Effect of risk of malnutrition on 30-day mortality among older patients with acute heart failure in Emergency Departments

Global prevalence of malnutrition in older adults: A comprehensive systematic review and meta-analysis

Objectives

Early detection and management of malnutrition is essential for the general health and well-being of the elderly. Various studies have reported different types of malnutrition prevalence in the elderly. the present study was aimed to determine the prevalence of malnutrition in the world' elderly through conducting a systematic review study and meta-analysis.Study Design: systematic review and meta-analysis.

Methods

In this review study, data was extracted by searching in national and international databases of SID, MagIran, Google scholar, ScienceDirect, Scopus, PubMed and Web of Science (WoS) without time limit until August 25, 2023. For analysis, Begg and Mazumdar test at a significance level of 0.1 and the corresponding Funnel plot were used. Data analysis was performed with Comprehensive Meta-Analysis software (Version 2).

Results

In the review of 98 studies with a total sample size of 79976, the prevalence of malnutrition in the world's elderly was obtained as 18.6 % (95 % confidence interval: 16.4-21.1 %), so that the highest prevalence of malnutrition was in the elderly of Africa with 35.7 %, followed by the America with 20.3 %. According to the subgroup analysis regarding the indicators of malnutrition in the elderly, the highest prevalence of malnutrition in the elderly was obtained as 39.9 % according the NRS-2002 index.

Conclusion

Therefore, in addition to raising awareness among families about malnutrition in the elderly and its negative effects on the quality of life of the elderly, it is necessary to take the necessary measures to provide more care for the elderly and also to pay serious attention to the importance of nutrition during old age.

Prognostic Impact of Hospital Discharge After Heart Failure Admission Without Structured Heart Failure Follow-Up

(1) Objective. The aim was to evaluate the risk of new exacerbations of heart failure (HF) in patients discharged from hospital emergency departments (EDs) without a structured HF follow-up. (2) Methods. This prospective, single-center cohort study included patients discharged from the ED following hospital admission for acute HF. The study analyzed the profile of patients seen in the ED and assessed their risk of new ED visits or HF-related hospitalizations within 12 months of discharge. (3) Results. A total of 779 patients were included, with a mean age of 82 ± 8 years; 471 were women (60.4%), and 674 (86.7%) had a history of prior HF episodes. Of these, 591 patients (76.1%) were referred to an unstructured HF follow-up in primary care (PC). Patients who experienced HF exacerbations within 12 months of ED discharge had a higher incidence of chronic kidney disease, elevated natriuretic peptide levels, and a higher number of prior HF exacerbations and were more likely to receive unstructured HF follow-up in PC. The presence of the last two factors was associated with the highest risk of HF exacerbation within 12 months of discharge (HR: 2.83; 95% CI: 1.60-5.03; p < 0.001). (4) Conclusions. Patients discharged from the ED after an HF episode and referred to PC without a structured HF follow-up have a high risk of ED revisits or rehospitalization for HF.

What is the level of nutrition care provided to older adults attending emergency departments? A scoping review

BACKGROUND

Older adults often experience adverse health outcomes including malnutrition following discharge from emergency departments (ED). Discharge to community care is a transitionary time where nutritional vulnerability could be mitigated with the instigation of targeted nutrition care pathways in ED settings.

AIMS AND OBJECTIVES

This scoping review aimed to establish and describe the level of nutrition care provided to older adults admitted and subsequently discharged from EDs.

RESEARCH DESIGN

Systematic searches of nine academic and grey literature databases (Medline (Ovid), Pubmed, CINAHL Complete (EBSCOhost), EMBASE, Cochrane Library and Scopus), grey literature sources (DART-Europe E-theses portal, Open Grey, and Trip Medical database) and four websites (Google, Google Scholar, NICE and LENUS) for relevant professional and organisational publications of research, policy, practice, and guidelines between January 2011 to 2023 were completed. Eligible studies included a population of older adults (≥ 65 years) with an ED attendance and subsequent community discharge, and where nutrition screening had identified malnutrition. Data were extracted on the level of nutrition and dietetic care initiated for older adults in the ED according to the Nutrition Care Process Model and summarised descriptively.

