Nutrition Assessment and Dietary Interventions in Heart Failure: JACC Review Topic of the Week

Prognostic value of advanced lung cancer inflammation index in heart failure patients: A comprehensive analysis

AIMS

The prognosis of heart failure (HF) is closely linked to inflammation and nutritional status. The advanced lung cancer inflammation index (ALI) is a composite indicator consisting of several parameters used to assess inflammation and nutritional status. Our study aimed to investigate the prognostic value of ALI in HF patients.

METHODS

The data from Study 1, which included 1359 HF patients, were extracted from the National Health and Nutrition Examination Survey (NHANES) database spanning the years 1999 to 2018. Study 2 analysed data from patients with HF who underwent cardiac magnetic resonance imaging examinations from 2020 to 2023. Kaplan-Meier curve analysis, Cox proportional hazard model, time-dependent receiver operating characteristic (ROC) curve and restricted cubic spline (RCS) were used to evaluate the relationship between ALI and long-term prognosis of patients with HF in Study 1. Logistic regression analysis was used to evaluate the correlation between ALI and left ventricular reverse remodelling, and RCS was used to determine any dose-response relationship. Spearman correlation was used to evaluate the relationship between ALI and indicators of cardiac structural changes.

RESULTS

Study 1 found that the average age of the patients was 68 years [inter-quartile range (IQR) 58-76], the proportion of males was 54.3%, and there were 699 all-cause mortality and 293 cardiovascular mortality cases. After adjusted by multivariable Cox regression analysis, elevated ALI levels were significantly associated with increased risks of all-cause [hazard ratio (HR) = 0.58, 95% confidence interval (CI) = 0.42-0.79, P < 0.001] and cardiovascular mortality (HR = 0.61, 95% CI = 0.38-0.97, P = 0.036) in patients with HF. A linear negative correlation was observed between ALI and both all-cause (P = 0.0011 and P < 0.001, P for nonlinear = 0.3993) and cardiovascular mortality (P = 0.0011, P for nonlinear = 0.5198). Time-dependent ROC curves showed the predictive value of ALI for all-cause mortality [area under the curve (AUC) = 0.678 in 3 years, AUC = 0.674 in 5 years and AUC = 0.683 in 10 years] and cardiovascular mortality (AUC = 0.694 in 3 years, AUC = 0.685 in 5 years and AUC = 0.697 in 10 years). Study 2 included 79 patients; the average age of the patients was 44 years (IQR 35-55); and the proportion of males was 74.7%. Adjusted multivariable logistic regression analysis indicated that high ALI levels were associated with left ventricular reverse remodelling (LVRR) in patients with HF following discharge from the hospital [odds ratio (OR) = 3.16, 95% CI = 1.06-10.8, P = 0.049]. Spearman analysis revealed a correlation between ALI and extracellular volume (ECV) (r = -0.25, P = 0.023).

CONCLUSION

ALI is associated with all-cause and cardiovascular mortality risk and structural changes in the heart in patients with HF.

Prognostic Significance of Nutritional Scores in Patients With Heart Failure: Insights From the PARAGON-HF Trial

BACKGROUND

The Controlling Nutritional Status (CONUT) and Geriatric Nutritional Risk Index (GNRI) are indices that identify individuals at risk of malnutrition. Our study sought to examine the incidence and prognostic implications of abnormal CONUT and/or GNRI in patients with heart failure with preserved ejection fraction.

METHODS AND RESULTS

The CONUT score and GNRI were serially analyzed in this post hoc analysis of the PARAGON-HF (Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor With Angiotensin-Receptor Blockers Global Outcomes in Heart Failure With Preserved Ejection Fraction) trial. A CONUT score >2 or GNRI ≤98 was considered to be abnormal. The association between abnormal CONUT and/or GNRI (analyzed using a time-updated approach) and total heart failure hospitalizations and cardiovascular death was analyzed. Other outcomes included cardiovascular death, all-cause death, total heart failure hospitalizations, first all-cause hospitalization, and first noncardiovascular hospitalization. We also explored the effect of incident hospitalization on subsequent incident abnormal CONUT and/or GNRI. In 4794 patients (55% women, mean age 72±8 years), 1119 (23.3%) had at least 1 abnormal score at randomization. Among the remaining 3675 patients, 1405 (38.2%) developed at least 1 abnormal score over a median follow-up of 2.9 years. Any abnormal score during follow-up was associated with a significantly higher risk of fatal and nonfatal outcomes, and all types of hospitalizations (all-cause, heart failure, and noncardiovascular hospitalizations). Among patients with normal scores at randomization, any hospitalization during follow-up was associated with a significantly higher risk of developing at least 1 abnormal score posthospitalization, compared with prehospitalization and never-hospitalized patients (adjusted hazard ratio, 1.37 [95% CI, 1.22-1.55]).

CONCLUSIONS

Among patients with heart failure with preserved ejection fraction, the rate of individuals with abnormal CONUT and/or GNRI was high, especially following a heart failure hospitalization, and was linked with excess cardiovascular and noncardiovascular events.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01920711.

Lentinan alleviates angiotensin II-induced myocardial remodeling through LMP7-SOCS3 signaling

Myocardial remodeling is a major pathological mechanism causing heart failure. As a critical negative modulator of cardiac remodeling, suppressor of cytokine signaling 3 (SOCS3) is regulated by immunoproteasome subunit large multifunctional peptidase 7 (LMP7). Lentinan (LNT), a β-polysaccharide extracted from Lentinus edodes, has anti-inflammatory and antioxidant properties. However, the role and molecular mechanisms of LNT in angiotensin II (Ang II)-triggered myocardial remodeling are unclear. Myocardial remodeling was established using Ang II infusion (1000 or 200 ng/kg/min) for 2 weeks. Cardiomyocytes and cardiac fibroblasts were triggered by Ang II. LNT was administered daily by oral gavage to mice starting 1 day before Ang II or saline treatment. Here, we found that LNT supplementation dose-dependently ameliorated Ang II-triggered myocardial dysfunction and remodeling (hypertrophy, fibrosis, inflammation, and superoxide production). Mechanistically, LNT suppressed SOCS3 protein degradation by downregulating immunoproteasome LMP7 activity and expression, thereby inactivating downstream signaling, such as STAT3, ERK, AKT, NF-κB, and TGF-β. Conversely, SOCS3 knockdown significantly blocked the protective effect of LNT on myocardial remodeling in Ang II-infused mice. Together, our findings suggest that LNT may be a new therapeutic approach for myocardial remodeling and heart failure.

Apixaban in patients with nonvalvular atrial fibrillation, heart failure and low body weight: A report from a global federated research dataset

BACKGROUND

Atrial fibrillation (AF) and low body weight (BW, <60 kg) are common in patients with heart failure (HF). However, the safety and effectiveness of direct oral anticoagulants (DOACs) in this group remain unclear. This study compares the efficacy and safety of apixaban versus vitamin K antagonists (VKAs) in patients with nonvalvular AF, low BW and HF.

METHODS

We analysed 155,152 patients with HF and AF, weighing ≤100 kg and treated with oral anticoagulants (apixaban 86,493; VKA 68,659), from the TriNetX Global Research Network. Outcomes included ischaemic stroke/systemic embolism (SEE), clinically relevant bleedings, intracranial haemorrhage (ICH), all-cause death and net clinical benefit (composite of stroke/SEE, bleedings and all-cause death) across three BW categories: 60-100 kg (reference), 50-60 kg (low BW) and ≤50 kg (very low BW). Propensity score matching was used to balance the treatment groups.

RESULTS

Patients with low BW had a higher risk of adverse events compared to those with reference BW, regardless of treatment. Apixaban consistently reduced the risk of ischaemic stroke/SEE and bleeding (including ICH) across all BW ranges (all p-interaction >.10), and improved net clinical benefit compared to VKA (reference BW: HR .82 [95% CI: .80-.84]; low BW: HR .79 [95% CI: .74-.85]; very low BW: HR .86 [95% CI: .78-.95], p-interaction = .366). However, a significant BW-treatment interaction was observed for all-cause mortality, indicating reduced relative effectiveness of apixaban vs. VKA as BW decreases.

CONCLUSION

In this large real-world analysis, treatment with apixaban was associated with a superior effectiveness and safety profile compared to VKA in patients with AF, HF and low BW. These results remained consistent, albeit slightly attenuated, in patients with very low BW. These findings provide preliminary evidence supporting the use of apixaban in this high-risk population.

Cachectic biomarkers as confounders behind the obesity paradox in patients with acute decompensated heart failure

BACKGROUND

Obesity is a risk factor for heart failure (HF) development but is associated with a lower incidence of mortality in HF patients. This obesity paradox may be confounded by unrecognized comorbidities, including cachexia.

