Prognostic value of malnutrition assessed by Controlling Nutritional Status score for long-term mortality in patients with acute heart failure

Clinical Significance of the Triglyceride-Glucose Index in Patients Requiring Nonsurgical Intensive Care

The evaluation of triglyceride-glucose (TyG) index has not been sufficient in patients requiring nonsurgical intensive care.A total of 3,906 patients who required intensive care were enrolled. We computed the TyG index using the value on admission by the following formula: ln [triglyceride (mg/dL) × glucose (mg/dL) /2]. Patients were divided into three groups according to the TyG index quartiles: low (quartile 1 [Q1]; TyG index ≤ 8.493, n = 977), middle (Q2/Q3; 8.494 ≤ TyG index ≤ 9.536, n = 1,953), and high (Q4; TyG index > 9.537, n = 976). The median (interquartile range) TyG index was 9.00 (8.50-9.54); acute coronary syndrome (ACS) had the highest TyG index among all etiologies at 9.12 (8.60-9.68). A multivariate logistic regression model showed that ACS (odds ratio [OR], 2.133; 95% confidence interval [CI], 1.783-2.552) were independently correlated with high TyG index. A Cox proportional hazards regression model revealed that, in ACS, the Q2/Q3 and Q4 groups were independent predictors of 30-day all-cause mortality (hazard ratio [HR], 1.778; 95% CI, 1.014-3.118; HR, 2.986; 95% CI, 1.680-5.308; respectively) and that in acute heart failure [AHF], the Q4 group was a converse independent predictor of 30-day all-cause mortality (HR, 0.488; 95% CI, 0.241-0.988).High TyG index was linked to ACS and negative outcomes in the ACS group; in contrast, low TyG index was associated with adverse outcomes in the AHF group.

Prognostic impact of nutrition measures in patients with heart failure varies with coexisting physical frailty

AIMS

Malnutrition is prevalent among patients with heart failure (HF); however, the effects of coexisting malnutrition and frailty on prognosis are unknown. This study examines the impact of malnutrition and frailty on the prognosis of patients with HF.

METHODS AND RESULTS

We examined 1617 patients with HF aged 65 years or older (age: 78.6 ± 7.4; 44% female) from a Japanese multicentre prospective cohort study. The nutritional status was evaluated using the Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status (CONUT), and Mini Nutritional Assessment Short Form on discharge. Frailty was assessed using the criteria determined in a previous study on patients with HF. The prognostic impact of each nutrition measure on the risk of composite all-cause mortality and cardiac readmissions within 2 years of hospital discharge was assessed using Kaplan-Meier survival curves and Cox proportional hazards model analysis for non-frail and frail groups. Over 2324.2 person-years of follow-up, 88 patients died and 448 patients experienced readmission due to HF. In the non-frail group, poor nutritional status assessed using the GNRI and CONUT was associated with an increased hazard ratio (HR) of composite outcomes in the crude model; however, adjustment for potential confounders diminished the association. In the frail group, all three nutritional indicators were associated with the cumulative incidence of the study outcome (log-rank test, P < 0.05). In multivariate analysis, only the CONUT score was associated with an increased HR even after adjustment for confounders.

CONCLUSIONS

The CONUT score predicted a poor prognosis in HF patients with coexisting physical frailty, highlighting the potential clinical benefit of nutritional assessment based on biochemical data for further risk stratification.

Prognostic value of nutritional screening tools in hospitalized patients with decompensated heart failure: A systematic review and meta-analysis

Nutritional risk screening is fundamental to prevent undesirable outcomes in heart failure (HF). Current reviews of nutritional screening tools encompass both hospitalized and outpatient settings, which may not be suitable because of different clinical manifestations. We hypothesize that multidimensional tools would better identify prognosis of decompensated patients because the tools assess more than isolated aspects. This systematic review aims to explore the association of multidimensional nutritional risk screening tools and prognosis in patients hospitalized with decompensated HF. Five databases were searched for studies that assessed nutritional risk through multidimensional screening tools and its association with prognosis in adults hospitalized with decompensated HF. The 95% confidence interval and relative risk were computed using a random-effects model. Inverse variance method was used. Thirty-eight studies were included. Most studies demonstrated higher nutritional risk was significantly associated with worse prognosis. Quantitative analysis identified higher nutritional risk by using the Mini Nutritional Assessment Short Form (MNA-SF), Controlling Nutritional Status, Geriatric Nutritional Risk Index, and Prognostic Nutritional Index to be associated with all-cause mortality. The MNA-SF demonstrated greater magnitude of association with all-cause mortality in older subjects (relative risk, 4.85; 95% confidence interval, 2.0-11.75). Higher nutritional risk was associated with poor prognosis and higher mortality in patients hospitalized with decompensated HF, especially when screened by MNA-SF. Tools were not directly compared. That might reinforce the importance of evaluating multiple aspects when screening hospitalized HF patients once symptoms associated with decompensation frequently mask the underlying nutritional status and risk. PROSPERO registration number (CRD42021256271).

Association between Malnutrition and Migraine Risk Assessed Using Objective Nutritional Indices

Dietary triggers are frequently linked to migraines. Although some evidence suggests that dietary interventions might offer a new avenue for migraine treatment, the connection between migraine and nutrition remains unclear. In this study, we explored the association between nutritional status and migraines. Clinical data spanning 11 years were sourced from the Smart Clinical Data Warehouse. The nutritional statuses of 6603 migraine patients and 90,509 controls were evaluated using the Controlling Nutrition Status (CONUT) score and the Prognostic Nutrition Index (PNI). The results showed that individuals with mild, moderate, and severe malnutrition were at a substantially higher risk of migraines than those with optimal nutrition, as determined by the CONUT score (adjusted odds ratio [aOR]: 1.72, 95% confidence interval [CI]: 1.63-1.82; aOR: 5.09, 95% CI: 4.44-5.84; aOR: 3.24, 95% CI: 2.29-4.59, p < 0.001). Similarly, moderate (PNI: 35-38) and severe (PNI < 35) malnutrition were associated with heightened migraine prevalence (aOR: 4.80, 95% CI: 3.85-5.99; aOR: 3.92, 95% CI: 3.14-4.89, p < 0.001) compared to those with a healthy nutritional status. These findings indicate that both the CONUT and PNI may be used as predictors of migraine risk and underscore the potential of nutrition-oriented approaches in migraine treatment.

Controlling nutritional status score predicts 2-year outcomes in elderly patients admitted for acute heart failure

BACKGROUND

Heart failure (HF) is a major cause of death among the elderly. Its prevalence increases dramatically with age. The prevalence of malnourished subjects is high in hospitalized elderly patients. We aimed to investigate the prognostic role of malnutrition, assessed by controlling nutritional status (CONUT) score, on adverse clinical outcomes in the elderly admitted for acute HF.

METHODS

We enrolled 293 patients (mean age 84 years; 48% men) consecutively admitted for acute HF to the Internal Medicine or Geriatrics Divisions at the 'IRCCS Sacro Cuore-Don Calabria' Hospital of Negrar (Verona, Italy) from 2013 to 2015. We predicted the risk of all-cause death, re-hospitalizations for HF and non-HF causes, and the composite of all-cause death or hospitalizations over 2-year follow-up. Patients were divided into four groups according to CONUT score: normal-CONUT (0-1; n = 30); mild-CONUT (2-3; n = 56); moderate-CONUT (4-7; n = 171); and severe-CONUT (≥ 8; n = 36).

RESULTS

Higher CONUT scores were associated with older age and lower entry blood pressures. No difference in hemodynamics was noted at the discharge. Kaplan-Meier curves showed a significant association between worsening CONUT scores and risk of all-cause death (p < 0.01), re-hospitalizations (p < 0.01), or both (p < 0.001). Cox regression analysis revealed these significant associations persisted after adjustment for age, sex, pre-existing cardiovascular disease, diabetes, chronic kidney disease, heart rate, systolic blood pressure, and plasma brain natriuretic peptide levels at discharge (all-cause mortality HR = 1.29 (1.00-1.66), p = 0.049; hospitalization for HF HR = 1.36 (1.03-1.81), p = 0.033; hospitalization for non-HF HR = 1.38 (1.03-1.86), p = 0.034; composite outcome HR = 1.33 (1.07-1.64), p = 0.01).

CONCLUSIONS

Malnutrition, assessed by the CONUT score, is common among elderly patients admitted for acute HF and is strongly related to increased long-term risk of all-cause death and re-hospitalizations.

The association between malnutrition status and hemorrhagic transformation in patients with acute ischemic stroke receiving intravenous thrombolysis

OBJECTIVES

We evaluated the impact of malnutrition as estimated by the controlling nutritional status (CONUT) score and prognostic nutritional index (PNI) on hemorrhagic transformation (HT) and stroke outcomes after intravenous thrombolysis (IVT).

MATERIALS AND METHODS

Using a multicenter registry database, we enrolled 808 patients with acute ischemic stroke who received IVT between August 2013 and May 2021. We defined malnutrition as a CONUT score ≥ 2 and low PNI. The primary outcome measure was the occurrence of symptomatic HT contributing to early neurologic deterioration (END-SHT) after IVT. Multivariable analysis was performed to analyze the association between CONUT score, PNI, and END-SHT after IVT.