RESULTS

Overall, 22 studies were included in the review. Nutrition status was screened on admission to the ED using validated tools: Mini Nutritional Assessment-Short Form (n = 13), Malnutrition Universal Screening Tool (n = 2), Short Nutritional Assessment Questionnaire (n = 2), NRS-2002 (n = 1) and the Mini Nutritional Assessment - Full Form (n = 1). A full nutrition assessment was reported by 5 studies. Only one study referred to documentation of malnutrition in healthcare records. Subsequent nutrition intervention after discharge from the ED for older adults was not described in any study.

CONCLUSION

While there is evidence to support malnutrition screening is taking place in EDs, there is a lack of information about subsequent nutrition care including assessment and therapy interventions. This points to the need for comprehensive exploration of nutrition care pathways, practice, policy, and research to inform models of integrated care for older persons.

Malnutrition stratified by marasmus and kwashiorkor in adult patients with heart failure

Malnutrition is classified into marasmus and kwashiorkor in children. However, the clinical significance of these aspects is unclear in adult patients with heart failure (HF). We divided 2308 adult patients with HF into four groups according to marasmus type (body mass index < 18.5 kg/m2) and kwashiorkor type (serum albumin < 3.4 g/dL) malnutrition: Group C (no malnutrition, n = 1511, 65.5%), Group M (marasmus type malnutrition, n = 133, 5.8%), Group K (kwashiorkor type malnutrition, n = 554, 24.0%) and Group MK (marasmic-kwashiorkor type malnutrition, n = 110, 4.8%). Group M showed the lowest blood pressure. Groups K and MK showed higher levels of B-type natriuretic peptide. Right atrial pressure was lowest in Groups M and MK. Kaplan-Meir analysis demonstrated that Group MK had the lowest event-free rate of all-cause death and cardiac death. In the multivariable Cox proportional hazard analysis, Groups M, K, and MK were associated with all-cause death (hazard ratio 1.790, 1.657 and 2.313, respectively) and cardiac death (hazard ratio 2.053, 1.855 and 3.001, respectively) compared to Group C as a reference. Marasmus type and kwashiorkor type malnutrition are associated with distinct profiles and high mortality, and marasmic-kwashiorkor type malnutrition has the poorest prognosis.

Oral nutritional supplements in older outpatients with heart failure: rationale and design of the ALIMENT-HF trial

AIMS

The ALIMENT-HF trial aims to determine whether high-calorie and high-protein oral nutritional supplements (ONS) are safe and beneficial for older adult outpatients with heart failure (HF).

METHODS AND RESULTS

This multicentre, single-arm, interventional pilot trial is designed to evaluate the tolerance, efficacy, and safety of ONS in older adult outpatients with chronic HF, malnutrition, and anorexia. In total, 80 outpatients with HF regardless of their left ventricular ejection fraction will be treated with ONS, including high-energy (900 kcal/day) and high protein (36 g/day) supplementation, at eight sites in Japan. Inclusion criteria are as follows: age, ≥65 years; outpatients receiving maximally tolerated guideline-directed medical therapy for HF and without change in their diuretic dosage during the last 3 months; outpatients at risk of malnutrition, defined as a Malnutrition Universal Screening Tool score ≥1 point, and anorexia, defined using a Simplified Nutritional Appetite Questionnaire for the Japanese Elderly (SNAQ-JE) score of ≤14 points. Nutritional intervention will continue for up to 120 days, with an observational period lasting for a further 60 days. The primary outcome is a change in body weight between baseline and day 120.

CONCLUSIONS

The ALIMENT-HF trial will evaluate the tolerance, efficacy, and safety of high-calorie and high-protein-rich ONS in older outpatients with HF co-morbid with malnutrition and anorexia and will provide insightful information for future randomized controlled trials.

Establishment of in-hospital nutrition support program for middle-aged and elderly patients with acute decompendated heart failure

OBJECTIVE

To construct a nutrition support program for middle-aged and elderly patients with acute decompensated heart failure (ADHF) during hospitalization.

METHODS

Based on the JBI Evidence-Based Health Care Model as the theoretical framework, the best evidence was extracted through literature analysis and a preliminary nutrition support plan for middle-aged and elderly ADHF patients during hospitalization was formed. Two rounds of expert opinion consultation were conducted using the Delphi method. The indicators were modified, supplemented and reduced according to the expert's scoring and feedback, and the expert scoring was calculated.

