Prognostic value of simple frailty and malnutrition screening tools in patients with acute heart failure due to left ventricular systolic dysfunction

Prognostic Nutritional Index (PNI) as an Independent Predictor of 3-Year Postoperative Mortality in Elderly Patients with Hip Fracture: A Post hoc Analysis of a Prospective Cohort Study

OBJECTIVE

The prognostic nutritional index (PNI) has been reported as a significant predictor in various diseases. However, the prognostic value of the PNI in geriatric hip fracture patients has not been thoroughly evaluated. This study aimed to investigate the association between admission PNI and 3-year mortality in those patients.

METHODS

In this post hoc analysis, we included patients aged ≥65 years who underwent surgery for hip fracture between 2018 and 2019. The admission PNI was calculated as serum albumin (g/L) +5 × total lymphocyte count (×109/L). Patients were categorized into four groups based on PNI quartiles (≤ 43.55, 43.55-46.55, 46.55-49.20, and >49.20, respectively). The median follow-up duration was 3.1 years. Cox proportional hazards models were used to calculate the hazard ratio (HR). Receiver operating characteristic curve (ROC) was conducted for using PNI to predict mortality.

RESULTS

Of the 942 eligible patients, 190 (20.2%) patients died during the follow-up. Compared to patients in the first quartile (Q1), those in the second (Q2), third (Q3), and fourth (Q4) quartiles had significantly lower mortality risks (HRs 0.50, 95% CI 0.35-0.74; 0.41, 95% CI 0.26-0.64; and 0.26, 95% CI 0.15-0.45, respectively). The optimal cutoff of PNI for predicting mortality was set as 45.275 (sensitivity, 0.674; specificity, 0.692; area under the curve (AUC), 0.727). Patients with higher PNI (>45.275) had a significant lower mortality risk (HR 0.39, 95% CI 0.28-0.55) compared to those with lower PNI (≤ 45.275).

CONCLUSION

PNI is a reliable and independent predictor of 3-year mortality after hip fracture surgery in the elderly.

Interrelationship between Altered Left Ventricular Ejection Fraction and Nutritional Status in the Post-Acute Myocardial Infarction Patient

There is currently little research on the effects of reduced left ventricular ejection fraction and altered nutritional status in patients with acute myocardial infarction. We therefore examined the interrelationship between the parameters of left ventricular dysfunction after acute myocardial infarction and changes in the Geriatric Nutrition Risk Index (GNRI) and the Nutrition Status Control Index (CONUT). Based on the evidence, frailty is considered to be an important factor affecting the prognosis of cardiovascular disease, so it is important to detect malnutrition early to prevent adverse cardiovascular events. This study was an observational, prospective study that included a total of 73 subjects who presented at the 3-month AMI follow-up. All subjects were subjected to laboratory tests and the groups were divided as follows: group 1, in which we calculated the CONUT score, (CONUT < 3 points, n = 57) patients with normal nutritional status and patients with moderate to severe nutritional deficiency (CONUT ≥ 3, n = 16). In group 2, the GNRI score was calculated and out of the 73 patients we had: GNRI ≥ 98, n = 50, patients with normal nutritional status, and GNRI < 98, n = 23, patients with altered nutritional status. The results of this study showed that we had significant differences between LVEF values at 3 months post-infarction where, in the CONUT group, patients with altered nutritional status had lower LVEF values (46.63 ± 3.27% versus 42.94 ± 2.54%, p < 0.001) compared to CONUT < 3. Also, in the GNRI group, we had lower LVEF values in patients with impaired nutritional status (46.48 ± 3.35% versus 44.39 ± 3.35%, p = 0.01). It can be seen that LVEF values are improved at 3 months post infarction in both groups, in patients with impaired nutritional status and in patients with good nutritional status. Patients with impaired nutritional status have lower ejection fraction and worse outcomes in both the CONUT and GNRI groups at 3 months post acute myocardial infarction.

Predictive value of the prognostic nutritional index combined with serum chloride levels for the prognosis of patients with acute decompensated heart failure

BACKGROUND

The prognostic nutritional index (PNI) and serum chloride level are related to adverse outcomes in patients with heart failure. However, little is known about the relationship between the PNI and serum chloride level in predicting the poor prognosis of patients with acute decompensated heart failure (ADHF).

