Nutritional Deficiency in Patients with Heart Failure

The Hospital Frailty Risk Score as a Predictor of Mortality, Complications, and Resource Utilization in Heart Failure: Implications for Managing Critically Ill Patients

Background: Frailty, with a high prevalence of 40-80% in heart failure, may have a significant bearing on outcomes in patients. This study utilizes the Hospital Frailty Risk Score (HFRS), a validated tool derived from the administrative International Classification of Diseases, 10th Revision, Clinical Modifications (ICD-10-CM) codes, in investigating the mortality, morbidity, and healthcare resource utilization among heart failure hospitalizations using the Nationwide Inpatient Sample (NIS). Methods: A retrospective analysis of the 2021 NIS database was assessed to identify adult patients hospitalized with heart failure. These patients were stratified by the HFRS into three groups: low frailty (LF: <5), intermediate frailty (IF: 5-15), and high frailty (HF: >15). The outcomes analyzed included inpatient mortality, length of stay (LOS), hospitalization charges, and complications including cardiogenic shock, cardiac arrest, acute kidney injury, and acute respiratory failure. These outcomes were adjusted for age, race, gender, the Charlson comorbidity score, hospital location, region, and teaching status. Multivariate logistic and linear regression analyses were used to assess the association between frailty and clinical outcomes. STATA/MP 18.0 was used for statistical analysis. Results: Among 1,198,988 heart failure admissions, 47.5% patients were in the LF group, whereas the IF and HF groups had 51.1% and 1.4% patients, respectively. Compared to the LF group, the IF group showed a 4-fold higher (adjusted OR = 4.60, p < 0.01), and the HF group had an 11-fold higher (adjusted OR 10.90, p < 0.01) mortality. Frail patients were more likely to have a longer length of stay (4.24 days, 7.18 days, and 12.1 days in the LF, IF, and HF groups) and higher hospitalization charges (USD 49,081, USD 84,472, and USD 129,516 in the LF, IF, and HF groups). Complications were also noticed to be significantly (p < 0.01) higher with increasing frailty from the LF to HF groups. These included cardiogenic shock (1.65% vs. 4.78% vs. 6.82%), cardiac arrest (0.37% vs. 1.61% vs. 3.16%), acute kidney injury (19.2% vs. 54.9% vs. 74.6%), and acute respiratory failure (29.6% vs. 51.2% vs. 60.3%). Conclusions: This study demonstrates the application of HFRS in a national dataset as a predictor of outcome and resource utilization measures in heart failure admissions. Stratifying patients based on HFRS can help in holistic assessment, aid prognostication, and guide targeted interventions in heart failure.

The Dual Burden of Frailty and Heart Failure

Frailty is highly prevalent among patients with heart failure (HF) and independently predicts adverse outcomes. However, optimal frailty definitions, assessments, and management in HF remain unclear. Frailty is common in HF, affecting up to 80% of patients depending on population characteristics. Even pre-frailty doubles mortality risk versus robust patients. Frailty worsens HF prognosis through systemic inflammation, neurohormonal changes, sarcopenia, and micronutrient deficiency. Simple screening tools like gait speed and grip strength predict outcomes but lack HF-specificity. Comprehensive geriatric assessment is ideal but not always feasible. Exercise, nutrition, poly-pharmacy management, and multidisciplinary care models can help stablize frailty components and improve patient-centred outcomes. Frailty frequently coexists with and exacerbates HF. Routine frailty screening should guide supportive interventions to optimize physical, cognitive, and psychosocial health. Further research on HF-specific frailty assessment tools and interventions is warranted to reduce this dual burden.

Association between dietary selenium and zinc intake and risk of dilated cardiomyopathy in children: a case-control study

BACKGROUND

Dilated cardiomyopathy (DCMP) is characterized by the enlargement and weakening of the heart and is a major cause of heart failure in children. Infection and nutritional deficiencies are culprits for DCMP. Zinc is an important nutrient for human health due to its anti-oxidant effect that protects cell against oxidative damage. This case-control study aimed to investigate the relationship between dietary intake of zinc and selenium and the risk of DCMP in pediatric patients.

METHODS

A total of 36 DCMP patients and 72 matched controls were recruited, and their dietary intakes were assessed via a validated food frequency questionnaire. We used chi-square and sample T-test for qualitative and quantitative variables, respectively. Logistic regression analysis was applied to assess the relationship between selenium and zinc intake with the risk of DCMP.

RESULTS

After fully adjusting for confounding factors, analyses showed that selenium (OR = 0.19, CI = 0.057-0.069, P trend < 0.011) and zinc (OR = 0.12, CI = 0.035-0.046, P trend < 0.002) intake were strongly associated with 81% and 88% lower risk of pediatric DCMP, respectively.

CONCLUSIONS

This study highlights the protective role of adequate dietary intake of selenium and zinc in decreasing the risk of DCMP in children. Malnutrition may exacerbate the condition and addressing these micronutrient deficiencies may improve the cardiac function. Further studies are recommended to detect the underlying mechanisms and dietary recommendations for DCMP prevention.

Mediterranean Diet, Vitamin D, and Hypercaloric, Hyperproteic Oral Supplements for Treating Sarcopenia in Patients with Heart Failure-A Randomized Clinical Trial

BACKGROUND

Malnutrition and sarcopenia frequently affect patients with heart failure (HF), in which clinical outcomes and survival is decreased. Thus, appropriate nutritional screening and early nutrition support are highly recommended. Currently, nutritional support is not a standard of care in patients with HF, and the use of commercially available oral supplements (OSs) could provide an additional benefit to medical treatment in these patients.

AIM

To compare the effect of the Mediterranean diet in combination with hypercaloric, hyperproteic OS in patients with HF.

PATIENTS AND METHODS

An open label, controlled clinical study in which patients were randomly assigned to receive a Mediterranean diet (control group) vs. hypercaloric, hyperproteic OS (intervention group) for twenty-four weeks. Thirty-eight patients were included; epidemiological, clinical, anthropometric, ultrasound (muscle echography of the rectus femoris muscle of the quadriceps and abdominal adipose tissue), and biochemical evaluations were performed. All patients received additional supplementation with vitamin D.

RESULTS

Baseline malnutrition according to the GLIM criteria was observed in 30% of patients, while 65.8% presented with sarcopenia. Body cell mass, lean mass, and body mass increased in the intervention group (absolute increase of 0.5, p = 0.03, 1.2 kg, p = 0.03, and 0.1 kg, p = 0.03 respectively). In contrast, fat mass increased in the control group (4.5 kg, p = 0.05). According to the RF ultrasound, adipose tissue, muscle area, and circumference tended to decrease in the intervention group; it is probable that 24 weeks was too short a period of time for evaluating changes in muscle area or circumference, as previously observed in another group of patients. In contrast, functionality, determined by the up-and-go test, significantly improved in all patients (difference 12.6 s, p < 0.001), including the control (10 s improvement, p < 0.001) and the intervention group (improvement of 8.9 s, p < 0.001). Self-reported QoL significantly increased in all groups, from 68.7 ± 22.2 at baseline to 77.7 ± 18.7 (p = 0.01). When heart functionality was evaluated, LVEF increased in the whole cohort (38.7 ± 16.6 vs. 42.2 ± 8.9, p < 0.01); this increase was higher in the intervention group (34.2 ± 16.1 at baseline vs. 45.0% ± 17.0 after 24 weeks, p < 0.05). Serum values of NT-proBNP also significantly decreased in the whole cohort (p < 0.01), especially in the intervention group (p = 0.02). After adjusting by age and sex, nutritional support, baseline LVEF, NT-proBNP, and body composition parameters of functionality tests were not associated with mortality or new hospital admissions in this cohort.

CONCLUSION

Nutritional support with hypercaloric, hyperproteic OS, Mediterranean diet, and vitamin D supplementation were associated with decreased NT-proBNP and improvements in LVEF, functionality, and quality of life in patients with HF, despite a significant decrease in hospital admissions.

