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.

Role of Nutritional Status in Acute Coronary Syndrome Patients with Diabetes

Background and Objectives: This study aims to investigate the effect of Type 2 diabetes mellitus (DM) on nutritional status in acute coronary syndrome (ACS) patients and its relationship with various metabolic and hematologic parameters. Materials and Methods: A retrospective and cross-sectional design was used to analyze 485 acute coronary syndrome (ACS) patients who underwent angiography at Fethi Sekin City Hospital between 1 January 2020 and 1 January 2025. Clinical data, biochemical parameters (hemogram, glucose, creatinine, uric acid, lactate dehydrogenase (LDH), albumin, and cholesterol levels) were retrospectively analyzed. The Prognostic Nutrition Index (PNI) and CONUT score were calculated manually. Results: A total of 485 patients were included in this study. Patients were divided into two groups: patients with DM (n = 167) and patients without DM (n = 318). Glucose levels (p < 0.001) and triglyceride levels (p = 0.014) were significantly higher in patients with diabetes, while LDL cholesterol and total cholesterol levels were lower (p < 0.01). In addition, hemoglobin (p < 0.001), albumin (p = 0.010), and PNI scores (p = 0.014) were lower in patients with diabetes. Although CONUT scores were higher in patients with diabetes, this difference was not statistically significant (p = 0.267). Significant differences were observed in lipid profile and inflammation parameters in STEMI and NSTEMI subgroups, especially in patients with diabetes. In particular, triglyceride and neutrophil levels were found to be higher in NSTEMI patients among patients with diabetes. Conclusions: The PNI score may be a useful prognostic tool for predicting cardiovascular complications and determining treatment strategies in acute coronary syndrome patients with diabetes mellitus in whom nutritional status, inflammation, and lipid metabolism are significantly correlated.

Predictive value of nutritional scores in non-valvular atrial fibrillation patients: Insights from the AFTER-2 study

BACKGROUND AND AIM

Many scoring systems are used to evaluate malnutrition, but there is no consensus on which scoring system would be more appropriate. We aimed to investigate the effect of malnutrition in patients with non-valvular atrial fibrillation (NVAF) and to compare three scoring systems.

METHODS AND RESULTS

A total of 2592 patients with non-valvular AF from 35 different centers in Turkey were included in this prospective study. All participants were divided into two groups: 761 patients who died and 1831 patients who were alive. The malnutrition status of all participants was evaluated with three scoring systems. The primary outcome was all-cause mortality. The mean age of the population was 68.7 ± 11.1 years, and 55.5 % were female. According to Cox regression analysis, the geriatric nutritional risk index (GNRI) (HR = 0.989, 95 % CI: 0.982-0.997, p = 0.007), controlling nutritional status (CONUT) score (HR = 1.121, 95 % CI: 1.060-1.185, p < 0.001), and prognostic nutritional index (PNI) (HR = 0.980, 95 % CI: 0.962-0.999, p = 0.036) were found to be significant mortality predictors. ROC curve analysis indicated GNRI (AUC = 0.568), CONUT (AUC = 0.572), and PNI (AUC = 0.547) had moderate predictive values. Kaplan-Meier analysis showed that increasing the risk class based on GNRI (p < 0.001) and CONUT (p < 0.001) was associated with decreased survival, while PNI staging had no statistically significant effect (p = 0.266).

CONCLUSIONS

Malnutrition, determined by three scoring systems, was found to be an independent predictor of all-cause mortality in NVAF patients. Nutritional examination may provide useful information for prognosis and risk stratification in patients with NVAF.

Poor clinical outcomes associated to multimorbidity, frailty and malnutrition in patients with atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) patients often present with a higher prevalence of comorbidities, frailty, and malnutrition. We investigated if multimorbidity, frailty and malnutrition were associated with clinical outcomes in patients with AF starting vitamin K antagonist (VKA) therapy.

METHODS

Prospective observational cohort study including AF outpatients starting VKAs from July 2016 to June 2018. Multimorbidity was assessed by the number of comorbidities, frailty was evaluated using the Clinical Frailty Scale (CFS), and nutritional status was appraised using the Controlling Nutritional Status (CONUT). During 2-years of follow-up, ischemic strokes/transient ischemic attacks (TIA), major bleeds, and all-cause deaths, were recorded.

RESULTS

1050 AF patients (51.4% female; median age 77 years, IQR 70-83) were included. Of these, 912 (86.9%) had multimorbidity (≥2 comorbidities additional to AF), 186 (17.7%) exhibited any frailty degree (CFS ≥ 5), and 76 (7.2%) had moderate-to-severe malnutrition (CONUT ≥ 5). The crude number of comorbidities and the CFS were significantly associated with major bleeds, whereas the CFS and the CONUT score were related to all-cause mortality. After adjustment, any frailty degree was associated with higher risks of major bleeding (aHR 3.04, 95% CI 1.67-5.52) and death (aHR 2.04, 95% CI 1.39-3.01). Moderate-to-severe malnutrition increased risk for ischemic stroke/TIA (aHR 2.25, 95% CI 1.11-4.56) and all-cause mortality (aHR 3.21, 95% CI 2.14-4.83).

CONCLUSIONS

In this real-world prospective cohort of AF taking VKAs, most patients had multiple comorbidities, frailty and malnutrition. Frailty and malnutrition were important risk factors for bleeding, stroke, and mortality in these patients.