RESULTS

The response rates of the experts in the two rounds of consultation were 86.7% and 100%, respectively, and the coefficient of variation (CV) for each round was between 0.00% and 29.67% (all < 0.25). In the first round of expert consultation, 4 items were modified, 3 items were deleted, and 3 items were added. In the second round of the expert consultation, one item was deleted and one item was modified. Through two rounds of expert consultation, expert consensus was reached and a nutrition support plan for ADHF patients was finally formed, including 4 first-level indicators, 7 s-level indicators, and 24 third-level indicators.

CONCLUSION

The nutrition support program constructed in this study for middle-aged and elderly ADHF patients during hospitalization is authoritative, scientific and practical, and provides a theoretical basis for clinical development of nutrition support program for middle-aged and elderly ADHF patients during hospitalization.

Prognostic value of nutritional screening tools in hospitalized patients with decompensated heart failure: A systematic review and meta-analysis

Nutritional risk screening is fundamental to prevent undesirable outcomes in heart failure (HF). Current reviews of nutritional screening tools encompass both hospitalized and outpatient settings, which may not be suitable because of different clinical manifestations. We hypothesize that multidimensional tools would better identify prognosis of decompensated patients because the tools assess more than isolated aspects. This systematic review aims to explore the association of multidimensional nutritional risk screening tools and prognosis in patients hospitalized with decompensated HF. Five databases were searched for studies that assessed nutritional risk through multidimensional screening tools and its association with prognosis in adults hospitalized with decompensated HF. The 95% confidence interval and relative risk were computed using a random-effects model. Inverse variance method was used. Thirty-eight studies were included. Most studies demonstrated higher nutritional risk was significantly associated with worse prognosis. Quantitative analysis identified higher nutritional risk by using the Mini Nutritional Assessment Short Form (MNA-SF), Controlling Nutritional Status, Geriatric Nutritional Risk Index, and Prognostic Nutritional Index to be associated with all-cause mortality. The MNA-SF demonstrated greater magnitude of association with all-cause mortality in older subjects (relative risk, 4.85; 95% confidence interval, 2.0-11.75). Higher nutritional risk was associated with poor prognosis and higher mortality in patients hospitalized with decompensated HF, especially when screened by MNA-SF. Tools were not directly compared. That might reinforce the importance of evaluating multiple aspects when screening hospitalized HF patients once symptoms associated with decompensation frequently mask the underlying nutritional status and risk. PROSPERO registration number (CRD42021256271).

Effect of protein underdosing on the prognosis of patients with severe acute heart failure in the early acute phase: A single-institutional retrospective cohort study

BACKGROUND

The appropriate protein dose during the early acute phase of severe acute heart failure (AHF) remains unknown. We hypothesized that protein underdosing during this period may lead to a poor prognosis. Thus, we investigated the relationship between protein sufficiency rate and prognosis during the early acute phase in patients with severe AHF.

METHODS

This retrospective observational study investigated patients with AHF requiring invasive mechanical ventilation who were admitted in the intensive care and cardiac care units between January 2015 and August 2021. These patients were ranked according to the tertile of protein sufficiency rate on intubation day 2. Univariate and multivariate logistic regression analyses were performed to determine whether a low protein sufficiency rate on intubation day 2 was an independent factor for in-hospital mortality. Patients were weighted using the inverse probability of treatment weighting (IPTW) method to determine the differences in baseline characteristics.

RESULTS

A total of 118 patients were included in the study and divided into low-protein (n = 40) and non-low-protein (n = 78) groups with protein sufficiency rates of ≤10% and >10%, respectively.In the multivariate analysis of in-hospital mortality, low protein sufficiency on day 2 was identified as an independent factor (odds ratio [OR] = 2.77, 95% confidence interval [CI] = 1.05-7.27, P = 0.039). After adjusting for baseline characteristics using the IPTW method, multiple logistic regression analysis of in-hospital mortality revealed low protein sufficiency on day 2 as an independent factor (OR = 3.32, 95% CI = 1.18-9.32, P = 0.023).

CONCLUSION

Protein underdosing in the early acute phase of severe AHF may be associated with increased in-hospital mortality.

Comparison of Mini Nutritional Assessment-Short and Long Form to predict all-cause mortality up to 7 years in geriatric outpatients

BACKGROUND

We aimed to find out whether the Mini Nutritional Assessment-Short Form (MNA-SF) can predict mortality up to 7 years when compared with the Mini Nutritional Assessment-Long Form (MNA-LF) in geriatric outpatients.

