In total, 186 patients diagnosed with HF, New York Heart Association (NYHA) class II-IV (mean age 70.7, 30% female), were included. Physical activity was measured using a multi-sensor actigraph for seven days and with a self-reported numeric rating scale. Physical capacity was measured by the six-minute walk test. Appetite was measured using the Council on Nutrition Appetite Questionnaire. Data were collected at inclusion and after 18 months. A series of linear regression analyses, adjusted for age, NYHA class, and B-type natriuretic peptide were conducted.

RESULTS

At baseline, higher levels of physical activity and functional capacity were significantly associated with a higher level of appetite in the unadjusted models. In the adjusted models, number of steps ( p = 0.019) and the six-minute walk test ( p = 0.007) remained significant. At the 18-month follow-up, all physical activity variables and functional capacity were significantly associated with appetite in the unadjusted regression models. In the adjusted models, number of steps ( p = 0.001) and metabolic equivalent daily averages ( p = 0.040) remained significant.

CONCLUSION

A higher level of physical activity measured by number of steps/day was associated with better self-reported appetite, both at baseline and the 18-month follow-up. Further research is needed to establish causality and explore the intertwined relationship between activity and appetite in patients with HF.

Mini nutritional assessment is a better predictor of mortality than subjective global assessment in heart failure out-patients

BACKGROUND & AIMS

There is no consensus on the best method for nutritional screening and assessment in patients with heart failure (HF). This study aimed to determine which nutritional assessment method had the highest prognostic significance for patients with HF treated in outpatient clinics. We also aimed to identify a fast, reliable screening method for detecting malnutrition in these patients.

METHODS

This prospective study included 151 subjects that attended an outpatient HF clinic at a university hospital. All patients completed three nutritional screening tools: the Malnutrition Universal Screening Tool (MUST), the MNA-short form (MNA-SF), and the Malnutrition Screening Tool (MST), and then, two nutritional assessment questionnaires: the Subjective Global Assessment (SGA) and the Mini Nutritional Assessment®(MNA). Patients were followed-up for 2 years. The primary endpoint was all-cause mortality.

RESULTS

Malnutrition or nutritional risk was identified in 15.9% of patients with the SGA and in 25.1% of patients with the MNA. Age, New York Heart Association (NYHA) functional class, and MNA were the only independent all-cause death predictors after adjusting for age, gender, NYHA functional class, body mass index, Barthel index, 25-hydroxyvitamin D concentrations, treatment with angiotensin converting enzyme inhibitors or angiotensin II receptor blockers, and treatment with beta-blockers. The SGA could not independently predict all-cause mortality in a multivariate analysis that included the same covariates. The MNA-SF had the best sensitivity, specificity, and kappa coefficient for screening malnutrition, based on the MNA and the SGA as references, compared to the other screening methods.

CONCLUSIONS

In our cohort, malnutrition assessed by MNA, but not by SGA, was an independent predictor of mortality. MNA-SF showed remarkable sensitivity and specificity; thus, it might be a valuable tool for rapidly identifying malnutrition risk in outpatients with HF.

Review of nutritional screening and assessment tools and clinical outcomes in heart failure

Recent studies have suggested that undernutrition as defined using multidimensional nutritional evaluation tools may affect clinical outcomes in heart failure (HF). The evidence supporting this correlation is unclear. Therefore, we conducted this systematic review to critically appraise the use of multidimensional evaluation tools in the prediction of clinical outcomes in HF. We performed descriptive analyses of all identified articles involving qualitative analyses. We used STATA to conduct meta-analyses when at least three studies that tested the same type of nutritional assessment or screening tools and used the same outcome were identified. Sensitivity analyses were conducted to validate our positive results. We identified 17 articles with qualitative analyses and 11 with quantitative analysis after comprehensive literature searching and screening. We determined that the prevalence of malnutrition is high in HF (range 16-90 %), particularly in advanced and acute decompensated HF (approximate range 75-90 %). Undernutrition as identified by multidimensional evaluation tools may be significantly associated with hospitalization, length of stay and complications and is particularly strongly associated with high mortality. The meta-analysis revealed that compared with other tools, Mini Nutritional Assessment (MNA) scores were the strongest predictors of mortality in HF [HR (4.32, 95 % CI 2.30-8.11)]. Our results remained reliable after conducting sensitivity analyses. The prevalence of malnutrition is high in HF, particularly in advanced and acute decompensated HF. Moreover, undernutrition as identified by multidimensional evaluation tools is significantly associated with unfavourable prognoses and high mortality in HF.

