Inferior Outcomes of Patients With Acute Myocardial Infarction and Comorbid Protein‐Energy Malnutrition

Enteral Access Outcomes in Patients Hospitalized With Cardiac Disease: A Retrospective Cohort Study

INTRODUCTION

Patients admitted with principal cardiac diagnosis (PCD) can encounter difficult inpatient stays that are often marked by malnutrition. In this setting, enteral feeding may improve nutritional status. This study examined the association of PCD with perioperative outcomes after elective enteral access procedures.

METHODS

Adult patients who underwent enteral access procedures between 2018 and 2020 at a tertiary care institution were reviewed retrospectively. Differences in baseline characteristics between patients with and without PCD were adjusted using entropy balancing. Multivariable logistic and linear regressions were subsequently developed to evaluate the association between PCD and nutritional outcomes, perioperative morbidity and mortality, length of stay, and nonelective readmission after enteral access.

RESULTS

912 patients with enteral access met inclusion criteria, of whom 84 (9.2%) had a diagnosis code indicating PCD. Compared to non-PCD, patients with PCD more commonly received percutaneous endoscopic gastrostomy by general surgery and had a higher burden of comorbidities as measured by the Charlson comorbidity index. Multivariable risk adjustment generated a strongly balanced distribution of baseline covariates between patient groups (standardized differences ranged from -2.45 × 10-8 to 3.18 × 108). After adjustment, despite no significant association with in-hospital mortality, percentage change prealbumin, length of stay, or readmission, PCD was associated with an approximately 2.25-day reduction in time to meet goal feeds (95% CI -3.76 to -0.74, P = 0.004) as well as decreased odds of reoperation (adjusted odds ratio 0.28, 95% CI 0.09-0.86, P = 0.026) and acute kidney injury (adjusted odds ratio 0.24, 95% CI 0.06-0.91, P = 0.035).

CONCLUSIONS

Despite having more comorbidities than non-PCD, adult enteral access patients with PCD experienced favorable nutritional and perioperative outcomes.

Undernutrition Severity Is Associated With Worse Outcomes in Patients With Acute Myocardial Infarction

Malnutrition has been associated with inferior outcomes in patients admitted with acute myocardial infarction (AMI). However, there is a lack of data to assess if the degree of malnutrition correlates with outcome severity. We used the Nationwide Readmission Database for 2016 to 2019 in our cross-sectional study. First, we extracted all cases older than 18 years that include a primary diagnosis of AMI. Appropriate survey and domain analyses were applied to obtain the national estimates using Statistical Analysis Software 9.4. We identified 2,280,393 discharges for AMI. Malnutrition was present in 4% of the study cohort (or 89,490 cases). Half of the patients with malnutrition (or 44,919) had moderate-to-severe malnutrition. The other 44,371 (or 50%) had a milder degree of malnutrition. Patients with malnutrition were younger than those without malnutrition (mean age 72 vs 75 years, p <0.001) and were more often women (48% vs 37%, p <0.001). Patients with malnutrition had a higher prevalence of underlying heart failure, dementia, coagulopathy, and chronic (liver, renal, and lung) diseases (p <0.001). Patients with malnutrition also had a significantly higher inpatient mortality (12.5% vs 4.6%, p <0.001), length of stay (mean of 13 vs 7 days, p <0.001), and 30-day all-cause readmission rates (19% vs 13%, p <0.001). Inpatient mortality on readmission was also higher in those with malnutrition (2% vs 0.6%, p <0.001). The univariate analysis showed that the severity of malnutrition also correlated with a higher inpatient mortality (odds ratio [OR] 2.34 [2.24 to 2.46] for mild malnutrition and 3.65 [3.49 to 3.82] for advanced malnutrition). After adjusting for age, gender, heart failure, dementia, coagulopathy, chronic (liver, renal, and lung) diseases, and history of cardiovascular revascularization, the presence of malnutrition and the severity of malnutrition continued to be associated with a higher inpatient mortality than those without malnutrition (OR 1.20 [1.14 to 1.26] for mild malnutrition and OR 1.69 [1.61 to 1.78] for more severe malnutrition). In conclusion, underlying malnutrition is associated with worse outcomes in patients hospitalized with AMI. The severity of malnutrition also correlates with worse outcomes.