METHODS AND RESULTS

We reviewed 1221 consecutive patients with ADHF admitted to the First Affiliated Hospital of Kunming Medical University from January 2017 to October 2021. After excluding patients with in hospital death, missing follow-up data, missing chloride data, missing lymphocyte (LYM) count data, or missing serum albumin data, 805 patients were included. PNI was calculated using the formula: serum albumin (ALB) (g/L) + 5 × LYM count (10^9/L). Patients were divided into 4 groups according to the quartiles of the PNI, and the highest PNI quartile (PNI Q4: PNI ≥ 47.3) was set as the reference group. The patients in the lowest PNI quartile (PNI Q1: PNI < 40.8) had the lowest cumulative survival rate, and mortality risk decreased progressively through the quartiles (log-rank χ2 142.283, P < 0.0001). Patients with ADHF were divided into 8 groups by quartiles of PNI and median levels of serum chloride. After adjustment, the hazard ratio (HR) for all-cause mortality in ADHF patients in Group 1 was 8.7 times higher than that in the reference Group 8. Furthermore, the addition of serum chloride level and PNI quartile to the Cox model increased the area under the Receiver operating characteristic (ROC) curve by 0.05, and the area under the ROC curve of the new model was higher than that of the original model with traditional risk factors.

CONCLUSIONS

Both the lowest PNI quartiles and low chloride level indicate a higher risk of all-cause death in patients with ADHF.

What is the additive value of nutritional deficiency to VA-FI in the risk assessment for heart failure patients?

OBJECTIVES

To assess the impact of adding the Prognostic Nutritional Index (PNI) to the U.S. Veterans Health Administration frailty index (VA-FI) for the prediction of time-to-death and other clinical outcomes in Veterans hospitalized with Heart Failure.

METHODS

A retrospective cohort study of veterans hospitalized for heart failure (HF) from October 2015 to October 2018. Veterans ≥50 years with albumin and lymphocyte counts, needed to calculate the PNI, in the year prior to hospitalization were included. We defined malnutrition as PNI ≤43.6, based on the Youden index. VA-FI was calculated from the year prior to the hospitalization and identified three groups: robust (≤0.1), prefrail (0.1-0.2), and frail (>0.2). Malnutrition was added to the VA-FI (VA-FI-Nutrition) as a 32nd deficit with the total number of deficits divided by 32. Frailty levels used the same cut-offs as the VA-FI. We compared categories based on VA-FI to those based on VA-FI-Nutrition and estimated the hazard ratio (HR) for post-discharge all-cause mortality over the study period as the primary outcome and other adverse events as secondary outcomes among patients with reduced or preserved ejection fraction in each VA-FI and VA-FI-Nutrition frailty groups.

RESULTS

We identified 37,601 Veterans hospitalized for HF (mean age: 73.4 ± 10.3 years, BMI: 31.3 ± 7.4 kg/m2). In general, VA-FI-Nutrition reclassified 1959 (18.6%) Veterans to a higher frailty level. The VA-FI identified 1,880 (5%) as robust, 8,644 (23%) as prefrail, and 27,077 (72%) as frail. The VA-FI-Nutrition reclassified 382 (20.3%) from robust to prefrail and 1577 (18.2%) from prefrail to frail creating the modified-prefrail and modified-frail categories based on the VA-FI-Nutrition. We observed shorter time-to-death among Veterans reclassified to a higher frailty status vs. those who remained in their original group (Median of 2.8 years (IQR:0.5,6.8) in modified-prefrail vs. 6.3 (IQR:1.8,6.8) years in robust, and 2.2 (IQR:0.7,5.7) years in modified-frail vs. 3.9 (IQR:1.4,6.8) years in prefrail). The adjusted HR in the reclassified groups was also significantly higher in the VA-FI-Nutrition frailty categories with a 38% increase in overall all-cause mortality among modified-prefrail and a 50% increase among modified-frails. Similar trends of increasing adverse events were also observed among reclassified groups for other clinical outcomes.