METHODS

This retrospective study was conducted in patients (≥65 years) who were admitted to the geriatric outpatient clinic of a university hospital. MNA-SF and MNA-LF results were available for all patients. Patients were grouped as normal nutrition status (score 12-14), at risk of malnutrition (score between 8 and 11), or malnourished (score ≤7) according to MNA-SF. Based on MNA-LF, patients had normal nutrition status (score ≥24), were at risk of malnutrition (score 17-23.5), or were malnourished (score <17). Survival of the patients was assessed retrospectively.

RESULTS

The study included 209 patients (62.2% female). During the 7-year follow-up, 77 (36.8%) patients died. After adjusting for age, sex, and Charlson comorbidity index, MNA-SF was significantly associated with all-cause mortality during 6-month, 1-year, 3-year, 5-year, and 7-year follow-up time. MNA-LF was superior to MNA-SF to estimate 6-month (P = 0.004) and 1-year mortality (P = 0.031). There was no difference between MNA-SF and MNA-LF regarding 3-year, 5-year, and 7-year mortality.

CONCLUSION

MNA-SF can predict short-term and long-term mortality in geriatric outpatients as well as MNA-LF. A cut-off value of 11, indicating risk of malnutrition according to MNA-SF, may be used for the risk estimation of 1-year, 3-year, and 5-year mortality. Therefore, this study highlights the importance of screening all geriatric outpatients for malnutrition and especially the risk of malnutrition for early intervention and treatment.

Combined prognostic value of malnutrition using GLIM criteria and renal insufficiency in elderly heart failure

AIMS

We aimed to investigate the prognostic impact of malnutrition, defined by the Global Leadership Initiative on Malnutrition (GLIM) criteria, stratified by renal function in hospitalized patients with acute decompensated heart failure (HF).

METHODS AND RESULTS

In this retrospective study, 314 patients who were hospitalized for acute decompensated HF from August 2019 to October 2020 were enrolled. We evaluated malnutrition using the GLIM criteria during the time of admission. The primary outcome was 90-day all-cause mortality. The median patient age was 82 years, and 90-day mortality was 14.0%. In total, 76 (24.2%) patients were malnourished according to the GLIM criteria. Malnutrition defined by the GLIM criteria [adjusted hazard ratio (HR) 1.41, 95% confidence interval (CI) 1.02-1.91, P = 0.036] and renal insufficiency [adjusted HR 2.59, 95% CI 1.07-6.28, P = 0.035 for estimated glomerular filtration rate (eGFR) < 30 mL/min/1.73 m2 vs. ≥60 mL/min/1.73 m2 ] were identified as independent predictors of 90-day mortality after adjustment for age, systolic blood pressure, and serum sodium level. In the combined setting of both variables, patients with malnutrition and eGFR < 30 mL/min/1.73 m2 had a markedly higher risk of 90-day mortality compared with those without malnutrition and eGFR ≥ 60 mL/min/1.73 m2 (adjusted HR 3.92, 95% CI 1.10-13.9, P = 0.035). Adding both eGFR and malnutrition, defined by the GLIM criteria, to the baseline model with established risk factors improved both net reclassification and integrated discrimination greater than that of the baseline model (0.606, P < 0.001 and 0.050, P = 0.002, respectively), even when compared with the model with malnutrition by the GLIM alone (0.463, P = 0.002 and 0.034, P < 0.001, respectively).

CONCLUSIONS

Nutrition screening using the GLIM criteria stratified by renal function could clearly predict 90-day mortality in hospitalized patients with acute decompensated HF.

[Nutrition in Case of Heart Failure]

Nutrition in Case of Heart Failure Abstract. Despite the complexity of the subject, nutritional medicine has made important advances in recent years, especially regarding cardiovascular health and for patients with heart failure. There is quite good evidence on specific diets, such as the Mediterranean and plant-based diets, but also on individual micronutrients, such as intravenous iron supplementation of iron deficiency in heart failure. No precise quantities can yet be named when dealing with the recommended amount of salt in heart failure patients, but the intake of high amounts of salt (>12 g/day) should be avoided. Considering the risk of malnutrition in this vulnerable patient population, an individualized nutritional therapy is advisable for some patients. This requires targeted screening for malnutrition. Nutritional medicine research still lacks many answers to further questions regarding heart failure patients. More randomized controlled trials and their meta-analyses are therefore required. Studies available so far have - among other shortcomings - paid too little attention to differences in nutrition in the different types and stages of heart failure. Interdisciplinary collaboration between cardiologists, hospital internists, general practitioners and nutritional therapists is in any case crucial for optimal treatment of patients with heart failure.