Protein-energy malnutrition and worse outcomes after major cancer surgery: A nationwide analysis

Background

Protein-energy malnutrition (PEM) has been recognized as a poor prognostic factor in many clinical issues. However, nationwide population studies concerning the impact of PEM on outcomes after major cancer surgery (MCS) are lacking. We aimed to evaluate the postoperative outcomes associated with PEM following MCS.

Methods

By using the Nationwide Inpatient Sample database, data of patients undergoing MCS including colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy, or prostatectomy were analyzed retrospectively from 2009 to 2015, resulting in a weighted estimate of 1,335,681 patients. The prevalence trend of PEM, as well as mortality and major complications after MCS were calculated. Multivariable regression analysis was applied to estimate the impact of PEM on postoperative outcomes after MCS.

Results

PEM showed an estimated annual percentage increase of 7.17% (95% confidence interval (CI): 4-10.44%) from 2009 to 2015, which contrasts with a 4.52% (95% CI: -6.58-2.41%) and 1.21% (95% CI: -1.85-0.56%) annual decrease in mortality and major complications in patients with PEM after MCS. PEM was associated with increased risk of mortality (odds ratio (OR)=2.26; 95% CI: 2.08-2.44; P < 0.0001), major complications (OR=2.46; 95% CI: 2.36-2.56; P < 0.0001), higher total cost ($35814 [$22292, $59579] vs. $16825 [$11393, $24164], P < 0.0001), and longer length of stay (14 [9-21] days vs. 4 [2-7] days, P < 0.0001), especially in patients underwent prostatectomy, hysterectomy and lung resection.

Conclusions

PEM was associated with increased worse outcomes after major cancer surgery. Early identification and timely medical treatment of PEM for patients with cancer are crucial for improving postoperative outcomes.

Nutritional Status as a Risk Factor for New-Onset Atrial Fibrillation in Acute Myocardial Infarction

Purpose

Our study aimed to identify new-onset atrial fibrillation (NOAF) risk factors in acute myocardial infarction (AMI) patients after treatment with percutaneous coronary intervention (PCI) and investigate whether their nutritional status can be a predicting factor of NOAF.

Patients and Methods

We analyzed 662 AMI patients after PCI for NOAF occurrence during follow-up hospitalization and divided them into an NOAF and non-NOAF group. The patients' nutritional status was assessed using the controlling nutritional status (CONUT) score and geriatric nutritional risk index (GNRI). The Kaplan‒Meier analysis was used to assess NOAF-free survival in varying degrees of malnutrition. Cox proportional hazards models were used to identify the risk factors for NOAF.

Results

Eighty-four (12.7%) patients developed NOAF during hospitalization. There was a statistically significant difference in the occurrence of NOAF among different categories of nutritional status. The CONUT score and GNRI classifications were independent predictors of NOAF. NOAF occurrence was associated with older age, higher uric acid levels, higher N-terminal pro-B-type natriuretic peptide levels, greater left atrial size, and worse Killip class upon admission.

Conclusion

The nutritional status can affect NOAF occurrence in AMI patients after PCI. The CONUT score and GNRI are ideal tools for evaluating the nutritional status of AMI patients, with an excellent predictive effect on NOAF.

The burden of malnutrition & frailty in patients with coronary artery disease: An under-recognized problem

Elderly patients with coronary artery disease have a high prevalence of frailty and malnutrition. Frailty syndrome is associated with poor outcomes in patients with myocardial infarction. There is a known overlap between frailty and malnutrition, yet these are two different entities. Fried Frailty Phenotype, Frail Scale, timed up and go test, and gait speed are rapid screening tests that may identify patients with frailty in everyday clinical setting. Short Form MNA is a sensitive tool to screen for malnutrition. Despite the availability of several tools for screening for both these conditions, the screening rates remain low. We aim to create awareness about the impacts of frailty and malnutrition, provide a brief overview of tools available and highlight the importance of screening in this high-risk population.

The Evaluation and Management of Macronutrient Deficiency Dermatoses

In industrialized countries, nutritional dermatoses are likely underdiagnosed and result in increased disease morbidity and utilization of hospital resources. These findings underscore the need for physicians to be able to correctly identify these deficiencies. Nutritional dermatoses may be split into micronutrient deficiencies and macronutrient deficiencies. This article is intended to serve as a supplement to a two-part review of micronutrient deficiency dermatoses and highlights cutaneous findings in patients with protein-energy malnutrition and essential fatty acid deficiency. This article reviews the evaluation, cutaneous manifestations, and management of macronutrient deficiencies.

