Prognostic Impact and Prevalence of Cachexia in Patients With Heart Failure: A Systematic Review and Meta-Analysis

BACKGROUND

Cachexia, defined as the combination of weight loss, weakness, fatigue, anorexia and abnormal biochemical markers based on Evans' criteria, is known to exacerbate the prognosis of heart failure (HF) patients. This systematic review and meta-analysis investigates the prognostic impact and prevalence of cachexia, as defined by Evans' criteria, in patients with HF.

METHODS

PubMed, Cochrane Library, Scopus and Web of Science were searched from inception until December 2023, including HF patients for whom the Evans' criteria were applied to explore the prevalence and prognostic impact of cachexia. This study employed a meta-analyses using the random-effects model and inverse-variance method that was adhered to the revised 2020 PRISMA guidelines for systematic reviews and meta-analyses (CRD42023446443).

RESULTS

Six prospective or retrospective studies of 2252 patients with HF were included, whereby all-cause mortality was significantly greater in patients with cachexia with low heterogeneity among studies (HR: 1.60, 95% CI 1.31-1.95, p < 0.001; I2 = 0%). For the studies that used full, uniformly defined Evans' criteria, among 1844 patients, mortality remained greater in patients with cachexia (HR: 1.58, 95% CI 1.27-1.97, p < 0.001; I2 = 0%). In a subgroup analysis among 1714 of HF with reduced ejection fraction, the results were consistent (HR: 1.57, 95% CI 1.28-1.92, p < 0.001; I2 = 0%). Additionally, 10 studies comprising 2862 patients indicated a 31% risk of cachexia in HF (95% CI 21-43%, I2 = 94%).

CONCLUSIONS

Cachexia is an independent predictor for increased all-cause mortality among patients with HF with a notable prevalence of 31%. Interventions aiding in improving fatigue, anorexia and exercise capacity could help improve the quality of life of this clinical population.

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.

Effects of weight loss in heart failure patients with overweight and obesity: a systematic review and meta-analysis

AIMS

To perform a systematic review and meta-analysis to evaluate the impact of weight loss (WL) on the prognosis of overweight and obese patients with heart failure (HF).

METHODS AND RESULTS

We reviewed the literature up to 1 February 2023 from PubMed, Web of Science, Embase, Cochrane Library, and Chinese databases for cohort studies, and randomized controlled trials (RCTs). Data from eligible studies were extracted, and statistical analyses were performed using Review Manager 5.3. A total of 19 studies (involving 449 882 patients) were included in the systematic review and meta-analyses. The results showed that WL did not reduce the mortality and rehospitalization rates in overweight and obese HF patients, but could improve the quality of life (P = 0.002), cardiac function (P = 0.0001), and exercise capacity (P = 0.03). The subgroup analysis showed that WL from bariatric surgery (BS) reduced the risk of death (P < 0.00001), WL from medication or exercise was not significantly associated with the risk of death (P = 0.18), and WL was associated with a higher mortality in the subgroup with unspecified WL modality or unintentional WL (P < 0.00001). In addition, it did not reduce the risk of short-term rehospitalization (P = 0.11), but reduced the rehospitalization rates over the long-term (P = 0.03).

CONCLUSION

WL improves the long-term rehospitalization (>3 months), quality of life, cardiac function, and exercise capacity in overweight and obese HF patients. Although overall WL is not proven effective, subgroup analysis shows that BS can reduce mortality.

Prognostic relevance of gradual weight changes on long-term mortality in chronic heart failure

BACKGROUND AND AIMS

While obesity has been linked to better ouctomes (the obesity paradox), cachexia is associated with higher mortality in patients with heart failure with reduced ejection fraction (HFrEF). As opposed to overt cachexia, little is known about the prognostic impact of gradual, long-term weight changes in stable HFrEF.

METHODS AND RESULTS

We included ambulatory patients with clinically stable chronic HFrEF on individually optimized treatment. Next to other clinical and functional parameters, changes in body weight over the past one (n = 733, group 1) or two (n = 636, group 2) years were recorded. Four-year mortality was analysed with respect to baseline BMI and changes in body weight or BMI using fractional polynomials. In addition, outcome was stratified by BMI categories (18.5-25 kg/m²: normal weight, >25-30 kg/m²: overweight, >30 kg/m²: obesity). An obesity paradox was present in both groups, with overweight and obese patients having the best prognosis. In both groups, a gradual weight gain of 5% was associated with the lowest mortality, whereas mortality steadily increases with increasing weight loss. Excessive weight gain >10% was also related to higher mortality. Stratification by baseline BMI categories revealed that weight loss was most detrimental in normal weight patients, whereas the prognostic impact of weight change was weaker in obese patients.

CONCLUSION

In patients with chronic HFrEF, gradual weight loss is associated with steadily increasing mortality, whereas a weight gain of 5% is related to the best prognosis. Prevention of any inappropriate weight loss might be a therapeutic goal in HFrEF patient care.

Prognostic value of geriatric nutritional risk index in elderly patients with heart failure: a meta-analysis

BACKGROUND

Geriatric Nutritional Risk Index (GNRI) is a promising tool for predicting nutrition-related complications. This meta-analysis sought to determine the prognostic utility of GNRI in elderly patients with heart failure.

METHODS

We comprehensively searched the PubMed and Embase databases from their inception to July 2019. Original studies investigating the prognostic value of GNRI in patients with heart failure were included. Outcome of interests were all-cause mortality and major cardiovascular events. The prognostic value of GNRI was expressed as risk ratios (RR) with 95% confidence intervals (CI) for the lowest versus the highest GNRI category or continuous GNRI analysis.

RESULTS

Eleven articles (10 studies) involving 10,589 elderly heart failure patients were included. Meta-analysis indicated that heart failure patients with the lowest GNRI had an increased risk of all-cause mortality (RR 2.11; 95% CI 1.72-2.58) and major cardiovascular events (RR 2.00; 95% CI 1.24-3.22) after adjustment for confounding. In addition, each unit reduction in GNRI significantly increased 6% risk of all-cause mortality.

CONCLUSION

Lower GNRI independently predicts all-cause mortality and major cardiovascular events in elderly patients with heart failure. Determination of nutritional status using GNRI may improve risk stratification in elderly patients with heart failure.