The controlling nutritional status score and clinical outcomes in patients with heart failure: Pool analysis of observational studies

CONUT Score as a Predictor of Mortality Risk in Acute and Chronic Heart Failure: A Meta-Analytic Review

Heart failure (HF) is a major global health burden and a leading cause of morbidity and mortality. Nutritional status has emerged as an essential factor influencing outcomes in HF, with the Controlling Nutritional Status (CONUT) score gaining attention as a simple, objective marker derived from serum albumin, total cholesterol, and lymphocyte count. This meta-analysis evaluated the prognostic value of the CONUT score in predicting all-cause mortality in patients with acute and chronic heart failure. A systematic search was conducted in the PubMed, MEDLINE, Google Scholar, and Cochrane Library databases for the past ten years, using combinations of keywords such as "heart failure", "CONUT score", "malnutrition", and "mortality". Studies were included if they reported hazard ratios (HRs) for all-cause mortality in relation to CONUT score categories in adult HF populations. Eight eligible studies comprising 15,761 patients were included. Pooled analysis showed that higher CONUT scores were significantly associated with increased all-cause mortality (pooled HR = 1.47; 95% CI: 1.30-1.66). Despite substantial heterogeneity (I2 = 80%), the direction of effect was consistent across studies. The CONUT score is a useful prognostic marker in acute and chronic heart failure patients. Further research should explore the effects of targeted nutritional interventions in high-risk HF patients identified by elevated CONUT scores and efforts to standardize malnutrition cut-offs in clinical practice.

A case of destination therapy for post-fulminant myocarditis with myelodysplastic syndrome

We encountered a 64-year-old woman who experienced fulminant myocarditis and underwent treatment with veno-arterial extracorporeal membrane oxygenation and Impella CP support. Subsequently, she underwent a device upgrade to Impella 5.5 and received continuous hemodiafiltration for 3 months. During mechanical circulatory support, she developed refractory anemia and thrombocytopenia, leading to a diagnosis of myelodysplastic syndrome. Following the removal of the devices, she no longer required blood transfusions. She received HeartMate 3 left ventricular assist device implantation as a destination therapy indication despite the presence of myelodysplastic syndrome. She was successfully managed by aspirin-free antithrombotic therapy without any hemocompatibility-related adverse events for 4 months after index discharge on foot. We present a patient with a unique and rare presentation, wherein HeartMate 3 was implanted and successfully managed without aspirin to prevent bleeding complications associated with myelodysplastic syndrome.

Association between controlling nutritional status score and the prognosis of patients with acute myocardial infarction: a systematic review and meta-analysis

Background

Recent studies have reported growing evidence supporting applying the controlling nutritional status (CONUT) score in acute myocardial infarction (AMI) patients. This investigation intended to ascertain the link between CONUT scores and the prognosis in the AMI population.

Methods

Multiple electronic databases, encompassing PubMed, Web of Science, Embase, and the Cochrane Library, were retrieved from the inception of the databases until July 20, 2024, to explore the link between CONUT scores and adverse clinical outcomes in individuals with AMI. Primary outcomes consisted of major adverse cardiovascular events (MACE) and mortality, while secondary outcomes encompassed stroke, cardiac death, myocardial reinfarction, revascularization, ventricular arrhythmias, and atrioventricular block. A random-effects meta-analysis was executed, with CONUT scores treated as either categorical or continuous variables. Sensitivity analyses and Egger's test were conducted to appraise the robustness of results and publication bias, respectively. Subgroup analyses were executed to account for various confounding factors. Moreover, the GRADE system was leveraged to appraise the quality of evidence for all outcomes.