RESULTS

The rate of END-SHT was higher with increasing CONUT scores and PNI values. In the multivariable analysis, CONUT score ≥ 5 and low PNI were significantly associated with END-SHT (odds ratio [95% confidence interval], CONUT score ≥ 5: 12.23 [2.41-62.07], p = 0.003; low PNI: 4.98 [1.76-14.09], p = 0.003). The receiver operating characteristic curve showed that both the CONUT score and PNI had good predictive ability. The cutoff values for CONUT and PNI were 5 and 42.3, respectively, for END-SHT.

CONCLUSION

Malnutrition, as denoted by a higher CONUT score and lower PNI, was associated with END-SHT. The joint application of both nutritional markers could be useful in predicting END-SHT after IVT.

Prognostic Value of Cheyne-Stokes Respiration and Nutritional Status in Acute Decompensated Heart Failure

Malnutrition frequently coexists with heart failure (HF), leading to series of negative consequences. Cheyne-Stokes respiration (CSR) is predominantly detected in patients with HF. However, the effect of CSR and malnutrition on the long-term prognosis of patients with acute decompensated HF (ADHF) remains unclear. We enrolled 162 patients with ADHF (median age, 62 years; 78.4% men). The presence of CSR was assessed using polysomnography and the controlling nutritional status score was assessed to evaluate the nutritional status. Patients were divided into four groups based on CSR and malnutrition. The primary outcome was all-cause mortality. In total, 44% of patients had CSR and 67% of patients had malnutrition. The all-cause mortality rate was 26 (16%) during the 35.9 months median follow-up period. CSR with malnutrition was associated with lower survival rates (log-rank p < 0.001). Age, hemoglobin, albumin, lymphocyte count, total cholesterol, triglyceride, low-density lipoprotein cholesterol, creatinine, estimated glomerular filtration rate, B-type natriuretic peptide, administration of loop diuretics, apnea-hypopnea index and central apnea-hypopnea index were significantly different among all groups (p < 0.05). CSR with malnutrition was independently associated with all-cause mortality. In conclusion, CSR with malnutrition is associated with a high risk of all-cause mortality in patients with ADHF.

The clinical value of the Controlling Nutritional Status score for predicting prognosis in systolic heart failure cases in the vulnerable phase

Background

Malnutrition, a commonly encountered complication of heart failure, has an association with poor prognosis. The vulnerable phase of heart failure constitutes the most vulnerable stage of heart failure cases after discharge (usually within 3 months). At present, the prognostic value of Controlling Nutritional Status (CONUT) score in the vulnerable phase of systolic heart failure is unclear.

Methods

Totally 187 systolic heart failure cases were retrospectively assessed at the Second Affiliated Hospital of Dalian Medical University. Based on CONUT score at admission, cases were assigned to 3 groups, including the normal nutrition, and mild and moderate or severe malnutrition groups. The primary endpoint was all-cause death in the 90 days following discharge. The secondary, composite outcome encompassed all-cause death and rehospitalization due to heart failure. Kaplan-Meier method and log-rank test were performed to compare outcome event rates between groups. The independent risk factors for outcome events were obtained by multivariate COX regression analysis. The receiver operating characteristic (ROC) curve analysis and the Delong test were used to compare the prediction performance of the CONUT score and other independent risk factors for all-cause death.

Results

During the 90 days of follow-up, 8.6% of HF patients had the primary endpoint and 23.5% had the secondary outcome. All-cause mortality was markedly elevated in the moderate or severe malnutrition group (Logrank: p < 0.001). Compared with the normal nutrition group, composite endpoint events had starkly increased incidence rates in both malnutrition groups, and the incidence increased with the severity of malnutrition (Logrank: p < 0.05). Multivariate COX risk analysis revealed higher CONUT score [hazard ratio (HR) = 1.791, 95% confidence interval (CI) 1.379-2.327], age (HR = 1.08, 95% CI 1.028-1.134), B-type natriuretic peptide (BNP) (HR = 1.001, 95% CI 1.000-1.001), and aspartate aminotransferase (AST) (HR = 1.008, 95% CI 1.001-1.015) at admission as independent predictive factors of all-cause mortality. And higher CONUT score (HR = 1.162, 95% CI 1.024-1.318) and lower estimated glomerular filtration rate (eGFR) (HR = 0.98, 95% CI 0.966-0.993) for the secondary endpoint. The addition of the CONUT score significantly increased the predictive performance of age, BNP and AST, as well as their combination for all-cause death (Delong test: all p < 0.05).

Conclusion

The CONUT score at admission independently predicts poor prognosis during the vulnerable phase in patients with systolic heart failure and may be combined with conventional risk factors to further improve the predictive efficacy.

Correlation between the prognostic nutritional index and outcomes in older patients aged ≥ 60 years with chronic heart failure

BACKGROUND

Nutritional status is related to clinical outcomes in patients with chronic heart failure (CHF). The prognostic nutritional index (PNI) is a simple tool to assess nutrition.

AIM

To evaluate the association between the PNI score and clinical outcomes in patients (60 years and older) hospitalized due to an acute exacerbation of CHF.

METHOD

This was a retrospective observational study. Patients hospitalized for acute CHF exacerbation between July 2015 and May 2020 were analyzed. Patients were followed until January 31, 2021. The primary end point was cardiovascular-related readmissions and all-cause mortality after hospital discharge. Secondary outcomes were factors associated with all-cause mortality. Patients were divided into normal nutrition (PNI > 38), moderate malnutrition (PNI = 35-38), and severe malnutrition (PNI < 35) groups.

RESULTS

The study included 355 patients (mean age 78 ± 9 years). The median follow-up was 769 days. Compared to survivors (n = 214), patients who expired (n = 133) were (1) older; (2) had lower PNI scores, lymphocyte counts, hemoglobin, albumin, total cholesterol, and serum sodium level; but (3) had higher serum creatinine levels, log(N-terminal-pro-B-type natriuretic peptide), and cardiac troponin I (P < 0.05). Multivariate analyses revealed that PNI was independently associated with all-cause mortality. The hazard ratio (HR) for moderate malnutrition versus normal nutrition was 1.624 (95% confidence interval [CI] 1.011-2.609, P = 0.045), while HR for severe malnutrition versus normal nutrition was 1.892 (95%CI 1.119-3.198, P = 0.017). Malnourished patients had significantly higher rates of cardiovascular readmissions and all-cause mortality.

CONCLUSION

Lower PNI (malnutrition) was associated with worse clinical outcomes and was independently associated with all-cause mortality in patients with CHF.

[Malnutrition management of hospitalized patients with diabetes/hyperglycemia and heart failure]

Introduction

Heart failure (HF) is one of the leading causes of morbidity and mortality among older people, making it a major public health problem. Cardiovascular diseases in general, and HF in particular, are common comorbidities in people with type 2 diabetes (DM2). The concurrence of DM2 and HF is associated with more severe clinical symptoms and signs, and poorer quality of life and prognosis. Furthermore, due to the hypercatabolic state and nutrient absorption disorders, malnutrition is present in many HF cases. This article describes the results of the expert consensus and the responses of the panelists on the nutritional management in routine clinical practice of patients with diabetes/hyperglycemia hospitalized (non-critically ill) with HF.

Predicting prognosis of heart failure using common malnutrition assessment tools: A systematic review and meta-analysis

BACKGROUND AND AIMS

COUNT score, PNI score, and GNRI scores are associated with cardiovascular events. This review identifies the most accurate malnutrition assessment tools based on these scores in predicting mortality and readmission outcomes in HF patients.

MATERIAL AND METHODS

PubMed via MEDLINE, EMBASE were searched to identify studies assessing malnutrition using CONUT, PNI and GNRI. A meta-analysis was carried out to pool the hazard ratios on mortality and readmission rates. The methodological quality was assessed using the Newcastle-Ottawa Scale.

RESULTS

The mortality in HF patients with malnutrition assessed by CONUT showed pooled HR of 1.23. HF patients with all severe, moderate, and mild risk of malnutrition showed mortality with HR 3.56, 2.71 and 1.57 respectively. For malnutrition assessed with GNRI, HF patients with all severe, moderate, and mild risk of malnutrition showed mortality with HR 4.17, 2.73 and 1.73 respectively. No significance difference in association of CONUT score with pooled HR of readmission rate was observed HR 0.99. With PNI, HF patients with all severe and moderate risk of malnutrition showed mortality with HR 2.14 and HR 1.68 respectively, although they failed to achieve significance.

CONCLUSION

CONUT and GNRI are the superior prognostic indicator than PNI in prediction of mortality associated with risk of malnutrition.