CONCLUSION

Adding PNI to VA-FI provides a more accurate and comprehensive assessment among Veterans hospitalized for HF. Clinicians should consider adding a specific nutrition algorithm to automated frailty tools to improve the validity of risk prediction in patients hospitalized with HF.

Frailty, Sarcopenia, Cachexia, and Malnutrition in Heart Failure

With global aging, the number of patients with heart failure has increased markedly. Heart failure is a complex condition intricately associated with aging, organ damage, frailty, and cognitive decline, resulting in a poor prognosis. The relationship among frailty, sarcopenia, cachexia, malnutrition, and heart failure has recently received considerable attention. Although these conditions are distinct, they often exhibit a remarkably close relationship. Overlapping diagnostic criteria have been observed in the recently proposed guidelines and position statements, suggesting that several of these conditions may coexist in patients with heart failure. Therefore, a comprehensive understanding of these conditions is essential, and interventions must not only target these conditions individually, but also provide comprehensive management strategies. This review article provides an overview of the epidemiology, diagnostic methods, overlap, and prognosis of frailty, sarcopenia, cachexia, and malnutrition in patients with heart failure, incorporating insights from the FRAGILE-HF study data. Additionally, based on existing literature, this article discusses the impact of these conditions on the effectiveness of guideline-directed medical therapy for patients with heart failure. While recognizing these conditions early and promptly implementing interventions may be advantageous, further data, particularly from well-powered, large-scale, randomized controlled trials, are necessary to refine personalized treatment strategies for patients with heart failure.

Establishment of in-hospital nutrition support program for middle-aged and elderly patients with acute decompendated heart failure

OBJECTIVE

To construct a nutrition support program for middle-aged and elderly patients with acute decompensated heart failure (ADHF) during hospitalization.

METHODS

Based on the JBI Evidence-Based Health Care Model as the theoretical framework, the best evidence was extracted through literature analysis and a preliminary nutrition support plan for middle-aged and elderly ADHF patients during hospitalization was formed. Two rounds of expert opinion consultation were conducted using the Delphi method. The indicators were modified, supplemented and reduced according to the expert's scoring and feedback, and the expert scoring was calculated.

RESULTS

The response rates of the experts in the two rounds of consultation were 86.7% and 100%, respectively, and the coefficient of variation (CV) for each round was between 0.00% and 29.67% (all < 0.25). In the first round of expert consultation, 4 items were modified, 3 items were deleted, and 3 items were added. In the second round of the expert consultation, one item was deleted and one item was modified. Through two rounds of expert consultation, expert consensus was reached and a nutrition support plan for ADHF patients was finally formed, including 4 first-level indicators, 7 s-level indicators, and 24 third-level indicators.

CONCLUSION

The nutrition support program constructed in this study for middle-aged and elderly ADHF patients during hospitalization is authoritative, scientific and practical, and provides a theoretical basis for clinical development of nutrition support program for middle-aged and elderly ADHF patients during hospitalization.

The Impact of Acute Heart Failure on Frailty Degree and Outcomes in Elderly Patients with Severe Aortic Stenosis and Chronic Heart Failure with Preserved Ejection Fraction

Frailty degree plays a critical role in the decision-making and outcomes of elderly patients with severe aortic stenosis (AS). Acute heart failure (AHF) results in a severely worse clinical hemodynamic status in this population. This study aimed to evaluate the impact of AHF on frailty degree and outcomes in older patients referred for tailored interventional treatment due to AS. A total of 109 patients (68% female; mean age 83.3 ± 5.4), evaluated by a multidisciplinary path for "frailty-based management" of valve disease, were divided into two groups, one with (AHF+) and one without AHF (AHF-) and preserved ejection fraction (mean value EF: 57.4 ± 8.6). AHF occurred a mean value of 55 days before geriatric, clinical, and surgical assessment. A follow-up for all-cause mortality and readmission was conducted at 20 months. AHF+ patients showed a higher frequency of advanced frailty (53.3% vs. 46.7%, respectively), rehospitalization (35.5% vs. 12.8; p = 0.007), and death (41.9% vs. 12.8%; p < 0.001). In stepwise logistic regression analysis, AHF emerged as an independent risk factor for advanced frailty (OR: 3.8 CI 1.3-10.7; p = 0.01) and hospital readmission (OR: 3.6 CI 1.1-11.6; p = 0.03). In addition, preceding AHF was an independent determinant associated with a higher risk of mortality (HR 2.65; CI 95% 1.04-6.74; p-value 0.04). AHF is independently associated with advanced frailty and poor outcomes in elderly patients with severe AS. So, this population needs careful clinical and geriatric monitoring and the implementation of interventional therapy for AS in the early stages of frailty to avoid the occurrence of AHF and poor outcomes.

