Valor pronóstico del índice de masa corporal y el perímetro de cintura en los pacientes con insuficiencia cardiaca crónica (Registro Español REDINSCOR)

Increased estimated fat-free mass and fat mass associated with improved clinical outcome in heart failure

BACKGROUND

Increased weight measured by body mass index is associated with better clinical outcomes in heart failure (HF). The effect of specific components of body mass on outcome is limited. We evaluated the impact of fat-free mass and fat mass on mortality and cardiovascular hospitalization in a large real-world cohort of patients with chronic HF.

METHODS

Body measurements were assessed in patients with chronic HF. Fat-free mass, fat mass and waist circumference were calculated based on specifically derived formulas.

RESULTS

The cohort included 6328 HF patients. Mean follow-up was 744 days. Increased body composition indices including body mass index, fat-free mass index and fat mass index, per cent body fat and waist circumference were associated with better survival. Cox regression analysis after adjustment for other significant parameters demonstrated that these indices were all associated with improved survival. The strongest association was seen with fat-free mass index with a graded increase in survival; lowest death in the highest quartile compared to reference second quartile (hazard ratio 0.79, 95% confidence interval 0.67-0.93, P < .01). There was no interaction with sex or HF type. Analysis of the clinical outcome of death and cardiovascular hospitalization demonstrated that a worse prognosis was in the lowest quartile of all the indices. A sensitivity analysis, analysing these indices as continuous parameters using restricted cubic splines, demonstrated a clear continuous association between these indices and increased survival in both sexes.

CONCLUSIONS

Body mass including fat-free mass and fat mass was associated with improved survival in patients with HF.

Obesity phenotypes and their paradoxical association with cardiovascular diseases

The pro-inflammatory state of the visceral adipose tissue (VAT) is supposed to accelerate cardiovascular (CV) and metabolic diseases in obese subjects. Some studies have recently reported an improved CV prognosis in certain obese and overweight patients as compared with leaner ones. This phenomenon, known as the "obesity paradox" (OP), has been described in many chronic diseases. This narrative review is based on the material searched for and obtained via PubMed and Web of Science up to May 2017. The search terms we used were: "obesity, paradox, adipose tissue" in combination with "cardiovascular, coronary heart disease, heart failure, arrhythmias". Using the current Body Mass Index (BMI)-based obesity definition, individuals with different clinical and biochemical characteristics are gathered together in the same category. Emerging evidence point to the existence of many "Obesity phenotypes" with different association with CV risk, accordingly to physical and life-style features. In this narrative review, we discussed if obesity phenotypes may be associated with a different CV risk, potentially explaining the OP. As a globally accepted definition of obesity is still lacking, we emphasized the need of a new approach, which should consider the heterogeneity of obesity. Better defining "obesities" and related CV risk is critical to markedly improve the classical BMI-based definition of obesity.

Association between obesity and heart failure symptoms in male and female patients

In patients with heart failure (HF), higher body mass index (BMI) has been associated with lower rates of hospitalization and mortality (obesity paradox). Symptoms are antecedents of hospitalizations, but little is known about the relationship between BMI and symptoms and gender differences. To examine the association of BMI with symptoms in male and female patients with HF, controlling for covariates (sample characteristics, depressive symptoms and sodium intake). In this cross-sectional correlational study, patients (N = 247) provided data on BMI, symptoms and covariates. BMI was categorized into four groups: normal/underweight (<25 kg/m² ), overweight (25-29.9 kg/m² ), obese I (30-34.9 kg/m² ) and obese II/III (≥35 kg/m² ). General linear regression was used to analyse the data. The Obese II/III group had more severe HF symptoms than other groups only in male patients. In male patients, older age, Caucasian race, more comorbidities and more severe depressive symptoms were also associated with more severe symptoms. In female patients, more severe depressive symptoms, more comorbidities and higher sodium intake were associated with more severe symptoms. The obesity paradox does not fully extend to symptoms, and gender has a role in the relationship between obesity and symptoms.

Weight Loss in Obese Patients With Heart Failure

BACKGROUND

In heart failure (HF), weight loss (WL) has been associated with an adverse prognosis whereas obesity has been linked to lower mortality (the obesity paradox). The impact of WL in obese patients with HF is incompletely understood. Our objective was to explore the prevalence of WL and its impact on long-term mortality, with an emphasis on obese patients, in a cohort of patients with chronic HF.