Association between patient's age and the utility of prognostic markers after pancreaticoduodenectomy for pancreatic cancer

BACKGROUND ＆ AIMS: Optimizing treatments balancing prognosis and therapeutic invasiveness is important in the management of pancreatic cancer (PC) owing to global ageing. This study aimed to verify the different utility of biomarkers by patients' age. MATERIALS ＆ METHODS: This is a single-center, retrospective cohort analysis involving 160 patients who undertook pancreaticoduodenectomy (PD) for PC. After comparing clinicopathological factors and survival after PD between aged (≥70 y/o) and young (＜70 y/o) patients, we compared neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), controlling nutrition (CONUT) score, carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 as well as clinicopathological factors between long and short survivors in each group. We also performed Kaplan-Meyer analysis between patients stratified by biomarkers. RESULTS: Overall survival (OS) was significantly worse in aged patients (p = 0.002). In aged patients, CEA was significantly higher in short survivors. In young patients, CONUT score and CA19-9 were higher in short survivors. Kaplan-Meyer analysis showed that NLR and CEA stratified OS in aged patients, whereas CONUT score and CA19-9 could stratify OS in young patients. CONCLUSION: Our current results suggest that these biomarkers had different impact on survivals according to the patients' age.

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

Background and aims

Malnutrition is very common in patients with heart failure (HF) and is associated with a worse clinical outcome. The Controlling Nutritional Status (CONUT) score is an easily derived index for the evaluation of malnutrition. This study aimed to evaluate the association between the CONUT score and the prognosis in patients with HF.

Methods and results

Electronic databases were searched for potential studies from inception up to February 15, 2022. Observational cohort studies included adult participants with HF, and reported the associations between the CONUT score and the adjusted relative risk (RR) of all-cause mortality, and patients with composite major adverse cardiac outcomes (MACEs) were included. We finally included 18 studies comprising 12,532 participants with HF for analysis. The median age of the patients was 70.5 years old, and 35.4% were women. After a median follow-up duration of 32.5 months, patients with HF with a higher CONUT score were associated with a higher risk of all-cause mortality (per 1 increment of the CONUT score: RR, 1.21, 95% CI, 1.13–1.29, I² = 68%, P for heterogeneity = 0.002) and MACEs (per 1 increment of the CONUT score: RR, 1.14, 95% CI, 1.06–1.23, I² = 81%, P for heterogeneity <0.0001) after adjusting for other prognostic factors. When the CONUT score was divided into the normal nutritional status and malnourished status, malnourished patients with HF were associated with increased risks of all-cause death (RR, 1.61, 95% CI, 1.40–1.85, I² = 17%, P for heterogeneity = 0.29) and MACEs (RR, 2.12, 95% CI, 1.49–3.02, I² = 87%, P for heterogeneity <0.0001), compared with those with normal nutritional status.

Conclusions

The CONUT score is associated with the clinical outcomes in patients with HF, and can be used as a screening tool of nutritional status in HF to improve prognosis.

Serum Prealbumin: a potential predictor of Right Ventricular Dysfunction in patients receiving programmed hemodialysis

OBJECTIVE

Prealbumin has been a reliable marker to predict protein energy malnutrition and hypercatabolic state. In this analysis, we particularly aimed to investigate the potential association between serum prealbumin levels and right ventricular dysfunction in patients receiving programmed hemodialysis.

METHODS

A total of 57 subjects were included in the analysis. The subjects were then categorized into two groups: right ventricular dysfunction (n=18) and non-right ventricular dysfunction (n=39) groups. In all patients, detailed transthoracic echocardiography (following hemodialysis) were performed along with the evaluation of complete blood count, routine biochemistry parameters, and, in particular, serum prealbumin levels.

RESULTS

Mortality rate at 3 years was found to be significantly higher in the right ventricular dysfunction group (p=0.042). Serum prealbumin levels were also significantly lower in the right ventricular dysfunction group compared with the non-right ventricular dysfunction group (23.83±8.50 mg/dL versus 31.38±6.81 mg/dL, p=0.001). In the receiver operating characteristics curve analysis, a prealbumin cutoff value of <28.5 mg/dL was found to predict right ventricular dysfunction, with a sensitivity of 67% and a specificity of 62% (area under the curve: 0.744). In the correlation analysis, a moderate yet significant positive correlation was demonstrated between serum prealbumin and tricuspid annular plane systolic excursion (r=0.365, p=0.005).

CONCLUSION

This study suggests that low serum prealbumin might serve as a potential predictor of right ventricular dysfunction (and its clinical consequences) in patients receiving programmed hemodialysis.

A Comparative Study of Three Nutritional Risk/Screening Indices for Predicting Cardiac Events and Physical Functioning Among Patients with Acute Heart Failure

Undernutrition is very common among patients with heart failure (HF). This study evaluated the prognostic values of three nutritional risk/screening indices among patients with acute HF. We retrospectively calculated scores for 465 patients with acute HF using the Controlling Nutritional Status (CONUT) tool, the Geriatric Nutritional Risk Index (GNRI), and the Mini-Nutritional Assessment Short Form (MNA-SF). The outcomes of interest were the 1-year rate of cardiac events (cardiac-related death or HF-related readmission) and the Barthel index as an index of physical function during hospitalization. The CONUT, GNRI, and MNA-SF scores were significantly correlated, although the proportions of a normal nutritional state varied (CONUT: 18.3%, GNRI: 32.9%, and MNA-SF: 43.9%). Kaplan-Meier estimates revealed that cardiac events were more common among patients with undernutrition based on the CONUT score, and multivariable regression analysis revealed that only the CONUT score independently predicted poor outcomes. Furthermore, changes in the Barthel index during hospitalization were significantly correlated with the CONUT score but not with the GNRI and MNA-SF scores. In receiver operating characteristic analyses, the CONUT score had the most powerful predictive values on both the postdischarge incidence of cardiac events and the decline of physical function during hospitalization compared with the GNRI and the MNA-SF. These results indicate that the CONUT score might provide useful information for predicting poor outcomes in patients with acute HF.

Prediction of all-cause mortality with malnutrition assessed by nutritional screening and assessment tools in patients with heart failure：a systematic review

BACKGROUND AND AIMS

In the absence of a gold standard or scientific consensus regarding the nutritional evaluation of heart failure (HF) patients, this study aimed to summarize and systematically evaluate the prognostic value of nutritional screening and assessment tools used for all-cause mortality in HF patients.

METHODS AND RESULTS

Relevant studies were retrieved from major databases (PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang Data, and China Biology Medicine disc (CMB)) and searched from the earliest available date until July 2021. If three or more studies used the same tool, meta-analysis using RevMan 5.3 was performed. This systematic review was registered at PROSPERO (number CRD42021275575). A total of 36 articles involving 25,141 HF patients were included for qualitative analysis and 31 studies for quantitative analysis. Meta-analysis of these studies indicated, poor nutritional status evaluated by using 5 nutritional screening tools (Prognostic Nutritional Index (PNI), Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status Score (CONUT), Nutritional Risk Index (NRI), and Short Form Mini Nutritional Assessment (MNA-SF)) or 2 nutritional assessment tools (the Mini Nutritional Assessment (MNA) and Generated Subjective Global Assessment (SGA)) predicted all-cause mortality in HF patients. Of all tools analyzed, MNA had the maximum HR for mortality [HR = 2.62, 95%CI 1.11-6.20, P = 0.03] and MNA-SF [HR = 1.94, 95%CI 1.40-2.70, P＜0.001] was the best nutritional screening tools.

CONCLUSION

Poor nutritional status predicted all-cause mortality in HF patients. MNA may be the best nutritional assessment tool, and MNA-SF is most recommended for HF patient nutritional screening. The application value of MNA, especially in patients with reduced left ventricular ejection fraction (LVEF), needs to be further confirmed. The clinical application value of Mini-Nutrition Assessment Special for Heart Failure (MNA-HF) and Global Leadership Initiative on Malnutrition (GLIM) in HF patients needs to be confirmed.

Prognostic Value of the Controlling Nutritional Status (CONUT) Score in Patients at Dialysis Initiation

Protein-energy wasting (PEW) is common in patients with chronic kidney disease (CKD), and affects their prognosis. The Controlling Nutritional Status (CONUT) score is a nutritional screening tool calculated using only blood test data. This study aimed to investigate the prognostic value of CONUT score in patients just initiating dialysis. A total of 311 CKD patients who stably initiated dialysis were enrolled. Only 27 (8.7%) patients were classified as having normal nutritional status. The CONUT score was also independently correlated with elevated C-reactive protein levels (β = 0.485, p < 0.0001). During the median follow-up of 37 months, 100 patients (32.2%) died. The CONUT score was an independent predictor of all-cause mortality (adjusted hazard ratio 1.13, 95% confidence interval 1.04−1.22, p < 0.0024). As model discrimination, the addition of the CONUT score to a prediction model based on established risk factors significantly improved net reclassification improvement (0.285, p = 0.028) and integrated discrimination improvement (0.025, p = 0.023). The CONUT score might be a simplified surrogate marker of the PEW with clinical utility and could predict all-cause mortality, in addition to improving the predictability in CKD patients just initiating dialysis. The CONUT score also could predict infectious-disease mortality.