METHODS

A retrospective assessment was conducted using data from a prospectively recruiting multicenter registry, which included consecutive acute heart failure patients. A low, normal, and high body mass index (BMI) was defined as <20 kg/m2, 20-25 kg/m2, and ≥25 kg/m2, respectively. Cachexia was defined as a combination of BMI < 20 kg/m2 and any biochemical abnormalities including albumin, hemoglobin, or C-reactive protein. Patients with either of the three biochemical abnormalities were categorized as those with cachectic biomarkers. Two-year all-cause, cardiac, and noncardiac mortality were evaluated.

RESULTS

This study evaluated 3314 patients (mean BMI, 22 ± 4 kg/m2 [low BMI with cachexia, 828 (25%); low BMI without cachexia, 273 (8%); normal BMI, 1584 (48%); high BMI, 629 (19%)]). Overall, an increase of 1 point in BMI was associated with a decreased incidence of all-cause mortality (adjusted hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.90-0.94; p < 0.001). Regardless of the mode of death, the low BMI with cachexia indicated the worst prognosis, while the low BMI without cachexia showed a similar prognosis to the normal BMI. Cachectic biomarkers, which were observed more frequently in the low BMI, predicted a higher incidence of 2-year all-cause mortality across the BMI categories (adjusted HR for the low BMI, 1.90; 95% CI, 1.30-2.77; p = 0.001; adjusted HR for the normal BMI, 1.94; 95% CI, 1.34-2.79; p < 0.001; adjusted HR for the high BMI, 3.60; 95% CI, 1.61-8.08; p = 0.002).

CONCLUSIONS

BMI could be only a surrogate marker. The cachectic biomarkers may reflect the underlying conditions and contribute to elucidating the obesity paradox.

Tracking Pathways Linking Obesity with Heart Failure

Obesity can cause the onset of heart failure and exacerbate the status of the pre-existing disease. Through intricate pathways, obesity activates hormonal factors that encourage the development of inflammation and lead to increased congestion. Consequently, this complex parallel pathophysiological cascade contributes to the echocardiographic and clinical signs of heart failure. In these patients, obesity frequently coexists with nutritional and muscular profile abnormalities that manifest as cachexia or sarcopenia. Patients with heart failure have a higher chance of surviving when obesity is treated. Interventional, pharmaceutical, and dietary strategies are used as forms of therapy. This review delves into the evaluation of the relationship between obesity and heart failure, and it targets to highlight the therapeutical impact of weight-loss programs on cardiac function in individuals with heart failure and obesity.

Prevalence and prognostic value of malnutrition in adults with Fontan circulation: retrospective cohort study

BACKGROUND

Malnutrition is a relevant prognostic factor in cardiovascular disease. However, it has not been studied in adults with CHD and Fontan circulation.

METHODS

Retrospective, single-centre cohort study including all consecutive adults with Fontan circulation. Objectives: 1. To evaluate the prevalence of malnutrition, defined according to Controlling Nutritional Status score, which includes albumin, lymphocytes, and cholesterol and 2. To assess its utility as a prognostic marker.

RESULTS

We included 93 patients (55.9% male) with a mean age of 32.7 ± 8.3 years. After a median follow-up of 5.5 years (interquartile range 2.2 – 10.6), 14 patients met the combined primary outcome of death or heart transplant (15.1%). Moderate or severe malnutrition (Controlling Nutritional Status score ≥ 5) was detected in 18.3%. Overweight was found in 21.5% of patients, obesity in 4.3%, and low weight in 8.6%, with no significant differences in malnutrition parameters across weight categories. Patients with malnutrition had worse functional capacity (58.8% in New York Heart Association—NYHA-class III–IV, vs. 33.3% in patients without malnutrition, p = 0.05).In univariate analysis, malnutrition was associated with a worse prognosis (death or heart transplant) with a hazard ratio of 3.7 (95% confidence interval 1.3 to 10.7, p = 0.01). In the adjusted model including cyanosis, functional class, and protein-losing enteropathy, malnutrition did not reach statistical significance (p = 0.81).

CONCLUSION

Malnutrition as defined by Controlling Nutritional Status score is common in adults with Fontan circulation and represents a strong prognostic marker. Controlling Nutritional Status scale could be used in Fontan patients as a simple tool to identify a high-risk population.

Comparing GLIM and SGA Nutritional Criteria for Malnutrition Assessment and Prognosis in Chronic Heart Failure Patients

Background

Chronic heart failure (CHF) is a prevalent condition with high morbidity and mortality. Malnutrition is common in CHF patients and is associated with poor prognosis. The Subjective Global Assessment (SGA) and Global Leadership Initiative on Malnutrition (GLIM) criteria are widely used to assess nutritional status, but their prognostic value in CHF remains unclear. This study aimed to compare the effectiveness of SGA and GLIM criteria in assessing malnutrition and predicting adverse outcomes in CHF patients.

Material and Methods

This retrospective cohort study included 240 CHF patients admitted between January 2022 and June 2024. Nutritional status was assessed using both SGA and GLIM within 48 hours of admission. The primary outcome was the occurrence of adverse events (worsening heart failure, readmission, or all-cause mortality) within 90 days post-discharge. Statistical analyses included Cohen's kappa for agreement, Receiver Operating Characteristic (ROC) curves for predictive value, and multivariate logistic regression to identify independent risk factors for adverse outcomes.

Results

The agreement between SGA and GLIM criteria was good (Cohen's Kappa = 0.8). ROC analysis showed an AUC of 0.744 for SGA and 0.793 for GLIM in predicting adverse outcomes. The DeLong test revealed that GLIM had a significantly better predictive value (Z = -1.93, p = 0.043). Multivariate analysis identified malnutrition (both SGA and GLIM), smoking, and elevated BNP as independent risk factors for adverse outcomes. Nomograms incorporating these factors showed good predictive accuracy, with the GLIM model yielding a higher AUC of 0.854 compared to 0.816 for SGA.

Conclusion

Malnutrition was identified in 38.8% of patients when assessed by the SGA and in 40.0% when evaluated using the GLIM criteria. GLIM criteria are a reliable and superior tool for predicting adverse outcomes in CHF patients compared to SGA. Incorporating nutritional assessments, BNP, and smoking history into predictive models can enhance risk stratification and guide clinical decision-making in managing CHF patients.

The nutritional impact of 7 versus 21 home-delivered medically tailored meals in patients with heart failure and malnutrition risk: a random order crossover feeding trial (MEDIMEALS)

BACKGROUND

Heart failure (HF) is frequently associated with malnutrition or malnutrition risk. The delivery of medically tailored meals (MTM) to the homes of patients with HF and malnutrition risk or malnutrition after hospital discharge holds promise for improving outcomes. However, the number of MTM needed to provide benefit is not established.

METHODS

A random order crossover study was designed to compare the delivery of 7 versus 21 MTM for four weeks each to patients discharged from the hospital with HF and malnutrition risk. Telephone surveys were conducted at baseline, 30, and 60 days post-discharge to evaluate change in malnutrition risk, American Heart Association (AHA) diet goals, sarcopenia risk, and 30-day readmissions.

RESULTS

Forty-six patients were enrolled. Patients had reduced odds of having malnutrition risk relative to the baseline score at one and two months (OR 0.18, 95% CI 0.04-0.74 and OR 0.21, 95% CI 0.05-0.99, respectively). The AHA diet score improved over time from baseline by 0.73 ± 0.22 units at one month (p = 0.0014), and by 0.48 ± 0.23 units at two months (p = 0.0430), regardless of the number of MTM provided. Sarcopenia risk improved over time (p = 0.01), decreasing by 0.43 ± 0.2 units by one (p = 0.03) and 0.59 ± 0.21 units by two months (p = 0.007) regardless of the number of MTM provided. Readmissions by 30 days were not significantly different based on the number of MTM provided (9% for 21 MTM vs 12.5% for 7 MTM), but well below national data at 23%.

CONCLUSION

The provision of at least seven MTM per week in the early window after hospital discharge to patients with HF and malnutrition or malnutrition risk is a promising strategy to improve malnutrition and sarcopenia risk and diet adherence, while keeping readmissions below national averages.

TRIAL REGISTRATION

Clinicaltrials.gov NCT06142903, registered 11/23/2023.