Micronutrients/miRs/ATP networking in mitochondria: Clinical intervention with ferroptosis, cuproptosis, and calcium burden

The mitochondrial electron transport chain (mtETC) requires mainly coenzyme Q10 (CoQ10), copper (Cu2+), calcium (Ca2+), and iron (Fe2+) ions for efficient ATP production. According to cross-sectional research, up to 50% of patients with micronutrient imbalances have been linked to oxidative stress, mitochondrial dysfunction, reduced ATP production, and the prognosis of various diseases. The condition of ferroptosis, which is caused by the downregulation of CoQ10 and the activation of non-coding micro RNAs (miRs), is strongly linked to free radical accumulation, cancer, and neurodegenerative diseases. The entry of micronutrients into the mitochondrial matrix depends upon the higher threshold level of mitochondrial membrane potential (ΔΨm), and high cytosolic micronutrients. The elevated micronutrient in the mitochondrial matrix causes the utilization of all ATP, leading to a drop in ATP levels. Mitochondrial calcium uniporter (MCU) and Na+/Ca2+ exchanger (NCX) play a major role in Ca2+ influx in the mitochondrial matrix. The mitochondrial Ca2+ overload is regulated by specific miRs such as miR1, miR7, miR25, miR145, miR138, and miR214, thereby reducing apoptosis and improving ATP production. Cuproptosis is primarily brought on by increased Cu+ build-up and mitochondrial proteotoxic stress, mediated by ferredoxin-1 (FDX1) and long non-coding RNAs. Cu importers (SLC31A1) and exporters (ATP7B) influence intracellular Cu2+ levels to control cuproptosis. According to literature reviews, very few randomized micronutrient interventions have been carried out, despite the identification of a high prevalence of micronutrient deficiencies. In this review, we concentrated on essential micronutrients and specific miRs associated with ATP production that balance oxidative stress in mitochondria.

Diagnosis and Management of Malnutrition in Patients with Heart Failure

Heart failure is a disease with an increasingly greater prevalence due to the aging population, the development of new drugs, and the organization of healthcare processes. Malnutrition has been identified as a poor prognostic factor in these patients, very often linked to frailty or to other comorbidities, meaning that early diagnosis and treatment are essential. This paper reviews some important aspects of the pathophysiology, detection, and management of malnutrition in patients with heart failure.

Red cell distribution width (RDW) is correlated to time of oxygen desaturation < 90% and length of sleep apneas in patients with sleep disorder breathing (SDB) and acute heart failure with preserved ejection fraction (HFpEF)

Background

Heart failure with preserved ejection fraction (HFpEF) is very frequently associated to sleep breathing disorders (SDB). Red blood cell distribution width (RDW) has been shown to be a potential inflammatory index linked to the degree of hypoxia and oxidative stress.

Aim

To identify the existence of a possible relationship between sleep apnea, oxygen saturation (SaO2) and RDW in a population of subjects affected by acute HFpEF (AHFpEF).

Methods

AHFpEF patients with known history of SDB were enrolled and performed blood chemistry, echocardiography, and 24-h polysomnography (PSG).

Results

A total of 34 acute HFpEF patients (mean age 72.8 +/-8.63) were enrolled in the study. A control group of 24 non-HF patients were considered. Compared to controls, HFpEF patients showed a higher mean apnea hypopnea index (AHI), with prevalence of central apneas. A moderate to severe desaturation pattern was observed in AHFpEF vs. controls. RDW was significantly higher in AHFpEF patients vs. controls (mean value 14.7 +/-2.6 % vs. 9.1 +/-2.2, p < 0.05). In AHFpEF, RDW showed a positive correlation with time of SaO2 < 90% (r = 0.35, p = 0.04), and with mean length of apneic events (60 +/-28 s, r = 0.29, p = 0.03).

Conclusion

In patients with AHFpEF and SDB, a dependence relationship between RDW and duration of oxygen desaturation was observed, as if oxidative stress and inflammation related to RDW increase could also be linked to severity of sleep disorders in this population.

Analysis of malnutrition factors for inpatients with chronic kidney disease

Objective

Malnutrition is a common complication of Chronic Kidney Disease (CKD), and it is the risk factor of CKD prognosis. This study aim to evaluate the nutritional status of inpatients with CKD by using the Subjective Global Assessment (SGA), and to analyze the related factors of malnutrition; and to provide effective reference for early detection of malnutrition status in patients with CKD and timely nutrition intervention.

Methods

A total of 426 patients (238 male patients, 188 female patients) aged 62.62 ± 14.61 and 61.14 ± 14.82, respectively admitted to the Nephrology Department of Wannan Medical College from February 2020 to December 2020 were selected and included in to this study by convenience sampling. 426 patients with CKD were evaluated by SGA. Human body weight, hemoglobin (Hb), total protein (TP), albumin (ALB), pre-albumin (PA), qualitative analysis of urinary protein and other laboratory indexes were collected and measured. The correlation between malnutrition and age, education, gender, diet, CKD stage and other factors was analyzed by spearman correlation analysis.

Results

The incidence of malnutrition was 85.7% among 426 patients with CKD. Gender, age, education level, CKD stage, diabetes mellitus, weight loss and reduced food intake were related to SGA nutritional assessment (P < 0.05). The expression levels of ALB, PA and Hb in the malnutrition group were significantly lower than those in the normal group (P < 0.05). The degree of malnutrition in CKD patients was significant negatively correlated with the expression levels of ALB (r = -0.188), PA (r = -0.262) and Hb (r = -0.176) (P < 0.05). The multivariate Logistic regression analysis model showed that female (OR = 2.155), ≥60 years old (OR = 7.671), weight loss (OR = 10.691), reduced food intake (OR = 28.953), moderate and severe serum ALB expression (OR = 3.391 and 8.326) were risk factors for malnutrition in patients with CKD (P < 0.05). Malnutrition was correlated with the results of qualitative examination of urinary protein (r = 0.268, P < 0.05).

Conclusion

Gender, age, weight loss, reduced food intake, serum ALB expression were independently associated with malnutrition in patients with chronic kidney disease, Hence, the medical staff should take timely and effective nutrition intervention for the patients with malnutrition, delay the renal function damage of patients with CKD and improve the quality of life of patients. Inpatients with CKD, especially women, should increase their dietary intake, maintain normal weight and improve their nutritional status.

Micronutrient deficiencies in heart failure: Mitochondrial dysfunction as a common pathophysiological mechanism?

Heart failure is a devastating clinical syndrome, but current therapies are unable to abolish the disease burden. New strategies to treat or prevent heart failure are urgently needed. Over the past decades, a clear relationship has been established between poor cardiac performance and metabolic perturbations, including deficits in substrate uptake and utilization, reduction in mitochondrial oxidative phosphorylation and excessive reactive oxygen species production. Together, these perturbations result in progressive depletion of cardiac adenosine triphosphate (ATP) and cardiac energy deprivation. Increasing the delivery of energy substrates (e.g., fatty acids, glucose, ketones) to the mitochondria will be worthless if the mitochondria are unable to turn these energy substrates into fuel. Micronutrients (including coenzyme Q10, zinc, copper, selenium and iron) are required to efficiently convert macronutrients to ATP. However, up to 50% of patients with heart failure are deficient in one or more micronutrients in cross-sectional studies. Micronutrient deficiency has a high impact on mitochondrial energy production and should be considered an additional factor in the heart failure equation, moving our view of the failing myocardium away from an "an engine out of fuel" to "a defective engine on a path to self-destruction." This summary of evidence suggests that supplementation with micronutrients-preferably as a package rather than singly-might be a potential therapeutic strategy in the treatment of heart failure patients.