Nutritional support in the cardiac intensive care unit

Optimal care of critically ill patients in the cardiac intensive care unit includes adequate nutritional support. This review highlights the high prevalence of malnutrition in acute heart failure, acute coronary syndrome, cardiogenic shock, and post-cardiac arrest and its adverse impact on prognosis. There is a lack of robust evidence regarding appropriate nutritional support in this patient population. Initiation of nutritional support with a comprehensive assessment of the patient's nutritional status is critical. High-risk cardiac patients who are not critically ill can receive oral nutrition adapted to individual risk factors or deficiencies, although overfeeding should be avoided in the acute phase. For critically ill patients at risk of or with malnutrition on admission, general principles include initiation of nutritional support within 48 h of admission, preference for enteral over parenteral nutrition, preference for hypocaloric nutrition in the first week of intensive care unit admission, and adequate micronutrient supplementation. Enteral nutrition in haemodynamically unstable patients carries a risk, albeit low, of intestinal ischaemia. In the case of malnutrition, the risk of refeeding syndrome should always be considered.

Quality of life in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation: tools and evidence

Aortic stenosis is the most prevalent valvular heart disease requiring intervention, especially in the elderly population. Surgical aortic valve replacement and transcatheter aortic valve implantation (TAVI) are well established treatment options for symptomatic patients with severe aortic stenosis, as they provide a significant survival benefit. Aortic stenosis may have an important impact on patients' quality of life (QoL). However, advanced age, comorbidities and frailty may limit the beneficial effect of aortic stenosis interventions in terms of QoL. Current guidelines mention the importance of frailty and avoiding the futility of interventions, but lack specific indications about decision-making. Also, there are limited data on how to specifically assess QoL in aortic stenosis patients since the most used questionnaires are validated in different populations (i.e. heart failure). The aim of this review is to summarize all the available tools for QoL assessment in patients with aortic stenosis; to report current evidence on the impact of TAVI on QoL; and to discuss the role of frailty and comorbidities in this setting.

Low Prognostic Nutritional Index Predicts Adverse Outcomes in Patients With Heart Failure: A Systematic Review and Meta-analysis

The association of low prognostic nutritional index (PNI) with adverse outcomes remains conflicting in heart failure patients. To address these knowledge gaps, we performed this meta-analysis to investigate the predictive value of PNI in patients with heart failure (HF). PubMed and Embase databases were comprehensively searched until January 19, 2023, to identify studies that evaluated the predictive role of PNI in HF patients. Outcomes of interest included all-cause mortality and/or combined endpoint of mortality and re-hospitalization. Twelve studies involving 9365 patients with HF were included and analyzed. Comparison of the lowest with the highest PNI, the pooled multivariate adjusted risk ratio (RR) was 1.79 (95% confidence interval [CI] 1.40-2.30) and 2.67 (95% CI 1.92-3.71) for long-term all-cause mortality and combined endpoint of mortality and re-hospitalization, respectively. Furthermore, per unit reduction in PNI was associated with 8% higher risk of all-cause mortality. However, there was no clear association of low PNI with in-hospital mortality. Low PNI may be an independent predictor of long-term all-cause mortality and re-hospitalization in patients with HF. Estimation of nutritional state using the PNI may provide an important clue for risk stratification in these patients.