Malnutrition, hemodynamics and inflammation in heart failure with reduced, mildly reduced and preserved ejection fraction

In patients with heart failure (HF) with reduced ejection fraction (HFrEF), malnutrition can be associated with intestinal congestion and systemic inflammation. These relationships have not been fully investigated in HF with mildly reduced EF (HFmrEF) and with preserved EF (HFpEF). We analyzed 420 patients with HF who underwent right heart catheterization. The relationships between hemodynamic parameters, C-reactive protein, and the controlling nutritional (CONUT) score were investigated in HFrEF, HFmrEF and HFpEF. The CONUT score of all patients was 2 [1, 4] (median [interquartile range]), and was not significantly different between the left ventricular EF (LVEF) categories (2 [1, 3] for HFrEF, 2 [1, 3] for HFmrEF, and 3 [1, 4] for HFpEF, p = 0.279). In multivariate linear regression analyses, there was a significant association between CRP and the CONUT score in HFmrEF and HFpEF, while brain natriuretic peptide and right atrial pressure were significantly associated with the CONUT score in HFrEF. Higher CONUT scores predicted a higher incidence of the composite endpoint of death or HF hospitalization within 12 months without an interaction with LVEF (p = 0.980). The CONUT score was an independent predictor of the composite endpoint, death, and HF hospitalization after adjustment for confounders in the multivariate analysis. In conclusion, inflammation was associated with malnutrition in HFmrEF and HFpEF, while congestion was an independent predictor of malnutrition in HFrEF. Malnutrition predicted worse outcomes regardless of LVEF.

Immune-Nutritional Status as a Novel Prognostic Predictor of Bell's Palsy

INTRODUCTION

The prognosis of Bell's palsy, idiopathic facial nerve palsy (FNP), is usually predicted by electroneuronography in subacute phase. However, it would be ideal to establish a reliable and objective examination applicable in acute phase to predict the prognosis of FNP. Immune-nutritional status (INS) calculated from peripheral blood examination is recently reported as the prognostic factor in various disease. However, the validity of INS as the prognostic factor in Bell's palsy is not well known. Thus, we conducted a retrospective study to investigate the usefulness of INS as prognostic predictors of Bell's palsy.

METHODS

We reviewed the medical records of 79 patients with Bell's palsy and divided into two groups as "complete recovery" and "incomplete recovery" groups. Clinical features such as severity of FNP and INS, including neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), prognostic nutritional index (PNI), and controlling nutrition status (CONUT) score, were assessed.

RESULTS

In univariate analysis, statistically significant differences were observed in clinical score of facial movement, NLR, LMR, PNI, and CONUT score at the initial examination between the two groups (p < 0.05). Furthermore, in multivariate analysis, statistically significant differences were also observed in facial movement score and PNI at the initial examination (p < 0.05).

CONCLUSION

Immune and nutritional condition play important roles in the pathogenesis of Bell's palsy, suggesting that INS would be one of the useful prognostic factors in Bell's palsy.

Association of Four Nutritional Scores With All-Cause and Cardiovascular Mortality in the General Population

Background and Aims

Malnutrition is a well known risk factor for adverse outcomes in patients with cancer, cardiovascular disease (CVD) and chronic kidney disease, but epidemiological evidence on its relationship with the long-term risk of all-cause mortality and cardiovascular death is limited.

Methods

A total of 20,116 adults from the United States National Health and Nutrition Examination Survey 2007–2014 were enrolled. The Geriatric Nutritional Risk Index (GNRI), Prognostic Nutritional Index (PNI), Controlling Nutritional Status (CONUT) score, and Triglycerides (TG) × Total Cholesterol (TC) × Body Weight (BW) Index (TCBI) were calculated at baseline. Cox regression and the Kaplan–Meier analysis were conducted when participants were divided into three groups according to the tertiles of objective nutritional scores. Restricted cubic spline was performed to further explore the shape of the relationship between all-cause mortality, cardiovascular death, and nutritional scores. In addition, the area under the curve (AUC), continuous net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were conducted to assess which nutritional scores have the greatest predictive value for all-cause death and cardiovascular death in the general population.

Results

The cumulative incidence of all-cause death and cardiovascular death was significantly higher in participants with a higher CONUT score, lower GNRI, and lower PNI. TCBI showed the worst performance on grading and risk assessment. After adjusting confounding factors, the lowest PNI and GNRI tertile and highest COUNT score were independently and significantly associated with increased risk of all-cause death (all P < 0.01) and cardiovascular death (all P < 0.05) analyzed by a multivariate Cox regression model. An L-shaped association between the HR (hazard ratio) of all-cause mortality and nutritional scores (GNRI, PNI and TCBI) was observed in the overall populations. In addition, the PNI had the highest predictive value for all-cause mortality [AUC: 0.684, 95% confidence interval (CI): 0.667–0.701] and cardiovascular death (AUC: 0.710, 95% CI: 0.672–0.749) in the general population compared with other nutritional scores.

Conclusion

The poorer the nutritional status of the general population, the higher the all-cause mortality and cardiovascular mortality. The PNI score may provide more useful predictive values than other nutritional scores.

Validity of the Controlling Nutritional Status score as a Nutritional Assessment Tool early after stroke

Malnutrition is relatively common in stroke survivors and it also affects weight loss and muscle strength. Various nutritional assessment tools have been used to monitor changes in nutritional status. Among such tools, the Controlling Nutritional Status (CONUT) score is a convenient and cost-effective index calculated from serum albumin level, total peripheral lymphocyte count, and total cholesterol level. This study investigated the prognostic role of malnutrition, as assessed by the CONUT scoring system. We hypothesized that malnutrition negatively affects outcomes as expressed by Functional Independence Measure (FIM) motor or Berg Balance Scale (BBS) change in stroke patients. This was a retrospective cohort study involving 117 individuals including first-time subacute stroke inpatients from March 2017 to February 2020. All participants were evaluated with BBS and FIM. We used multiple linear regression analysis with backward stepwise selection to examine the association between CONUT and changes during rehabilitation. After adjusting for independent predictors, we found the CONUT score to be associated with FIM motor (B = -1.848 ± 5.811, P < 0.001) and BBS change (B = -2.035 ± 0.424, P < 0.001). The present study showed that the malnutritional status calculated by the CONUT score at admission might help to predict the functional outcomes of stroke patients. The CONUT score is a comprehensive and feasible marker that could provide information for the nutritional management of stroke patients to significantly improve their clinical outcomes.

Clinical significance of the N-terminal pro-brain natriuretic peptide and B-type natriuretic peptide ratio in the acute phase of acute heart failure

AIMS

Serum N-terminal pro-brain natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP) levels are rarely evaluated simultaneously in the acute phase of acute heart failure (AHF).

METHOD AND RESULTS

A total of 1207 AHF patients were enrolled, and 1002 patients were analysed. Blood samples were collected within 15 min of admission. Patients were divided into two groups according to the median value of the NT-proBNP/BNP ratio [low-NT-proBNP/BNP group (Group L) vs. high-NT-proBNP/BNP group (Group H)]. A multivariate logistic regression model showed that the C-reactive protein level (per 1-mg/dL increase), Controlling Nutrition Status score (per 1-point increase), and estimated glomerular filtration rate (eGFR, per 10-mL/min/1.73 m2 increase) were independently associated with Group H [odds ratio (OR) 1.049, 95% confidence interval (CI) 1.009-1.090, OR 1.219, 95% CI 1.140-1.304, and OR 1.543, 95% CI 1.401-1.698, respectively]. A Kaplan-Meier curve analysis showed that the prognosis was significantly poorer in Group H than in Group L, and a multivariate Cox regression model revealed Group H to be an independent predictor of 180-day mortality [hazard ratio (HR) 3.084, 95% CI 1.838-5.175] and HF events (HR 1.963, 95% CI 1.340-2.876). The same trend in the prognostic impact was significantly observed in the low-BNP (<810 pg/mL, n = 501), high-BNP (≥810 pg/mL, n = 501), and low-eGFR (<60 mL/min/1.73 m2, n = 765) cohorts, and tended to be observed in normal-eGFR (≥60 mL/min/1.73 m2, n = 237) cohort.

CONCLUSION

A high NT-proBNP/BNP ratio was associated with a non-cardiac condition (e.g. inflammatory reaction, nutritional status, and renal dysfunction) and is independently associated with adverse outcomes in AHF.

The Prognostic Impact of Hospital Transfer after Admission due to Acute Heart Failure

The prognostic impact of transfer to another hospital among acute heart failure (AHF) patients has not been well elucidated.Of the 800 AHF patients analyzed, 682 patients were enrolled in this study for analysis. The subjects were divided into two groups according to their discharge location: discharge home (Group-H, n = 589) or transfer to another hospital for rehabilitation (Group-T, n = 93). The Kaplan-Meier curves revealed a poorer prognosis, including all-cause death and heart failure (HF) events (death, readmission-HF), in Group-T than that in Group-H (P < 0.001, respectively). A multivariate Cox regression model showed that Group-T was an independent predictor of 365-day all-cause death (hazard ratio: 2.618, 95% confidence interval [CI]: 1.510-4.538, P = 0.001). The multivariate logistic regression analysis showed that aging (per 1-year-old increase, odds ratio [OR]: 1.056, 95% CI: 1.028-1.085, P < 0.001), female gender (OR: 2.128, 95% CI: 1.287-3.521, P = 0.003), endotracheal intubation during hospitalization (OR: 2.074, 95% CI: 1.093-3.936, P = 0.026), and increased Controlling Nutritional Status score on admission (per 1.0-point increase, OR: 1.247, 95% CI: 1.131-1.475, P < 0.001) were associated with transfer to another hospital after AHF admission. The prognosis, including all-cause death, was determined to be significantly poorer in patients who were transferred to another hospital, as their activities of daily living were noted to lessen before discharge (n = 11) compared to others (n = 82).Elderly AHF patients suffering from malnutrition were difficult to discharge home after AHF admission, and transfer to another hospital only led to adverse outcomes. Appropriate rehabilitation during definitive hospitalization appears necessary for managing elderly patients in the HF pandemic era.