The Nutritional Status of Patients with Heart Failure and Its Impact on Patient' Outcomes-The Center's Own Experience

Background. The nutritional status of patients in hospitals has a significant impact on the effectiveness of treatment, the occurrence of complications, and the length of hospitalization. The purpose of this study was to evaluate the nutritional status of patients with heart failure (HF) and its impact on patient outcomes. Material and Methods. This study included 213 patients (153 men, 71.8%) aged 74.7 ± 14.3 years treated for HF at the cardiology clinic of the 4th Military Clinical Hospital between 2018 and 2021. Sociodemographics, clinical data, the Model for End-Stage Liver Disease (MELD), CHILD-PUGH, and the Nutritional Risk Score (NRS) were analyzed. Results. Patients at high nutritional risk (NRS ≥ 3 score) were older (85 years vs. 75 years; p < 0.001), had longer hospitalizations (12 days vs. 9 days, p = 0.027), lower hemoglobin (10.5 g/dL vs. 11.7 g/dL, p = 0.001), lower TIBC (292 vs. 336; p = 0.012), and iron (32 mg/nL vs. 39 ng/mL, p = 0.009) compared with patients at low risk (NRS < 3 score). Patients hospitalized ≤7 days had significantly lower CHILD-PUGH score compared with patients hospitalized >7 days. Patients hospitalized ≥14 days were significantly more likely to die compared with other groups of HF patients (10.6% vs. 0.0%, p = 0.004). Conclusions. Abnormal nutritional status among hospitalized HF patients is associated with longer hospitalization duration and higher rates of death. In addition to clinical factors, the CHILD-PUGH scale can be helpful in estimating the length of hospitalization of HF patients. It is necessary to determine the impact of nutritional status on the outcome of patients with heart failure in further multicenter prospective or interventional studies.

Malnutrition and outcomes in patients with tricuspid regurgitation undergoing transcatheter tricuspid valve repair

AIMS

The impact of malnutrition in patients with tricuspid regurgitation (TR) undergoing tricuspid transcatheter edge-to-edge repair (T-TEER) is not well established. We evaluated the impact of malnutrition among patients with symptomatic TR undergoing T-TEER.

METHODS AND RESULTS

Baseline nutritional status was evaluated using the geriatric nutritional risk index (GNRI), based on serum albumin concentrations and body weight to ideal body weight ratio, among patients with symptomatic TR undergoing T-TEER, enrolled in the multicentre EuroTR registry between March 2016 and February 2024. Malnutrition was defined as GNRI ≤98. The primary outcome of interest was all-cause mortality. A total of 1034 patients were included (mean age 78.4 ± 7.3 years, 47.7% male). Among them, GNRI ≤98 (i.e. malnutrition) was observed in 211 patients (20.4%). Estimated rates of all-cause death at 2 years were 45.9% and 28.2% in patients with and without malnutrition, respectively (log-rank p < 0.001). After multivariable adjustment, malnutrition was independently associated with an increased risk of mortality (adjusted hazard ratio 1.53, 95% confidence interval 1.11-2.10, p = 0.009), also confirmed at inverse probability of treatment weighting-adjusted analysis. As compared to post-procedural residual TR ≥3+, residual TR ≤2+ was associated with a similar lower risk of mortality in patients with and without malnutrition (interaction p = 0.947).

CONCLUSION

In the large, real-world, multicentre EuroTR registry, malnutrition was present in one out of five patients with symptomatic TR undergoing T-TEER and was independently associated with increased mortality. The prognostic benefit of successful T-TEER in reducing mortality was consistently observed in patients with and without malnutrition.

Prediction model and scoring system for in-hospital mortality risk in infants with heart failure aged 1-36 months: A retrospective case-control study

Background

Existing studies report very few factors influencing the mortality of infant and toddler heart failure patients during hospitalization. Due to its high mortality rate, it is an important health issue. Therefore, this study aims to explore the factors influencing infant and toddler heart failure patients during hospitalization, establish predictive models, and a mortality scoring table.

Methods

The study ultimately included 544 cases of infant heart failure patients. They were randomly divided into a training set (380 cases) and a validation set (164 cases) in a ratio of 7:3. The training set was then further divided into the death group and the survival group for further analysis of indicators during hospitalization.

Results

Using the Lasso regression method, this study selected the best 14 variables from 88 independent variables of infants and toddlers with heart failure. Multivariate Logistic regression results show that TP < 65 g/L (OR = 2.34), pH < 7.35 (OR = 2.79), and Respiratory rate (1-12 months: <30times/min and 13-36 months: <25times/min, OR = 2.34) are independent risk factors. The model evaluation results for the train and test sets of infant and toddler heart failure patients are as follows: C-index values for discrimination in the train and test sets are 0.721 and 0.728, respectively. Fit test calibration evaluations show P values of 0.9958 and 0.9998, both greater than 0.05, indicating good calibration. The AUC values for the train and test sets are 0.75 and 0.64, respectively, showing a good predictive effect of the model. The mortality scoring table divides patients in the train and test sets into low risk, moderate-risk, and high risk categories. Compared to the low risk group, the OR values for the occurrence of mortality in the Medium risk group and high risk group in the train set are 3.78 and 11.67, respectively; in the test set, the OR values for the moderate-risk group and high-risk group are 1.73 and 6.33, respectively.

Conclusion

The predictive models and scoring tables established in this study have a good predictive role in assessing the risk of death in infant and toddler heart failure patients aged 1-36 months during hospitalization, providing clinical guidance and reference value.

Clinical impacts of malnutrition based on the GLIM criteria using the MNA-SF for nutritional screening in patients with acute heart failure

The Global Leadership Initiative on Malnutrition (GLIM) suggested a two-step framework for the assessment of malnutrition based on screening and diagnosis. Malnutrition, as defined by the GLIM criteria, and the risk of malnutrition determined through nutritional screening are associated with adverse outcomes in patients with heart failure (HF). This study investigated the prognostic impact of malnutrition, as defined by the GLIM criteria, compared with the risk of malnutrition determined by the Mini Nutritional Assessment-Short Form (MNA-SF) screening tool among patients hospitalized for acute HF. A total of 446 patients with acute HF who underwent nutritional screening using the MNA-SF and were diagnosed with malnutrition based on the GLIM criteria were include in this study. The primary outcome was the incidence of all-cause death or HF-related readmission after discharge. Patients diagnosed with malnutrition based on both indices had a higher incidence of adverse events within one year post-discharge than patients diagnosed without malnutrition. However, a landmark analysis of years one to three post-discharge found that the incidence of the primary outcome was comparable between patients diagnosed with malnutrition and those that here not. Furthermore, although malnutrition as defined by the GLIM criteria was found to be an independent predictor of the 1 year incidence of all-cause death or rehospitalization for HF even after adjusting for other prognostic indicators (hazard ratio, 1.593; 95% confidence interval, 1.056-2.403; P = 0.026), the risk of malnutrition based on the MNA-SF was not. In conclusion, a diagnosis of malnutrition based on the GLIM criteria provides better prognostic stratification in the first year post-discharge in patients with acute HF as compared with nutritional screening based only on the MNA-SF.

Impact of geriatric nutritional risk index and diabetes mellitus on prognosis in ischaemic heart failure with reduced ejection fraction

It is unclear whether diabetes mellitus (DM) affects the role of malnutrition in heart failure (HF). We evaluated the effect of the geriatric nutritional risk index (GNRI) on HF prognosis and DM's role in this relationship. This single-centre retrospective cohort study included 540 HF patients with nutritional data grouped by DM status and GNRI score. The primary endpoint was all-cause mortality. Eighty-four patients (15.6%) were classified as malnourished (GNRI ≤ 98). Over a median follow-up of 4.0 years, 102 patients died. The DM/low GNRI (L-GNRI) group had the highest risk of all-cause death (HRadj: 3.253, 95% CI 1.643-6.474, P < 0.001) and cardiac death (HRadj: 3.411, 95% CI 1.606-7.243, P < 0.001) compared to the non-DM/high GNRI group. The adverse impact of L-GNRI was more pronounced in DM than in non-DM patients (Pinteraction < 0.05). In the total population and DM subgroup, GNRI was independently associated with an increased risk of all-cause and cardiac death after adjustment (all P < 0.05). In patients with DM, the GNRI classification significantly enhanced the predictive value of the model (all P < 0.05). A negative correlation between GNRI and HbA1c was observed only in patients with DM. Patients with HF with DM and malnutrition had the poorest prognosis. Poor glycemic control is related to increased malnutrition risk.

Malnutrition risk, weight loss, and subsequent survival in patients listed for heart transplantation

Background

Higher malnutrition risk is associated with mortality among patients with heart failure and heart transplantation (HT). We investigated which malnutrition risk scores - geriatric nutrition risk index (GNRI), prognostic nutritional index (PNI), or controlling nutritional status (CONUT) - have the strongest mortality association for HT candidates, and whether they are prognostic at the time of HT listing or HT operation.

Methods

We reviewed adults listed for primary HT at a single center 1987-March 2022, with survival follow-up to November 2022. We constructed Cox proportional hazards models and restricted cubic spline curves for each risk score at both HT listing and HT operation and inputted HT operation as a time-varying covariate for models commencing at listing. Risk scores were assessed as continuous and binary variables. Weight change between listing and HT was evaluated similarly.

Results

The 1,024 patients [76% male; median age 55 (46-61) years; HT operation n = 656] had median follow-up of 4.6 (interquartile range 1.6-8.7) years. As a continuous variable, lower GNRI at HT listing (greater malnutrition risk) was independently associated with higher mortality. As binary variables, higher risk GNRI, PNI or CONUT scores at listing were all associated with higher mortality. Conversely, risk scores at time of HT operation were not associated with subsequent mortality. There was a non-significant trend towards higher mortality with greater weight loss between listing and HT operation.