Results

Fifteen studies were included in our analysis. The statistical analyses on both categorical and continuous variables unraveled that a high CONUT score was markedly linked to an elevated risk of MACE [categorical variable: odds ratio (OR) = 1.75, 95% confidence interval (CI) = 1.42-2.15; continuous variable: standardized mean difference (SMD) = 1.02, 95% CI = 0.78-1.26], mortality (categorical variable: OR = 2.08, 95% CI = 1.70-2.55; continuous variable: SMD = 1.16, 95% CI = 0.57-1.74), cardiac death (categorical variable: OR = 2.81, 95% CI = 1.67-4.73), myocardial reinfarction (categorical variable: OR = 2.21, 95% CI = 1.28-3.83), and atrioventricular block (categorical variable: OR = 5.21, 95% CI = 1.83-14.89) in AMI patients. However, no significant association was found between a high CONUT score and stroke (categorical variable: OR = 1.52, 95% CI = 0.98-2.35), revascularization (categorical variable: OR = 2.92, 95% CI = 0.58-14.79), and ventricular arrhythmias (categorical variable: OR = 2.57, 95% CI = 0.06-107.21).

Conclusion

The CONUT score may serve as a promising and cost-effective prognostic biomarker for individuals with AMI.

Systematic review registration

PROSPERO: CRD42024574048.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Patients with Severe Trauma Having an Injury Severity Score of 24 and above Develop Nutritional Disorders

In this single-center, retrospective, observational study, we aimed to assess the severity at which patients with trauma tend to develop metabolic disturbances that worsen their Controlling Nutritional Status (CONUT) scores. Participants were general adult patients with trauma hospitalized for at least one week. Injury Severity Scores (ISSs) at admission and CONUT scores one week later were calculated, and correlation coefficients were examined. The receiver operating characteristic (ROC) curve was used to calculate the ISS cutoff value for a CONUT score of 5 or more on day 7 of hospitalization. The ISS was assessed using multiple logistic regression analysis to determine whether it predicts worse nutritional status. Forty-nine patients were included. ISSs correlated with CONUT scores on day 7 (r = 0.373, p = 0.008). Using the ROC curve, the cutoff value for the ISS was 23.5. Multiple logistic regression analyses showed that a high ISS (odds ratio [OR], 1.158; 95% confidence interval [CI], 1.034-1.296; p = 0.011) and older age (OR, 1.094; 95% CI, 1.027-1.165; p = 0.005) were associated with a CONUT score 5 or more on day 7 of hospitalization. Patients with trauma with an ISS of 24 or higher have worsening CONUT scores during hospitalization; these patients require careful nutritional management.

Interpretations of the Role of Plasma Albumin in Prognostic Indices: A Literature Review

This review assesses how publications interpret factors that influence the serum or plasma albumin (PA) level in prognostic indices, focusing on inflammation and nutrition. On PubMed, a search for "albumin AND prognosis" yielded 23,919 results. From these records, prognostic indices were retrieved, and their names were used as search strings on PubMed. Indices found in 10 or more original research articles were included. The same search strings, restricted to "Review" or "Systematic review", retrieved yielded on the indices. The data comprised the 10 latest original research articles and up to 10 of the latest reviews. Thirty indices had 294 original research articles (6 covering two indices) and 131 reviews, most of which were from recent years. A total of 106 articles related the PA level to inflammation, and 136 related the PA level to nutrition. For the reviews, the equivalent numbers were 54 and 65. In conclusion, more publications mention the PA level as a marker of nutrition rather than inflammation. This is in contrast to several general reviews on albumin and nutritional guidelines, which state that the PA level is a marker of inflammation but not nutrition. Hypoalbuminemia should prompt clinicians to focus on the inflammatory aspects in their patients.