Association of Malnutrition, Left Ventricular Ejection Fraction Category, and Mortality in Patients Undergoing Coronary Angiography: A Cohort With 45,826 Patients

Background: The regulatory effect of the left ventricular ejection fraction (LVEF) categories on the association of malnutrition and all-cause mortality in patients undergoing coronary angiography (CAG) have not been adequately addressed.

Methods: Forty-five thousand eight hundred and twenty-six patients consecutively enrolled in the Cardiorenal ImprovemeNt (CIN) study (ClinicalTrials.gov NCT04407936) from January 2008 to July 2018 who underwent coronary angiography (CAG). The Controlling Nutritional Status (CONUT) score was applied to 45,826 CAG patients. The hazard ratios of mortality across combined LVEF and/or malnutrition categories were estimated by Cox regression models. Variables adjusted for in the Cox regression models included: age, gender, hypertension (HT), DM, PCI, coronary artery disease (CAD), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglyceride (TRIG), chronic kidney disease (CKD), statins, atrial fibrillation (AF), anemia, and stroke. Population attributable risk (PAR) was estimated for eight groups stratified by nutritional status and LVEF categories.

Results: In our study, 42,181(92%) of patients were LVEF ≥ 40%, of whom, 41.55 and 9.34% were in mild and moderate or severe malnutrition status, respectively, while 46.53 and 22.28% in mild and moderate or severe malnutritional status among patients with LVEF < 40%. During a median follow-up time of 4.5 years (percentile 2.8–7.1), 5,350 (11.7%) patients died. After fully adjustment, there is no difference of mortality on malnutrition in LVEF < 40% group (mild, moderate and severe vs. normal, HR (95%CI): [1.00 (0.83–0.98)], [1.20 (0.95–1.51)], [1.41 (0.87–2.29)], respectively, p for trend =0.068), but malnutrition was related to markedly increased risk of mortality in LVEF ≥ 40% group (mild, moderate, and severe vs. normal, HR (95%CI): [1.21 (1.12–1.31)], [1.56 (1.40–1.74)], and [2.20(1.67–2.90)], respectively, p for trend < 0.001, and p for interaction < 0.001). Patients with LVEF ≥ 40% had a higher malnutrition-associated risk of mortality and a higher PAR than those with LVEF < 40%.

Conclusions: Malnutrition is common in CAG patients and it has a greater effect on all-cause mortality and a higher PAR in patients with LVEF ≥ 40% than LVEF < 40%.

Nutritional status during hospitalization is associated with the long-term prognosis of patients with heart failure

Aims

The CONtrolling NUTritional status (CONUT) score represents the nutritional status of patients with heart failure (HF). Although high CONUT scores on admission are associated with increased risks of cardiovascular (CV) events in patients with HF, the impact of CONUT changes during hospitalization on their long‐term prognosis is unclear. This study aimed to investigate the impact of CONUT score changes on the clinical outcomes of patients with HF after discharge.

Methods and results

This observational study included 1705 patients hospitalized with HF who were discharged alive. The patients were categorized depending on their CONUT scores at admission and discharge into persistently high, high at admission and normal at discharge, normal at admission and high at discharge, and persistently normal CONUT groups. The primary endpoint was a composite of CV death and readmission for HF after discharge. The primary endpoint occurred in 652 patients (38%) during the median 525 day follow‐up period. Patients with persistently high CONUT scores had the highest composite endpoint rate (log‐rank trend test: P < 0.001). After adjusting for covariates, the hazard ratio for the composite outcome was significantly lower for the patients with high CONUT scores at admission and normal CONUT scores at discharge than that for those with persistently high CONUT scores (hazard ratio: 0.69; 95% confidence interval: 0.49–0.98).

Conclusions

Nutritional status changes in patients with HF that occurred during hospitalization were associated with CV events after discharge. Improving the nutritional status of patients may improve their clinical outcomes.

Impact of the Malnutrition on Mortality in Elderly Patients Undergoing Percutaneous Coronary Intervention

Purpose

Malnutrition has been shown to be related to adverse clinical outcomes in patients with heart failure, hypertension, atrial fibrillation and other cardiovascular diseases. However, in the patients with coronary artery disease (CAD) undergoing percutaneous coronary interventions (PCI), especially in the elderly, the association of nutritional state and all-cause mortality remains unknown. We aimed to investigate the association of malnutrition with all-cause mortality in the elder patients undergoing PCI.

Patients and Methods

Based on the largest retrospective and observational cohort study from January 2007 to December 2017, the Controlling Nutritional Status (CONUT) score was applied to 21,479 consecutive patients with age ≥60 who undergoing PCI for nutritional assessment. Participants were classified as absent, mild, moderate and severe malnutrition by CONUT score. The Kaplan-Meier method was used to compare all-cause mortality among the above four groups. Multivariable Cox proportional hazard regression analyses were performed to examine the association of malnutrition with all-cause mortality.

Results

According to the CONUT score, 48.19%, 15.08% and 0.94% patients were mildly, moderately and severely malnourished, respectively. During a median follow-up of 5.16 years (interquartile range: 3.02 to 7.89 years), 3173 (14.77%) patients died. Kaplan-Meier analysis showed that the risk of all-cause mortality was significantly higher in patients with a worse nutritional status. Compared with normal nutritional state, malnutrition was associated with significantly increased risk for all-cause mortality (adjusted hazard ratio for mild, moderate and severe degrees of malnutrition, respectively: 1.20 [95% confidence interval (CI): 1.09 to 1.33], 1.32 [95% CI: 1.17 to 1.49] and 1.76 [95% CI: 1.33 to 2.33]).

Conclusion

Malnutrition is prevalent among elderly patients with CAD undergoing PCI, and is strongly related to the all-cause mortality increasing. For elderly patients with CAD undergoing PCI, it is necessary to assess the status of nutrition, and evaluate the efficacy of nutritional interventions.

Predictive Value of the Serum Cystatin C/Prealbumin Ratio in Combination With NT-proBNP Levels for Long-Term Prognosis in Chronic Heart Failure Patients: A Retrospective Cohort Study

Aim: The present study was established to investigate the use of the serum cystatin C/prealbumin (Cys-C/PAB) ratio as a predictive factor for long-term prognosis in patients with chronic heart failure.

Methods: We divided our retrospective cohort of 6,311 patients admitted to hospital due to an episode of heart failure (HF) into three groups according to the Cys-C/PAB ratio. The endpoints were cardiovascular and all-cause mortality. Median follow-up time were 3.3 years (2–8 years), during which 2,945 (46.7%) patients died.

Results: The Cys-C/PAB ratio was revealed to be an independent predictor of cardiovascular mortality (HR: 1.12, 95% CI: 1.15–1.23, P < 0.01) and all-cause mortality (HR: 1.19, 95% CI: 1.13–1.24, P < 0.01) by multivariable Cox analysis. Integrated discrimination improvement (IDI) showed that the Cys-C/PAB ratio in conjunction with the level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) conferred a significant improvement in predicting individual risks of cardiovascular (P = 0.023) and all-cause (P = 0.028) mortality. For those with a high Cys-C/PAB ratio in combination with a high NT-proBNP level, the long-term cardiovascular mortality risk ratio was 8.6-times higher than for those with low values, and 7.51-times for all-cause mortality. Our study also showed that Cys-C/PAB and NT-proBNP in combination displayed higher value for the prediction of cardiovascular and all-cause in-hospital mortality in patients with HF.

Conclusions: The Cys-C/PAB ratio is valuable for predicting cardiovascular and all-cause mortality in patients with HF and offers additional information to that provided by NT-proBNP.

Prediction of all-cause mortality with malnutrition assessed by controlling nutritional status score in patients with heart failure: a systematic review and meta-analysis

OBJECTIVE

The aim of this meta-analysis was to investigate the association between malnutrition assessed by the controlling nutritional status (CONUT) score and all-cause mortality in patients with heart failure.

DESIGN

Systematic review and meta-analysis.

SETTINGS

A comprehensively literature search of PubMed and Embase databases was performed until 30 November 2020. Studies reporting the utility of CONUT score in prediction of all-cause mortality among patients with heart failure were eligible. Patients with a CONUT score ≥2 are grouped as malnourished. Predictive values of the CONUT score were summarized by pooling the multivariable-adjusted risk ratios (RR) with 95 % CI for the malnourished v. normal nutritional status or per point CONUT score increase.

PARTICIPANTS

Ten studies involving 5196 patients with heart failure.

RESULTS

Malnourished patients with heart failure conferred a higher risk of all-cause mortality (RR 1·92; 95 % CI 1·58, 2·34) compared with the normal nutritional status. Subgroup analysis showed the malnourished patients with heart failure had an increased risk of in-hospital mortality (RR 1·78; 95 % CI 1·29, 2·46) and follow-up mortality (RR 2·01; 95 % CI 1·58, 2·57). Moreover, per point increase in CONUT score significantly increased 16% risk of all-cause mortality during the follow-up.