Nutritional Risk Index Improves the GRACE Score Prediction of Clinical Outcomes in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Background: Malnutrition has been shown to be associated with adverse cardiovascular outcomes in many patient populations.

Aims: To investigate the prognostic significance of malnutrition as defined by nutritional risk index (NRI) in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) and whether NRI could improve the GRACE score based prognostic models.

Methods: This study applied NRI among 1,718 patients with ACS undergoing PCI. Patients were divided into three nutritional risk groups according to their baseline NRI: no nutritional risk (NRI ≥ 100), mild nutritional risk (97.5 ≤ NRI <100), and moderate-to-severe nutritional risk (NRI <97.5). The primary endpoint was the composite of major adverse cardiovascular events (MACE), including all-cause death, non-fatal stroke, non-fatal myocardial infarction, or unplanned repeat revascularization.

Results: During a median follow-up of 927 days, 354 patients developed MACE. In the overall population, compared with normal nutritional status, malnutrition was associated with increased risk for MACE [adjusted HR for mild and moderate-to-severe nutritional risk, respectively: 1.368 (95%CI 1.004–1.871) and 1.473 (95%CI 1.064–2.041)], and NRI significantly improved the predictive ability of the GRACE score for MACE (cNRI: 0.070, P = 0.010; IDI: 0.005, P < 0.001). In the diabetes subgroup, malnutrition was associated with nearly 2-fold high adjusted risk of MACE, and the GRACE score combined with NRI appeared to have better predictive ability than that in the overall population.

Conclusion: Malnutrition as defined by NRI was independently associated with MACE in ACS patients who underwent PCI, especially in individuals with diabetes, and improved the predictive ability of the GRACE score based prognostic models.

Prognostic nutritional index predicts clinical outcomes in patients with cerebral venous sinus thrombosis

Background

Lower prognostic nutritional index (PNI) is related to the poor prognosis of cardiovascular diseases. However, little is known about PNI and its relationship with the prognosis of cerebral venous sinus thrombosis (CVST).

Methods

CVST patients were retrospectively identified from January 2013 till June 2019. Patients in the acute / subacute phase were selected as subjects. Poor prognosis was defined as a modified Rankin Scale (mRS) of 3–6. Multivariate logistic regression analysis was used to confirm if lower PNI was associated with a poor prognosis.

Results

A total of 297 subjects with follow-up data were enrolled. Thirty-three (11.1%) had a poor outcome. Multivariate logistic regression analysis suggested that PNI was an important predictive factor of poor outcome in acute/subacute CVST (odds ratio, 0.903; 95% CI, 0.833–0.978; P = 0.012). The optimal cut-off value for predicting the poor prognosis of PNI was 44.2. Kaplan-Meier analysis and log-rank test suggested that the lower the PNI value, the higher the mortality rate (P < 0.001). In addition, the nomogram that was set up showed that lower PNI was an index of poor prognosis. The c-index for acute/subacute patients with CVST was 0.872.

Conclusion

Lower PNI is correlated with a higher risk of adverse clinical outcomes in patients with acute/subacute CVST.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02436-w.

Individualized Nutritional Support for Hospitalized Patients With Chronic Heart Failure

BACKGROUND

Deterioration of nutritional status during hospitalization in patients with chronic heart failure increases mortality. Whether nutritional support during hospitalization reduces these risks, or on the contrary, may be harmful due to an increase in salt and fluid intake, remains unclear.

OBJECTIVES

The purpose of this trial was to study the effect of nutritional support on mortality in patients hospitalized with chronic heart failure who are at nutritional risk.

METHODS

A total of 645 patients with chronic heart failure (36% [n = 234] with acute decompensation) participated in the investigator-initiated, open-label EFFORT (Effect of early nutritional support on Frailty, Functional Outcomes and Recovery of malnourished medical inpatients) trial. Patients were randomized to protocol-guided individualized nutritional support to reach energy, protein, and micronutrient goals (intervention group) or standard hospital food (control group). The primary endpoint was all-cause mortality at 30 days.

RESULTS

Mortality over 180 days increased with higher severity of malnutrition (odds ratio per 1-point increase in Nutritional Risk Screening 2002 score: 1.65; 95% confidence interval [CI]: 1.21 to 2.24; p = 0.001). By 30 days, 27 of 321 intervention group patients (8.4%) died, compared with 48 of 324 (14.8%) control group patients (odds ratio: 0.44; 95% CI: 0.26 to 0.75; p = 0.002). Patients at high nutritional risk showed the most benefit from nutritional support. Mortality effects remained significant at 180-day follow-up. Intervention group patients also had a lower risk for major cardiovascular events at 30 days (17.4% vs. 26.9%; odds ratio: 0.50; 95% CI: 0.34 to 0.75; p = 0.001).