Machine learning-based gait analysis to predict clinical frailty scale in elderly patients with heart failure

Aims

Although frailty assessment is recommended for guiding treatment strategies and outcome prediction in elderly patients with heart failure (HF), most frailty scales are subjective, and the scores vary among raters. We sought to develop a machine learning-based automatic rating method/system/model of the clinical frailty scale (CFS) for patients with HF.

Methods and results

We prospectively examined 417 elderly (≥75 years) with symptomatic chronic HF patients from 7 centres between January 2019 and October 2023. The patients were divided into derivation (n = 194) and validation (n = 223) cohorts. We obtained body-tracking motion data using a deep learning-based pose estimation library, on a smartphone camera. Predicted CFS was calculated from 128 key features, including gait parameters, using the light gradient boosting machine (LightGBM) model. To evaluate the performance of this model, we calculated Cohen's weighted kappa (CWK) and intraclass correlation coefficient (ICC) between the predicted and actual CFSs. In the derivation and validation datasets, the LightGBM models showed excellent agreements between the actual and predicted CFSs [CWK 0.866, 95% confidence interval (CI) 0.807-0.911; ICC 0.866, 95% CI 0.827-0.898; CWK 0.812, 95% CI 0.752-0.868; ICC 0.813, 95% CI 0.761-0.854, respectively]. During a median follow-up period of 391 (inter-quartile range 273-617) days, the higher predicted CFS was independently associated with a higher risk of all-cause death (hazard ratio 1.60, 95% CI 1.02-2.50) after adjusting for significant prognostic covariates.

Conclusion

Machine learning-based algorithms of automatically CFS rating are feasible, and the predicted CFS is associated with the risk of all-cause death in elderly patients with HF.

Prolonged hospitalization and 1-year mortality are associated with sarcopenia and malnutrition in older patients with type 2 diabetes: A prospective cohort study

AIM

To assess the relationship of the presence of sarcopenia and malnutrition with unfavorable clinical outcomes: prolonged length of hospital stay (LOS), readmission, and one-year mortality in older patients with type 2 diabetes (T2D).

METHODS

Were included 319 patients with ≥ 60 years of age with T2D hospitalized at a university hospital in Southern Brazil. Sarcopenia was diagnosed according to handgrip strength (HGS), calf circumference (CC), and the timed up and go (TUG) walking test, and malnutrition according to the subjective global assessment (SGA) and the mini nutritional assessment long form (MNA-LF). Multivariate analyses, adjusted for confounders, were performed to assess the association of sarcopenia and malnutrition with clinical outcomes. One-year survival was compared using Kaplan-Meier analysis.

RESULTS

The association between sarcopenia and malnutrition increased by 2.42 times (95 %CI 1.35-4.36) the probability of LOS ≥ 14 days and by 2.01 times (95 %CI 1.09-3.72) the risk of one-year mortality. Older patients with malnutrition and sarcopenia have a higher risk of one-year mortality (log-rank p < 0.05) compared with well-nourished patients without sarcopenia.

CONCLUSION

In older patients with type 2 diabetes, those with sarcopenia, and malnutrition have higher odds of prolonged hospitalization and risk of mortality within one year after hospital discharge.

Predicting mortality and re-hospitalization for heart failure: a machine-learning and cluster analysis on frailty and comorbidity

BACKGROUND

Machine-learning techniques have been recently utilized to predict the probability of unfavorable outcomes among elderly patients suffering from heart failure (HF); yet none has integrated an assessment for frailty and comorbidity. This research seeks to determine which machine-learning-based phenogroups that incorporate frailty and comorbidity are most strongly correlated with death or readmission at hospital for HF within six months following discharge from hospital.

METHODS

In this single-center, prospective study of a tertiary care center, we included all patients aged 65 and older discharged for acute decompensated heart failure. Random forest analysis and a Cox multivariable regression were performed to determine the predictors of the composite endpoint. By k-means and hierarchical clustering, those predictors were utilized to phenomapping the cohort in four different clusters.