Fluid and Salt Balance and the Role of Nutrition in Heart Failure

The main challenges in heart failure (HF) treatment are to manage patients with refractory acute decompensated HF and to stabilize the clinical status of a patient with chronic heart failure. Beyond the use of medications targeted in the inhibition of the neurohormonal system, the balance of salt and fluid plays an important role in the maintenance of clinical compensation in respect of renal function. In the case of heart failure, a debate of opinion exists on salt restriction. Restricted dietary sodium might lead to worse outcomes in heart failure patients due to the activation of the neurohormonal system and malnutrition. On the contrary, positive sodium balance is the primary driver of water retention and, ultimately, volume overload in acute HF. Some recent studies reported associations of decreased salt consumption with higher readmission rates and increased mortality. Thus, the usefulness of salt restriction in heart failure management remains debated. The use of individualized nutritional support, compared with standard hospital food, was effective in reducing these risks, particularly in the group of patients at high nutritional risk.

The Impact of Frailty and Comorbidities on Heart Failure Outcomes

Frailty is a multisystemic process leading to reduction of physiological reserve and a reduction in physical activity. Heart failure (HF) is recognised as a global cause of morbidity and mortality, increasing in prevalence over recent decades. Because of shared phenotypes and comorbidities, there is significant overlap and a bidirectional relationship, with frail patients being at increased risk of developing HF and vice versa. Despite this, frailty is not routinely assessed in patients with HF. Identification of these patients to direct multidisciplinary care is key, and the development of a frailty assessment tool validated in a large HF population is also an unmet need that would be of considerable benefit in directing multidisciplinary-team management. Non-pharmacological treatment should be included, as exercise and physical rehabilitation programmes offer dual benefit in frail HF patients, by treating both conditions simultaneously. The evidence for nutritional supplementation is mixed, but there is evidence that a personalised approach to nutritional support in frail HF patients can improve outcomes.

Food insecurity and cardiovascular disease: Current trends and future directions

Food insecurity (FI) - a state of limited access to nutritionally adequate food - is notably more prominent among patients with cardiovascular disease (CVD) than the general population. Current research suggests that FI increases the risk of cardiovascular morbidity and mortality through various behavioral and biological pathways. Importantly, FI is more prevalent among low-income households and disproportionately affects households with children, particularly those led by single mothers. These disparities necessitate solutions specifically geared towards helping these high-risk subgroups, who also experience increased risk of CVD associated with FI. Further, individuals with CVD may experience increased risk of FI due to the financial burden imposed by CVD care. While participation in federal aid programs like the Supplemental Nutrition Assistance Program and the Special Supplemental Nutrition Program for Women, Infants, and Children has been associated with cardiovascular health benefits, residual FI and lower dietary quality among many families suggest a need for better outreach and expanded public assistance programs. Healthcare systems and community organizations can play a vital role in screening individuals for FI and connecting them with food and educational resources. While further research is needed to evaluate sociodemographic differences in the FI-CVD relationship, interventions at the policy, health system, and community levels can help address both the burden of FI and its impacts on cardiovascular health.

A novel nutritional index as a predictor of mortality in dilated cardiomyopathy: a retrospective study

BACKGROUND

Research has associated nutritional status with the prognosis of cardiovascular diseases. This study aimed to investigate the prognostic value of a novel nutritional index, triglycerides × total cholesterol × body weight index (TCBI), in patients with dilated cardiomyopathy (DCM).

METHODS

This retrospective cohort study enrolled 445 patients with DCM. The median follow-up period was 2.8 years, and the primary endpoint was all-cause death.

RESULTS

During follow-up, the all-cause mortality was observed in 135 out of 445 patients (30.3%). In Kaplan-Meier survival analysis, the third TCBI tertile had a lower mortality risk (T3 vs. T2 vs. T1: 16.9% vs. 35.1% vs. 38.9%; log-rank P < 0.001). In the multivariable Cox regression analysis, patients in the third tertile were associated with a decreased mortality, whereas there was no significant difference between the T2 and T1 groups. Moreover, TCBI could significantly improve risk stratification (continuous net reclassification improvement and integrated discrimination improvement) over the Geriatric Nutritional Risk Index (GNRI) and N-terminal pro-brain natriuretic peptide (NT-proBNP).

CONCLUSIONS

TCBI is independently associated with long-term survival in patients with DCM. Combination of TCBI and other biomarkers, such as GNRI and NT-proBNP, can significantly improve prognostic prediction. Further studies with larger sample size are required to validate our results.

Dietary Management of Heart Failure: DASH Diet and Precision Nutrition Perspectives

Heart failure (HF) is a major health care burden increasing in prevalence over time. Effective, evidence-based interventions for HF prevention and management are needed to improve patient longevity, symptom control, and quality of life. Dietary Approaches to Stop Hypertension (DASH) diet interventions can have a positive impact for HF patients. However, the absence of a consensus for comprehensive dietary guidelines and for pragmatic evidence limits the ability of health care providers to implement clinical recommendations. The refinement of medical nutrition therapy through precision nutrition approaches has the potential to reduce the burden of HF, improve clinical care, and meet the needs of diverse patients. The aim of this review is to summarize current evidence related to HF dietary recommendations including DASH diet nutritional interventions and to develop initial recommendations for DASH diet implementation in outpatient HF management. Articles involving human studies were obtained using the following search terms: Dietary Approaches to Stop Hypertension (DASH diet), diet pattern, diet, metabolism, and heart failure. Only full-text articles written in English were included in this review. As DASH nutritional interventions have been proposed, limitations of these studies are the small sample size and non-randomization of interventions, leading to less reliable evidence. Randomized controlled interventions are needed to offer definitive evidence related to the use of the DASH diet in HF management.

Concentrations of Mg, Ca, Fe, Cu, Zn, P and anthropometric and biochemical parameters in adults with chronic heart failure

Background

The study investigated the relationship between the concentrations of Mg, Ca, Fe, Cu, Zn, P and anthropometric and biochemical parameters in the blood serum of patients with heart failure (HF) and the potential influence on the development and progression of HF.

Material & methods

The study included 214 patients (155 men and 59 women), aged 40–87 years, presenting symptoms or signs typical of HF (according to the NYHA functional classification). Serum concentrations were determined for Mg, Ca, Fe, Cu, Zn, P, C-reactive protein (CRP), creatinine, urea, triglyceride levels (TG), total cholesterol (CH), high density protein (HDL), low density protein (LDL). The levels of macro-and microminerals were analysed using inductively coupled serum optical emission spectrometry (ICP-OES).

Results

Our study confirmed the role of known risk factors in the development of heart failure, including: overweight, diabetes, hypertension, high triglycerides (TG), high total cholesterol (CH), high levels of low density protein (LDL) and reduced levels of high density protein (HDL), high CRP, high creatinine. Moreover, deficient serum concentrations of Mg (47% of the studied men and 54% of the women) and Cu (in 44% of men and more than 30% of women) were observed, as well as subnormal serum Fe (2% of women) and Zn (1% of men). Elevated serum Ca was found in 50% of men and 49% of women. In 44% of the studied men and 52% of the studied women, P levels in serum were also above-average. The study revealed a significant positive correlation between serum levels of Ca and Mg, and also Ca and Cu in women. In men, serum Cu was positively correlated with Mg and Ca concentrations. In patients from group 1 (NYHA I–II), Mg content was positively correlated with Ca and Cu. In this patient group, Ca was also positively associated with Cu content in serum. In group 2 (NYHA III-IV), serum Mg concentration was significantly positively correlated with that of Cu and Ca.

Conclusions

Changes in the serum concentrations of macro-and microminerals may significantly affect the severity of HF in Polish patients.