Negative Association of GNRI with All-Cause Mortality in Chinese Atrial Fibrillation Patients: A Multicenter Retrospective Cohort Study

INTRODUCTION

Malnutrition is common in older atrial fibrillation (AF) patients and results in poor clinical outcomes. The Geriatric Nutritional Risk Index (GNRI) is a straightforward method for evaluating nutritional health. However, its prognostic value in AF patients is unclear. This research focused on examining the correlation between GNRI and overall mortality in Chinese individuals with AF.

METHODS

We performed a multicenter retrospective study at four Chinese hospitals involving patients diagnosed with AF between January 2019 and August 2023. Using GNRI, nutritional status was evaluated, classifying patients into three categories. Multivariable logistic regression and restricted cubic spline analysis assess the relationship between GNRI and mortality, with exploratory subgroup analyses investigating potential effect modifiers.

RESULTS

The study included 4,878 AF patients with a median follow-up of 19 months. The mean age was 71 (63-78), and the mean GNRI was 102 (95-108). Malnutrition was identified in 1,776 patients (36.41%). During the study, 419 (8.59%) deaths occurred. After controlling for confounders, moderate to severe malnutrition was linked to an increased risk of all-cause mortality compared to no malnutrition (odds ratio 1.50; 95% CI, 1.17-1.94). The relationship between GNRI and mortality risk was approximately linear, with consistent associations across subgroups.

CONCLUSION

Malnutrition, as assessed by GNRI, is prevalent among Chinese AF patients and is independently linked to higher all-cause mortality risk.

Relative performance evaluation of four bleeding risk scores in atrial fibrillation patients. What does the new DOAC score provide?

BACKGROUND

Recently, the direct oral anticoagulant (DOAC) score was developed and better predicted major bleeding in DOAC-treated patients with atrial fibrillation (AF) than HASBLED did. Little is known on the new score's performance regarding other bleeding risk in AF.

METHODS

We studied 14,672 patients diagnosed with AF between 2014 and 2018. During follow-up, we assessed the performance of DOAC score compared with the HASBLED, ORBIT and SWISS scores at predicting major bleeding in DOACs and non-DOACs users. Discrimination, calibration and decision curve analysis (DCA) were used to assess the risk scorer's performance.

RESULTS

There were 1484 (10.1%) patients on DOACs, 9730 on vitamin K antagonist (VKA), and 3458 on non-oral anticoagulants. Over a median of 3.5 years of follow-up, 79 major bleedings occurred in the DOAC patients, and 486 in the VKA patients (cumulative incidences = 7.4 and 13.9 per 100 patient-years, respectively). Amongst the DOAC patients, the DOAC score discrimination was moderate (C-statistic = 0.711), but significantly higher than HASBLED (C = 0.640; p = 0.03), ORBIT (C = 0.660; p = 0.04), and SWISS scores (C = 0.637; p = 0.002). The DCA showed higher net benefit using DOAC score compared with the remaining scores. In the VKA patients, DOAC score showed the highest discrimination (c-statistic = 0.709), followed by ORBIT (C = 0.692; p = 0.07), HASBLED and SWISS (C = 0.635 and 0.624, respectively; p < 0.01). All risk scores calibrated well, although HASBLED showed relatively poor calibration.

CONCLUSIONS

The new DOAC bleeding risk score is a valid and reasonable predictor of major bleeding over a median of 3.5 years of follow-up. Physicians can be reassured about the applicability of DOAC score for bleeding risk stratification in AF patients.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04364516.

Oral anticoagulant therapy in older adults

Patients aged ≥65 years not only account for the majority of patients with atrial fibrillation (AF) and venous thromboembolism (VTE), they are also at a higher risk of morbidity, mortality, and undertreatment than younger patients. Several age-related physiological changes with effects on drug pharmacokinetics/-dynamics and blood vessel fragility as well as the higher prevalence of geriatric conditions such as frailty, multimorbidity, polypharmacy, fall risk, dementia, and malnutrition make older persons more vulnerable to disease- and anticoagulation-related complications. Moreover, because older patients with AF/VTE are underrepresented in oral anticoagulation (OAC) trials, evidence on OAC in older adults with AF/VTE is mainly based on subgroup analyses from clinical trials and observational studies. A growing body of such limited evidence suggests that direct oral anticoagulants (DOACs) may be superior in terms of efficacy and safety compared to vitamin K antagonists in older persons with AF/VTE and that specific DOACs may have a differing risk-benefit profile. In this narrative review, we summarize the evidence on epidemiology of AF/VTE, impact of age-related physiological changes, efficacy/safety of OAC, specifically considering individuals with common geriatric conditions, and review OAC guideline recommendations for older adults with AF/VTE. We also propose a research agenda to improve the evidence basis on OAC older individuals with AF/VTE, including the conduct of advanced age-specific and pragmatic studies using less restrictive eligibility criteria and patient-reported health outcomes, in order to compare the effectiveness and safety of different DOACs, and investigate lower-dose regimens and optimal OAC durations in older patients.

Effects of Anticoagulant Therapy and Frailty in the Elderly Patients with Atrial Fibrillation

Objective

This study explored whether anticoagulation is safe for frail and non-frail elderly patients who have nonvalvular atrial fibrillation (NVAF).

Methods

At hospital discharge, the anticoagulant regimen and frailty status were recorded for 361 elderly patients (aged ≥75 y) with NVAF. The patients were followed for 12 months. The endpoints included occurrence of thrombosis; bleeding; all-cause death; and cardiovascular events.