CONCLUSIONS

Malnutrition defined by the CONUT score is an independent predictor of all-cause mortality in patients with heart failure. Assessment of nutritional status using CONUT score would be helpful for improving risk stratification of heart failure.

Comparison of Soluble ST2, Pentraxin-3, Galectin-3, and High-Sensitivity Troponin T of Cardiovascular Outcomes in Patients With Acute Decompensated Heart Failure

BACKGROUND

Data regarding a direct comparison of soluble suppression of tumorigenesis-2 (sST2), pentraxin 3 (PTX3), galectin-3 (Gal-3), and high-sensitivity troponin T of cardiovascular outcome in patients with heart failure (HF) are lacking.

METHODS AND RESULTS

A total of 616 hospitalized patients with HF were evaluated prospectively. Biomarker data were obtained in the stable predischarge condition. sST2 levels were associated with age, sex, body mass index, inferior vena cava diameter, B-type natriuretic peptide (BNP), PTX3, C-reactive protein, and Gal-3 levels. During follow-up, 174 (28.4%) primary composite end points occurred, including 58 cardiovascular deaths and 116 HF rehospitalizations. sST2 predicted the end point after adjustment for 13 clinical variables (hazard ratio 1.422; 95% confidence interval [CI] 1.064 to 1.895, P = .018). The association between sST2 and the end point was no longer statistically significant after adjustment for BNP (P = .227), except in the subgroup of patients with preserved ejection fraction (hazard ratio 1.925, 95% CI 1.102-3.378, P = .021). Gal-3 and high-sensitivity troponin T predicted the risk for the end point after adjustment for age and sex, but were not significant after adjustment for clinical variables. The prognostic value of PTX3 was not observed (age and sex adjusted, P = .066).

CONCLUSIONS

This study did not show significant additional value of biomarkers to BNP for risk stratification, except sST2 in patients with preserved ejection fraction.

Risk Stratification Towards Precision Medicine in Heart Failure - Current Progress and Future Perspectives

Clinical risk stratification is a key strategy used to identify low- and high-risk subjects to optimize the management, ranging from pharmacological treatment to palliative care, of patients with heart failure (HF). Using statistical modeling techniques, many HF risk prediction models that combine predictors to assess the risk of specific endpoints, including death or worsening HF, have been developed. However, most risk prediction models have not been well-integrated into the clinical setting because of their inadequacy and diverse predictive performance. To improve the performance of such models, several factors, including optimal sampling and biomarkers, need to be considered when deriving the models; however, given the large heterogeneity of HF, the currently advocated one-size-fits-all approach is not appropriate for every patient. Recent advances in techniques to analyze biological "omics" information could allow for the development of a personalized medicine platform, and there is growing awareness that an integrated approach based on the concept of system biology may be an excessively naïve view of the multiple contributors and complexity of an individual's HF phenotype. This review article describes the progress in risk stratification strategies and perspectives of emerging precision medicine in the field of HF management.

Tools for the Assessment of the Malnutrition Status and Possible Interventions in Elderly with Cardiovascular Diseases

Malnutrition represents a common and important feature in elderly people affected by cardiovascular diseases. Several studies have investigated its prevalence and prognostic role in most clinical settings, including cardiovascular disease. However, in daily practice it usually remains unrecognized and consequently untreated. The present review was ideated to answer the main questions about nutritional status assessment in patients with cardiovascular disease: why, when, where, how to evaluate it, and what to do to improve it. The three main cardiovascular diseases, namely aortic stenosis, ischaemic heart disease, and heart failure were considered. First, the main evidence supporting the prognostic role of malnutrition are summarized and analyzed. Second, the main tools for the assessment of malnutrition in the hospital and outpatient setting are reported for each condition. Finally, the possible strategies and interventions to address malnutrition are discussed.

How Can Malnutrition Affect Autophagy in Chronic Heart Failure? Focus and Perspectives

Chronic heart failure (CHF) is a disease with important clinical and socio-economic ramifications. Malnutrition and severe alteration of the protein components of the body (protein disarrangements), common conditions in CHF patients, are independent correlates of heart dysfunction, disease progression, and mortality. Autophagy, a prominent occurrence in the heart of patients with advanced CHF, is a self-digestive process that prolongs myocardial cell lifespan by the removal of cytosolic components, such as aging organelles and proteins, and recycles the constituent elements for new protein synthesis. However, in specific conditions, excessive activation of autophagy can lead to the destruction of molecules and organelles essential to cell survival, ultimately leading to organ failure and patient death. In this review, we aim to describe the experimental and clinical evidence supporting a pathophysiological role of nutrition and autophagy in the progression of CHF. The understanding of the mechanisms underlying the interplay between nutrition and autophagy may have important clinical implications by providing molecular targets for innovative therapeutic strategies in CHF patients.

The impact of malnutrition on atrial fibrillation recurrence post ablation

BACKGROUND AND AIMS

Both malnutrition and atrial fibrillation (AF) are the major health problems in modern society. Only a few studies focused on the relationship between malnutrition and recurrence of atrial arrhythmias post AF ablation (AF recurrence), which used body mass index (BMI) as nutrition assessment tool. However, BMI can't credibly reflect body composition and has limitation in patients with water-sodium retention. In this study, we used controlling nutritional status score (CONUT score) and geriatric nutritional risk index (GNRI) to identify the malnutrition patients and explored the effect of malnutrition on AF recurrence.

METHODS AND RESULTS

This retrospective study included 246 patients who underwent AF ablation. During a median 11-month follow-up, 77 patients (31.3%) experienced AF recurrence. The recurrence group had higher CONUT score (2.3 ± 1.5 vs. 0.9 ± 1.0, P < 0.001) and lower GNRI (99.9 ± 7.6 vs. 103.9 ± 5.6, P < 0.001). After balancing the traditional risk factors, both CONUT score (OR: 2.614, 95%CI: 1.831-3.731, P < 0.001) and GNRI (OR: 0.884, 95%CI: 0.828-0.944, P < 0.001) were the independent predictors for AF recurrence. Pre-ablation CONUT score ≥1 and GNRI≥95.66 are indicative of AF recurrence. Adding CONUT score or GNRI to the base prediction model for AF recurrence significantly improved the discrimination and calibration. However, adding BMI to the base prediction model did not improve the model performance.

CONCLUSIONS

CONUT score and GNRI are ideal tools to evaluate the nutrition status of AF patients. Undernourished patients are more likely to suffer from AF recurrence. Improving nutrition status may be a potential target for reducing the postoperative recurrence rate.

Prognostic significance of the controlling nutritional (CONUT) score in patients with acute coronary syndrome

BACKGROUND

Malnutrition is an independent predictor of adverse outcomes in patients with acute coronary syndrome. The controlling nutritional (CONUT) score has been applied to assess nutritional status, and has been reported to be associated with poor prognosis in patients with heart failure. However, the prognostic impact of the CONUT score in patients with acute coronary syndrome (ACS) remains to be elucidated.

METHODS

We evaluated the CONUT score in 196 patients with ACS who underwent percutaneous coronary intervention. We divided the patients into four groups according to CONUT score (undernutrition degree: normal, CONUT 0-1 (reference); mild, CONUT 2-4; moderate, CONUT 5-8; severe, CONUT 9-12). The endpoint of the present study was composite events including all-cause death, acute coronary syndrome, target vessel revascularization, and stroke.

RESULTS

The median CONUT score was significantly higher in patients with composite events than in those without events (P = 0.0058). Kaplan-Meier analysis revealed that a significantly higher event rate in patients with severe malnutrition (log-rank test, P = 0.0222). In the multivariate Cox proportional hazards analysis, CONUT score was independently associated with composite events after adjustment for confounding factors (adjusted hazard ratio 1.284, 95% confidence interval 1.126-1.457, P = 0.0003).

CONCLUSION

Higher CONUT scores were associated with unfavorable outcomes in patients with ACS. Malnutrition assessed by the CONUT score may provide valuable prognostic information in patients with ACS.

＜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.

Sarcopenia in patients after an episode of acute decompensated heart failure: An underdiagnosed problem with serious impact

BACKGROUND & AIMS

Sarcopenia is a multifactorial syndrome resulting in a decrease in both muscle mass and function. Little is known about the prevalence and prognostic impact of sarcopenia in patients with acutely decompensated chronic heart failure (ADHF). We aimed to evaluate the prevalence (main endpoint) and impact of sarcopenia on ADHF patients.

METHODS

140 ADHF patients were enrolled between November 2014 and September 2018 in a multicenter prospective longitudinal study. A similar, independent multi-departmental cross-sectional study in 165 ADHF patients was used for external validation of prevalence data. All subjects were assessed on the European Working Group on Sarcopenia criteria.