Selenoprotein DIO2 Is a Regulator of Mitochondrial Function, Morphology and UPRmt in Human Cardiomyocytes

Members of the fetal-gene-program may act as regulatory components to impede deleterious events occurring with cardiac remodeling, and constitute potential novel therapeutic heart failure (HF) targets. Mitochondrial energy derangements occur both during early fetal development and in patients with HF. Here we aim to elucidate the role of DIO2, a member of the fetal-gene-program, in pluripotent stem cell (PSC)-derived human cardiomyocytes and on mitochondrial dynamics and energetics, specifically. RNA sequencing and pathway enrichment analysis was performed on mouse cardiac tissue at different time points during development, adult age, and ischemia-induced HF. To determine the function of DIO2 in cardiomyocytes, a stable human hPSC-line with a DIO2 knockdown was made using a short harpin sequence. Firstly, we showed the selenoprotein, type II deiodinase (DIO2): the enzyme responsible for the tissue-specific conversion of inactive (T4) into active thyroid hormone (T3), to be a member of the fetal-gene-program. Secondly, silencing DIO2 resulted in an increased reactive oxygen species, impaired activation of the mitochondrial unfolded protein response, severely impaired mitochondrial respiration and reduced cellular viability. Microscopical 3D reconstruction of the mitochondrial network displayed substantial mitochondrial fragmentation. Summarizing, we identified DIO2 to be a member of the fetal-gene-program and as a key regulator of mitochondrial performance in human cardiomyocytes. Our results suggest a key position of human DIO2 as a regulator of mitochondrial function in human cardiomyocytes.

Creatine deficiency and heart failure

Impaired cardiac energy metabolism has been proposed as a mechanism common to different heart failure aetiologies. The energy-depletion hypothesis was pursued by several researchers, and is still a topic of considerable interest. Unlike most organs, in the heart, the creatine kinase system represents a major component of the metabolic machinery, as it functions as an energy shuttle between mitochondria and cytosol. In heart failure, the decrease in creatine level anticipates the reduction in adenosine triphosphate, and the degree of myocardial phosphocreatine/adenosine triphosphate ratio reduction correlates with disease severity, contractile dysfunction, and myocardial structural remodelling. However, it remains to be elucidated whether an impairment of phosphocreatine buffer activity contributes to the pathophysiology of heart failure and whether correcting this energy deficit might prove beneficial. The effects of creatine deficiency and the potential utility of creatine supplementation have been investigated in experimental and clinical models, showing controversial findings. The goal of this article is to provide a comprehensive overview on the role of creatine in cardiac energy metabolism, the assessment and clinical value of creatine deficiency in heart failure, and the possible options for the specific metabolic therapy.

Relevance of nutritional assessment and treatment to counteract cardiac cachexia and sarcopenia in chronic heart failure

Chronic heart failure (CHF) is frequently associated with the involuntary loss of body weight and muscle wasting, which can determine the course of the disease and its prognosis. While there is no gold standard malnutrition screening tool for their detection in the CHF population, several bioelectrical and imaging methods have been used to assess body composition in these patients (such as Dual Energy X-Ray Absorptiometry and muscle ultrasound, among other techniques). In addition, numerous nutritional biomarkers have been found to be useful in the determination of the nutritional status. Nutritional considerations include the slow and progressive supply of nutrients, avoiding high volumes, which could ultimately lead to refeeding syndrome and worsen the clinical picture. If oral feeding is insufficient, hypercaloric and hyperproteic supplementation should be considered. β-Hydroxy-β-methylbutyrate and omega-3 polyunsaturated fatty acid administration prove to be beneficial in certain patients with CHF, and several interventional studies with micronutrient supplementation have also described their possible role in these subjects. Taking into account that CHF is sometimes associated with gastrointestinal dysfunction, parenteral nutritional support may be required in selected cases. In addition, potential therapeutic options regarding nutritional state and muscle wasting have also been tested in clinical studies. This review summarises the scientific evidence that demonstrates the necessity to carry out a careful nutritional evaluation and nutritional treatment to prevent or improve cardiac cachexia and sarcopenia in CHF, as well as improve its course.

Congestive Heart Failure Exhibited Higher BMI With Lower Energy Intake and Lower Physical Activity Level: Data From the National Health and Examination Nutrition Survey

Background: Despite that nutritional deficiency existed in congestive heart failure (CHF), there is a large amount of CHF patients suffering from obesity. This study aimed to identify the differences for increased BMI or obesity in CHF patients.

Methods: This cross-sectional study included adults from the National Health and Nutrition Examination Survey 2007–2016. Differences were compared between CHF participants vs. non-CHF participants, and BMI ≥ 30 kg/m² vs. BMI < 30 kg/m² CHF participants.

Results: CHF participants were with higher BMI, lower energy and macronutrient intake, lower physical activity level and longer rest time, and lower hematocrit and hemoglobin level (all P < 0.05) than non-CHF participants. The prevalence of BMI ≥ 30 kg/m² in participants with CHF was 53.48%. There was no significant difference observed in energy and macronutrient intake between CHF participants with BMI ≥ 30 kg/m² or <30 kg/m². The water intake (P = 0.032), sedentary time (P = 0.002), and hematocrit (P = 0.028) were significantly different between CHF with BMI ≥ 30 kg/m² and with <30 kg/m².

Conclusion: Compared with non-CHF participants, CHF participants exhibited higher BMI with lower energy and macronutrient intake, lower physical activity level, longer rest time, and hemodilution with lower hematocrit and hemoglobin level. Among CHF participants with BMI ≥ 30 kg/m², higher sedentary time and hematocrit were observed.

Handgrip strength in patients with acute decompensated heart failure: Accuracy as a predictor of malnutrition and prognostic value

OBJECTIVES

The aim of this study was to determine whether handgrip strength (HGS) has diagnostic accuracy for malnutrition assessment and whether it is an independent predictor of 90-d mortality in patients with acute decompensated heart failure (ADHF).

METHODS

This cohort study evaluated patients with ADHF within 36 h of hospital admission. Subjective global assessment and handgrip dynamometry were performed and the patients' medical records were analyzed. Mortality was monitored by phone contact and/or medical record search after 90 d. Diagnostic accuracy was tested with receiver operating characteristic (ROC) curves, and survival was tested in a Cox model.

RESULTS

The sample consisted of 161 patients with ADHF who were predominantly male (62%) and older (77%), with a mean age of 68 y (60-75 y) and an ejection fraction of 37.7% ± 16.2%. According to subjective global assessment, 60% were suspected of malnourishment or were moderately or severely malnourished and these patients had lower HGS values than the well-nourished patients (P < 0.001). The ROC curve for HGS was sufficiently accurate to assess malnutrition (area under the curve [AUC] = 0.696; 95% confidence interval [CI], 0.614-0.779; P < 0.001) and had very good accuracy to predict severe malnutrition (AUC = 0.817; 95% CI, 0.711-0.923, P < 0.001). When analyzed by sex, HGS could only accurately detect malnutrition in men, although it could detect severe malnutrition in both men and women. During the 90-d follow-up period, there were 16 deaths (9.9%). An HGS cutoff value of 25.5 kg for men was considered significant for 90-d mortality (hazard ratio, 8.6; 95% CI, 1.1-70.9; P = 0.045).

CONCLUSION

The results suggested that HGS is an independent indicator of malnutrition in patients with ADHF and can serve as a prognostic marker of 3-mo mortality in men.

High-protein vs. standard-protein diets in overweight and obese patients with heart failure and diabetes mellitus: findings of the Pro-HEART trial

AIMS

The intermediate-term effects of dietary protein on cardiometabolic risk factors in overweight and obese patients with heart failure and diabetes mellitus are unknown. We compared the effect of two calorie-restricted diets on cardiometabolic risk factors in this population.