Results

At hospital discharge, frailty affected 50.42% of the population and the anticoagulation rate was 44.04%. At discharge, age (OR 0.948, P = 0.006), paroxysmal NVAF (OR 0.384, P < 0.001), and bleeding history (OR 0.396, P = 0.001) were associated with a decrease in rate of receiving anticoagulation, while thrombotic events during hospitalization (OR 2.281, P = 0.021) were associated with an increase. Relative to non-frail patients, those with frailty showed a higher rate of ischemic stroke (5.33% cf. 3.01%), bleeding (P = 0.006) events, and all-cause mortality (P = 0.001). Relative to the group without anticoagulation, in those with anticoagulation the rate of thrombotic events was lower (6.99 cf. 10.98%) and bleeding events were higher (20.98 cf. 12.72%), but the risk of major bleeding was comparable.

Conclusion

In the elderly patients with NVAF, the decision toward anticoagulation therapy at hospital discharge was influenced by age, bleeding history, paroxysmal atrial fibrillation diagnosis, and absence of thrombosis. Frail patients were at greater risk of bleeding and all-cause mortality. Anticoagulation tended to reduce the risk of thrombotic events.

Predictive value of nutritional indices for left atrial thrombus in patients with valvular atrial fibrillation

BACKGROUND

The prognostic nutritional index (PNI) and geriatric nutritional risk index (GNRI) are well known indicators for adverse outcomes in various diseases, but there is no evidence on their association with the risk of left atrial thrombus (LAT) in patients with valvular atrial fibrillation (VAF).

METHODS

A comparative cross-sectional analytical study was conducted on 433 VAF patients. Demographics, clinical characteristics and echocardiographic data were collected and analyzed. Patients were grouped by the presence of LAT detected by transesophageal echocardiography.

RESULTS

LAT were identified in 142 patients (32.79%). The restricted cubic splines showed an L-shaped relationship between PNI and LAT. The dose-response curve flattened out near the horizontal line with OR = 1 at the level of 49.63, indicating the risk of LAT did not decrease if PNI was greater than 49.63. GNRI was negative with the risk of LAT and tended to be protective when greater than 106.78. The best cut-off values of PNI and GNRI calculated by receiver operating characteristics curve to predict LAT were 46.4 (area under these curve [AUC]: 0.600, 95% confidence interval [CI]:0.541-0.658, P = 0.001) and 105.7 (AUC: 0.629, 95% CI:0.574-0.684, P<0.001), respectively. Multivariable logistic regression analysis showed that PNI ≤ 46.4 (odds ratio: 2.457, 95% CI:1.333-4.526, P = 0.004) and GNRI ≤ 105.7 (odds ratio: 2.113, 95% CI:1.076-4.149, P = 0.030) were independent predictors of LAT, respectively.

CONCLUSIONS

Lower nutritional indices (GNRI and PNI) were associated with increased risk for LAT in patients with VAF.

Cardiovascular Outcomes in Acute Coronary Syndrome and Malnutrition: A Meta-Analysis of Nutritional Assessment Tools

Background

There is emerging evidence that malnutrition is associated with poor prognosis among patients with acute coronary syndrome (ACS).

Objectives

This study seeks to elucidate the prognostic impact of malnutrition in patients with ACS and provide a quantitative review of most commonly used nutritional assessment tools.

Methods

Medline and Embase were searched for studies reporting outcomes in patients with malnutrition and ACS. Nutritional screening tools of interest included the Prognostic Nutrition Index, Geriatric Nutritional Risk Index, and Controlling Nutritional Status. A comparative meta-analysis was used to estimate the risk of all-cause mortality and cardiovascular events based on the presence of malnutrition and stratified according to ACS type, ACS intervention, ethnicity, and income.

Results

Thirty studies comprising 37,303 patients with ACS were included, of whom 33.5% had malnutrition. In the population with malnutrition, the pooled mortality rate was 20.59% (95% CI: 14.95%-27.67%). Malnutrition was significantly associated with all-cause mortality risk after adjusting for confounders including age and left ventricular ejection fraction (adjusted HR: 2.66, 95% CI: 1.78-3.96, P = 0.004). There was excess mortality in the group with malnutrition regardless of ACS type (P = 0.132), ethnicity (P = 0.245), and income status (P = 0.058). Subgroup analysis demonstrated no statistically significant difference in mortality risk between individuals with and without malnutrition (P = 0.499) when using Controlling Nutritional Status (OR: 7.80, 95% CI: 2.17-28.07, P = 0.011), Geriatric Nutritional Risk Index (OR: 4.30, 95% CI: 2.78-6.66, P < 0.001), and Prognostic Nutrition Index (OR: 4.67, 95% CI: 2.38-9.17, P = 0.023).

Conclusions

Malnutrition was significantly associated with all-cause mortality risk following ACS, regardless of ACS type, ethnicity, and income status, underscoring the importance of screening and interventional strategies for patients with malnutrition.

Inappropriate Combined Antiplatelet and Anticoagulant Therapy in Older Patients with Atrial Fibrillation: Trend over Time (2009-18)

BACKGROUND AND OBJECTIVES

Antiplatelet therapy, when prescribed in combination with anticoagulant therapy to older patients with atrial fibrillation and no recent cardiovascular event, is inappropriate and a reversible risk factor of major bleeding. We aimed to assess the trend over time of the prevalence of inappropriate combined antiplatelet and anticoagulant therapy and to determine its associated factors during the direct oral anticoagulant era.