Conclusion

Malnutrition risk scores showed prognostic utility only at time of HT listing. As a continuous variable, GNRI at HT listing was independently associated with subsequent mortality.

Beyond Guideline-Directed Medical Therapy: Nonpharmacologic Management for Patients With Heart Failure

Heart failure (HF) is a leading cause of cardiovascular morbidity, mortality, and health care expenditure. Guideline-directed medical therapy and device-based therapy in HF are well established. However, the role of nonpharmacologic modalities to improve HF care remains underappreciated, is underused, and requires multimodal approaches to care. Diet, exercise and cardiac rehabilitation, sleep-disordered breathing, mood disorders, and substance use disorders are potential targets to reduce morbidity and improve function of patients with HF. Addressing these factors may improve symptoms and quality of life, reduce hospitalizations, and improve mortality in heart failure. This state-of-the-art review discusses dietary interventions, exercise programs, and the management of sleep-disordered breathing, mood disorders, and substance use in individuals with heart failure. The authors review the latest data and provide optimal lifestyle recommendations and recommended prescriptions for nonpharmacologic therapies.

Association between red cell distribution width-albumin ratio and all-cause mortality in intensive care unit patients with heart failure

Aim

The association between red cell distribution width-albumin ratio (RAR) and the risk of all-cause mortality in intensive care unit (ICU) patients with heart failure remains uncertain. This study aimed to investigate this association.

Methods

Clinical data from MIMIC-Ⅳ (version 2.2) database was utilized for the analysis of ICU patients with heart failure. Patients were categorized into quartiles (Q1-Q4) based on RAR levels. Kaplan-Meier survival analysis and multivariate adjusted Cox regression models were employed to assess the association between RAR levels and mortality outcomes within 1 year. Subgroup analysis was used to evaluate the prognostic impact of RAR across diverse populations. Restricted cubic spline curves and threshold effect analysis were utilized to quantify the dose-response relationship between RAR levels and mortality. The time-concordance index curve was carried out to explore the additional prognostic value of RAR on mortality over the existing scoring systems, Serial Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ).

Results

The analysis encompassed a cohort of 4,506 patients, with Kaplan-Meier curves indicating that individuals with higher RAR levels exhibited an elevated risk of all-cause mortality (p < 0.001). Multivariate adjusted Cox regression and subgroup analysis demonstrated that individuals in Q2 [hazard ratio (HR) 1.15, 95%CI 0.98-1.34], Q3 (HR 1.65, 95%CI 1.39-1.96) and Q4 (HR 2.16, 95%CI 1.74-2.68) had an increased risk of mortality compared to individuals in Q1 (p for trend < 0.001), and this relationship was consistently observed across most subgroups, except for different ages. Subsequent analysis revealed that the inclusion of RAR significantly improved the prognostic value on the basis of SOFA and APACHE Ⅱ, and the concordance index increased from 0.636 to 0.658 for SOFA, from 0.682 to 0.695 for APACHE Ⅱ (p < 0.001 for both).

Conclusion

The study found that high level of RAR was independently associated with an increased risk of 1-year all-cause mortality in ICU patients with heart failure, with a stronger effect in young and middle-aged patients and a threshold effect, which could potentially serve as an early warning indicator for high-risk populations.

Long-term changes in frailty and incident atrial fibrillation, heart failure, coronary heart disease, and stroke: A prospective follow-up study

BACKGROUND

People with frailty have increased prevalence and incidence of atrial fibrillation (AF).

OBJECTIVE

The study aimed to further investigate the association of long-term changes in frailty with risk of new-onset AF. Its associations with heart failure (HF), coronary heart disease (CHD), and stroke were also evaluated as a secondary aim.

METHODS

More than 50,000 participants from UK Biobank cohort were included, with frailty index (FI) data and free of AF, HF, CHD, or stroke in baseline and follow-up assessments. Frailty status of the participants was categorized into nonfrail, prefrail, and frail based on their FI scores. FI in baseline and follow-ups are used to calculate the trajectories of frailty (ΔFI).

RESULTS

During a median of 5.1 years of follow-up from the final assessment, 1729 cases of AF were recorded. Frailty trajectory analysis showed that even a 0.01 point per year increase in ΔFI was associated with 14% (95% confidence interval [CI] 1.08-1.20) higher risk of AF, independent of baseline FI after adjusting for potential confounders. Compared with maintained nonfrail participants, those with sustained frail status had the highest risk of incident AF (hazard ratio [HR] 1.95, 1.61-2.36). The risk declined by 30% (95% CI 0.53-0.94) when frail participants regressed to nonfrail or prefrail status, compared with sustained frail participants. These associations were similar in HF and CHD however not significant in stroke.

CONCLUSION

In middle-aged and elderly individuals, frailty remission or nonfrailty maintenance was associated with lower risk of AF, HF, and CHD compared with persistent frailty, regardless of previous frailty status and established risk factors.

Association of Immune Nutrition Indices with the Risk of All-Cause Mortality and Cardiovascular Mortality in Patients with Heart Failure in the NHANES (1999-2018)

Background

Heart failure (HF) remains a global challenge with disappointing long-term outcomes. Malnutrition is prevalent in patients with HF and disrupts the equilibrium of immune and inflammatory responses, resulting in further deterioration of the HF. Novel indicators emerge as immune nutrition indices, including the prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio (NLR), Controlling Nutritional Status (CONUT) score, and cholesterol-modified prognostic nutritional index (CPNI). This study examines the correlation between immune nutrition indices and all-cause and cardiovascular mortality in patients with HF.

Methods

The data source for this study was the National Health and Nutrition Examination Survey (NHANES). A total of 1232 participants with HF were included. Weighted Cox proportional hazards models were employed to assess the independent association of different immune nutrition indices with mortality risk, alongside subgroup analyses and Kaplan-Meier survival curves. Restricted cubic spline analysis was utilized to clarify the detailed association between immune nutrition indices and hazard ratio (HR). A time-dependent receiver operating characteristic curve analysis was conducted to assess the predictive ability.

Results

After full adjustments, PNI is independently related to all-cause mortality (HR = 0.94, 95% CI: 0.92-0.97) and cardiovascular mortality (HR = 0.94, 95% CI: 0.90-0.99). CPNI, CONUT, and NLR also showed an independent association with the prognosis of HF. Time-dependent receiver operating characteristic curve analysis indicated that PNI exhibited the highest predictive power for mortality among the CPNI, CONUT, and NLR indexes.

Conclusions

Our study revealed that immune nutrition indicators, including CPNI, could predict all-cause mortality and cardiovascular mortality in the HF population. Compared with other indicators, PNI is the most effective predictor.

Dietary Interventions in Heart Failure With Preserved Ejection Fraction: A Scoping Review

Patients with heart failure with preserved ejection fraction (HFpEF) are burdened by multiple diet-sensitive comorbidities, including obesity and malnutrition. Despite this, a low percentage of patients with HFpEF have been enrolled in dietary intervention trials in heart failure and few dietary interventions have been conducted in HFpEF exclusively. This scoping review will examine available evidence regarding dietary interventions in patients with HFpEF, highlight existing gaps in knowledge, and discuss emerging dietary therapies in this population.

Nutritional Status of Very Elderly Outpatients with Heart Failure and Its Influence on Prognosis

BACKGROUND/OBJECTIVES

Malnutrition has been associated with increased morbidity and mortality in elderly patients diagnosed with heart failure (HF). However, nutritional problems are underdiagnosed in these patients. This study aimed to analyse malnutrition prevalence in elderly HF patients and its impact on survival.

METHODS

We conducted a retrospective observational study including patients aged ≥85 years diagnosed with HF followed up by a specific HF unit between 2015 and 2023. All patients underwent a nutritional assessment at the start of follow-up. Demographic characteristics, comorbidities, functional, cognitive and frailty status, heart disease characteristics and laboratory data, as well as admissions, emergency department visits and survival, were collected. The sample was categorised according to nutritional status into normonutrition and impaired nutritional status, and differences were evaluated.

RESULTS

Of a total of 413 patients, 52.8% were female, and the mean age was 88.4 ± 2.9 years. A total of 25.4% were at risk of malnutrition and 2.2% malnourished. Dementia [OR = 3.99, 95%CI (2.32-6.86); p < 0.001], hip fracture [OR = 3.54, 95%CI (1.75-7.16); p < 0.001)], worse Barthel index score [OR = 5.44, 95%CI (3.15-9.38); p < 0.001), worse Pfeiffer test [OR = 5.45; 95%CI (3.29-9.04); p < 0.001), worse Frail index [OR = 6.19; 95%CI (2.45-15.61); p < 0.001] and higher Charlson index [OR = 1.95; 95%CI (1.21-3.15); p = 0.006] were associated with worse nutritional status. In addition, patients with poor nutritional status lived 16.69 months less (p < 0.001) than normonutrited patients.