METHODS AND RESULTS

In this randomized controlled study, 76 overweight and obese (mean weight, 107.8 ± 20.8 kg) patients aged 57.7 ± 9.7 years, 72.4% male, were randomized to a high-protein (30% protein, 40% carbohydrates, and 30% fat) or standard-protein diet (15% protein, 55% carbohydrates, and 30% fat) for 3 months. Reductions in weight and cardiometabolic risks were evaluated at 3 months. Both diets were equally effective in reducing weight (3.6 vs. 2.9 kg) and waist circumference (1.9 vs. 1.3 cm), but the high-protein diet decreased to a greater extent glycosylated haemoglobin levels (0.7% vs. 0.1%, P = 0.002), cholesterol (16.8 vs. 0.9 mg/dL, P = 0.031), and triglyceride (25.7 vs. 5.7 mg/dL, P = 0.032), when compared with the standard-protein diet. The high-protein diet also significantly improved both systolic and diastolic blood pressure than the standard-protein diet (P < 0.001 and P = 0.040, respectively).

CONCLUSIONS

Both energy-restricted diets reduced weight and visceral fat. However, the high-protein diet resulted in greater reductions in cardiometabolic risks relative to a standard-protein diet. These results suggest that a high-protein diet may be more effective in reducing cardiometabolic risk in this population, but further trials of longer duration are needed.

Iron deficiency as therapeutic target in heart failure: a translational approach

Heart failure (HF) is a potentially debilitating condition, with a prognosis comparable to many forms of cancer. It is often complicated by anemia and iron deficiency (ID), which have been shown to even further harm patients' functional status and hospitalization risk. Iron is a cellular micronutrient that is essential for oxygen uptake and transportation, as well as mitochondrial energy production. Iron is crucially involved in electrochemical stability, maintenance of structure, and contractility of cardiomyocytes. There is mounting evidence that ID indeed hampers the homeostasis of these properties. Animal model and stem cell research has verified these findings on the cellular level, while clinical trials that treat ID in HF patients have shown promising results in improving real patient outcomes, as electromechanically compromised cardiomyocytes translate to HF exacerbations and arrhythmias in patients. In this article, we review our current knowledge on the role of iron in cardiac muscle cells, the contribution of ID to anemia and HF pathophysiology and the capacity of IV iron therapy to ameliorate the patients' arrhythmogenic profile, quality of life, and prognosis.

Impact of Inadequate Calorie Intake on Mortality and Hospitalization in Stable Patients with Chronic Heart Failure

Malnutrition is highly prevalent in patients with heart failure (HF), but the precise impact of dietary energy deficiency on HF patients' clinical outcomes is not known. We investigated the associations between inadequate calorie intake and adverse clinical events in 145 stable outpatients with chronic HF who had a history of hospitalization due to worsening HF. To assess the patients' dietary pattern, we used a brief self-administered diet-history questionnaire (BDHQ). Inadequate calorie intake was defined as <60% of the estimated energy requirement. In the total chronic HF cohort, the median calorie intake was 1628 kcal/day. Forty-four patients (30%) were identified as having an inadequate calorie intake. A Kaplan-Meier analysis revealed that the patients with inadequate calorie intake had significantly worse clinical outcomes including all-cause death and HF-related hospitalization during the 1-year follow-up period versus those with adequate calorie intake (20% vs. 5%, p < 0.01). A multivariate logistic regression analysis showed that inadequate calorie intake was an independent predictor of adverse clinical events after adjustment for various factors that may influence patients' calorie intake. Among patients with chronic HF, inadequate calorie intake was associated with an increased risk of all-cause mortality and rehospitalization due to worsening HF. However, our results are preliminary and larger studies with direct measurements of dietary calorie intake and total energy expenditure are needed to clarify the intrinsic nature of this relationship.

Nutrition as Treatment Modality in Heart Failure

PURPOSE OF REVIEW

This review aims to discuss recent evidence and controversies regarding nutrition as a treatment modality for heart failure (HF) patients.

RECENT FINDINGS

Adequate nutrition is known to promote health-related quality of life by addressing malnutrition and promoting optimal functioning among older adults and has an established role in the prevention of HF; however, evidence is limited on the effects of nutrition as a treatment modality in HF. While guidance of sodium restriction to address fluid overload is an ongoing debate among experts, evidence from case studies and small clinical trials suggest a positive impact of plant-based and Dietary Approaches to Stop Hypertension (DASH) dietary patterns on HF-related pathophysiology, quality of life, hospital admissions, and mortality. More clinical trials are needed to establish an evidence base to support dietary management strategies for patients with HF. Clinical and Translational Science Alliances (CTSAs) may provide infrastructure to overcome enrollment barriers.

＜Editors' Choice＞ Prognostic utility of multipoint nutritional screening for hospitalized patients with acute decompensated heart failure

This study aimed to evaluate the impact of serial changes in nutritional status on 1-year events including all-cause mortality or rehospitalization owing to heart failure (HF) among hospitalized patients with acute decompensated HF (ADHF). The study subjects comprised 253 hospitalized patients with ADHF. The controlling nutritional status (CONUT) score was assessed both at hospital admission and discharge. The subjects were divided into three groups according to nutritional status using CONUT score: normal (0 and 1), mild risk (2-4), and moderate to severe risk defined as malnutrition (5-12). We observed nutritional status was improved or not. The incidence of malnutrition was 30.4% at hospital admission and 23.7% at discharge, respectively. Malnutrition was independently associated with 1-year events among hospitalized patients with ADHF. Presence or absence of improvement in nutritional status was significantly associated with 1-year events (P < 0.05), that was independent of percentage change in plasma volume in multivariate Cox regression analyses. We determined a reference model, including gender and estimated glomerular filtration rate, using multivariate logistic regression analysis (P < 0.05). Adding the absence of improvement in nutritional status during hospitalization to the reference model significantly improved both NRI and IDI (0.563, P < 0.001 and 0.039, P = 0.001). Furthermore, malnutrition at hospital discharge significantly improved NRI (0.256, P = 0.036) In conclusion, serial changes in the nutritional status evaluated on the basis of multiple measurements may provide more useful information to predict 1-year events than single measurement at hospital admission or discharge in hospitalized patients with ADHF.

The effect of malnutrition on the infectious outcomes of hospitalized patients with cirrhosis: analysis of the 2011-2017 hospital data

BACKGROUND

In patients with cirrhosis, there is a clinical concern that the development of protein-calorie malnutrition will affect the immune system and predispose these patients to increased infectious outcomes.

AIMS

In this study, we evaluate the effects of malnutrition on the infectious outcomes of patients admitted with cirrhosis.

MATERIALS AND METHODS

This study used the 2011-2017 National Inpatient Sample to identify patients with cirrhosis. These patients were stratified using malnutrition (protein-calorie malnutrition, cachexia, and sarcopenia) and matched using age, gender, and race with 1:1 nearest neighbor matching method. The endpoints included mortality and infectious outcomes.

RESULTS

After matching, there were 96 842 malnutrition-present cohort and equal number of controls. In univariate analysis, the malnutrition cohort had higher hospital mortality [10.40 vs. 5.04% P < 0.01, odds ratio (OR) 2.18, 95% confidence interval (CI) 2.11-2.26]. In multivariate models, malnutrition was associated with increased mortality [P < 0.01, adjusted odds ratio (aOR) 1.32, 95% CI 1.27-1.37] and infectious outcomes, including sepsis (P < 0.01, aOR 1.94, 95% CI 1.89-2.00), pneumonia (P < 0.01, aOR 1.68, 95% CI 1.63-1.73), UTI (P < 0.01, aOR 1.39, 95% CI 1.35-1.43), cellulitis (P < 0.01, aOR 1.09, 95% CI 1.05-1.13), cholangitis (P < 0.01, aOR 1.39, 95% CI 1.26-1.55), and clostridium difficile (P < 0.01, aOR 2.11, 95% CI 1.92-2.31).

CONCLUSION

The results of this study indicate that malnutrition is an independent risk factor of hospital mortality and local/systemic infections in patients admitted with cirrhosis.