METHODS AND RESULTS

Weight at first visit and the 1-year follow-up and vital status after 3 years were assessed in 1000 consecutive ambulatory, chronic HF patients (72.7% men; mean age 65.8±12.1 years). Significant WL was defined as a loss of ≥5% weight between baseline and 1 year. Obesity was defined as body mass index ≥30 kg/m(2) (N=272). Of the 1000 patients included, 170 experienced significant WL during the first year of follow-up. Mortality was significantly higher in patients with significant WL (27.6% versus 15.3%, P<0.001). In univariable Cox regression analysis, patients with significant WL had 2-fold higher mortality (hazard ratio 1.95 [95% CI 1.39-2.72], P<0.001). In multivariable analysis, adjusting for age, sex, body mass index, New York Heart Association functional class, left ventricular ejection fraction, HF duration, ischemic etiology, diabetes, and treatment, significant WL remained independently associated with higher mortality (hazard ratio 1.89 [95% CI 1.32-2.68], P<0.001). Among obese patients with HF, significant WL was associated with an even more ominous prognosis (adjusted hazard ratio for death of 2.38 [95% CI 1.31-4.32], P=0.004) than that observed in nonobese patients (adjusted hazard ratio 1.83 [95% CI 1.16-2.89], P=0.01).

CONCLUSIONS

Weight loss ≥5% in patients with chronic HF was associated with high long-term mortality, particularly among obese patients with HF.

Características basales y cambios en el tratamiento tras el periodo de optimización de los pacientes incluidos en el estudio EFICAR

Objetivo

Se describen los datos basales de clase y capacidad funcional, comorbilidades, calidad de vida y cambios en la medicación durante la optimización del tratamiento, en pacientes con insuficiencia cardiaca y función sistólica deprimida (ICFSD) incluidos en el estudio EFICAR.

Diseño

Ensayo clínico aleatorizado multicéntrico.

Emplazamiento

Siete Centros de Salud.

Participantes

Ciento cincuenta pacientes con ICFSD; edad 68 ± 10 años, 77% varones

Mediciones

Variables sociodemográficas e índice de Charlson. Se evaluó la calidad de vida y la capacidad funcional Se realizó optimización del tratamiento.

Resultados

La etiología principal fue la cardiopatía isquémica (45%). Índice de Charlson global: 2,03 ± 1,05. El 31% ingresaron durante el último año por insuficiencia cardiaca. Fracción de eyección media: 37% ± 8. Clase funcional ii: 89%. Capacidad funcional con prueba de esfuerzo: 6,3 ± 1,6. Test 6 min: 446 ± 78 m. Test de la silla: 13,7 ± 4,4 s. Dinamómetro: 34,53 ± 10,12 kgf y 0,58 ± 0,16 bar. Short Form-36 Health Survey: salud física: 43,3 ± 8,4; salud mental: 50,1 ± 10,6. Minnesota Living with Heart Failure Questionnaire global: 22,8 ± 18,7. Tras optimizar el tratamiento no varió el porcentaje de pacientes ni la dosis media de fármacos analizados.

Conclusiones

La mayoría de los sujetos están en clase funcional ii, con capacidad funcional y calidad de vida disminuida e índice de comorbilidad elevado. Un ajuste protocolizado del tratamiento no consigue aumentar la dosis ni el número de pacientes con fármacos eficaces para la insuficiencia cardiaca con función cardiaca deprimida.

Micronutrient Deficiencies in Patients With Heart Failure: Relationships With Body Mass Index and Age

BACKGROUND

It is conceivable that lean patients (body mass index 18.5-24.9 kg/m(2)) with heart failure (HF) have low body weight due to low food consumption and that this may contribute to micronutrient deficiencies and to their poorer prognosis compared with overweight/obese patients. We hypothesized that lean patients have a greater number of inadequate micronutrient intakes (<50% of recommendations) than overweight/obese patients and that this also depends on age.

METHODS AND RESULTS

Lean (n = 15) and overweight/obese (n = 49) patients underwent 24-hour diet and physical activity recall interviews. Inadequate essential micronutrient intakes were ubiquitous (intakes of 13 ± 1 of 27 micronutrients were inadequate) and did not depend on race, status, or access to supermarkets. Younger (40-64 y) lean patients had inadequate intakes of 20 ± 2 micronutrients, which was more than the other weight/age subgroups (all P < .01). Physical activity levels did not differ across weight and age groups.