CONCLUSIONS

At least one in four elderly patients with HF under outpatient follow-up has an impaired nutritional status. This is associated with hip fracture and greater functional and cognitive decline. Patients who are malnourished or at risk of malnutrition survive less than those who are not malnourished.

Nutritional intervention in chronic heart failure patients: A randomized controlled clinical trial

BACKGROUND AND OBJECTIVES

Malnutrition is common in patients with heart failure (HF) and is associated with poor prognosis. We evaluated the prognostic and clinical impact of a nutritional intervention in malnourished patients with chronic HF.

METHODS

A randomized controlled clinical trial was carried out in patients with chronic HF who were malnourished or at risk. Participants were randomized to receive an individualized nutritional intervention or conventional management. The primary endpoint was a composite of all-cause mortality or time-to-first HF hospitalizations at the 12-month follow-up. The secondary endpoints were changes in nutritional status and functional capacity.

RESULTS

We screened 225 patients, 86 of whom had some degree of malnutrition and were randomized. At 12 months, the primary outcome occurred in 10 patients (23.8%) in the intervention group and in 22 patients (50.0%) in the control group (HR=0.39; 95% CI, 0.19-0.83). This effect was mainly related to a lower risk of hospitalization for HF in the intervention group: 8 patients (19.0%) versus 18 patients (40.9%) in the control group (HR=0.39; 95% CI=0.17-0.89). We observed an improvement in nutritional status and functional capacity in the intervention group versus the control group.

CONCLUSIONS

In patients with chronic HF and some degree of malnutrition, individualized nutritional intervention may reduce the risk of all-cause mortality or HF hospitalisations and improve nutritional status and functional capacity. These results underline the need for further randomized controlled trials with this approach to confirm the potential prognostic benefit.

Inflammation and nutritional status in relation to mortality risk from cardio-cerebrovascular events: evidence from NHANES

Objective

Inflammation and nutritional status are closely associated with the mortality risk of survivors of cardio-cerebrovascular events. This study aims to evaluate the relationship between inflammation and nutritional indices and mortality among, identifying the most predictive indices.

Methods

This study included cohort data of the survivors of major adverse cardiovascular and cerebrovascular events (MACCE) from the National Health and Nutrition Examination Survey (NHANES) in 1999-2010. MACCE is defined as a composite of myocardial infarction, heart failure and stroke, and at least one of the three events occurs. The main outcomes were all-cause mortality and cardiovascular mortality. Kaplan-Meier analysis and receiver operating characteristic curves were used to compare the correlation between seven inflammatory nutritional indices (such as Advanced Lung Cancer Inflammation Index, ALI) and mortality among the survivors. A multivariable-adjusted Cox regression and restricted cubic splines analysis identified the most predictive index, with the optimal number of nodes determined by the Akaike information criterion. Subgroup and sensitivity analyses were conducted to assess model stability.

Results

A total of 2,045 MACCE survivors were included. The higher levels of ALI and serum albumin were significantly associated with lower risks of all-cause and cardiovascular mortality among these individuals. Increases in C-reactive protein to Lymphocyte Ratio, Neutrophil to Serum Albumin Ratio, Neutrophil-to-Lymphocyte Ratio, Systemic Immune-Inflammation Index (SII), and C-reactive protein were similarly correlated with higher mortality risk. ALI outperformed other indices, displaying a distinct L-shaped nonlinear relationship with both all-cause and cardiovascular mortality among MACCE survivors, with an inflection point at 90 indicating the lowest risk. To the left of this inflection, each unit increase in ALI was associated with a 1.3% decrease in all-cause and cardiovascular mortality risk among MACCE patients. To the right, the risk might increase by 0.2%, although the change was not statistically significant. Subgroup analyses and sensitivity analyses showed that the association between ALI and risk of mortality remained stable in most MACCE survivor populations.

Conclusion

Routine and dynamic monitoring of ALI is helpful for clinicians to assess the mortality risk among MACCE survivors. Anti-inflammatory therapies and appropriate nutritional support are crucial for reducing mortality in these individuals.

Association between malnutrition risk and the prognosis of geriatric heart failure patients undergoing left ventricular assist device implantation

BACKGROUND

Evidence regarding the association between malnutrition risk and the prognosis of geriatric heart failure (HF) patients undergoing left ventricular assist device (LVAD) implantation is lacking. Our study aims to investigate how malnutrition risk, assessed using the geriatric nutritional risk index (GNRI) values, relates to the outcomes of geriatric HF patients undergoing LVAD, using data from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) registry.

METHODS

A retrospective analysis was conducted using data from INTERMACS registry. Patients aged 65 and above who received LVAD implantation between 2008 and 2017 were included. The GNRI was used to stratify patients into three groups: absence of risk (GNRI > 98), mild risk (GNRI 92-98), and moderate to severe risk (GNRI < 92). The primary outcome was long-term survival for up to four years following LVAD implantation.

RESULTS

We included 5429 patients aged 65 and above undergoing LVADs. The malnutrition risk was presented in 75.8% of the patients before implantation, decreasing to 32.4% at 3 months, and 59.5% at 24 months post-implantation. Moderate-to-severe malnutrition risk, both pre-implant and 6 months post-implant, was associated with an increased risk of death (pre-implant: hazard ratio (HR): 1.25 [95% CI: 1.12-1.40], p < 0.001; 6 months: HR: 2.36 [95% CI: 2.01-2.77], p < 0.001). Mortality decreased with increasing pre-implant GNRI up to approximately 100 and 6-month post-implant GNRI up to 104. Patients with malnutrition risk also had an increased risk of infection, poor quality of life (QoL), and reduced functional exercise capacity after the LVAD implantation.

CONCLUSIONS

Malnutrition risk was highly prevalent in HF patients aged 65 and above undergoing LVADs implantation. The presence of malnutrition risk was associated with an increased risk of death, infection, poor quality of life, and reduced functional exercise capacity.

Geriatric nutritional risk index is associated with the occurrence of acute kidney injury in critically ill patients with acute heart failure

Background: During the acute heart failure (AHF), acute kidney injury (AKI) is highly prevalent in critically ill patients. The occurrence of the latter condition increases the risk of mortality in patients with acute heart failure. The current research on the relationship between nutritional risk and the occurrence of acute kidney injury in patients with acute heart failure is very limited. Methods: This retrospective cohort study utilized data from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version 2.1) database. We included adult patients with AHF who were admitted to the intensive care unit in the study. Results: A total of 1310 critically ill patients with acute heart failure were included. The AUC of geriatric nutritional risk index (GNRI) (0.694) is slightly superior to that of controlling nutritional status (CONUT) (0.656) and prognostic nutritional index (PNI) (0.669). The Log-rank test revealed a higher risk of acute kidney injury in patients with high nutritional risk (p < 0.001). Multivariate COX regression analysis indicated that a high GNRI (adjusted HR 0.62, p < 0.001) was associated with a reduced risk of AKI during hospitalization in AHF patients. The final subgroup analysis demonstrated no significant interaction of GNRI in all subgroups except for diabetes subgroup and ventilation subgroup (P for interaction: 0.057-0.785). Conclusion: Our study findings suggest a correlation between GNRI and the occurrence of acute kidney injury in patients hospitalized with acute heart failure.

Lymphocyte-to-C-reactive protein ratio and score in patients with heart failure: Nutritional status, physical function, and prognosis

AIMS

In heart failure (HF), inflammation is linked to malnutrition and impaired physical function. In this study, we aimed to assess how novel nutritional-inflammatory markers and lymphocyte-to-C-reactive protein ratio (LCR) and score (LCS) are associated with the nutritional status, physical function, and prognosis of patients with HF.

METHODS AND RESULTS

This study was a secondary analysis of the FRAGILE-HF study, a prospective observational study conducted across 15 hospitals in Japan. We included 1212 patients (mean age, 80.2 ± 7.8 years; 513 women) hospitalized with HF, who were classified into three groups according to their LCS score: 0 (n = 498), 1 (n = 533), and 2 (n = 181). Baseline data on physical examination, echocardiography, blood test results (including lymphocyte counts and CRP levels), and oral medication usage were collected in a clinically compensated state before discharge. Nutritional status and physical function were evaluated using several indices and tests. The primary outcome of this study was all-cause death within 2 years. Univariate and multivariate linear regression analyses were performed to evaluate the associations among the nutritional status, physical function, and LCR/LCS. Patients with an LCS score of 2 were older and had a lower body mass index than those in the other two groups. Multivariate linear regression analysis revealed that lower LCR and higher LCS were independently associated with worse nutritional status, lower handgrip strength, shorter physical performance battery score, and shorter 6-min walk distance. At 2 years, all-cause death occurred in 254 patients: 86 (17.6%), 113 (21.5%), and 55 (30.9%) with LCS scores of 0, 1, and 2, respectively (P = 0.001). Cox proportional hazards analysis revealed that LCR and LCS were significantly associated with 2-year mortality even after adjusting for the conventional risk model (LCS score, 0 vs. 2: hazard ratio, 1.64; 95% confidence interval [CI]; 1.14-2.35; P = 0.007; log-transformed LCR: hazard ratio, 0.88; 95% CI, 0.81-0.95; P = 0.002). LCR yielded additional prognostic predictability compared with the conventional risk model (continuous net reclassification improvement, 0.153; 95% CI, 0.007-0.299; P = 0.041).