RESULTS

A total of 571 patients were included in the study. Cluster analysis identified four different clusters according to frailty, burden of comorbidities and BNP. As compared with Cluster 4, we found an increased 6-month risk of poor outcomes patients in Cluster 1 (very frail and comorbid; HR 3.53 [95% CI 2.30-5.39]), Cluster 2 (pre-frail with low levels of BNP; HR 2.59 [95% CI 1.66-4.07], and in Cluster 3 (pre-frail and comorbid with high levels of BNP; HR 3.75 [95% CI 2.25-6.27])).

CONCLUSIONS

In older patients discharged for ADHF, the cluster analysis identified four distinct phenotypes according to frailty degree, comorbidity, and BNP levels. Further studies are warranted to validate these phenogroups and to guide an appropriate selection of personalized, model of care.

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).

Which frailty tool best predicts morbidity and mortality in ambulatory patients with heart failure? A prospective study

BACKGROUND

Frailty is common in patients with heart failure (HF) and is associated with adverse outcome, but it is uncertain how frailty should best be measured.

OBJECTIVES

To compare the prognostic value of commonly-used frailty tools in ambulatory patients with HF.

METHODS AND RESULTS

We assessed, simultaneously, three screening tools [clinical frailty scale (CFS); Derby frailty index (DFI); acute frailty network (AFN) frailty criteria), three assessment tools (Fried criteria; Edmonton frailty score (EFS); deficit index (DI)) and three physical tests (handgrip strength, timed get-up-and-go test (TUGT), 5-metre walk test (5MWT)] in consecutive patients with HF attending a routine follow-up visit. 467 patients (67% male, median age = 76 years, median NT-proBNP = 1156 ng/L) were enrolled. During a median follow-up of 554 days, 82 (18%) patients died and 201 (43%) patients were either hospitalised or died. In models corrected for age, Charlson score, haemoglobin, renal function, sodium, NYHA, atrial fibrillation (AF), and body mass index, only log[NT-proBNP] and frailty were independently associated with all-cause death. A base model for predicting mortality at 1 year including NYHA, log[NT-proBNP], sodium and AF, had a C-statistic = 0.75. Amongst screening tools: CFS (C-statistic = 0.84); amongst assessment tools: DI (C-statistic = 0.83) and amongst physical test: 5MWT (C-statistic = 0.80), increased model performance most compared with base model (P <0.05 for all).

CONCLUSION

Frailty is strongly associated with adverse outcomes in ambulatory patients with HF. When added to a base model for predicting mortality at 1 year including NYHA, NT-proBNP, sodium, and AF, CFS provides comparable prognostic information with assessment tools taking longer to perform.

Effectiveness of out-patient based acute heart failure care: a pilot randomised controlled trial

OBJECTIVES

Acute heart failure (AHF) hospitalisation is associated with 10% mortality. Outpatient based management (OPM) of AHF appeared effective in observational studies. We conducted a pilot randomised controlled trial (RCT) comparing OPM with standard inpatient care (IPM).

METHODS

We randomised patients with AHF, considered to need IV diuretic treatment for ≥2 days, to IPM or OPM. We recorded all-cause mortality, and the number of days alive and out-of-hospital (DAOH). Quality of life, mental well-being and Hope scores were assessed. Mean NHS cost savings and 95% central range (CR) were calculated from bootstrap analysis. Follow-up: 60 days.

RESULTS

Eleven patients were randomised to IPM and 13 to OPM. There was no statistically significant difference in all-cause mortality during the index episode (1/11 vs 0/13) and up to 60 days follow-up (2/11 vs 2/13) [p = .86]. The OPM group accrued more DAOH {47 [36,51] vs 59 [41,60], p = .13}. Two patients randomised to IPM (vs 6 OPM) were readmitted [p = .31]. Hope scores increased more with OPM within 30 days but dropped to lower levels than IPM by 60 days. More out-patients had increased total well-being scores by 60 days (p = .04). OPM was associated with mean cost savings of £2658 (95% CR 460-4857) per patient.

CONCLUSIONS

Patients with acute HF randomised to OPM accrued more days alive out of hospital (albeit not statistically significantly in this small pilot study). OPM is favoured by patients and carers and is associated with improved mental well-being and cost savings.