METHODS

This was a study of consecutive older patients (age ≥ 75 years) with atrial fibrillation, receiving anticoagulant therapy upon admission, and undergoing a comprehensive geriatric assessment during their first admission in a Belgian teaching hospital between 2009 and 2018. Antiplatelet therapy was considered inappropriate in the absence of a recent cardiovascular event. We studied the prevalence of inappropriate combined antiplatelet and anticoagulant therapy by 2-year periods and assessed its associated factors since the year 2013.

RESULTS

Inappropriate combined antiplatelet and anticoagulant therapy was identified in 21% of the 654 patients (median age 84 years, 51% women), with a prevalence decreasing (p ≤ 0.01) from 25% (2009-10) to 14.8% (2017-18). Among the 469 patients recruited during the direct oral anticoagulant era, inappropriate combined antiplatelet and anticoagulant therapy (19%) was associated in a multivariable analysis with a history of stroke/transient ischemic attack (odds ratio 2.13, p = 0.007), anticoagulation with low-molecular-weight heparin (odds ratio 3.44, p = 0.015), and a history of vascular disease (odds ratio 5.68, p < 0.001).

CONCLUSIONS

While inappropriate combined antiplatelet and anticoagulant therapy has declined over the last decade, there is still room for improvement. Antiplatelet deprescribing should be considered in all patients with inappropriate combined antiplatelet and anticoagulant therapy, including those with vascular disease and no recent cardiovascular event.

Meta-Analysis on the Association Between Nutritional Status and Outcomes After Transcatheter Aortic Valve Implantation

Malnutrition is a common co-morbidity among candidates for transcatheter aortic valve implantation (TAVI). This study aimed to investigate the association between nutritional status determined by objective nutritional indices and outcomes of patients who underwent TAVI. We systematically searched PubMed, Embase, Web of Science, Scopus, and Cochrane Library from inception until April 18, 2022 to identify studies examining the association of preprocedural nutritional status with post-TAVI outcomes. Malnutrition was defined by objective nutritional indices-controlling nutritional index, nutritional risk index, geriatric nutritional risk index (GNRI), and prognostic nutritional index (PNI). The primary end point was 1-year all-cause mortality. The review included 13 observational studies and 6,785 patients who underwent TAVI. Malnutrition was associated with a higher risk of 1-year all-cause mortality, as defined by either the controlling nutritional index (hazard ratio [HR] 2.70, 95% confidence interval [CI] 1.21 to 6.03, p = 0.015), GNRI (HR 1.79, 95% CI 1.09 to 2.93, p = 0.021), or PNI (HR 1.17, 95% CI 1.11 to 1.23, p <0.001). In the meta-analysis of adjusted results, lower GNRI was independently associated with higher 1-year mortality (HR 1.70, 95% CI 1.16 to 2.50, p = 0.006). Lower GNRI was associated with increased risk of acute kidney injury (relative risk [RR] 2.21, 95% CI 1.63 to 2.99, p <0.001) and 1-year cardiovascular mortality (RR 2.50, 95% CI 1.66 to 3.78, p <0.001). Lower PNI was associated with a higher risk of major vascular complications (RR 2.99, 95% CI 1.38 to 6.51, p = 0.006). In conclusion, baseline malnutrition, as assessed by objective indices, is associated with worse outcomes after TAVI. Future studies should focus on the value of nutritional assessment and interventions to improve nutritional status in patients who underwent TAVI.

Impact of the risk of malnutrition on bleeding, mortality, and ischemic events in patients with acute myocardial infarction

BACKGROUND & AIMS

Data regarding the relationship between malnutrition and clinical outcomes of acute myocardial infarction (AMI) is limited. The study aims to evaluate the clinical impact of malnutrition in AMI patients after percutaneous coronary intervention (PCI).

METHODS AND RESULTS

The COREA-AMI registries identified 10,161 AMI patients who underwent PCI from January 2004 to August 2014. Patients with geriatric nutritional risk index (GNRI) scores of <82, 82 to <92, 92 to <98, and ≥98 were categorized as having severe, moderate, mild malnutrition risk, and absence of risk, respectively. Associations of GNRI with Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding, all-cause death, and major cardiovascular events (MACEs; a composite of cardiovascular death, myocardial infarction, or ischemic stroke) were evaluated. Over 50% of AMI patients were malnourished, with 25.0%, 22.7%, and 4.9% having mild, moderate, and severe malnutrition risks, respectively. Over a median 4.9-year follow-up, patients with malnutrition risk had higher risks of BARC 3 or 5 bleeding (adjusted hazard ratios [aHRs], 1.27, 1.55, and 2.02 for mild, moderate, and severe, respectively; p < 0.001), all-cause death (aHRs, 1.26, 1.46, and 1.85 for mild, moderate, and severe, respectively; p < 0.001), and MACEs (aHRs, 1.14, 1.32, and 1.67 for mild, moderate, and severe, respectively; p < 0.001) than patients without risk.

CONCLUSION

Elevated malnutrition risk was common among AMI patients undergoing PCI and was strongly associated with a higher risk of major bleeding, all-cause death, and major ischemic events.

Association between malnutrition risk and hemorrhagic transformation in patients with acute ischemic stroke

Background and aims

Malnutrition is a prevalent problem occurring in different diseases. Hemorrhagic transformation (HT) is a severe complication of acute ischemic stroke (AIS). Few studies have evaluated the association between malnutrition risk and hemorrhagic transformation in patients with acute stroke. We aim to investigate the influence of malnutrition risk on the risk of hemorrhagic transformation in patients with AIS.