CONCLUSIONS

LCR and LCS emerge as potential predictors of nutritional status, physical function, and prognosis in older patients with HF.

NIR-II Image-Guided Wound Healing in Hypoxic Diabetic Foot Ulcers: The Potential of Ergothioneine-Luteolin-Chitin Hydrogels

Hypoxic diabetic foot ulcers (HDFUs) pose a challenging chronic condition characterized by oxidative stress damage, bacterial infection, and persistent inflammation. This study introduces a novel therapeutic approach combining ergothioneine (EGT), luteolin (LUT), and quaternized chitosan oxidized dextran (QCOD) to address these challenges and facilitate wound healing in hypoxic DFUs. In vitro, assessments have validated the biosafety, antioxidant, and antimicrobial properties of the ergothioneine-luteolin-chitin (QCOD@EGT-LUT) hydrogel. Furthermore, near-infrared II (NIR-II) fluorescence image-guided the application of QCOD@EGT-LUT hydrogel in simulated HDFUs. Mechanistically, QCOD@EGT-LUT hydrogel modulates the diabetic wound microenvironment by reducing reactive oxygen species (ROS). In vivo studies demonstrated increased expression of angiogenic factors mannose receptor (CD206) and latelet endothelial cell adhesion molecule-1 (PECAM-1/CD31), coupled with decreased inflammatory factors tumor necrosis factor-α (TNF-α) and Interleukin-6 (IL-6), thereby promoting diabetic wound healing through up-regulation of transforming growth factor β-1 (TGF-β1).

The Association Between Preoperative Pectoralis Muscle Quantity and Outcomes After Cardiac Transplantation

BACKGROUND

Sarcopenia is underappreciated in advanced heart failure and is not routinely assessed. In patients receiving a left ventricular assist device, preoperative sarcopenia, defined by using computed-tomography (CT)-derived pectoralis muscle-area index (muscle area indexed to body-surface area), is an independent predictor of postoperative mortality. The association between preoperative sarcopenia and outcomes after heart transplant (HT) is unknown.

OBJECTIVES

The primary aim of this study was to determine whether preoperative sarcopenia, diagnosed using the pectoralis muscle-area index, is an independent predictor of days alive and out of the hospital (DAOHs) post-transplant.

METHODS

Patients who underwent HT between January, 2018, and June, 2022, with available preoperative chest CT scans were included. Sarcopenia was diagnosed as pectoralis muscle-area index in the lowest sex-specific tertile. The primary endpoint was DAOHs at 1 year post-transplant.

RESULTS

The study included 169 patients. Patients with sarcopenia (n = 55) had fewer DAOHs compared to those without sarcopenia, with a median difference of 17 days (320 vs 337 days; P = 0.004). Patients with sarcopenia had longer index hospitalizations and were also more likely to be discharged to a facility other than home. In a Poisson regression model, sarcopenia was a significant univariable and the strongest multivariable predictor of DAOHs at 1 year (parameter estimate = -0.17, 95% CI -0.19 to -14; P = < 0.0001).

CONCLUSIONS

Preoperative sarcopenia, diagnosed using the pectoralis muscle-area index, is an independent predictor of poor outcomes after HT. This parameter is easily measurable from commonly obtained preoperative CT scans and may be considered in transplant evaluations.

The RICA-2 registry: design and baseline characteristics of the first 1,000 patients

BACKGROUND AND OBJECTIVE

Heart failure (HF) is a syndrome of epidemic proportions and one of the main reasons for hospital admission. Patient registries provide real-world clinical practice information which is complementary to clinical trials. RICA-2 is a registry of the Spanish Society of Internal Medicine. Its main goal is to know the clinical and epidemiological characteristics and prognostic factors of patients with HF treated in Internal Medicine Departments. The objective of this study is to present the design of the RICA-2, the baseline characteristics of the first 1000 patients included and their comparison with those of the historical cohort of the RICA registry.

METHODS

Observational, multicentre and prospective study of patients with HF with the following inclusion criteria: age equal to or greater than 18 years old, diagnosis of HF according to the European Guidelines, indistinct inclusion in decompensation or stable phase, of patients with de novo HF or chronic HF, regardless of left ventricular ejection fraction, aetiology and comorbidities.

RESULTS

RICA-2 patients have advanced age (83 years old) and 51% are women. The comorbidity burden is higher than in the RICA registry (5 points in the Charlson comorbidity index), with predominating chronic decompensated HF (74%), hypertensive aetiology (39%) and preserved ejection fraction (52%). Most patients are pre-frail or vulnerable and are at risk of malnutrition.

CONCLUSION

The RICA-2 represents a contemporary cohort of patients that will provide us with clinical, epidemiological and prognostic information on patients with acute and chronic HF treated in Internal Medicine.

International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024

The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.

Impact of multiple comorbidities on long-term mortality in older patients following transcatheter aortic valve replacement

Background

Older candidates for transcatheter aortic valve replacement (TAVR) frequently present with both cardiac and noncardiac comorbidities. There are few risk scores that evaluate a wide range of comorbidities.

Methods

Patients who underwent TAVR for severe aortic stenosis were retrospectively evaluated. A new prediction model (Cardiac and nonCardiac Comorbidities risk score: 3C score) was determined based on coefficient in the multivariate Cox regression analysis for two-year all-cause mortality. C-statistics were assessed to compare the predictive abilities of the 3C score, the Charlson Comorbidities Index (CCI) score, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, and the Model for End-stage Liver Disease eXcluding International normalized ratio (MELD-XI) score.

Results

The present study included 226 patients (age, 86 ± 5 years; males, 38 %). The values of the CCI score, EuroSCORE II, and MELD-XI score were 2 (1-3), 3.36 (2.12-4.58), and 5.35 (3.05-8.55), respectively. Multivariate Cox regression analysis identified two cardiac (left ventricular ejection fraction [LVEF] <40 % [2 points]; pulmonary hypertension [1 point]) and three noncardiac comorbidities (hepatobiliary system impairment [3 points]; estimated glomerular filtration rate <30 ml/min/1.73 m2 [1 point]; cachexia [1 point]). The C-statistics of the 3C score, EuroSCORE II, MELD-XI score, and CCI score were 0.767 (0.666-0.867), 0.610 (0.491-0.729), 0.580 (0.465-0.696), and 0.476 (0.356-0.596), respectively (p < 0.001).

Conclusions

Among cardiac and noncardiac comorbidities, special attention should be given to hepatobiliary system impairment and reduced LVEF in older patients following TAVR. The 3C score may contribute to the risk stratification.

A Narrative Review of the Diagnosis and Treatment of Sarcopenia and Malnutrition in Patients with Heart Failure

The prevalence of sarcopenia (loss of muscle strength, mass and function) in individuals with heart failure (HF) stands at a considerable level (approximately 20%), contributing to heightened mortality rates and diminished quality of life. The underlying pathophysiological mechanisms involve the presence of low-grade inflammation and a disturbance of the anabolic-catabolic protein balance. The nutritional assessment of patients with HF is a key aspect, and diverse diagnostic tools are employed based on patient profiles (outpatient, inpatient and nursing home). The Global Leadership Initiative on Malnutrition (GLIM) criteria serves as a consensus for diagnosing malnutrition. Given that edema can impact body mass index (BMI) in patients with HF, alternative body assessment technical methods, such as bioelectrical vector impedance (BiVA), BIA (without vector mode), computer tomography (CT) or clinical ultrasound (US), are useful. Scientific evidence supports the efficacy of both aerobic and resistance physical exercises in ameliorating and preventing muscle wasting associated with HF. Dietary strategies emphasize the importance of protein intake, while certain micronutrients like coenzyme Q10 or intravenous iron may offer benefits. This narrative review aims to present the current understanding of the pathogenesis, diagnosis and treatment of muscle loss in individuals with heart failure and its consequential impact on prognosis.

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.

Implication of geriatric nutritional risk index on treatment response and long-term prognosis in patients with cardiac resynchronization therapy

PURPOSE

Geriatric Nutritional Risk Index (GNRI) is a simple tool for assessing the nutritional status of the aging population. This study aims to explore the clinical implication of GNRI on treatment response and long-term clinical outcomes in heart failure (HF) patients receiving cardiac resynchronization therapy (CRT).

METHODS

Patients who underwent CRT implantation or upgrade at our hospital were retrospectively included. The association of GNRI and its tertiles with the echocardiographic response, all-cause mortality or heart transplantation, and the first hospitalization due to HF were investigated.