CONCLUSIONS

Patients with HF may be at risk of malnutrition due to numerous inadequate micronutrient intakes; younger lean patients may have an especially high risk. Future studies are needed to confirm these preliminary findings and to investigate the possibility that incorporating a micronutrient-dense meal plan will improve patient outcomes.

Multimarker Strategy for Heart Failure Prognostication. Value of Neurohormonal Biomarkers: Neprilysin vs NT-proBNP

INTRODUCTION AND OBJECTIVES

Neprilysin breaks down numerous vasoactive peptides. The soluble form of neprilysin, which was recently identified in heart failure, is associated with cardiovascular outcomes. Within a multibiomarker strategy, we directly compared soluble neprilysin and N-terminal pro-B-type natriuretic peptide as risk stratifiers in a real-life cohort of heart failure patients.

METHODS

Soluble neprilysin, N-terminal pro-B-type natriuretic peptide, ST2, and high-sensitivity troponin T levels were measured in 797 consecutive ambulatory heart failure patients followed up for 4.7 years. Comprehensive multivariable analyses and soluble neprilysin vs N-terminal pro-B-type natriuretic peptide head-to-head assessments of performance were performed. A primary composite endpoint included cardiovascular death or heart failure hospitalization. A secondary endpoint explored cardiovascular death alone.

RESULTS

Median soluble neprilysin and N-terminal pro-B-type natriuretic peptide concentrations were 0.64ng/mL and 1187 ng/L, respectively. Both biomarkers significantly correlated with age (P<.001) and ST2 (P<.001), but only N-terminal pro-B-type natriuretic peptide significantly correlated with estimated glomerular filtration rate (P<.001), body mass index (P<.001), left ventricular ejection fraction (P=.02) and high-sensitivity troponin T (P<.001). In multivariable Cox regression analyses, soluble neprilysin remained independently associated with the composite endpoint (hazard ratio=1.14; 95% confidence interval, 1.02-1.27; P=.03) and cardiovascular death (hazard ratio=1.15; 95% confidence interval, 1.01-1.31; P=.04), but N-terminal pro-B-type natriuretic peptide did not. The head-to-head soluble neprilysin vs N-terminal pro-B-type natriuretic peptide comparison showed good calibration and similar discrimination and reclassification for both neurohormonal biomarkers, but only soluble neprilysin improved overall goodness-of-fit.

CONCLUSIONS

When added to a multimarker strategy, soluble neprilysin remained an independent prognosticator, while N-terminal pro-B-type natriuretic peptide lost significance as a risk stratifier in ambulatory patients with heart failure. Both biomarkers performed similarly in head-to-head analyses.

Nutritional Risk Index predicts mortality in hospitalized advanced heart failure patients

BACKGROUND

Hospitalized advanced heart failure (HF) patients are at high risk for malnutrition and death. The Nutritional Risk Index (NRI) is a simple, well-validated tool for identifying patients at risk for nutrition-related complications. We hypothesized that, in advanced HF patients from the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial, the NRI would improve risk discrimination for 6-month all-cause mortality.

METHODS

We analyzed the 160 ESCAPE index admission survivors with complete follow-up and NRI data, calculated as follows: NRI = (1.519 × discharge serum albumin [in g/dl]) + (41.7 × discharge weight [in kg] / ideal body weight [in kg]); as in previous studies, if discharge weight is greater than ideal body weight (IBW), this ratio was set to 1. The previously developed ESCAPE mortality model includes: age; 6-minute walk distance; cardiopulmonary resuscitation/mechanical ventilation; discharge β-blocker prescription and diuretic dose; and discharge serum sodium, blood urea nitrogen and brain natriuretic peptide levels. We used Cox proportional hazards modeling for the outcome of 6-month all-cause mortality.