Uncovering the Role of Gut Microbiota in Amino Acid Metabolic Disturbances in Heart Failure Through Metagenomic Analysis

Aims: Circulating amino acid (AA) abnormalities serve as predictors of adverse outcomes in patients with heart failure (HF). However, the role of the gut microbiota in AA disturbances remains unknown. Thus, we investigated gut microbial functions and their associations with AA metabolic alterations in patients with HF. Methods and Results: We performed whole-genome shotgun sequencing of fecal samples and mass spectrometry-based profiling of AAs in patients with compensated HF. Plasma levels of total essential AAs (EAAs) and histidine were significantly lower in patients with HF than in control subjects. HF patients also displayed increased and decreased abundance of gut microbial genes involved in the degradation and biosynthesis, respectively, of EAAs, including branched-chain AAs (BCAAs) and histidine. Importantly, a significant positive correlation was observed between the abundance of microbial genes involved in BCAA biosynthesis and plasma BCAA levels in patients with HF, but not in controls. Moreover, network analysis revealed that the depletion of Eubacterium and Prevotella, which harbor genes for BCAA and histidine biosynthesis, contributed to decreased abundance of microbial genes involved in the biosynthesis of those EAAs in patients with HF. Conclusions: The present study demonstrated the relationship between gut microbiota and AA metabolic disturbances in patients with HF.

Risk stratification scores for patients with acute heart failure in the Emergency Department: A systematic review

AIMS

This study aimed to systematically identify and summarise all risk scores evaluated in the emergency department setting to stratify acute heart failure patients.

METHODS AND RESULTS

A systematic review of PubMed and Web of Science was conducted including all multicentre studies reporting the use of risk predictive models in emergency department acute heart failure patients. Exclusion criteria were: (a) non-original articles; (b) prognostic models without predictive purposes; and (c) risk models without consecutive patient inclusion or exclusively tested in patients admitted to a hospital ward. We identified 28 studies reporting findings on 19 scores: 13 were originally derived in the emergency department (eight exclusively using acute heart failure patients), and six in emergency department and hospitalised patients. The outcome most frequently predicted was 30-day mortality. The performance of the scores tended to be higher for outcomes occurring closer to the index acute heart failure event. The eight scores developed using acute heart failure patients only in the emergency department contained between 4-13 predictors (age, oxygen saturation and creatinine/urea included in six scores). Five scores (Emergency Heart Failure Mortality Risk Grade, Emergency Heart Failure Mortality Risk Grade 30 Day mortality ST depression, Epidemiology of Acute Heart Failure in Emergency department 3 Day, Acute Heart Failure Risk Score, and Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure) have been externally validated in the same country, and two (Emergency Heart Failure Mortality Risk Grade and Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure) further internationally validated. The c-statistic for Emergency Heart Failure Mortality Risk Grade to predict seven-day mortality was between 0.74-0.81 and for Multiple Estimation of risk based on Emergency department Spanish Score In patients with Acute Heart Failure to predict 30-day mortality was 0.80-0.84.

CONCLUSIONS

There are several scales for risk stratification of emergency department acute heart failure patients. Two of them are accurate, have been adequately validated and may be useful in clinical decision-making in the emergency department i.e. about whether to admit or discharge.

Individualized Nutritional Support for Hospitalized Patients With Chronic Heart Failure

BACKGROUND

Deterioration of nutritional status during hospitalization in patients with chronic heart failure increases mortality. Whether nutritional support during hospitalization reduces these risks, or on the contrary, may be harmful due to an increase in salt and fluid intake, remains unclear.

OBJECTIVES

The purpose of this trial was to study the effect of nutritional support on mortality in patients hospitalized with chronic heart failure who are at nutritional risk.

METHODS

A total of 645 patients with chronic heart failure (36% [n = 234] with acute decompensation) participated in the investigator-initiated, open-label EFFORT (Effect of early nutritional support on Frailty, Functional Outcomes and Recovery of malnourished medical inpatients) trial. Patients were randomized to protocol-guided individualized nutritional support to reach energy, protein, and micronutrient goals (intervention group) or standard hospital food (control group). The primary endpoint was all-cause mortality at 30 days.