RESULTS

Totally, 647 patients were enrolled, with a median age of 60 [Interquartile Range (IQR): 52-67] years and mean score of GNRI at 107.9 ± 23.7. Super-response rates increased significantly among the GNRI T1, T2, and T3 groups (25.1%, 29.8% vs. 41.1%, P = 0.002). Patients with higher GNRI were more likely to have better LVEF improvement after multiple adjustments (OR = 1.13, 95% CI: 1.04-1.23, P = 0.010). Higher GNRI was independently associated with a lower risk of all-cause mortality or heart implantation (HR = 0.95, 95% CI: 0.93-0.96, P < 0.001) and HF hospitalization (HR = 0.96, 95% CI: 0.95-0.98, P < 0.001). The inclusion of GNRI enhanced the predictability of all-cause mortality based on traditional model, including sex, New York Heart Association functional class, left bundle branch block, QRS reduction, and N-terminal pro-B-type natriuretic peptide level (C statistics improved from 0.785 to 0.813, P = 0.007).

CONCLUSION

Higher GNRI was associated with better treatment response and long-term prognosis in HF patients with CRT. Evaluation of nutritional status among CRT population is necessary for individualized choice of potential responders.

Admission blood glucose and 30-day mortality in patients with acute decompensated heart failure: prognostic significance in individuals with and without diabetes

Objective

Diabetes is a significant risk factor for acute heart failure, associated with an increased risk of mortality. This study aims to analyze the prognostic significance of admission blood glucose (ABG) on 30-day mortality in Chinese patients with acute decompensated heart failure (ADHF), with or without diabetes.

Methods

This retrospective study included 1,462 participants from the JX-ADHF1 cohort established between January 2019 to December 2022. We conducted multivariate cox regression, restricted cubic spline, receiver operating characteristic curve analysis, and mediation analysis to explore the association and potential mechanistic pathways (inflammation, oxidative stress, and nutrition) between ABG and 30-day mortality in ADHF patients, with and without diabetes.

Results

During the 30-day follow-up, we recorded 20 (5.36%) deaths in diabetic subjects and 33 (3.03%) in non-diabetics. Multivariate Cox regression revealed that ABG was independently associated with 30-day mortality in ADHF patients, with a stronger association in diabetics than non-diabetics (hazard ratio: Model 1: 1.71 vs 1.16; Model 2: 1.26 vs 1.19; Model 3: 1.65 vs 1.37; Model 4: 1.76 vs 1.33). Further restricted cubic spline analysis indicated a U-shaped relationship between ABG and 30-day mortality in non-diabetic ADHF patients (P for non-linearity < 0.001), with the lowest risk at ABG levels approximately between 5-7 mmol/L. Additionally, receiver operating characteristic analysis demonstrated that ABG had a higher predictive accuracy for 30-day mortality in diabetics (area under curve = 0.8751), with an optimal threshold of 13.95mmol/L. Finally, mediation analysis indicated a significant role of inflammation in ABG-related 30-day mortality in ADHF, accounting for 11.15% and 8.77% of the effect in diabetics and non-diabetics, respectively (P-value of proportion mediate < 0.05).

Conclusion

Our study confirms that ABG is a vital indicator for assessing and predicting 30-day mortality risk in ADHF patients with diabetes. For ADHF patients, both with and without diabetes, our evidence suggests that physicians should be alert and closely monitor any changes in patient conditions when ABG exceeds 13.95 mmol/L for those with diabetes and 7.05 mmol/L for those without. Timely adjustments in therapeutic strategies, including endocrine and anti-inflammatory treatments, are advisable.

Impact of malnutrition in patients with severe heart failure

AIM

The role of malnutrition among patients with severe heart failure (HF) is not well established. We evaluated the incidence, predictors, and prognostic impact of malnutrition in patients with severe HF.

METHODS AND RESULTS

Nutritional status was measured using the geriatric nutritional risk index (GNRI), based on body weight, height and serum albumin concentration, with malnutrition defined as GNRI ≤98. It was assessed in consecutive patients with severe HF, defined by at least one high-risk 'I NEED HELP' marker, enrolled at four Italian centres between January 2020 and November 2021. The primary endpoint was all-cause mortality. A total of 510 patients with data regarding nutritional status were included in the study (mean age 74 ± 12 years, 66.5% male). Among them, 179 (35.1%) had GNRI ≤98 (malnutrition). At multivariable logistic regression, lower body mass index (BMI) and higher levels of natriuretic peptides (B-type natriuretic peptide [BNP] > median value [685 pg/ml] or N-terminal proBNP > median value [5775 pg/ml]) were independently associated with a higher likelihood of malnutrition. Estimated rates of all-cause death at 1 year were 22.4% and 41.1% in patients without and with malnutrition, respectively (log-rank p < 0.001). The impact of malnutrition on all-cause mortality was confirmed after multivariable adjustment for relevant covariates (adjusted hazard ratio 2.03, 95% confidence interval 1.43-2.89, p < 0.001).

CONCLUSION

In a contemporary, real-world, multicentre cohort of patients with severe HF, malnutrition (defined as GNRI ≤98) was common and independently associated with an increased risk of mortality. Lower BMI and higher natriuretic peptides were identified as predictors of malnutrition in these patients.

Frailty, Sarcopenia, Cachexia, and Malnutrition in Heart Failure

With global aging, the number of patients with heart failure has increased markedly. Heart failure is a complex condition intricately associated with aging, organ damage, frailty, and cognitive decline, resulting in a poor prognosis. The relationship among frailty, sarcopenia, cachexia, malnutrition, and heart failure has recently received considerable attention. Although these conditions are distinct, they often exhibit a remarkably close relationship. Overlapping diagnostic criteria have been observed in the recently proposed guidelines and position statements, suggesting that several of these conditions may coexist in patients with heart failure. Therefore, a comprehensive understanding of these conditions is essential, and interventions must not only target these conditions individually, but also provide comprehensive management strategies. This review article provides an overview of the epidemiology, diagnostic methods, overlap, and prognosis of frailty, sarcopenia, cachexia, and malnutrition in patients with heart failure, incorporating insights from the FRAGILE-HF study data. Additionally, based on existing literature, this article discusses the impact of these conditions on the effectiveness of guideline-directed medical therapy for patients with heart failure. While recognizing these conditions early and promptly implementing interventions may be advantageous, further data, particularly from well-powered, large-scale, randomized controlled trials, are necessary to refine personalized treatment strategies for patients with heart failure.

Association between extremely high prognostic nutritional index and all-cause mortality in patients with coronary artery disease: secondary analysis of a prospective cohort study in China

OBJECTIVES

Decreased prognostic nutritional index (PNI) was associated with adverse outcomes in many clinical diseases. This study aimed to evaluate the relationship between baseline PNI value and adverse clinical outcomes in patients with coronary artery disease (CAD).

DESIGN

The Personalized Antiplatelet Therapy According to CYP2C19 Genotype in Coronary Artery Disease (PRACTICE) study, a prospective cohort study of 15 250 patients with CAD, was performed from December 2016 to October 2021. The longest follow-up period was 5 years. This study was a secondary analysis of the PRACTICE study.

SETTING

The study setting was Xinjiang Medical University Affiliated First Hospital in China.

PARTICIPANTS

Using the 50th and 90th percentiles of the PNI in the total cohort as two cut-off limits, we divided all participants into three groups: Q1 (PNI <51.35, n = 7515), Q2 (51.35 ≤ PNI < 59.80, n = 5958) and Q3 (PNI ≥ 59.80, n = 1510). The PNI value was calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3).

PRIMARY OUTCOME

The primary outcome measure was mortality, including all-cause mortality (ACM) and cardiac mortality (CM).

RESULTS

In 14 983 participants followed for a median of 24 months, a total of 448 ACM, 333 CM, 1162 major adverse cardiovascular events (MACE) and 1276 major adverse cardiovascular and cerebrovascular events (MACCE) were recorded. The incidence of adverse outcomes was significantly different among the three groups (p <0.001). There were 338 (4.5%), 77 (1.3%) and 33 (2.2%) ACM events in the three groups, respectively. A restricted cubic spline displayed a J-shaped relationship between the PNI and worse 5-year outcomes, including ACM, CM, MACE and MACCE. After adjusting for traditional cardiovascular risk factors, we found that only patients with extremely high PNI values in the Q3 subgroup or low PNI values in the Q1 subgroup had a greater risk of ACM (Q3 vs Q2, HR: 1.617, 95% CI 1.012 to 2.585, p=0.045; Q1 vs Q2, HR=1.995, 95% CI 1.532 to 2.598, p <0.001).

CONCLUSION

This study revealed a J-shaped relationship between the baseline PNI and ACM in patients with CAD, with a greater risk of ACM at extremely high PNI values.

TRIAL REGISTRATION NUMBER

NCT05174143.