RESULTS

Thirty of 160 patients died within 6 months of hospital discharge. The median NRI was 96 (IQR 91 to 102), reflecting mild-to-moderate nutritional risk. The NRI independently predicted 6-month mortality, with adjusted HR 0.60 (95% CI 0.39 to 0.93, p = 0.02) per 10 units, and increased Harrell's c-index from 0.74 to 0.76 when added to the ESCAPE model. Body mass index and NRI at hospital admission did not predict 6-month mortality. The discharge NRI was most helpful in patients with high (≥ 20%) predicted mortality by the ESCAPE model, where observed 6-month mortality was 38% in patients with NRI < 100 and 14% in those with NRI > 100 (p = 0.04).

CONCLUSIONS

The NRI is a simple tool that can improve mortality risk stratification at hospital discharge in hospitalized patients with advanced HF.

Critical appraisal of the obesity paradox in cardiovascular disease: how to manage patients with overweight in heart failure?

Overweight has been shown in multiple studies to carry a survival benefit in heart failure (HF) patients. This finding is, of course, counterintuitive to the well-established role of obesity as a modifiable risk factor for incident cardiovascular disease. The debate on the relevance of this obesity paradox is on-going, and clinical, methodological and teleological aspects are discussed. Particularly, younger age and a seemingly favourable clinical status of obese patients are repeatedly discussed together with the lack of prospective data to question the validity of the observed survival advantage in obese HF patients. Recent risk score calculators, however, have included body weight as an inverse risk factor, i.e. higher body mass index is predicting better outcome. Emerging prospective interventional trials support the concept that in patients with established disease, intentional weight reduction may not necessarily translate into improved outcome. The clinically most relevant consequence from the emerging data is, of course, the practical recommendation on body weight management that we may give our (overweight) patients. While the terminology as a paradox is critically discussed, a more differentiated concept for weight management should be emphasized that distinguishes between healthy subjects and those with an established cardiovascular disease such as heart failure.

Update in cardiology: vascular risk and cardiac rehabilitation

As in other fields, understanding of vascular risk and rehabilitation is constantly improving. The present review of recent epidemiological update shows how far we are from achieving good risk factor control: in diet and nutrition, where unhealthy and excessive societal consumption is clearly increasing the prevalence of obesity; in exercise, where it is difficult to find a balance between benefit and risk, despite systemization efforts; in smoking, where developments center on programs and policies, with the electronic cigarette seeming more like a problem than a solution; in lipids, where the transatlantic debate between guidelines is becoming a paradigm of the divergence of views in this extensively studied area; in hypertension, where a nonpharmacological alternative (renal denervation) has been undermined by the SYMPLICITY HTN-3 setback, forcing a deep reassessment; in diabetes mellitus, where the new dipeptidyl peptidase-4 and sodium-glucose cotransporter type 2 inhibitors and glucagon like peptide 1 analogues have contributed much new information and a glimpse of the future of diabetes treatment, and in cardiac rehabilitation, which continues to benefit from new information and communication technologies and where clinical benefit is not hindered by advanced diseases, such as heart failure. Our summary concludes with the update in elderly patients, whose treatment criteria are extrapolated from those of younger patients, with the present review clearly indicating that should not be the case.

Reasons why patients suffering from chronic heart failure at very high risk for death survive

BACKGROUND

An accurate prognostic stratification is essential for optimizing the clinical management and treatment decision-making of patients with chronic heart failure (HF). Among the best available models, we used the Cardiac and Comorbid Conditions HF (3C-HF) Score, to predict all-cause mortality in patients with CHF.

METHODS

we selected and characterized the subgroup of patients at very high risk with the worst mid-term prognosis belonging to the highest decile of 3C-HF score with the aim to assess predictors of survival in subjects with an expected probability of 1-year mortality near to 45%.

METHODS AND RESULTS

We recruited 1777 consecutive chronic HF patients at 3 Italian Cardiology Units. Median age was 76 ± 10 years, 43% were female, and 32% had preserved ejection fraction. Subjects belonging to the highest decile of 3C-HF score were 246 (13.8% of total population). During a median follow-up of 21 [12-40] months, 110 of these patients (45%) survived and 136 (55%) died. The variables that contributed to survival prediction emerged by Cox regression multivariate analysis were the lower degree of renal dysfunction and higher body mass index.

CONCLUSIONS

The prognostic stratification of chronic HF patients allows in daily practice to select patients at different risk for death and identify prognosticators of survival in outliers at very high risk of death. The reasons why these patients outlive the matching part of subjects who expectedly die are related to the maintenance of a satisfactory renal function and body mass index.