Prognostic value of malnutrition assessed by Controlling Nutritional Status score for long-term mortality in patients with acute heart failure
Introduction
Although evidence-based management of heart failure (HF) has improved outcomes, the absolute mortality of HF remains as high as 50% within 5 years of diagnosis [1], [2]. HF not only decreases the health-related quality of life for patients, but also loads a heavy annual economic burden of > 30 billion dollars in the United States [3]. The need for a multidisciplinary approach is greater than ever in order to achieve better clinical outcomes and cost effectiveness [4], [5], [6].
Nutritional management is one of the non-pharmacological approaches with high expectations in HF. It is listed as a component of the management program for patients with HF in the recent updated guidelines for HF [4], [6]. It is expected that early identification of malnutrition may lead to early nutritional intervention and a better clinical outcome [7]; nevertheless, a universally accepted definition of malnutrition and evidence-based methodology for nutritional assessment of HF patients have not been established.
Various nutritional indices have been examined, and Controlling Nutritional Status (CONUT) score is reported to be one of the most promising [8], [9]. It was originally proposed by Ignacio de Ulíbarri et al. as a screening tool for undernutrition in hospitalized patients [10] and the score consists of three indices; serum albumin, total cholesterol, and lymphocyte count.
In view of the importance of earlier identification of malnutrition, an appropriate nutritional assessment tool that can be used in the decompensated phase of HF might be useful [7]. Although malnutrition assessed by CONUT score has been shown to be related to worse clinical outcomes in chronic HF patients [8], [9] the usefulness of the score in acute HF (AHF) patients remains unclear.
Hence, the purpose of this study was first to investigate the prognostic significance of malnutrition status assessed by CONUT score on admission in AHF patients, and second to validate the clinical application of the score by comparing it with other nutritional indices and by adding it to the existing outcome prediction model for AHF.
Section snippets
Study design
Data from the NaDEF (National cerebral and cardiovascular center acute DEcompensated heart Failure) registry, which were obtained between January 2013 and March 2015, were retrospectively analyzed. The NaDEF registry is a single-center, observational, on-going, prospective cohort that includes all consecutive patients aged above 20 requiring hospitalization to our institution from January 2013 for the first episode of rapid onset or worsening symptoms and/or signs of heart failure which were
Patient characteristics
The distribution of the CONUT score on admission is shown in Fig. 1. The median value (IQR) was 3 (3 to 5). The baseline clinical characteristics categorized by the CONUT score of the total 635 patients on admission are shown in Tables 2 and 3. Mean age was 75 years and 62% were male. Patients with a higher CONUT score had higher age, lower systolic blood pressure, lower hemoglobin, impaired renal function, and a state of malnutrition assessed with other indices such as BMI and NRI. Patients
Discussion
In the present study, we demonstrated that malnutrition expressed as a high CONUT score on admission was independently associated with increased risk of death in patients with AHF. Furthermore, CONUT score was shown to be more useful for the assessment of nutritional status among other markers and indices, from the perspective of outcome prediction. We further highlighted that the addition of nutritional assessment by CONUT score to the existing prediction model significantly increased the
Conclusion
Malnutrition assessed with the CONUT score on admission was an independent determinant of death in AHF patients. Moreover, addition of the CONUT score to the existing outcome prediction model increased the predictive ability for death with net reclassification improvement. These findings suggest that assessment of nutritional status by CONUT score should be considered in the decompensated phase of HF.
Conflicts of interest
The authors report no relationships that could be construed as a conflict of interest.
Acknowledgments
We are grateful for the contributions of all the investigators, clinical research coordinators, and data managers involved in the NaDEF study. This work was supported by a Grant from the Japan Cardiovascular Research Foundation (T.A., 24-4-2), and a Grant-in-Aid for Young Scientists from the Japan Society for the Promotion of Science (T.N., 15K19402).
References (43)
- et al.
2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
J. Am. Coll. Cardiol.
(2013) - et al.
Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials
J. Am. Coll. Cardiol.
(2004) - et al.
Prognostic importance of objective nutritional indexes in patients with chronic heart failure
J. Cardiol.
(2013) - et al.
Predicting outcome in patients with left ventricular systolic chronic heart failure using a nutritional risk index
Am. J. Cardiol.
(2012) - et al.
Serelaxin, recombinant human relaxin-2, for treatment of acute heart failure (RELAX-AHF): a randomised, placebo-controlled trial
Lancet
(2013) - et al.
Predictors of in-hospital mortality in patients hospitalized for heart failure: insights from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF)
J. Am. Coll. Cardiol.
(2008) - et al.
Predictors of mortality after discharge in patients hospitalized with heart failure: an analysis from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF)
Am. Heart J.
(2008) - et al.
A standardized definition of ischemic cardiomyopathy for use in clinical research
J. Am. Coll. Cardiol.
(2002) - et al.
The obesity paradox in elderly patients with heart failure: analysis of nutritional status
Nutrition
(2012) - et al.
Hypoalbuminemia in acute heart failure patients: causes and its impact on hospital and long-term mortality
J. Card. Fail.
(2014)
Cardiac cachexia: a systematic overview
Pharmacol. Ther.
Interleukin-6 spillover in the peripheral circulation increases with the severity of heart failure, and the high plasma level of interleukin-6 is an important prognostic predictor in patients with congestive heart failure
J. Am. Coll. Cardiol.
Elevated soluble CD14 receptors and altered cytokines in chronic heart failure
Am. J. Cardiol.
The endotoxin-lipoprotein hypothesis
Lancet
The relationship between cholesterol and survival in patients with chronic heart failure
J. Am. Coll. Cardiol.
Wasting as independent risk factor for mortality in chronic heart failure
Lancet
Trends in heart failure incidence and survival in a community-based population
JAMA
Long-term trends in the incidence of and survival with heart failure
N. Engl. J. Med.
Heart disease and stroke statistics—2014 update: a report from the American Heart Association
Circulation
2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC
Eur. J. Heart Fail.
The importance of assessing nutritional status in elderly patients with heart failure
Curr. Heart Fail. Rep.
Cited by (90)
Poor Preoperative Nutritional Status, but Not Hormone Levels, Are Associated With Mortality After Cardiac Surgery
2022, Journal of Cardiothoracic and Vascular AnesthesiaPrediction of all-cause mortality with malnutrition assessed by nutritional screening and assessment tools in patients with heart failure:a systematic review
2022, Nutrition, Metabolism and Cardiovascular DiseasesCitation Excerpt :There may also be different mechanistic association between malnutrition and mortality in acute versus chronic HF. In patients with acute HF, malnutrition was mainly associated with reduced cardiac output and subsequent hypoperfusion-associated neurohormonal, inflammatory activity, and anorexia caused by strict restriction of fluid intake [50,65]. In contrast, in patients with chronic HF, malnutrition was mainly associated with systemic inflammation, renal dysfunction, immune activity, and anemia [65,66].