RESULTS

Mortality over 180 days increased with higher severity of malnutrition (odds ratio per 1-point increase in Nutritional Risk Screening 2002 score: 1.65; 95% confidence interval [CI]: 1.21 to 2.24; p = 0.001). By 30 days, 27 of 321 intervention group patients (8.4%) died, compared with 48 of 324 (14.8%) control group patients (odds ratio: 0.44; 95% CI: 0.26 to 0.75; p = 0.002). Patients at high nutritional risk showed the most benefit from nutritional support. Mortality effects remained significant at 180-day follow-up. Intervention group patients also had a lower risk for major cardiovascular events at 30 days (17.4% vs. 26.9%; odds ratio: 0.50; 95% CI: 0.34 to 0.75; p = 0.001).

CONCLUSIONS

Among hospitalized patients with chronic heart failure at high nutritional risk, individualized nutritional support reduced the risk for mortality and major cardiovascular events compared with standard hospital food. These data support malnutrition screening upon hospital admission followed by an individualized nutritional support strategy in this vulnerable patient population. (Effect of Early Nutritional Therapy on Frailty, Functional Outcomes and Recovery of Undernourished Medical Inpatients Trial [EFFORT]; NCT02517476).

Association between early enteral nutrition and clinical outcome in patients with severe acute heart failure who require invasive mechanical ventilation

BACKGROUND

This study aimed to examine the association between early enteral nutrition (EEN) and clinical outcome in patients with severe acute heart failure (AHF).

METHODS

This retrospective observational study enrolled consecutive patients with AHF who required continuous invasive mechanical ventilation (IMV) for >48 h and were admitted to a single-center cardiac care unit (CCU). The primary outcome was CCU length of stay (LoS). We compared patients who were initiated on EN within 48 h of intubation (EEN group) with those who were initiated on EN after 49 h of intubation (delayed EN [DEN] group). Multivariate logistic regression analysis was performed to determine independent factors for primary and secondary outcomes. CCU LoS and IMV time were categorized using the median.

RESULTS

We included 86 patients with AHF (EEN group, n = 56; DEN group, n = 30) who met the inclusion criteria. The median CCU LoS was significantly shorter in the EEN group (10 [8-15] days) than in the DEN group (15 [12-26] days, P = .007). Multivariate analysis indicated that time to EN initiation was an independent factor for CCU LoS (odds ratio [OR], 8.39; 95% confidence interval [CI], 2.18-32.20; P = .002), IMV time (OR, 4.84; 95% CI, 1.37-17.20; P = .015), and incidence of infection (OR, 2.73; 95％ CI, 1.04-7.18; P = .042).

CONCLUSION

EEN (within 48 h of intubation) for patients with severe AHF who require continuous IMV might be associated with reduced CCU LoS, IMV time, and incidence of infection.

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.

Association between geriatric nutrition risk index and bone mineral density in elderly Chinese people

Malnutrition contributes to the occurrence of osteoporosis. This study showed that participants with higher GNRI values had higher levels of BMD. GNRIs were positively correlated with BMD and independently associated with total hip T-score. GNRIs may be a good indicator for identifying elderly who need further bone health nutritional support.

PURPOSE

To evaluate the relationship between geriatric nutrition risk index (GNRI) and bone mineral density (BMD) in elderly Chinese people.

METHODS

We recruited 1130 older adults (60-89 years old) between May 2018 and December 2019. Participants underwent clinical, laboratory, and densitometry examinations. Dual-energy x-ray absorptiometry densitometers and corresponding software were used to assess the BMD and T-scores of participants. Differences between study groups were assessed using one-way analysis of variance (ANOVA) for continuous variables and the chi-square test for categorical variables. Pearson's correlation coefficient was used to assess the correlation between two variables. Multivariate linear regressions with or without adjustments were constructed to explore the possible confounding variables.

RESULTS

Individuals with higher GNRI values had higher total hip and lumbar spine T-scores (P < 0.001, P = 0.029, respectively). Pearson's correlation demonstrated that GNRIs were positively correlated with BMD at different anatomical sites, in both sexes but especially in women. A multiple regression demonstrated that GNRIs were independently associated with total hip T-score in both sexes (β = 0.111 for men and 0.174 for women; P = 0.034 and 0.008, respectively).