Methods

A total of 182 consecutive adults with HT and 182 age- and sex-matched patients with stroke were enrolled in this study. The controlling nutritional status (CONUT) score was calculated to evaluate the malnutrition risk. HT was detected by follow-up imaging assessment and was radiologically classified as hemorrhagic infarction type 1 or 2 or parenchymal hematoma type 1 or 2. Logistic regression models were conducted when participants were divided into different malnutrition risk groups according to the objective nutritional score to assess the risk for HT.

Results

The prevalence of moderate to severe malnutrition risk in patients with AIS was 12.5%, according to the CONUT score. Univariate analysis showed that the CONUT score is significantly higher in patients with HT than those without HT. After adjusting for potential covariables, the patients with mild risk and moderate to severe malnutrition risk were associated with a higher risk of HT compared to the patients in the normal nutritional status group [odds ratio, 3.180 (95% CI, 1.139–8.874), P = 0.027; odds ratio, 3.960 (95% CI, 1.015–15.453), P = 0.048, respectively].

Conclusion

Malnutrition risk, measured by CONUT score, was significantly associated with an increased risk of hemorrhagic transformation in patients with AIS.

Nutrition status, obesity and outcomes in patients with atrial fibrillation

INTRODUCTION AND OBJECTIVES

A paradoxical protective effect of obesity has been previously reported in patients with atrial fibrillation (AF). The aim of this study was to determine the impact of nutritional status and body mass index (BMI) on the prognosis of AF patients.

METHODS

We conducted a retrospective population-based cohort study of patients with AF from 2014 to 2017 from a single health area in Spain. The CONUT score was used to assess nutritional status. Cox regression models were used to estimate the association of BMI and CONUT score with mortality. The association with embolism and bleeding was assessed by a competing risk analysis.

RESULTS

Among 14 849 AF patients, overweight and obesity were observed in 42.6% and 46.0%, respectively, while malnutrition was observed in 34.3%. During a mean follow-up of 4.4 years, 3335 patients died, 984 patients had a stroke or systemic embolism, and 1317 had a major bleeding event. On univariate analysis, BMI was inversely associated with mortality, embolism, and bleeding; however, this association was lost after adjustment by age, sex, comorbidities, and CONUT score (HR for composite endpoint, 0.98; 95%CI, 0.95-1.01; P=.719). Neither obesity nor overweight were predictors of mortality, embolism, and bleeding events. In contrast, nutritional status-assessed by the CONUT score-was associated with mortality, embolism and bleeding after multivariate analysis (HR for composite endpoint, 1.15; 95%CI, 1.14-1.17; P<.001).

CONCLUSIONS

BMI was not an independent predictor of events in patients with AF in contrast to nutritional status, which showed a strong association with mortality, embolism, and bleeding. The study was registered at ClinicalTrials.gov (Identifier: NCT04364516).

Prognostic Potential of the Controlling Nutritional Status (CONUT) Score in Predicting All-Cause Mortality and Major Adverse Cardiovascular Events in Patients With Coronary Artery Disease: A Meta-Analysis

Background

As defined by the Controlling Nutrition Status (CONUT) score, the prognostic significance of nutritional status has attracted attention in patients with cardiovascular disease. This meta-analysis aimed to determine the importance of CONUT score for prediction of all-cause mortality and major adverse cardiovascular events (MACE) in adult patients with coronary artery disease (CAD).

Methods

Observational studies conducted to evaluate the association of CONUT score with adverse clinical outcomes in patients with CAD were included. We searched MEDLINE, Embase, Scopus, Cochrane library, Google scholar, medRxiv pre-print as well as Science Direct search engine for studies published from the inception of each database until March 21, 2022. Studies reporting the utility of CONUT score in prediction of all-cause mortality and MACE among patients with CAD were eligible. Predictive potential of the CONUT score were summarized by pooling the multivariable adjusted hazard ratio (aHR) with 95% CI for the malnourished vs. normal nutritional status or per point CONUT score increase.

Results

Of 2,547 screened citation, nine observational studies involving 81,257 patients with CAD were analyzed. Malnutrition defined by the CONUT score was associated with significantly increased risk of all-cause mortality when compared with the normal nutritional state (aHR for mild, moderate, and severe malnutrition, respectively: (1.21 [95% CI: 1.15–1.27], I² = 0%), (1.53 [95% CI: 1.26–1.84], I² = 84%), and (2.24 [95% CI: 1.57–3.19], I² = 77%). Similarly, moderate (aHR 1.71 [95% CI: 1.44–2.03], I² = 0%) and severe (aHR 2.66 [95% CI: 1.82–3.89], I² = 0%) malnutrition was associated with a significantly higher risk of MACE compared with the normal nutritional state. Additionally, per point increase in the CONUT score was correlated with 20 and 23% additional risk of all-cause mortality and MACE, respectively.

Conclusion

As defined by the CONUT score, malnutrition is an independent predictor of all-cause mortality and MACE in CAD patients. Nutritional assessment with CONUT score could allow clinicians to identify patients with CAD at high risk for adverse clinical outcomes.