The impact of geriatric nutritional risk index on one-year outcomes in hospitalized elderly patients with heart failure

Background

Strategies that accurately predict outcomes in elderly heart failure (HF) patients have not been sufficiently established. In previous reports, nutritional status, ability to perform activities of daily living (ADL), and lower limb muscle strength are known prognostic factors associated with cardiac rehabilitation (CR). In the present study, we investigated which CR factors can accurately predict one-year outcomes in elderly patients with HF among the above factors.

Methods

Hospitalized patients with HF over 65 years of age from January 2016 to January 2022 were retrospectively enrolled in the Yamaguchi Prefectural Grand Medical (YPGM) Center. They were consequently recruited to this single-center retrospective cohort study. Nutritional status, ADL, and lower limb muscle strength were assessed by geriatric nutritional risk index (GNRI), Barthel index (BI), and short physical performance battery (SPPB) at discharge, respectively. One year after discharge, the primary and secondary outcomes were evaluated by all-cause death or HF readmission and major adverse cardiac and cerebrovascular events (MACCE), respectively.

Results

Overall, 1,078 HF patients were admitted to YPGM Center. Of those, 839 (median age 84.0, 52% female) met the study criteria. During the follow-up of 228.0 days, 72 patients reached all-cause death (8%), 215 experienced HF readmission (23%), and 267 reached MACCE (30%: 25 HF death, six cardiac death, and 13 strokes). A multivariate Cox proportional hazard regression analysis revealed that the GNRI predicted the primary outcome (Hazard ratio [HR]: 0.957; 95% confidence interval [CI]: 0.934-0.980; p < 0.001) and the secondary outcome (HR: 0.963; 95%CI: 0.940-0.986; p = 0.002). Furthermore, a multiple logistic regression model using the GNRI most accurately predicted the primary and secondary outcomes compared to those with the SPPB or BI models.

Conclusion

A nutrition status model using GNRI provided a better predictive value than ADL ability or lower limb muscle strength. It should be recognized that HF patients with a low GNRI at discharge may have a poor prognosis at one year.

Combined nutritional and frailty screening improves assessment of short-term prognosis in older adults following percutaneous coronary intervention

BACKGROUND

Frailty and malnutrition are well-known factors influencing outcomes of myocardial infarction (MI) in older adults. Due to considerable overlap between both entities, whether the simultaneous assessment of frailty and nutrition adds nonredundant value to risk assessment is unknown.

METHODS

We performed a prospective cohort study on 402 patients aged at least 65 years diagnosed with ST-elevation MI that underwent percutaneous coronary intervention. Nutritional status was assessed by Controlling Nutritional Status score (CONUT), Prognostic Nutritional Index, and Geriatric Nutritional Response Index. Frailty was assessed by Clinical Frailty Scale (CFS), Derby frailty index, and acute frailty network. Primary outcome was major adverse cardiac events (MACE), comprising all-cause mortality, non-fatal MI, and unplanned repeat revascularization during 28-day follow-up. Increment in Global Registry of Acute Coronary Events (GRACE) score performance following the addition of nutrition and frailty was assessed.

RESULTS

The incidence of MACE was 8.02 (6.38-9.95) per 1000 person-days. The CONUT score and CFS were the best predictors of MACE and independent predictors in the multivariate Cox-regression models [hazard ratios, 2.80 (1.54-5.09) and 2.54 (1.50-4.29)]. CONUT score classified 151 (37.6%) patients as malnourished, and CFS classified 131 (32.6%) as frail. The addition of both CONUT and CFS to the GRACE score led to better model discrimination and calibration through improved c-statistic (+0.165) ( P < 0.0001) and Akaike and Bayesian information criteria.

CONCLUSION

Combining CONUT and CFS provides nonredundant prognostic value despite their overlapping nature. Combined nutritional and frailty screening may improve risk prognostication in older adults following MI.