RESULTS

Ninety-one patients (65%) had sarcopenia (vs. 53.6% in the external replication regional cohort). Patients with sarcopenia were older and more likely to have eGFR <60 ml/min/1.73 m² (p < 0.001 and p = 0.002). Sarcopenia was associated with impaired functional status [lower 6 min walking test (220 ± 108 vs. 279 ± 170, p = 0.03) and 4 m gait speed (0.56 ± 0.24 vs. 0.80 ± 0.37, p < 0.001)] and autonomy [Instrumental activities of daily living: 6.7 ± 1.4 vs. 7.3 ± 1.2, p = 0.005]. Over up to 4 years' follow-up, 30 cardiovascular (CV) deaths and 42 non-CV deaths occurred. In a multivariable analysis, sarcopenia was associated with time to first non-CV hospitalization (hazard ratio 1.93; 95% confidence interval 1.14-3.24; p = 0.014) but not with any other hospitalization, any mortality endpoint, or a composite endpoint of CV death and HF hospitalization.

CONCLUSIONS

The prevalence of sarcopenia in ADHF patients is high and associated with greater risk of non-CV hospitalizations, highlighting the importance of identifying and managing the condition in a multidisciplinary approach.

CLINICAL TRIAL REGISTRATION

NCT03153774.

Importance of the Corrected Calcium Level in Patients With Acute Heart Failure Requiring Intensive Care

Background: Serum calcium (Ca) concentrations in the acute phase of acute heart failure (AHF) have not been not sufficiently investigated.

Methods and Results: This study enrolled 1,291 AHF patients and divided them into 3 groups based on original and corrected Ca concentrations: (1) hypocalcemia (both original and corrected Ca ≤8.7 mg/dL; n=651); (2) pseudo-hypocalcemia (original and corrected Ca ≤8.7 and >8.7 mg/dL, respectively; n=300); and (3) normal/hypercalcemia (both original and corrected Ca >8.7 mg/dL; n=340). AHF patients were also divided into 2 groups based on corrected Ca concentrations: (1) corrected hypocalcemia (corrected Ca ≤8.7 mg/dL; n=651); and (2) corrected normal/hypercalcemia (corrected Ca >8.7 mg/dL; n=640). Of the 951 patients with original hypocalcemia (≤8.7 mg/dL), 300 (31.5%) were classified as corrected normal/hypercalcemia after correction of Ca concentrations by serum albumin. The prognoses in the pseudo-hypocalcemia, low albumin, and corrected normal/hypercalcemia groups, including all-cause death within 730 days, were significantly poorer than in the other groups. Multivariate Cox regression analysis showed that classification into the pseudo-hypocalcemia, hypoalbumin, and corrected normal/hypercalcemia groups independently predicted 730-day all-cause death (hazard ratios [95% confidence intervals] of 1.497 [1.153–1.943], 2.392 [1.664–3.437], and 1.294 [1.009–1.659], respectively).

Conclusions: Corrected normal/hypercalcemia was an independent predictor of prognosis because this group included patients with pseudo-hypocalcemia, which was affected by the serum albumin concentration.

Prognostic Effect of a Novel Simply Calculated Nutritional Index in Acute Decompensated Heart Failure

The TCB index (triglycerides × total cholesterol × body weight), a novel simply calculated nutritional index based on serum triglycerides (TGs), serum total cholesterol (TC), and body weight (BW), was recently reported to be a useful prognostic indicator in patients with coronary artery disease. Thus, this study aimed to investigate the relationship between TCBI and long-term mortality in acute decompensated heart failure (ADHF) patients. Patients with a diagnosis of ADHF who were consecutively admitted to the cardiac intensive care unit in our institution from 2007 to 2011 were targeted. TCBI was calculated using the formula TG (mg/dL) × TC (mg/dL) × BW (kg)/1000. Patients were divided into two groups according to the median TCBI value. An association between admission TCBI and mortality was assessed using univariable and multivariable Cox proportional hazard analyses. Overall, 417 eligible patients were enrolled, and 94 (22.5%) patients died during a median follow-up period of 2.2 years. The cumulative survival rate with respect to all-cause, cardiovascular, and cancer-related mortalities was worse in patients with low TCBI than in those with high TCBI. In the multivariable analysis, although TCBI was not associated with cardiovascular and cancer mortalities, the association between TCBI and reduced all-cause mortality (hazard ratio: 0.64, 95% confidence interval: 0.44-0.94, p = 0.024) was observed. We computed net reclassification improvement (NRI) when TCBI or Geriatric Nutritional Risk Index (GNRI) was added on established predictors such as hemoglobin, serum sodium level, and both. TCBI improved discrimination for all-cause mortality (NRI: 0.42, p < 0.001; when added on hemoglobin and serum sodium level). GNRI can improve discrimination for cancer mortality (NRI: 0.96, p = 0.002; when added on hemoglobin and serum sodium level). TCBI, a novel and simply calculated nutritional index, can be useful to stratify patients with ADHF who were at risk for worse long-term overall mortality.

Iron deficiency in worsening heart failure is associated with reduced estimated protein intake, fluid retention, inflammation, and antiplatelet use

Aims

Iron deficiency (ID) is common in heart failure (HF) patients and negatively impacts symptoms and prognosis. The aetiology of ID in HF is largely unknown. We studied determinants and the biomarker profile of ID in a large international HF cohort.

Methods and results

We studied 2357 worsening HF patients from the BIOSTAT-CHF cohort. ID was defined as transferrin saturation <20%. Univariable and multivariable logistic regression models were constructed to identify determinants for ID. We measured 92 cardiovascular markers (Olink Cardiovascular III) to establish a biomarker profile of ID. The primary endpoint was the composite of all-cause mortality and first HF rehospitalization. Mean age (±standard deviation) of all patients was 69 ± 12.0 years, 26.1% were female and median N-terminal pro B-type natriuretic peptide levels (+interquartile range) were 4305 (2360–8329) ng/L. Iron deficiency was present in 1453 patients (61.6%), with highest prevalence in females (71.1% vs. 58.3%; P < 0.001). Independent determinants of ID were female sex, lower estimated protein intake, higher heart rate, presence of peripheral oedema and orthopnoea, chronic kidney disease, lower haemoglobin, higher C-reactive protein levels, lower serum albumin levels, and P2Y₁₂ inhibitor use (all P < 0.05). None of these determinants were sex-specific. The biomarker profile of ID largely consisted of pro-inflammatory markers, including paraoxonase 3 (PON3) and tartrate-resistant acid phosphatase type 5. In multivariable Cox proportional hazard regression analyses, ID was associated to worse outcome, independently of predictors of ID (hazard ratio 1.25, 95% confidence interval 1.06–1.46; P = 0.007).

Conclusion

Our data suggest that the aetiology of ID in worsening HF is complex, multifactorial and seems to consist of a combination of reduced iron uptake (malnutrition, fluid overload), impaired iron storage (inflammation, chronic kidney disease), and iron loss (antiplatelets).

Controlling Nutritional Status Score As a Predictive Marker for Patients With Implantable Left Ventricular Assist Device

Although a correlation between the nutritional status and the prognosis of patients with heart failure has been suggested, a correlation between the nutritional status and outcomes after the left ventricular assist device (LVAD) implantation remains unclear. We aimed to investigate the efficacy of the Controlling Nutritional Status (CONUT) score (range 0-12, including serum albumin, total cholesterol, and lymphocytes) as a nutritional index in speculating the prognosis of patients undergoing LVAD implantation. We examined 63 consecutive patients who underwent the continuous-flow LVAD implantation. Using the preoperative CONUT score, patients were categorized into two groups: lower CONUT score (0-4: normal to mild malnutrition) and higher CONUT score (5-12: moderate to severe malnutrition). We compared for the backgrounds and the clinical events after LVAD implantation. The higher CONUT group exhibited a significantly higher mean right atrial pressure (10.9 ± 4.7 vs. 7.3 ± 4.1 mmHg; p = 0.0019). In that group, the mortality rate was significantly higher (25% vs. 2.6%; p = 0.0059) and the Kaplan-Meier analysis showed lower survival rate. Furthermore, more bleeding events significantly occurred in the higher CONUT group. The preoperative CONUT score may reflect systemic venous congestion and offer a useful prognostic index of clinical courses after LVAD implantation.

Anabolism to Catabolism: Serologic Clues to Nutritional Status in Heart Failure

PURPOSE OF REVIEW

Malnutrition, sarcopenia, and cachexia are areas of increasing interest in the management of patients with heart failure (HF). This review aims to examine the serological markers useful in guiding the physician in identification of these patients.

RECENT FINDINGS

Traditional nutritional biomarkers including albumin/prealbumin, iron, and vitamin D deficiencies predict poor prognosis in malnutrition and HF. Novel biomarkers including ghrelin, myostatin, C-terminal agrin fragment, and adiponectin have been identified as possible substrates and/or therapeutic targets in cardiac patients with sarcopenia and cachexia, though clinical trial data is limited to date. Increased focus on nutritional deficiency syndromes in heart failure has led to the use of established markers of malnutrition as well as the identification of novel biomarkers in the management of these patients, though to date, their usage has been confined to the academic domain and further research is required to establish their role in the clinical setting.

Hospital malnutrition in northeast and southeast Asia: A systematic literature review

BACKGROUND & AIMS

Hospital malnutrition is a prevalent yet frequently under-recognised condition that is associated with adverse clinical and economic consequences. Systematic reviews from various regions of the world have provided regional estimates of the prevalence of malnutrition and the magnitude of the associated health and economic burden; however, a systematic assessment of the prevalence and consequences of hospital malnutrition in northeast and southeast Asia has not been conducted.