Incidence and Predictors of Bleeding in Patients With Cancer and Atrial Fibrillation

Despite patients with cancer having a higher incidence of atrial fibrillation (AF), little is known about the predictors of outcomes in this population. This study aimed to assess the incidence and predictors of bleeding in patients with AF and cancer. The study population comprised 16,056 patients from a Spanish health area diagnosed with AF between 2014 and 2018 (1,137 with cancer). Competing risk analysis were used to evaluate the association of cancer and bleeding. Discrimination and calibration of bleeding risk scores were assessed by the concordance statistic and the Brier score, respectively. During a median follow-up of 4.9 years, the incidence of bleeding in patients with cancer was 13.2 per 100 patients/year. After multivariate adjustment, a significant association between cancer and bleeding was detected (subdistribution hazard ratio [sHR] 1.18, 95% CI 1.07 to 1.30, p = 0.001), specifically in patients with active cancer or previous radiotherapy. Early age, male gender, diabetes, and anticoagulation were independent predictors of bleeding. However, only anticoagulation with vitamin K antagonist (sHR 1.36, 95% CI 1.03 to 1.78, p = 0.026), not with direct oral anticoagulants (sHR 1.25, 95% CI 0.84 to 1.85, p = 0.270), was associated with bleeding. Discrimination and calibration of Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, and Drugs/alcohol concomitantly (HAS-BLED), AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA), and Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age ≥75 years), Reduced platelet count or function, Rebleeding risk, Hypertension, Anaemia, Genetic factors, Excessive fall risk and Stroke (HEMORR₂HAGES) scores were poor in patients with cancer (concordance statistic <0.6 and Brier score >0.1). In summary, cancer was associated with an increased risk of bleeding in patients with AF. The predictive ability of bleeding risk scores was poor in this population. Anticoagulation with vitamin K antagonist but not with direct oral anticoagulants, was an independent predictor of bleeding in patients with cancer.

Prevalence and Prognostic Significance of Malnutrition in Hypertensive Patients in a Community Setting

BACKGROUND

Malnutrition is a significantly poor prognostic factor for a variety of cardiovascular diseases. However, its prevalence and prognostic value in hypertensive patients is still unclear. The present study sought to determine the prevalence and prognostic value of malnutrition in hypertensive patients in a community setting.

METHODS

We included 9,949 hypertensive patients from the National Health and Nutrition Examination Survey (NHANES) (2005-2014). The Controlling Nutritional Status (CONUT) score, the Nutritional Risk Index (NRI), and the Naples Prognostic Score (NPS) were applied to assess the nutritional status of participants. A Cox regression model was established to examine the association between malnutrition and cardiovascular and all-cause mortality.

RESULTS

In all, 19.9, 3.9, and 82.9% hypertensive patients were considered to have malnutrition as evaluated by the CONUT, NRI, and NPS, respectively. Malnutrition assessed by CONUT and NRI was independently associated with cardiovascular mortality (HR [95% CI]) for mild and moderate-to-severe degree of malnutrition, respectively: 1.41 (1.04-1.91) and 5.79 (2.34-14.29) for CONUT; 2.60 (1.34-5.07) and 3.30 (1.66-6.56) for NRI (all P < 0.05), and for all-cause mortality (HR [95% CI]) for mild and moderate-to-severe degree of malnutrition, respectively: 1.48 (1.30-1.70) and 4.87 (3.40-6.98) for CONUT; 1.72 (1.24-2.39) and 2.60 (1.96-3.44) for NRI (all P < 0.01). Naples Prognostic Score could only independently predict all-cause mortality.

CONCLUSIONS

Malnutrition was common among hypertensive patients and was closely associated with both long-term cardiovascular and all-cause mortality.

Malnutrition on admission increases the in-hospital mortality and length of stay in elder adults with acute ischemic stroke

Purpose

Malnutrition, as determined by the Controlling Nutritional Status (CONUT), has an effect on the 3‐month and long‐term prognosis of stroke patients. The association between malnutrition and in‐hospital mortality has not been well established. We aimed to investigate the relationship between the CONUT score on admission and in‐hospital mortality and length of stay (LOS) in elderly patients with acute ischemic stroke (AIS).

Methods

This study analyzed controls and patients with AIS. Malnutrition was determined using the CONUT score. A CONUT score of 5–12 was defined as undernutrition status. Based on the CONUT scores, the patients were divided into the low CONUT (0–4) and high CONUT (5–12) groups.

Results

In total, 1079 participants were recruited, comprising 288 controls and 791 AIS patients. Among the 791 patients, 64 (8.1%) had malnutrition and 63 (7.9%) had an in‐hospital death. Compared to the controls, the AIS patients presented higher CONUT scores, higher proportion of in‐hospital mortality (8.0%), and longer length of stay. Malnutrition was independently associated with in‐hospital mortality in the AIS patients (adjusted odds ratio: 3.77, 95% confidence interval [CI]: 1.55–9.15; p = 0.003). The general linear models showed an association between the CONUT score and LOS (β = 0.574, 95% CI: 0.208–0.934; p = 0.002). Furthermore, the effect of the interaction between infection and nutrition status on in‐hospital mortality showed borderline statistical significance (p = 0.06).

Conclusions

Malnutrition estimated by the CONUT score on admission can be a predictor of in‐hospital mortality and increased LOS in elderly AIS patients.

Prevalence and prognostic significance of malnutrition in diabetic patients with coronary artery disease: a cohort study

Background

Malnutrition is associated with poor prognosis in cardiovascular disease patients or in diabetic patients. However, the relationship between malnutrition and clinical outcomes in diabetic patients with coronary artery disease (CAD) is not well known. The aim of this study is to report the prevalence and prognostic consequences of malnutrition in diabetic patients with CAD.

Methods

In this retrospective observational study, the Controlling Nutritional Status (CONUT) score applied to 12,898 consecutive diabetic patients with CAD. The association between malnutrition and long-term all-cause mortality was examined using Cox proportional hazards regression analysis.