Relationship between Nutritional Risk, Clinical and Demographic Characteristics, and Pressure Ulcers in Patients with Severe Acquired Brain Injuries Attending a Rehabilitative Program

Preliminary evidence in the literature suggests a high prevalence of malnutrition (undernutrition) in patients with severe acquired brain injuries (sABI), with an expected negative impact on clinical outcomes and pressure ulcers (PUs) in particular. In a retrospective cohort study on patients discharged from intensive care units (ICU) and admitted to an intensive rehabilitation unit (IRU), the risk of malnutrition was systematically assessed, in addition to standard clinical procedures (including PUs evaluation), using two different tools: the Malnutrition Universal Screening Tool (MUST) and the Controlling Nutritional Status (CONUT) tool. Eighty-eight patients were included in the analysis. A high proportion (79.5%) of patients with sABI suffered from PUs, being older and more frequently men, with a longer ICU stay between the event and admission to IRU, and a greater MUST score. At discharge, when compared to patients whose PUs had healed, those with persisting PUs were more often men and had the worst cognitive performance at admission. As for nutritional risk, the baseline CONUT score was identified as an independent negative predictor of PUs at discharge by the logistic regression model. In conclusion, the assessment of nutritional risk using simple standard tools may be useful in the clinical evaluation of sABI patients with PUs.

Controlling Nutritional Status (CONUT) Score as a Predictive Marker in Hospitalized Frail Elderly Patients

The Controlling Nutritional Status (CONUT) score is a simple screening tool able to detect altered nutritional status as well as to predict clinical adverse outcomes in specific populations. No data are available in frail patients. This study aims to investigate the predictive role of the CONUT score on mortality and length of stay (LOS) in frail patients admitted to an Internal Medicine Department. We consecutively enrolled 246 patients aged 65 years or older, divided into two groups based on frailty status. The two groups were further divided according to low (<5) or high (≥5) CONUT score. Length of stay (LOS) was higher in frail patients than not-frail patients, as well as in the frail group with high CONUT scores compared to the frail group with low CONUT scores. Multiple linear regression showed an increase of 2.1 days for each additional point to the CONUT score. In-hospital mortality was higher in frail compared to not-frail patients, but it did not differ between frail patients with high CONUT scores and frail patients with low CONUT scores. An analysis of the survival curve for 30-day mortality showed a higher mortality rate for frail/high-CONUT-score patients as compared to the not-frail/low-CONUT-score group. The CONUT score shows high prognostic value for higher LOS-but not mortality-in the clinical setting of internal medicine departments for old frail patients.

Can Nutrition Contribute to a Reduction in Sarcopenia, Frailty, and Comorbidities in a Super-Aged Society?

Many countries are facing the advent of super-aging societies, where sarcopenia and frailty will become pertinent problems. The prevalence of comorbidities is a major problem in countries with aged populations as elderly people suffer from various diseases, such as diabetes, heart failure, chronic kidney disease and dementia. All of these diseases are associated with sarcopenia and frailty, and they frequently cause falls, fractures, and a decline in activities of daily living. Fractures in the elderly people are associated with bone fragility, which is influenced by diabetes and chronic kidney disease. Nutritional support for chronic disease patients and sarcopenic individuals with adequate energy and protein intake, vitamin D supplementation, blood glucose level management for individuals with diabetes, obesity prevention, nutritional education for healthy individuals, and the enlightenment of society could be crucial to solve the health-related problems in super-aging societies.

Prognostic significance of controlling nutritional status in older adults with heart failure with preserved ejection fraction: a prospective comparative study with other objective nutritional indices

OBJECTIVE

We explored the prognostic significance of controlling nutritional status (CONUT) score in older adults with heart failure with preserved ejection fraction (HFpEF) and compared CONUT with other objective nutritional indices.

METHODS

This is a single-center retrospective cohort study in older adult coronary artery disease patients undergoing HFpEF. Clinical data and laboratory results were collected before discharge. CONUT, geriatric nutritional risk index (GNRI), and prognostic nutritional index (PNI) were calculated according to the formula. The primary endpoint of this study was readmission due to heart failure and all-cause mortality in the first year after hospitalization.