Atherogenic index of plasma: a new indicator for assessing the short-term mortality of patients with acute decompensated heart failure

Objective

Arteriosclerosis is a primary causative factor in cardiovascular diseases. This study aims to explore the correlation between the atherogenic index of plasma (AIP) and the 30-day mortality rate in patients with acute decompensated heart failure (ADHF).

Methods

A total of 1,248 ADHF patients recruited from the Jiangxi-Acute Decompensated Heart Failure1 (JX-ADHF1) cohort between 2019 and 2022 were selected for this study. The primary outcome was the 30-day mortality rate. Multivariable Cox regression, restricted cubic splines (RCS), and stratified analyses were utilized to assess the relationship between AIP and the 30-day mortality rate in ADHF patients. Mediation models were employed for exploratory analysis of the roles of inflammation, oxidative stress, and nutrition in the association between AIP and the 30-day mortality rate in ADHF patients.

Results

During the 30-day follow-up, 42 (3.37%) of the ADHF patients died. The mortality rates corresponding to the quartiles of AIP were as follows: Q1: 1.28%, Q2: 2.88%, Q3: 2.88%, Q4: 6.41%. The multivariable Cox regression revealed a positive correlation between high AIP and the 30-day mortality rate in ADHF patients [Hazard ratio (HR) 3.94, 95% confidence interval (CI): 1.08-14.28], independent of age, gender, heart failure type, cardiac function classification, and comorbidities. It is important to note that there was a U-shaped curve association between AIP (<0.24) and the 30-day mortality rate before the fourth quartile, with the lowest 30-day mortality risk in ADHF patients around an AIP of -0.1. Furthermore, mediation analysis suggested significant mediating effects of inflammation and nutrition on the 30-day mortality rate in ADHF patients related to AIP, with inflammation accounting for approximately 24.29% and nutrition for about 8.16% of the mediation effect.

Conclusion

This retrospective cohort analysis reveals for the first time the association between AIP and the 30-day mortality rate in ADHF patients. According to our findings, maintaining an AIP around -0.1 in ADHF patients could be crucial for improving poor prognoses from a medical perspective. Additionally, for ADHF patients with high AIP, it is important to assess and, if necessary, enhance nutritional support and anti-inflammatory treatment.

Causal relationship between nutritional assessment phenotypes and heart failure: A Mendelian randomization study

Introduction

Malnutrition is strongly associated with heart failure (HF); however, the causal link remains unclear. We used Mendelian randomization (MR) to infer causal associations between different nutritional assessment phenotypes and HF and to analyze whether these associations were mediated by common HF risk factors.

Methods

Two-sample bidirectional MR was used to infer causal associations between nutritional assessment phenotypes and HF. Mutual influences between different nutritional assessment phenotypes and potential correlations were estimated using multivariate MR methods. Two-step MR was used to quantify the mediating effects of common HF risk factors on the causal associations.

Results

Three phenotypes were positively associated with the development of HF: waist circumference (WC) (odds ratio [OR] = 1.74; 95% confidence interval [CI], 1.60-1.90; P = 3.95 × 10-39), body mass index (BMI) (OR = 1.70; 95%CI, 1.60-1.80; P = 1.35 × 10-73), and whole body fat mass (WBFM) (OR = 1.54; 95%CI, 1.44-1.65; P = 4.82 × 10-37). Multivariate MR indicated that WBFM remained positively associated with HF after conditioning on BMI and WC (OR = 2.05; 95%CI, 1.27-3.31; P = 0.003). Three phenotypes were negatively correlated with the development of HF: usual walking pace (UWP) (OR = 0.40; 95%CI, 0.27-0.60; P = 8.41 × 10-6), educational attainment (EA) (OR = 0.73; 95%CI, 0.67-0.79; P = 2.27 × 10-13), and total cholesterol (TC) (OR = 0.90; 95%CI, 0.84-0.96; P = 4.22 × 10-3). There was a bidirectional causality between HF and UWP (Effect estimate = -0.03; 95%CI, -0.05 to -0.01; P = 1.95 × 10-3). Mediation analysis showed that common risk factors for HF (hypertension, coronary artery disease, cardiomyopathy, and valvular heart disease) mediated these causal associations (all P < 0.05).

Conclusions

BMI, WC, and WBFM are potential risk factors for HF, and the correlation between WBFM and HF was significantly stronger than that between BMI and WC, and HF. EA, UWP, and TC are potential protective factors against HF. Common risk factors for HF mediate these causal pathways. Early identification of potential risk or protective factors for HF patients from the dimension of nutritional status is expected to further improve patient outcomes.

Association between haemoglobin, albumin, lymphocytes, and platelets and mortality in patients with heart failure

AIMS

The combination of haemoglobin, albumin, lymphocytes, and platelets (HALP) is a new metric used to assess patient prognosis in many diseases. This study aimed to assess the relationship between HALP and short- and long-term mortality in patients with heart failure.

METHODS AND RESULTS

This retrospective cohort study included adult patients with heart failure who were hospitalized between 2019 and 2021. The primary outcomes were 1-month mortality and 1-year mortality. The multivariable logistic regression analysis was used to evaluate the association between HALP and the risk of mortality. Stratified analyses were conducted based on New York Heart Association functional classification (NYHA) stage (II/III, IV) and left ventricular ejection fraction (LVEF, <50%, ≥50%). The area under the receiver operating characteristic curve (AUC) was used to evaluate the ability of HALP, prognostic nutritional index (PNI), C-reactive protein (CRP), and the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC-HF) risk score in predicting mortality in patients with heart failure. A total of 730 patients with heart failure were included, of whom 61 (8.36%) died within 1 month and 77 (10.55%) died within 1 year. High HALP scores were associated with a reduced risk of 1-month mortality (odds ratio (OR) = 0.978, 95% confidence interval (CI): 0.963-0.992, P = 0.003) and 1-year mortality (OR = 0.987, 95% CI: 0.977-0.997, P = 0.009) in patients with heart failure. In patients with different NYHA stages or LVEF levels, high HALP scores were correlated with a reduced risk of 1-year mortality in patients with NYHA stage II/III (OR = 0.978, 95% CI: 0.957-1.000, P = 0.045) or LVEF ≥50% (OR = 0.970, 95% CI: 0.945-0.996, P = 0.024). The AUC for HALP, PNI, CRP, and MAGGIC-HF to predict 1-year mortality in patients with heart failure were 0.677 (95% CI: 0.619-0.735), 0.666 (95% CI: 0.608-0.723), 0.638 (95% CI: 0.572-0.704), and 0.654 (95% CI: 0.591-0.717), respectively.

CONCLUSIONS

HALP may be a potential marker for predicting mortality in patients with heart failure. Further exploration based on HALP may yield better clinical predictors of prognosis in patients with heart failure.

Nutrition Assessment and Education of Patients with Heart Failure by Cardiologists

Although nutritional assessment and education are important for hospitalized patients with heart failure, the extent of their implementation in real-world clinical practice is unknown. Therefore, this study aimed to investigate the evaluation and management of nutrition during hospitalization for heart failure using a questionnaire survey for cardiologists.In this cross-sectional multicenter survey, 147 cardiologists from 32 institutions completed a web-based questionnaire (response rate, 95%).The survey showed that 78.2% of the respondents performed a nutritional assessment for hospitalized patients, whereas 38.3% used objective tools. In contrast, only 9.5% of the respondents evaluated the presence or absence of cardiac cachexia. Most respondents (89.8%) reported providing nutritional education to their patients before hospital discharge. However, compared with the number of respondents who provided information on sodium (97.0%) and water (63.6%) restrictions, a limited number of respondents provided guidance on optimal protein (20.5%) and micronutrient (9.1%) intake as part of the nutritional education. Less than 50% of the respondents provided guidance on optimal calorie intake (43.2%) and ideal body weight (34.8%) as a part of the nutritional education for patients identified as malnourished.Although nutritional assessment is widely performed for hospitalized patients with heart failure, most assessments are subjective rather than objective. Nutritional education, frequently provided before hospital discharge, is limited to information on water or salt intake restrictions. Therefore, more comprehensive and individualized nutritional assessments and counselling with a scientific basis are required.

The current state of evidence for sodium and fluid restriction in heart failure

The field of heart failure has evolved in terms of the therapies that are available including pharmaceutical and device therapies. There is now substantial randomized trial data to indicate that dietary sodium restriction does not provide the reduction in clinical events with accepted heterogeneity in the clinical trial results. Dietary sodium restriction should be considered for some but not all patients and with different objectives than clinical outcomes but instead for potential quality of life benefit. In addition, fluid restriction, once the mainstay of clinical practice, has not shown to be of any additional benefit for patients in hospital or in the ambulatory care setting and therefore should be considered to be used cautiously (if at all) in clinical practice. Further developments and clinical trials are needed in this area to better identify patients who may benefit or have harm from these lower cost interventions and future research should focus on large scale, high quality, clinical trials rather than observational data to drive clinical practice.