Pathophysiological Basis for Nutraceutical Supplementation in Heart Failure: A Comprehensive Review

There is evidence demonstrating that heart failure (HF) occurs in 1-2% of the global population and is often accompanied by comorbidities which contribute to increasing the prevalence of the disease, the rate of hospitalization and the mortality. Although recent advances in both pharmacological and non-pharmacological approaches have led to a significant improvement in clinical outcomes in patients affected by HF, residual unmet needs remain, mostly related to the occurrence of poorly defined strategies in the early stages of myocardial dysfunction. Nutritional support in patients developing HF and nutraceutical supplementation have recently been shown to possibly contribute to protection of the failing myocardium, although their place in the treatment of HF requires further assessment, in order to find better therapeutic solutions. In this context, the Optimal Nutraceutical Supplementation in Heart Failure (ONUS-HF) working group aimed to assess the optimal nutraceutical approach to HF in the early phases of the disease, in order to counteract selected pathways that are imbalanced in the failing myocardium. In particular, we reviewed several of the most relevant pathophysiological and molecular changes occurring during the early stages of myocardial dysfunction. These include mitochondrial and sarcoplasmic reticulum stress, insufficient nitric oxide (NO) release, impaired cardiac stem cell mobilization and an imbalanced regulation of metalloproteinases. Moreover, we reviewed the potential of the nutraceutical supplementation of several natural products, such as coenzyme Q10 (CoQ10), a grape seed extract, Olea Europea L.-related antioxidants, a sodium-glucose cotransporter (SGLT2) inhibitor-rich apple extract and a bergamot polyphenolic fraction, in addition to their support in cardiomyocyte protection, in HF. Such an approach should contribute to optimising the use of nutraceuticals in HF, and the effect needs to be confirmed by means of more targeted clinical trials exploring the efficacy and safety of these compounds.

The influence of lifestyle factors on miRNA expression and signal pathways: a review

The term 'lifestyle' includes different factors that contribute to the maintenance of a good health status. Increasing evidences suggest that lifestyle factors may influence epigenetic mechanisms, such as miRNAs expression. The dysregulation of miRNAs can modify the expression of genes and molecular pathways that may lead to functional alterations. This review summarizes human studies highlighting that diet, physical activity, smoking and alcohol consumption may affect the miRNA machinery and several biological functions. Most miRNAs are involved in molecular pathways that influence inflammation, cell cycle regulation and carcinogenesis resulting in the onset or progression of pathological conditions. Investigating these interactions will be pivotal for understanding the etiology of pathologic processes, the potential new treatment strategies and for preventing diseases.

Iron status, catabolic/anabolic balance, and skeletal muscle performance in men with heart failure with reduced ejection fraction

BACKGROUND

Metabolic derangements related to tissue energetics constitute an important pathophysiological feature of heart failure. We investigated whether iron deficiency and catabolic/anabolic imbalance contribute to decreased skeletal muscle performance in men with heart failure with reduced ejection fraction (HFrEF), and whether these pathologies are related to each other.

METHODS

We comprehensively examined 23 men with stable HFrEF (median age [interquartile range]: 63 [59-66] years; left ventricular ejection fraction: 28 [25-35]%; New York Heart Association class I/II/III: 17/43/39%). We analyzed clinical characteristics, iron status, hormones, strength and fatigability of forearm flexors and quadriceps (surface electromyography), and exercise capacity (6-minute walking test).

RESULTS

None of the patients had anemia whereas 8 were iron-deficient. Flexor carpi radialis fatigability correlated with lower reticulocyte hemoglobin content (CHR, p < 0.05), and there was a trend towards greater fatigability in patients with higher body mass index and lower serum ferritin (both p < 0.1). Flexor carpi ulnaris fatigability correlated with lower serum iron and CHR (both p < 0.05). Vastus medialis fatigability was related to lower free and bioavailable testosterone (FT and BT, respectively, both p < 0.05), and 6-minute walking test distance was shorter in patients with higher cortisol/FT and cortisol/BT ratio (both p < 0.05). Lower ferritin and transferrin saturation correlated with lower percentage of FT and BT. Men with HFrEF and iron deficiency had higher total testosterone, but lower percentage of FT and BT.

CONCLUSIONS

Iron deficiency correlates with lower bioactive testosterone in men with HFrEF. These two pathologies can both contribute to decreased skeletal muscle performance in such patients.

Cardiac Cachexia: A Well-Known but Challenging Complication of Heart Failure

Heart failure (HF) is a common complication of various cardiac diseases, and its incidence constantly increases. This is caused mainly by aging of populations and improvement in the treatment of coronary artery disease. As HF patients age, they tend to develop comorbidities, creating new problems for health-care professionals. Sarcopenia, defined as the loss of muscle mass and function, and cachexia, defined as weight loss due to an underlying illness, are muscle wasting disorders of particular relevance in the heart failure population, but they go mostly unrecognized. The coexistence of chronic HF and metabolic disorders facilitates the development of cachexia. Cachexia, in turn, significantly worsens a patient’s prognosis and quality of life. The mechanisms underlying cachexia have not been explained yet and require further research. Understanding its background is crucial in the development of treatment strategies to prevent and treat tissue wasting. There are currently no specific European guidelines or recommended therapy for cachexia treatment in HF (“cardiac cachexia”).

Clinical significance of nutritional status in patients with chronic heart failure-a systematic review

Chronic heart failure (CHF) and nutritional disorders are recognized as major challenges for contemporary medicine. This study aims to estimate the role of nutritional disorders as risk factors for CHF development and prognostic factors for CHF patients and the outcome of nutritional intervention in CHF. Full-text English articles published between January 2013 and February 2019 available in the PubMed and Scopus databases were considered. Seventy-five prospective, retrospective, and cross-sectional studies as well as meta-analyses on patients with CHF, reporting correlation of their nutritional status with the risk and prognosis of CHF and the outcome of nutritional interventions in CHF were all included. Higher BMI increases the risk of CHF by 15-70%, especially when associated with severe, long-lasting and abdominal obesity. Overweight and obesity are associated with the reduction of mortality in CHF by 24-59% and 15-65%, respectively, and do not affect the outcome of invasive CHF treatment. Malnutrition increases the risk of mortality (by 2- to 10-fold) and the risk of hospitalization (by 1.2- to 1.7-fold). Favorable outcome of nutritional support in CHF patients was reported in a few studies. Nutritional disorders are prevalent in patients with CHF and play a significant role in the incidence, course, and prognosis of the disease. The existence of an "obesity paradox" in patients with CHF was confirmed. Further studies on the effect of nutritional support and body weight reduction in patients with CHF are necessary.

Heart failure, frailty, and pre-frailty: A systematic review and meta-analysis of observational studies

Frailty is a syndrome characterized by reduced physiological reserves, increased vulnerability to stressors and adverse health outcomes. Frailty can change the prognosis and treatment approach of several chronic diseases, including heart failure (HF). The aim of this study was to conduct a systematic review and meta-analysis assessing the association of HF with frailty and pre-frailty. We employed PRISMA guidelines for reporting the results. We searched PubMed, Web of Science, and Embase from 01/01/2002 to 29/11/2019.The quality of the studies was evaluated with the Newcastle Ottawa Scale. Pooled estimates were obtained through random-effect models and Mantel-Haenszel weighting. Homogeneity (I²) and publication bias were assessed. We selected 54 studies (52 cross-sectional, one longitudinal, and one with both designs). The pooled prevalence of pre-frailty in individuals with HF was 46% (95% CI = 38-53; I² = 93.1%) and 40% (95% CI = 31-48; I² = 97%) for frailty. The proportion of pre-frail individuals with HF was 20% (95%CI = 15-25; I² = 99.2%) and the proportion of frail individuals with HF was 31% (95% CI = 17-45; I² = 98.7%). Two studies using the same frailty definition reported estimates for the association between frailty and HF (pooled OR = 3.44; 95% CI = 0.75-15.73; I² = 95.8%). In conclusion, frailty and pre-frailty are frequent in people with HF. Persons with HF have 3.4-fold increased odds of frailty. Longitudinal studies examining bidirectional pathophysiological pathways between HF and frailty are needed to further clarify this relationship and to assess if specific treatment for HF may prevent or delay the onset of frailty and vice versa.