Results

According to CONUT score, 60.5% patients suffered from malnutrition; 46.4%, 13.2%, and 0.9% patients had mild, moderate, and severe malnutrition, respectively. During a median follow-up of 4.88 (2.83–7.51) years, 1973 (15.3%) patients died. After adjustment for confounders, malnutrition was associated with significantly increased risk for long-term all-cause mortality (adjusted hazard ratio for mild malnutrition and moderate to severe malnutrition, respectively: 1.38 [95% confidence interval (CI) 1.07–1.77]; P value = 0.012 and 1.63 [95% CI 1.18–2.24]; P value = 0.003). A similar association was observed around subgroups.

Conclusions

Malnutrition is common in diabetic patients with CAD and is strongly associated with increased mortality. It is necessary to adequately assess the nutritional status and take the effective nutritional guidance to improve the prognosis of diabetic patients with CAD.

Malnutrition and Risk of Procedural Complications in Patients With Atrial Fibrillation Undergoing Catheter Ablation

Background: Little is known about the prognostic value of nutritional status among patients undergoing atrial fibrillation (AF) catheter ablation (AFCA). We compared the risk of procedure-related complications and long-term rhythm outcomes of AFCA according to nutritional status.

Methods: We included 3,239 patients undergoing de novo AFCA in 2009-2020. Nutritional status was assessed using the controlling nutritional status (CONUT) score. The association between malnutrition and the risk of AFCA complications or long-term rhythm outcomes was evaluated. We validated the effects of malnutrition using an external cohort of 360 patients undergoing AFCA in 2013-2016.

Results: In the study population (26.8% women, median age: 58 years), 1,005 (31.0%) had malnutrition (CONUT scores ≥ 2); 991 (30.6%) had mild (CONUT 2–4) and 14 (0.4%) had moderate-to-severe (CONUT ≥ 5) malnutrition. The overall complication rates after AFCA were 3.3% for normal nutrition, 4.2% for mild malnutrition, and 21.4% for moderate-to-severe malnutrition. Moderate-to-severe malnutrition [odds ratio (OR) 6.456, 95% confidence interval (CI) 1.637-25.463, compared with normal nutrition], older age (OR 1.020 per 1-year increase, 95% CI 1.001-1.039), female sex (OR 1.915, 95% CI 1.302-2.817), and higher systolic blood pressure (OR 1.013 per 1-mmHg increase, 95% CI 1.000-1.026) were independent predictors for the occurrence of complications. In the validation cohort, malnutrition (CONUT ≥ 2) was associated with a 2.87-fold higher risk of AFCA complications (95% CI 1.174-7.033). The association between malnutrition and a higher risk of AFCA complications was consistently observed regardless of body mass index and sex. Malnutrition did not affect rhythm outcomes during the median follow-up of 40 months (clinical recurrence: 37.0% in normal nutrition vs. 36.5% in malnutrition).

Conclusion: Malnutrition, which is common in patients undergoing AFCA, was associated with a substantially higher risk for complications after AFCA.

Ischemic Stroke in Patients With Hypertrophic Cardiomyopathy According to Presence or Absence of Atrial Fibrillation

BACKGROUND AND PURPOSE

Patients with hypertrophic cardiomyopathy (HCM) have high risk of ischemic stroke (IS), especially if atrial fibrillation (AF) is present. Improvements in risk stratification are needed to help identify those patients with HCM at higher risk of stroke, whether AF is present or not.

METHODS

This French longitudinal cohort study from the database covering hospital care from 2010 to 2019 analyzed adults hospitalized with isolated HCM. A logistic regression model was used to construct a French HCM score, which was compared with the HCM Risk-CVA and CHA₂DS₂-VASc scores using c-indexes and calibration analysis.

RESULTS

In 32 206 patients with isolated HCM, 12 498 (38.8%) had AF, and 2489 (7.7%) sustained an IS during follow-up. AF in patients with HCM was independently associated with a higher risk for death (hazard ratio, 1.129 [95% CI, 1.088-1.172]), cardiovascular death (hazard ratio, 1.254 [95% CI, 1.177-1.337]), IS (hazard ratio, 1.210 [95% CI, 1.111-1.317]), and other major cardiovascular events. Independent predictors of IS in HCM were older age, heart failure, AF, prior IS, smoking and poor nutrition (all P<0.05). For the HCM Risk-CVA score, CHA₂DS₂-VASc score and a French HCM score, all c-indexes were 0.65 to 0.70, with good calibration. Among patients with AF, the CHA₂DS₂-VASc score had marginal improvement over the HCM Risk-CVA score but was less predictive compared with the French HCM score (P=0.001). In patients without AF, both HCM Risk-CVA score and the French HCM score had significantly better prediction compared with CHA₂DS₂-VASc (both P<0.0001). Decision curve analysis demonstrated that the French HCM score had the best clinical usefulness of the 3 tested risk scores.

CONCLUSIONS

Patients with HCM have a high prevalence of AF and a significant risk of IS, and the presence of AF in patients with HCM was independently associated with worse outcomes. A simple French HCM score shows good prediction of IS in patients with HCM and clinical usefulness, with good calibration.