CONCLUSIONS

Elderly people with higher GNRI values had higher total hip and lumbar spine T-scores, which suggested that GNRI is closely related to BMD. This relationship is maintained at the total hip, even after fully adjusting for possible confounding variables, and consequently, it may be a good indicator for identifying older people who need further bone health nutritional support.

The Additional Prognostic Value of Ghrelin for Mortality and Readmission in Elderly Patients with Acute Heart Failure

Purpose

To evaluate the prognostic value of ghrelin, a growth hormone-releasing peptide, for mortality and readmission in elderly patients with acute heart failure (AHF).

Patients and Methods

We measured plasma ghrelin and pro B-type natriuretic peptide (NT-proBNP) levels upon emergency admission in 241 prospectively recruited elderly AHF patients (61.0% men). The outcomes were all-cause mortality and/or readmission due to heart failure (HF). Multivariate Cox proportional hazards regression analyses were used to evaluate the prognostic value of ghrelin. Discrimination, calibration, and reclassification indices were compared between models, with or without ghrelin.

Results

During 1.2 years of follow-up, we observed 90 events (57 deaths and 33 readmissions due to HF). Plasma ghrelin levels were significantly elevated in elderly AHF patients, when compared to healthy control subjects (P < 0.001). Patients with events had significantly higher baseline ghrelin levels, when compared to those without (P < 0.001). Ghrelin levels were positively correlated with NT-proBNP levels and HF severity, whereas they were negatively correlated with nutritional status (all P < 0.05). Log transformed ghrelin levels were independently associated with AHF events (hazard ratio = 2.64, 95% confidence interval = 1.11–6.25, P = 0.028). The incorporation of ghrelin into the reference model, or reference with the NT-proBNP model, both improved C-statistics (from 0.742–0.780 and 0.836–0.857; P = 0.074 and 0.044, respectively), resulting in an improvement in net reclassification index (14.42% and 10.45%, P = 0.020 and 0.025, respectively), and integrated discrimination index (5.64% and 3.60%, both P < 0.001). Patients who displayed the above NT-proBNP and ghrelin median levels had a markedly higher risk of AHF adverse events (P < 0.001).

Conclusion

Plasma ghrelin is an independent predictor of adverse events in elderly AHF patients. Ghrelin may provide additional value to clinical parameters or NT-proBNP for prognostic risk stratification in AHF.

Impact of malnutrition in the embolic–haemorrhagic trade-off of elderly patients with atrial fibrillation

Aims

Nutrition is an important determinant of health above the age of 80 years. Malnutrition in the elderly is often underdiagnosed. The aim of this study was to report the prevalence and prognostic value of malnutrition in patients ≥80 years old with atrial fibrillation (AF) with and without anticoagulant therapy.

Methods and results

We assessed the nutritional status of 4724 octogenarian patients with diagnoses of AF in a single centre from Spain between 2014 and 2017 with the CONUT score. Malnutrition was confirmed in 2036 patients (43.1%). Anticoagulation prescription was more frequent in patients with good nutrition than in those malnourished (79.5% vs. 71.7%, P &lt; 0.001). The impact of malnutrition on mortality was evaluated by Cox regression, whereas its association with ischaemic stroke and major bleeding was studied through competing risk analysis. After multivariate adjusting, malnutrition was associated with mortality [hazard ratio (HR) 1.36, 95% confidence interval (CI) 1.24–1.49], stroke [sub-distribution HR (sHR) 1.37, 95% CI 1.10–1.69], and major bleeding (sHR 1.29, 95% CI 1.02–1.64). In anticoagulated patients, the embolic–haemorrhagic trade-off event was virtually neutral for those who had normal nutritional status [average daily rates (ADRs) for stroke and bleeding: 4.70 and 4.69 per 100 000 patients/day, respectively; difference = +0.01 per 100 000 patients/day; P = 0.99] and negative for those with malnutrition (ADR for stroke and bleeding: 5.38 and 7.61 per 100 000 patients/day, respectively; difference = −2.23 per 100 000 patients/day; P = 0.07).

Conclusion

Malnutrition is very common in octogenarian patients with AF, being a clinical predictor for poor prognosis. For anticoagulated patients, malnutrition was associated with a negative embolic–haemorrhagic balance.