METHODS

We performed a systematic literature search for articles on hospital malnutrition in 11 Asian countries published in English between January 1, 1997 and January 15, 2018. Studies reporting data on the prevalence, clinical consequences, or economic impact of hospital malnutrition in an adult inpatient population with a sample size ≥30 were eligible for inclusion.

RESULTS

The literature search identified 3207 citations; of these, 92 studies (N = 62,280) met the criteria for inclusion. There was substantial variability in study populations and assessment methods; however, a majority of studies reported a malnutrition prevalence of >40%. Malnutrition was associated with an increase in clinical complications, mortality, length of hospitalisation, hospital readmissions, and healthcare costs.

CONCLUSIONS

Hospital malnutrition is a highly prevalent condition among hospitalised patients in northeast and southeast Asia. Additionally, poor nutritional status is associated with increased morbidity and mortality and increased healthcare costs. Further research aimed at improving the identification and proactive management of hospitalised patients at risk for malnutrition is necessary to improve patient outcomes and alleviate the burden on local healthcare budgets.

Prevalence, Determinants, and Prognostic Significance of Hospital Acquired Pneumonia in Patients with Acute Heart Failure

The prognostic impact of hospital-acquired pneumonia (HAP) in acute heart failure (AHF) patients have not been fully elucidated. We evaluated 776 consecutive hospitalized AHF patients. The primary in-hospital outcomes were all-cause death and worsening heart failure (WHF), while the outcome following discharge was all-cause death. The clinical diagnosis of HAP was based on clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Patients with HAP had a significantly higher incidence of in-hospital death (12% vs. 1%, p < 0.001), WHF during the hospitalization (28% vs. 7%, p < 0.001), and longer length of hospital stay (p = 0.003) than those without. Among patients who survived at discharge, during a median follow-up period of 741 (interquartile range 422–1000) days, the incidence of all-cause death was significantly higher in patients with HAP than in those without (p < 0.001). In the multivariable Cox regression, HAP development was independently associated with all-cause death after discharge (HR [hazard ratio] 1.86, 95%CI [confidence interval] 1.08–3.19). Furthermore, older age (OR [odds ratio] 1.04, 95%CI 1.01–1.08), male sex (OR 2.21, 95%CI 1.14–4.28), and higher serum white blood cell count (OR 1.18, 95%CI 1.09–1.29) and serum C-reactive protein (OR 1.08, 95%CI 1.01–1.06) were independently associated with HAP development. In hospitalized patients with AHF, HAP development was associated with worse clinical outcomes, suggesting the importance of prevention and early screening for HAP.

Association of Controlling Nutritional Status Score With 2-Year Clinical Outcomes in Patients With ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

BACKGROUND

This study evaluated whether the Controlling Nutritional Status (CONUT) score could predict clinical outcomes in ST elevation myocardial infarction (STEMI) patients.

METHODS

We performed a retrospective cohort study of STEMI patients after primary percutaneous coronary intervention (pPCI). The endpoint was major adverse cardiac event (MACE). Information was obtained from medical records and via telephone calls. Patients were divided into three groups: normal (CONUT score 0-1; n=278), mild-moderate (score 2-4; n=418), and severe (score ≥5; n=55) groups.

RESULTS

During the 24.6±12 months follow-up, MACEs were observed in 65 (8.7%) patients. The incidence of MACEs was 6.1%, 5.5%, and 45.5% in the normal, mild-moderate, and severe group, respectively (p<0.001). Kaplan-Meier curves revealed that patients with a CONUT score ≥5 had the significantly highest rate of MACE, myocardial re-infarction, and vessel revascularisation. In three Cox proportional hazard models, the CONUT scores were unexceptionally associated with MACE, even after adjusting all other variables (hazard ratio, 12.09; 95% confidence interval [CI], 5.09-28.7; p<0.001). The C-statistic of the CONUT score for the prediction of MACE was 0.692 (95% CI, 0.613-0.771; p<0.001), which is close to that of Global Registry of Acute Coronary Events.

CONCLUSIONS

The nutritional status evaluated by the CONUT score can independently predict clinical outcomes in STEMI patients, which suggests that active nutritional management is meaningful for these patients after PCI.

Clinical Significance of the Controlling Nutritional Status (CONUT) Score in Patients with Infective Endocarditis

Risk stratification of patients with infective endocarditis (IE) is difficult. The Controlling Nutritional Status (CONUT) score is an index of immune function and nutritional status. We investigated the prognostic value of the CONUT score in IE and whether its prognostic value differed between IE patients with and without indications for surgery.Clinical records were retrospectively evaluated for 92 patients with IE treated at Nihon University Itabashi Hospital and Nihon University Hospital between January 2014 and May 2019. The CONUT score was determined upon admission, and patients were divided into two groups at the median score (≤ 7 [n = 50] and ≥ 8 [n = 42]). The primary outcome was all-cause mortality at 90 days after admission.The high CONUT group had significantly higher C-reactive protein and N-terminal pro-brain natriuretic peptide levels, as well as a significantly lower hemoglobin and estimated glomerular filtration rate (all P < 0.05), and considerably more valve perforation (26% versus 8%, P < 0.05). Kaplan-Meier analysis revealed that mortality was significantly higher in the high CONUT group (P < 0.001). Even after adjusting for the propensity score based on IE risk factors, a higher CONUT score was still associated with mortality. A receiver-operating characteristic analysis revealed that a CONUT score ≥ 8 had a sensitivity of 86% and specificity of 76% for predicting all-cause mortality. A CONUT score ≥ 8 was most strongly associated with mortality in patients with surgical indications (P < 0.001).In patients with IE, a higher CONUT score was significantly associated with inflammation, heart failure, renal dysfunction, anemia, valve dysfunction, and short-term mortality, especially in patients with surgical indications.

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.

Association between Preoperative Nutritional Status and Clinical Outcomes of Patients with Coronary Artery Disease Undergoing Percutaneous Coronary Intervention

Background: Malnutrition is associated with poor outcomes in patients with cancer, heart failure and chronic kidney disease. This study aimed to investigate the predictive value of the Controlling Nutritional Status (CONUT) score in coronary artery disease (CAD) patients. Methods: We recruited a cohort of 3118 patients with CAD undergoing percutaneous coronary intervention (PCI) from 2005 to 2015. Nutritional status was evaluated using the CONUT score, with higher scores reflecting worse nutritional status. Results: After adjustment for comorbidities and medication, an increased CONUT score was independently associated with a higher risk of acute myocardial infarction (AMI) (HR: 1.13; 95% CI: 1.03–1.24), cardiovascular (CV) death (HR: 1.18; 95% CI: 1.07–1.30), congestive heart failure (CHF) (HR: 1.11; 95% CI: 1.04–1.18), a major adverse cardiovascular event (MACE) (HR: 1.14; 95% CI: 1.07–1.22), and total CV events (HR: 1.11; 95% CI: 1.07–1.15). The subgroup analyses demonstrated that the association of the CONUT score existed independently of other established cardiovascular risk factors. In addition, CONUT significantly improved risk stratification for myocardial infarction (MI), cardiac death, CHF, MACEs and total CV events compared to conventional risk factors in CAD patients by the significant increase in the C-index (p < 0.05) and reclassification risk categories in cardiac death and MACEs. Conclusions: The CONUT score improved the risk prediction of adverse events compared to traditional risk factors in CAD patients after percutaneous coronary intervention (PCI).

Impact of the Geriatric Nutritional Risk Index on In-Hospital Mortality and Length of Hospitalization in Patients with Acute Decompensated Heart Failure with Preserved or Reduced Ejection Fraction

In patients with heart failure (HF), the impact of the Geriatric Nutritional Risk Index (GNRI) on in-hospital mortality and length of hospital stay remains unclear. We aimed to identify the factors associated with increased in-hospital mortality and longer length of hospital stay considering the GNRI in acute decompensated HF with reduced and preserved ejection fraction (HFrEF and HFpEF, respectively). Patients with acute decompensated HF who were admitted to our institution between 2007 and 2011 were investigated. A total of 451 (201, HFrEF; 250, HFpEF) patients were divided into the following: patients with GNRI < 92 and ≥92. In HFrEF, there were no significant differences in in-hospital mortality and length of hospital stay between patients with GNRI < 92 and ≥92 (median (interquartile range), 24.0 (23.8) days and 20.0 (15.0) days, respectively, p = 0.32). In HFpEF, despite no differences in in-hospital mortality, patients with GNRI < 92 had significantly longer length of hospital stay than those with GNRI ≥ 92 (median (interquartile range), 20.0 (22.3) days and 17.0 (16.0) days, respectively, p = 0.04). In HFpEF, GNRI < 92, along with lower hemoglobin, higher B-type natriuretic peptide, and elevated C-reactive protein levels, were the independent factors for longer length of hospital stay. Among patients with acute decompensated HF, assessment of nutritional status with GNRI is useful for stratifying patients at high risk for longer length of hospital stay in HFpEF but not in HFrEF. These observations are particularly important when considering the increasing elderly population and prevalence of HFpEF.