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

https://doi.org/10.1016/j.ijcard.2016.12.064Get rights and content

Highlights

  • The CONUT score enables multilateral evaluation of malnutrition underlying heart failure.

  • The CONUT score on admission is an independent determinant of long-term death in acute heart failure.

  • The CONUT score outweighs other nutritional indices in prediction of death.

  • Addition of CONUT score to the existing risk prediction model increases predictive ability.

Abstract

Background

The prognostic value of nutritional status is poorly understood and evidence-based nutritional assessment indices are required in acute heart failure (AHF). We investigated the prognostic value of malnutrition assessed by the Controlling Nutritional Status (CONUT) score (range 0–12, higher = worse, consisting of serum albumin, cholesterol and lymphocytes) in AHF patients.

Methods

The CONUT score was measured on admission in 635 consecutive AHF patients. The primary outcome was all-cause death.

Results

Median CONUT score was 3 (interquartile range 2 to 5). During the median follow-up of 324 days, CONUT score was independently associated with death (HR 1.26, 95% CI 1.11–1.42, P < 0.001) after adjustment for confounders in a multivariate Cox model. The CONUT score demonstrated the best C-statistic for predicting death (0.71) among other common nutritional markers in HF. Furthermore, addition of the CONUT score to an established risk prediction model from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure study significantly increased the C-statistic from 0.75 to 0.77 (P = 0.02). The net reclassification improvement afforded by CONUT score was 21% for all-cause death, 27% for survival and 49% overall (P < 0.001).

Conclusion

Malnutrition assessed by the CONUT score on admission was an independent determinant of long-term death in AHF, and its prognostic value outweighed that of other nutritional indices. Moreover, addition of the score to the existing risk prediction model significantly increased the predictive ability for death, indicating beneficial clinical application of the CONUT score in AHF patients.

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).

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