CONCLUSIONS

Among hospitalized patients with chronic heart failure at high nutritional risk, individualized nutritional support reduced the risk for mortality and major cardiovascular events compared with standard hospital food. These data support malnutrition screening upon hospital admission followed by an individualized nutritional support strategy in this vulnerable patient population. (Effect of Early Nutritional Therapy on Frailty, Functional Outcomes and Recovery of Undernourished Medical Inpatients Trial [EFFORT]; NCT02517476).

In-patient outcomes of patients with diabetic ketoacidosis and concurrent protein energy malnutrition: A national database study from 2016 to 2017

Introduction:Patients often present to the hospital with a well-known complication of diabetes mellitus, namely diabetic ketoacidosis (DKA). In this study, we assess the clinical outcomes of DKA hospitalizations with and without protein-energy malnutrition (PEM).Methods:This was a population-based, retrospective observational study using data gathered from the Nationwide Inpatient Sample (NIS) for 2016 and 2017. Hospitalizations of adults >/ = 18 years old with a principal diagnosis of DKA were obtained using ICD-10 codes and divided into groups based on a secondary diagnosis of PEM. The primary outcome was in-hospital mortality. Secondary outcomes included length of stay (LOS), total hospital charges (THC), and system-based complications.Results:Patients with PEM had a statistically significant difference in the adjusted odds for in-hospital mortality compared to patients without PEM (aOR 1.73, 95% CI: 1.20-2.49, p = 0.004). Patients with DKA and PEM had an increased risk of developing sepsis (aOR 2.99, 95% CI: 2.49-3.58, p < 0.001), septic shock (aOR 3.37, 95% CI: 2.31-4.91, p < 0.001), acute kidney failure (aOR 1.27, 95% CI: 1.17-1.37, p < 0.001), acute respiratory failure (aOR 2.23, 95% CI: 1.83-2.73, p < 0.001), deep vein thrombosis (aOR 1.91, 95% CI: 1.43-2.54, p < 0.001), and pulmonary embolism (aOR 2.36, 95% CI: 1.42-3.94, p = 0.001). Patients with DKA and PEM also had an increased mean THC (aOR 19,200, 95% CI 16,000-22,400, p < 0.001) in US dollars and increased LOS (aOR 2.26, 95% CI 1.96-2.57, p < 0.001) in days when compared to patients without PEM.Conclusion:Patients hospitalized for DKA with a secondary diagnosis of PEM within the same admission had a statistically significantly higher in-hospital mortality.

Different Hospital Readmissions and Outcomes of Acute Pancreatitis

OBJECTIVES

Although acute pancreatitis (AP) is associated with recurrent hospitalizations, the impact of different hospital readmissions (DHR) versus same hospital readmissions (SHR) on outcomes is unknown. We study the burden of DHR among readmissions after survival from AP hospitalizations.

METHODS

Among adult AP patients (Nationwide Readmissions Database), we calculated the prevalence, trends, and predictors of DHR, and its impact on mortality, hospital stay, and charges during 30- and 90-day readmissions.

RESULTS

From 2010 to 2014, 15% and 26% of AP hospitalizations (422,950) were readmitted in 30 and 90 days, respectively. The DHR rates were similar (26.3%, 30 days; 26.4%, 90 days) and unchanged from 2010 to 2014 (Ptrends > 0.10). The predictors of DHR were similar during both readmissions and included younger age category (18-45 years), hospital characteristics (nonteaching, small bed size, nonmicropolitan/metropolitan areas), substance abuse, comorbidities, and nonreception of cholecystectomy and pancreatectomy during index hospitalizations.During readmissions (30 and 90 days), DHR was associated with adjusted odds ratio (95% confidence interval), higher mortality (1.40 [1.19-1.64] and 1.50 [1.32-1.71]), longer hospital stay (1.3 days [1.1-1.7 days] and 1.1 days [0.9-1.3 days]), and higher charges (US $16,779 [US $13,898-US $20,254] and US $14,299 [US $12,299-US $16,623]).

CONCLUSIONS

Targeted measures are needed toward patients at risk for DHR to curb the poor outcomes.