Nutrition intervention in heart failure: should consumption of the DASH eating pattern be recommended to improve outcomes?

Heart failure (HF) is a chronic, systemic disorder that presents a serious and growing public health problem due to its high prevalence, mortality, and cost of care. Due to the aging of the population and medical advances that prolong the life of HF patients, more effective, widespread strategies for improved HF management in this rapidly growing patient population are needed. While the prevalence of malnutrition in HF patients has been well characterized, evidence is limited regarding the effects of specific macro- and micronutrient deficiencies on HF outcomes and their interaction with other aspects of HF management, including pharmacotherapy. There is a mounting appreciation for the effects of nutritional intervention on pathophysiology, treatment, and outcomes in patients with HF. Heart-healthy dietary patterns, such as the Dietary Approaches to Stop Hypertension (DASH), carry importance for the prevention and treatment of hypertension. While preliminary evidence looks promising regarding effects of DASH eating pattern consumption on ventricular function and 30-day hospitalizations in HF patients, more research is needed to confirm its effects on short-term and long-term HF outcomes while better understand underlying mechanisms in the context of HF pharmacotherapy.

Markers of Bone Mineral Metabolism and Cardiac Structure and Function in Perinatally HIV-Infected and HIV-Exposed but Uninfected Children and Adolescents

BACKGROUND

Disordered bone mineral metabolism and low vitamin D concentrations are associated with cardiovascular abnormalities; few studies have evaluated this relationship in HIV-infected youth.

SETTING

The Adolescent Master Protocol is a Pediatric HIV/AIDS Cohort Study network study conducted across 14 US sites.

METHODS

Among perinatally HIV-infected (PHIV) and perinatally HIV-exposed but uninfected (PHEU) youth enrolled in the Adolescent Master Protocol, we evaluated associations of vitamin D [measured as 25-hydroxy-vitamin D (25-OHD)], parathyroid hormone (PTH), calcium, phosphate, and fibroblast growth factor-23 (FGF-23) concentrations with echocardiographic measures of left ventricular (LV) structure, function, and concentrations of NT-proBNP, a biomarker of cardiac damage.

RESULTS

Among 485 participants (305 PHIV and 180 PHEU) with echocardiograms and bone mineralization measures, low 25-OHD (<20 ng/mL) was common among all participants (48% PHIV and 44% PHEU), but elevated PTH (>65 pg/mL) was identified more often among PHIV participants than PHEU participants (9% vs 3%, P = 0.02). After adjusting for HIV status and demographic covariates, both low 25-OHD and elevated PTH were associated with lower mean LV mass z-scores, whereas elevated PTH was associated with higher mean fractional shortening z-scores. Participants with low 25-OHD also had slightly higher mean LV end-systolic wall stress z-scores, but differences were more pronounced in PHEU participants than in PHIV participants. FGF-23 was inversely related to end-diastolic septal thickness, both overall and among PHIV participants.

CONCLUSIONS

In this cohort of PHIV and PHEU youth, we observed associations of 25-OHD, PTH, and FGF-23 with both structural and functional cardiac parameters, supporting links between bone mineral metabolism and cardiac status.

Association between the Prognostic Nutritional Index and Dietary Intake in Community-Dwelling Older Adults with Heart Failure: Findings from NHANES III

The objective of this study was to examine the association between nutritional status and dietary intake in community-dwelling older adults with heart failure (HF). A cross-sectional analysis of NHANES III data was conducted. The analytic sample was comprised of n = 445 individuals aged 50+ years with congestive HF (54.4% male, 22.9% non-Hispanic Black, 43.8% low-income). Nutritional status was measured using the Prognostic Nutritional Index (PNI). Participants were classified by PNI quintiles with lower PNI scores indicating lower nutritional status. Participants in quintile 5 showed significantly greater intakes of energy, protein, vegetables, magnesium, zinc, copper, potassium, red meat, saturated fat, and sodium. In multivariate analyses, increased intake of red meat (β = 0.253, p = 0.040) and vegetables (β = 0.255, p = 0.038) was associated with significantly better nutritional status. In the absence of comprehensive nutritional guidance for HF patients, it appears that small increases in energy, protein (red meat), and vegetable consumption are associated with improved nutritional status.

Coexisting Frailty With Heart Failure

People over 65 years of age constitute over 80% of patients with heart failure (HF) and the incidence of HF is 10 per 1,000 in people aged above 65 years. Approximately 25% of older patients with HF exhibit evidence of frailty. Frail patients with cardiovascular disease (CVD) have a worse prognosis than non-frail patients, and frailty is an independent risk factor for incident HF among older people. Planning the treatment of individuals with HF and concomitant frailty, one should consider not only the limitations imposed by frailty syndrome (FS) but also those associated with the underlying heart disease. It needs to be emphasized that all patients with HF and concomitant FS require individualized treatment.

Heart Failure and a Plant-Based Diet. A Case-Report and Literature Review

A 54-year-old female with grade 3 obesity body mass index (BMI 45.2 kg/m2) and type II diabetes (hemoglobin A1c 8.1%) presented to her primary care physician in May 2017 with a chief complaint of left lower extremity edema. Work-up revealed heart failure with depressed left ventricular systolic function. Upon diagnosis, she substantially altered her lifestyle, changing her diet from a "healthy western" one to a whole food plant-based one. Guideline directed medical therapy for heart failure was also utilized. Over five and a half months, she lost 22.7 kg and reversed her diabetes without the use of diabetes medications. Her left ventricular systolic function normalized. Although causality cannot be determined, this case highlights the potential role of a plant-based diet in helping to reverse heart failure with reduced ejection fraction. This article will review how a minimally processed whole food plant-based dietary pattern and similar dietary patterns, such as the Dietary Approach to Stop Hypertension diet, may contribute to the reversal of left ventricular dysfunction.

Assessment of Dietary Habits in Patients With Chronic Heart Failure

BACKGROUND

Nutritional deficiency is a critical factor in the development and prognosis of heart failure. An optimal diet should be ensured and maintained to manage the symptoms of heart failure.

PURPOSE

This study assessed the dietary habits of patients with chronic heart failure using diet quality indices with the goal of determining their nutritional status.

METHODS

Forty-four female patients and 56 male patients (mean age: 66 ± 11.38 years) who had been admitted to the cardiology clinics of a university hospital in Istanbul between March 2012 and August 2014 were included in this study.

RESULTS

In terms of body mass index, 34% of the participants were normal weight, 37% were overweight, and 21% were obese. Furthermore, this study found the mean daily total energy intake to be inadequate and the total mean score of the Healthy Eating Index to be 74.6 ± 9.32. The diet quality of most participants fell into the "needs improvement" category.

CONCLUSIONS

This study used the Healthy Eating Index, a measure developed to assess diet quality, to assess the food consumption patterns of patients with chronic heart failure. The findings support using this index before providing diet recommendations to patients.

The Influence of Diet on MicroRNAs that Impact Cardiovascular Disease

Food quality and nutritional habits strongly influence human health status. Extensive research has been conducted to confirm that foods rich in biologically active nutrients have a positive impact on the onset and development of different pathological processes, including cardiovascular diseases. However, the underlying mechanisms by which dietary compounds regulate cardiovascular function have not yet been fully clarified. A growing number of studies confirm that bioactive food components modulate various signaling pathways which are involved in heart physiology and pathology. Recent evidence indicates that microRNAs (miRNAs), small single-stranded RNA chains with a powerful ability to influence protein expression in the whole organism, have a significant role in the regulation of cardiovascular-related pathways. This review summarizes recent studies dealing with the impact of some biologically active nutrients like polyunsaturated fatty acids (PUFAs), vitamins E and D, dietary fiber, or selenium on the expression of many miRNAs, which are connected with cardiovascular diseases. Current research indicates that the expression levels of many cardiovascular-related miRNAs like miRNA-21, -30 family, -34, -155, or -199 can be altered by foods and dietary supplements in various animal and human disease models. Understanding the dietary modulation of miRNAs represents, therefore, an important field for further research. The acquired knowledge may be used in personalized nutritional prevention of cardiovascular disease or the treatment of cardiovascular disorders.