Predicting One-Year Deaths and Major Adverse Vascular Events with the Controlling Nutritional Status Score in Elderly Patients with Non-ST-Elevated Myocardial Infarction Undergoing Percutaneous Coronary Intervention

The prognostic value of malnutrition in elderly patients with non-ST-elevated myocardial infarction (NSTEMI) is not fully understood. Nutritional characteristics were evaluated by novel Controlling Nutritional status (CONUT), the prognostic nutritional index (PNI) and the geriatric nutritional risk index (GNRI) scores. The impact of these scores on major outcomes in 253 NSTEMI patients over 60 years and older were assessed. Compared to those with good nutritional status; malnourished patients had more major adverse cardiac and cerebrovascular events (MACCEs) at 1-year follow up. Multivariable cox regression analysis revealed that CONUT (hazard ratio = 1.372; p < 0.01) was independent predictor of MACCEs, whereas PNI (p = 0.44) and GNRI (p = 0.52) were not. The discriminating power of the CONUT (AUC: 0.79) was adequate and significantly superior to both the PNI (AUC: 0.68) and the GNRI (AUC: 0.60), with a p-value for both < 0.01. Patients with elevated CONUT exhibited the highest event rate for all-cause mortality and MACCEs in survival analysis (p < 0.01). We conclude that malnutrition is strongly associated with adverse outcomes in older patients with NSTEMI. In fact, the CONUT score adequately predicts one-year MACCEs among elderly NSTEMI patients who achieve complete revascularization after coronary intervention.

Prevalence and Prognostic Significance of Malnutrition in Patients With Acute Coronary Syndrome

BACKGROUND

Malnutrition is associated with poor prognosis in a wide range of illnesses. However, its prognostic impact in patients with acute coronary syndrome (ACS) is not well known.

OBJECTIVES

This study sought to report the prevalence, clinical associations, and prognostic consequences of malnutrition in patients with ACS.

METHODS

In this study, the Controlling Nutritional Status (CONUT) score, the Nutritional Risk Index (NRI), and the Prognostic Nutritional Index (PNI) was applied to 5,062 consecutive patients with ACS. The relationships between malnutrition risk and all-cause mortality and major cardiovascular events (MACEs) (cardiovascular mortality, reinfarction, or ischemic stroke) were examined.

RESULTS

According to the CONUT score, NRI, and PNI, 11.2%, 39.5%, and 8.9% patients were moderately or severely malnourished, respectively; 71.8% were at least mildly malnourished by at least 1 score. Although worse scores were most strongly related to lower body mass index, between 8.4% and 36.7% of patients with a body mass index of ≥25 kg/m² were moderately or severely malnourished, depending on the nutritional index used. During a median follow-up of 3.6 years (interquartile range: 1.3 to 5.3 years), 830 (16.4%) patients died, and 1,048 (20.7%) had MACEs. Compared with good nutritional status, malnutrition was associated with significantly increased risk for all-cause death (adjusted hazard ratio for moderate and severe degrees of malnutrition, respectively: 2.02 [95% confidence interval (CI): 1.65 to 2.49] and 3.65 [95% CI: 2.41 to 5.51] for the CONUT score, 1.40 [95% CI: 1.17 to 1.68] and 2.87 [95% CI: 2.17 to 3.79] for the NRI, and 1.71 [95% CI: 1.37 to 2.15] and 1.95 [95% CI: 1.55 to 2.45] for the PNI score; p values <0.001 for all nutritional indexes). Similar results were found for the CONUT score and PNI regarding MACEs. All risk scores improve the predictive ability of the GRACE (Global Registry of Acute Coronary Events) risk score for both all-cause mortality and MACEs.

CONCLUSIONS

Malnutrition is common among patients with ACS and is strongly associated with increased mortality and cardiovascular events. Clinical trials are needed to prospectively evaluate the efficacy of nutritional interventions on outcomes in patients with ACS.

Relationship between the nutritional status and safety and efficacy outcomes in atrial fibrillation patients aged 80 years and over receiving oral anticoagulants

BACKGROUND

Malnutrition has been reported to be associated with worse clinical outcomes in various cardiovascular diseases. We aimed to investigate the clinical significance of the nutritional status in atrial fibrillation (AF) patients aged 80 years and over receiving oral anticoagulants (OACs), focusing on the difference between direct OACs (DOACs) and warfarin treatment.

METHODS

This was a retrospective and observational study. We enrolled 332 consecutive AF patients aged 80 years and over who were treated with OACs: DOACs (n = 256) and warfarin (n = 76). A controlling nutritional status (CONUT) score was used to evaluate the nutritional status. The enrolled patients were divided into two groups based on the CONUT score: CONUT score <5 (n = 239) and CONUT score ≥5 (n = 93) groups. We investigated the relationship between the nutritional status and clinical outcomes.

RESULTS

The CONUT score ≥5 group had significantly higher incidence of major bleeding (MB) compared to the CONUT score <5 group (4.6/100 person-years vs. 0.7/100 person-years, p < 0.01). On Cox hazard analysis, CONUT score ≥5 group was significantly associated with increased MB compared with the CONUT score <5 group (hazard ratio: 5.80, 95% confidence interval: 1.44-23.33, p = 0.013). In the DOAC group, the incidence of MB did not differ between the CONUT score ≥5 and CONUT score <5 groups (p = 0.54). In the warfarin group, MB occurred more frequently in the CONUT score ≥5 group than CONUT score <5 group (p < 0.01). There was no significant difference in the incidence of thromboembolic events between the CONUT score ≥5 and CONUT score <5 groups in both the DOAC and warfarin groups.

CONCLUSIONS

The prognostic values of the nutritional status based on the CONUT score for MB differed between AF patients aged 80 years and over receiving DOACs and those receiving warfarin. It may be favorable to use DOACs to avoid bleeding events in those with malnutrition.