Factors associated with risk of malnutrition in the elderly in south-eastern Brazil

ABSTRACT: Objective: The aim of this study was to evaluate the prevalence of malnutrition risk and its association with socioeconomic, behavioral, and health characteristics in the community-dwelling elderly. Methods: A cross-sectional study with individuals aged ≥ 60 years. Nutritional status was evaluated using the Mini Nutritional Assessment. Socioeconomic, behavioral, and health information was also collected from all participants. The association between each variable and the risk of malnutrition was calculated and adjusted using Poisson hierarchical regression. Results: The initial sample consisted of 3,101 elderly people, of whom 28.3% (95%CI 25.3 - 31.4%) were at risk of malnutrition. The multivariate analysis showed that the risk of malnutrition was significantly higher in women without formal education, who did not live with a partner, and identified as black-skinned. The risk of malnutrition was twice as high in individuals with no family income as compared to those who earned at least three minimum wages. Smokers were also more likely to be at risk of malnutrition than individuals who had never smoked. Participants suffering from kidney, respiratory or heart disease were at higher risk of malnutrition than those with no history of such illnesses. Conclusion: These findings could be used to help in the development of health policies and in the establishment of adequate programs aimed at reducing the risk of malnutrition in this population.

Impact of prealbumin on mortality and hospital readmission in patients with acute heart failure

BACKGROUND

Prealbumin is a maker of nutritional status and inflammation of potential prognostic value in acute heart failure (HF). The aim of this study is to evaluate if low prealbumin levels on admission predict mortality and readmissions in patients with acute HF.

METHOD

We conducted a prospective observational cohort study including 442 patients hospitalized for acute HF. Patients were classified in two groups according to prealbumin levels: "normal" prealbumin (>15mg) and "low" prealbumin (≤15mg/dL). End-points were mortality and readmissions (all-cause and HF-related) and the combined end-point of mortality/readmission at 180days.

RESULTS

Out of 442 patients, 159 (36%) had low and 283 (64%) had normal prealbumin levels Mean age was 79.6 (73.9-84.2, p=0,405) years and 183 (41%, p=0,482) were males. After a median 180days of follow-up, 108 (24%, p=0,021) patients died and 170 (38%, p=0,067) were readmitted. Mortality was higher in the low prealbumin group. The combined end-point was more frequent in the low prealbumin group (57% vs. 50%, p=0.199). In the multivariate analysis the following variables were associated with mortality or readmission: older age, exacerbated chronic HF, higher comorbidity, low systolic blood pressure and hemoglobin values and higher pro brain natriuretic peptide levels.

CONCLUSIONS

Low prealbumin is common (36%) in patients with acute heart failure and it is associated with a higher short-term mortality.

Evaluation of Blood Biomarkers Associated with Risk of Malnutrition in Older Adults: A Systematic Review and Meta-Analysis

Malnutrition is a common yet under-recognized problem in hospitalized patients. The aim of this paper was to systematically review and evaluate malnutrition biomarkers among order adults. Eligible studies were identified through Cochrane, PubMed and the ProQuest Dialog. A meta-regression was performed on concentrations of biomarkers according to malnutrition risks classified by validated nutrition assessment tools. A total of 111 studies were included, representing 52,911 participants (55% female, 72 ± 17 years old) from various clinical settings (hospital, community, care homes). The estimated BMI (p < 0.001) and concentrations of albumin (p < 0.001), hemoglobin (p < 0.001), total cholesterol (p < 0.001), prealbumin (p < 0.001) and total protein (p < 0.05) among subjects at high malnutrition risk by MNA were significantly lower than those without a risk. Similar results were observed for malnutrition identified by SGA and NRS-2002. A sensitivity analysis by including patients with acute illness showed that albumin and prealbumin concentrations were dramatically reduced, indicating that they must be carefully interpreted in acute care settings. This review showed that BMI, hemoglobin, and total cholesterol are useful biomarkers of malnutrition in older adults. The reference ranges and cut-offs may need to be updated to avoid underdiagnosis of malnutrition.