RESULTS

A total of 371 older adults were enrolled. All patients were discharged and followed up for 1 year, and readmission for heart failure was 26% while all-cause mortality was 20%. Compared with the none and mild malnutrition risk group, the readmission rate for heart failure (HF) within 1 year (36% vs. 18%, 23%) and all-cause mortality rate in the moderate and severe malnutrition risk group (40% vs. 8%, 0%) were higher (P < 0.05). On multivariate logistic analysis, CONUT was not associated with readmission due to HF within 1 year. CONUT was significantly associated with all-cause mortality independently of GNRI or PNI, after adjustment for major confounders including age, bedridden; length of stay; history of chronic kidney disease; loop diuretics use; angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and beta-adrenergic blocking agents use; New York Heart Association (NYHA) functional class; hemoglobin; potassium; Creatinine; triglycerides; glycosylated hemoglobin; brain natriuretic peptide; left ventricular ejection fraction; GNRI and PNI via multivariable Cox analysis (HR (95% CI) 1.764 (1.503, 2.071); 1.646 (1.359, 1.992); 1.764 (1.503, 2.071), respectively). Kaplan-Meier analysis revealed that the risk of all-cause mortality significantly increased in accordance with a higher CONUT (CONUT 5-12 compare to 0-1:HR (95% CI) 6.16 (3.78, 10.06); CONUT 2-4 compare to 0-1:HR (95% CI) 0.16 (0.10, 0.26)). CONUT showed the best area under the curve value (0.789) for the prediction of all-cause mortality compared with the other objective nutritional indices.

CONCLUSION

CONUT is a simple and strong prognostic indicator for the prediction of all-cause mortality in older adults with HFpEF.

CLINICAL TRIALS

GOV IDENTIFIER

NCT05586828.

Development and validation of dynamic nomogram of frailty risk for older patients hospitalized with heart failure

Objective

This study aimed to establish and validate a dynamic online nomograph for predicting the risk of frailty in older patients hospitalized with heart failure in China.

Methods

A total of 451 older adults with heart failure hospitalized were selected between December 2021 and November 2022 at the Department of Cardiovascular Medicine in a Class A tertiary hospital in Shandong, China. The data of patients were obtained by using Barthel Index, instrumental activity of daily living scale, mini nutrition assessment-short form, Pittsburgh sleep quality index scale, Morse fall risk assessment scale and general information scale. The brain natriuretic peptide and echocardiographic indexes of patients were collected by electronic medical records. All participants were randomly divided into the training set (n = 319) and the validation set (n = 132) at the ratio of 7:3. The training set is used for model construction, and the validation set is used for internal validation. Using the Least Absolute Shrinkage and Selection Operator (LASSO) regression method to filter modeling variables, while the multivariable logistic regression was used to establish the nomogram based on the screened optimal variables. The performance of the model was evaluated by the area under the curve (AUC) of the receiver operator characteristic (ROC) curve, Hosmer-Lemeshow test, calibration plot, and decision curve analysis (DCA).

Results

The prevalence of frailty in 451 patients was 50.6%, 51.4%, and 48.5% in the training and validation sets, respectively. Drinking, grip strength, New York Heart Association (NYHA) class, multimorbidity, hospitalization history of heart failure, Barthel Index, the instrumental activities of daily living, nutritional status, sleep, fall, and left atrial end-diastolic diameter were used for LASSO regression analysis as the significant predictors of frailty. According to internal validation, the AUC of the ROC curve for the nomogram was 0.920, with a sensitivity of 86.8% and specificity of 84.4%. Moreover, in the validation set, the P-values of the H-L test were 0.742, and the calibration curve had good concordance between the estimated frailty risk and actual observation, indicating the model was well-calibrated. The DCA results confirmed that the nomogram had a well-performance in clinical suitability.

Conclusions

An online dynamic nomogram predicting frailty for older patients hospitalized for heart failure in China was well-established and identified in this study. This model benefits medical professionals in identifying high-risk frailty in older hospitalized patients with heart failure, which could reduce the medical and disease burden of heart failure to a certain extent. However, further verification is needed in the future.