Iron deficiency in heart failure

: Due to aging of the patients with heart failure, comorbidities are an emerging problem and, among them, iron deficiency is an important therapeutic target, independently of concomitant hemoglobin level. Iron deficiency affects up to 50% of heart failure patients, and it has been largely established its association with poor quality of life, impaired exercise tolerance and higher mortality. Randomized controlled trials (RCTs) and meta-analyses have demonstrated that intravenous iron supplementation in heart failure patients with iron deficiency positively affects symptoms, quality of life, exercise tolerance (as measured by VO2 peak and 6MWT), with a global trend to reduction of hospitalization rates. Current European Society of Cardiology Guidelines for heart failure recommend a diagnostic work-up for iron deficiency in all heart failure patients and intravenous iron supplementation with ferric carboxymaltose for symptomatic patients with iron deficiency, defined by ferritin level less than 100 μg/l or by ferritin 100-300 μg/l with TSAT less than 20%. On-going studies will provide new evidence for a better treatment of this important comorbidity of heart failure patients.

Heart Failure and Problems with Frailty Syndrome: Why it is Time to Care About Frailty Syndrome in Heart Failure

Frailty syndrome (FS) is an independent predictor of mortality in cardiovascular disease and is found in 15–74% of patients with heart failure (HF). The syndrome has a complex, multidimensional aetiology and contributes to adverse outcomes. Proper FS diagnosis and treatment determine prognosis and support the evaluation of treatment outcomes. Routine FS assessment for HF patients should be included in daily clinical practice as an important prognostic factor within a holistic process of diagnosis and treatment. Multidisciplinary team members, particularly nurses, play an important role in FS assessment in hospital and primary care settings, and in the home care environment. Raising awareness of concurrent FS in patients with HF patients and promoting targeted interventions may contribute to a decreased risk of adverse events, and a better prognosis and quality of life.

Benefits of multiple micronutrient supplementation in heart failure: A comprehensive review

BACKGROUND

Multiple micronutrient supplementation has been suggested to have a role on health outcomes in patients with heart failure (HF), but the evidence is inconclusive.

OBJECTIVE

To elucidate the role of multiple micronutrient supplementation in heart failure we performed a comprehensive review of the literature.

METHODS AND RESULTS

The search in databases included PUBMED (until June 2018) to detect randomized controlled trials (RCTs) and meta-analyzes that investigated the impact of micronutrient supplementation in HF.

RESULTS

With more than 2357 titles and abstracts reviewed, we included only the studies suitable for the final review. Whether alone or in combination, micronutrients have been found to improve the health outcomes of patients with HF by improving symptoms, work capacity and left ventricular ejection fraction (LVEF), thus increasing the quality of life in these patients.

CONCLUSION

Future studies are needed to document the effects of multiple micronutrient associations in order to include them in nutritional guidelines to increase survival and to improve quality of life in patients with heart failure.

Stress Coping Strategies in the Heart: An Integrated View

The heart is made up of an ordered amalgam of cardiac cell types that work together to coordinate four major processes, namely energy production, electrical conductance, mechanical work, and tissue remodeling. Over the last decade, a large body of information has been amassed regarding how different cardiac cell types respond to cellular stress that affect the functionality of their elaborate intracellular membrane networks, the cellular reticular network. In the context of the heart, the manifestations of stress coping strategies likely differ depending on the coping strategy outcomes of the different cardiac cell types, and thus may underlie the development of distinct cardiac disorders. It is not clear whether all cardiac cell types have similar sensitivity to cellular stress, how specific coping response strategies modify their unique roles, and how their metabolic status is communicated to other cells within the heart. Here we discuss our understanding of the roles of specialized cardiac cells that together make the heart function as an organ with the ability to pump blood continuously and follow a regular rhythm.

Impact of Nutrition on Cardiovascular Function

The metabolic sources of energy for myocardial contractility include mainly free fatty acids (FFA) for 95%, and in lesser amounts for 5% from glucose and minimal contributions from other substrates such lactate, ketones, and amino acids. However, myocardial efficiency is influenced by metabolic condition, overload, and ischemia. During cardiac stress, cardiomyocytes increase glucose oxidation and reduce FFA oxidation. In patients with ischemic coronary disease and heart failure, the low oxygen availability limits myocardial reliance on FFA and glucose utilization must increase. Although glucose uptake is fundamental to cardiomyocyte function, an excessive intracellular glucose level is detrimental. Insulin plays a fundamental role in maintaining myocardial efficiency and in reducing glycemia and inflammation; this is particularly evident in obese and type-2 diabetic patients. An excess of F availability increase fat deposition within cardiomyocytes and reduces glucose oxidation. In patients with high body mass index, a restricted diet or starvation have positive effects on cardiac metabolism and function while, in patients with low body mass index, restrictive diets, or starvation have a deleterious effect. Thus, weight loss in obese patients has positive impacts on ventricular mass and function, whereas, in underweight heart failure patients, such weight reduction adds to the risk of heart damage, predisposing to cachexia. Nutrition plays an essential role in the evolution of cardiovascular disease and should be taken into account. An energy-restricted diet improves myocardial efficiency but can represent a potential risk of heart damage, particularly in patients affected by cardiovascular disease. Micronutrient integration has a marginal effect on cardiovascular efficiency.

Dietary Patterns in Secondary Prevention of Heart Failure: A Systematic Review

BACKGROUND

Diet is an important factor in secondary prevention of heart failure (HF) but there is still no consensus as to which dietary model should be adopted by this population. This systematic review aims to clarify the relationship between dietary patterns and secondary prevention in HF.

METHODS

We searched the Medline, Embase and Cochrane databases for studies with different dietary patterns and outcomes of secondary prevention in HF. No limitation was used in the search.

RESULTS

1119 articles were identified, 12 met the inclusion criteria. Studies with Dietary Approaches to Stop Hypertension (DASH), Mediterranean, Hyperproteic and Low-carb diets were found. The DASH pattern showed improvement in cardiac function, functional capacity, blood pressure, oxidative stress and mortality. The Mediterranean diet had a correlation with inflammation, quality of life and cardiac function but just on cross-sectional studies. Regarding the Hyperproteic and Low-carb diets only one study was found with each pattern and both were able to improve functional capacity in patients with HF.

CONCLUSIONS

DASH pattern may have benefits in the secondary prevention of HF. The Mediterranean diet demonstrated positive correlation with factors of secondary prevention of HF but need more RCTs and cohort studies to confirm these effects. In addition, the Hyperproteic and Low-carb diets, despite the lack of studies, also demonstrated positive effects on the functional capacity in patients with HF.

Effects of aging and comorbidities on nutritional status and muscle dysfunction in patients with COPD

Chronic obstructive pulmonary disease (COPD) is a prevalent, complex and debilitating disease which imposes a formidable burden on patients and the healthcare system. The recognition that COPD is a multifaceted disease is not new, and increasing evidence have outlined the importance of its extra-pulmonary manifestations and its relation to other comorbid conditions in the clinical course of the disease and its societal cost. The relationship between aging, COPD and its comorbidities on skeletal muscle function and nutritional status is complex, multidirectional and incompletely understood. Despite this, the current body of knowledge allows the identification of various, seemingly partially independent factors related both to the normal aging process and to the independent deleterious effects of chronic diseases on muscle function and body composition. There is a dire need of studies evaluating the relative contribution of each of these factors, and their potential synergistic effects in patients with COPD and advanced age/comorbid conditions, in order to delineate the best course of therapeutic action in this increasingly prevalent population.