Geriatric nutritional risk index as a nutritional and survival risk assessment tool in stable outpatients with systolic heart failure

BACKGROUND AND AIMS

Malnutrition is frequent in heart failure (HF). However, the best tool for evaluating malnutrition in geriatric patients with HF with reduced ejection fraction (HFrEF) is unknown. This study aimed to evaluate the incremental prognostic value of the geriatric nutritional risk index (GNRI) in stable geriatric outpatients with HFrEF compared with a clinical/laboratory prognostic model.

METHODS AND RESULTS

A total of 143 outpatients with HFrEF, aged >65 years, a LVEF <40%, and who were stable and on optimal therapy were studied. Follow-up lasted 3 years. The outcome was all-cause death. The GNRI was calculated as follows: [(1.489 × serum albumin (g/L)) + (41.7 × (current body weight/ideal weight)]. The 3-year death rate was 36.4% and 16 (11.2%) patients were at risk of malnutrition (GNRI ≤98). Deceased patients had a lower GNRI (113.6 ± 9.1 vs. 105.6 ± 9.2; p < 0.001) than did survivors. Greater values of the GNRI (hazard ratio = 0.93, 95% confidence interval [CI] = 0.90-0.95; p < 0.001) and GNRI >98 (hazard ratio = 0.29, 95% CI 0.15-0.57; p < 0.001) were associated with better survival. These factors remained significant after adjustment of significant confounders. The GNRI was a better discriminator of death than weight and albumin. Adding the GNRI to the clinical/laboratory predictor survival model significantly increased the c-statistics from 0.93 to 0.95 (p < 0.001) and the chi-square likelihood ratio test from 106.15 to 119.9.

CONCLUSION

The risk of malnutrition, as assessed by the GNRI, in stable geriatric outpatients with HFrEF is a strong independent predictor of survival. The GNRI adds significant prognostic information to the clinical/laboratory model.

Heart Failure in Older Adults

Heart failure (HF) is a leading cause of morbidity, hospitalization, and mortality in older adults and a growing public health problem placing a huge financial burden on the health care system. Many challenges exist in the assessment and management of HF in geriatric patients, who often have coexisting multimorbidity, polypharmacy, cognitive impairment, and frailty. These complex "geriatric domains" greatly affect physical and functional status as well as long-term clinical outcomes. Geriatric patients have been under-represented in major HF clinical trials. Nonetheless, available data suggest that guideline-based medical and device therapies improve morbidity and mortality. Nonpharmacologic strategies, such as exercise training and dietary interventions, are an active area of research. Targeted geriatric evaluation, including functional and cognitive assessment, can improve risk stratification and guide management in older patients with HF. Clinical trials that enroll older patients with multiple morbidities and HF and evaluate functional status and quality of life in addition to mortality and cardiovascular morbidity should be encouraged to guide management of this age group.

The importance of assessing nutritional status in elderly patients with heart failure

Heart failure (HF) is a syndrome characterized by high morbidity and mortality, despite advances in medical and device therapy that have significantly improved survival. The outcome of HF in elderly patients results from a combination of biological, functional, psychological, and environmental factors, one of which is nutritional status. Malnutrition, as well as HF, is frequently present with aging. Early detection might lead to earlier intervention. It is our goal to review the importance of nutritional status in elderly patients with HF, as well as tools for assessing it. We also propose a simple decision algorithm for the nutritional assessment of elderly patients with HF.

Assessing parenteral diuretic treatment of decompensated heart failure in the community

Referrals of 46 patients with decompensated end-stage heart failure were reviewed by a community heart-failure specialist nurse as part of a pilot study to determine patient numbers suitable for parenteral diuretic treatment at home, and the appropriateness of the Mini Nutritional Assessment (MNA), Edmonton Symptom Assessment System (ESAS) and Carer's Stress Scales. Triage of patients resulted in the following care pathways: 14 (30%) received intravenous therapy, 11 (24%) received subcutaneous therapy, 9 (20%) required adjustment of medication, 8 (17%) could not be treated because of limited staffing resource, 4 (9%) met study exemption criteria. There were no adverse events following furosemide infusion. The majority of intravenous and subcutaneous treatments took 1-7 days (total 187 days). Parenteral diuretic therapy prevented admissions and reduced the severity heart failure symptoms in particular oedema. Patients and carers appreciated the service, which had a positive effect on carers stress. Of the nursing tools, the ESAS and the Carer's Stress Scales proved useful in the management of patients.