Geriatric Nutritional Risk Index at Hospital Admission or Discharge in Patients with Acute Decompensated Heart Failure

Geriatric Nutritional Risk Index (GNRI) is known both as a reliable indicator of nutritional status and a predictor of long-term survival among patients with acute decompensated heart failure (ADHF). However, the optimal timing to evaluate GNRI during hospitalization remains unclear. In the present study, we retrospectively analyzed patients hospitalized with ADHF in the West Tokyo Heart Failure (WET-HF) registry. GNRI was assessed at hospital admission (a-GNRI) and discharge (d-GNRI). Out of 1474 patients included in the present study, 568 (40.1%) and 796 (57.2%) patients had lower GNRI (<92) at hospital admission and discharge, respectively. After the follow-up (median 616 days), 290 patients died. The multivariable analysis showed that all-cause mortality was independently associated with d-GNRI (per 1 unit decrease, adjusted hazard ratio [aHR]: 1.06, 95% confidence interval [CI]: 1.04-1.09, p < 0.001), but not with a-GNRI (aHR: 0.99, 95% CI: 0.97-1.01, p = 0.341). The predictability of GNRI for long-term survival was more pronounced when evaluated at hospital discharge than at hospital admission (area under the curve 0.699 vs. 0.629, DeLong's test p < 0.001). Our study suggested that GNRI should be evaluated at hospital discharge, regardless of the assessment at hospital admission, to predict the long-term prognosis for patients hospitalized with ADHF.

The Association Between the Clinical Frailty Scale and Adverse Health Outcomes in Older Adults in Acute Clinical Settings - A Systematic Review of the Literature

Background

Frail older adults experience higher rates of adverse health outcomes. Therefore, assessing pre-hospital frailty early in the course of care is essential to identify the most vulnerable patients and determine their risk of deterioration. The Clinical Frailty Scale (CFS) is a frailty assessment tool that evaluates pre-hospital mobility, energy, physical activity, and function to generate a score that ranges from very fit to terminally ill.

Purpose

To synthesize the evidence of the association between the CFS degree and all-cause mortality, all-cause readmission, length of hospital stay, adverse discharge destination, and functional decline in patients >65 years in acute clinical settings.

Design

Systematic review with narrative synthesis.

Methods

Electronic databases (PubMed, EMBASE, CINAHL, Scopus) were searched for prospective or retrospective studies reporting a relationship between pre-hospital frailty according to the CFS and the outcomes of interest from database inception to April 2020.

Results

Our search yielded 756 articles, of which 29 studies were included in this review (15 were at moderate risk and 14 at low risk of bias). The included studies represented 26 cohorts from 25 countries (N = 44166) published between 2011 and 2020. All included studies showed that pre-hospital frailty according to the CFS is an independent predictor of all adverse health outcomes included in the review.

Conclusion

A primary purpose of the CFS is to grade clinically increased risk (i.e. risk stratification). Our results report the accumulated knowledge on the risk-predictive performance of the CFS and highlight the importance of routinely including frailty assessments, such as the CFS, to estimate biological age, improve risk assessments, and assist clinical decision-making in older adults in acute care. Further research into the potential of the CFS and whether implementing the CFS in routine practice will improve care and patients' quality of life is warranted.

A Systematic Review of Frailty Scores Used in Heart Failure Patients

BACKGROUND

Frailty is a complex, multi-dimensional syndrome commonly observed in patients with heart failure (HF). The presence of frailty in patients living with HF is strongly associated with increased vulnerability to adverse events, including falls, hospitalisation, and increased mortality. Several scoring systems have been developed to assess the presence of frailty in patients with HF. These scoring systems vary in their complexity and applicability; however, they provide the physician with a more comprehensive understanding of the biological, functional, and psycho-social needs of these patients.

OBJECTIVES

To assess the clinical applicability of frailty tools in HF patients and their prognostic value, specifically relating to outcomes such as mortality, readmissions, and clinical deterioration.

METHODS

A literature search using six electronic databases (PubMed, Scopus, Embase, Medline, Cochrane and Web of Science) was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Key search Medical Subject Headings (MeSH) terms combined "Frailty" AND "Heart failure". Studies were included if they assessed frailty using systematically defined criteria in a HF population. The PRISMA guidelines were used to include all relevant articles based on titles and abstracts. Full text articles were screened based on abstract relevance. A systematic narrative review of the literature was conducted on the final list of full text articles.

RESULTS

An initial search yielded 8,066 articles. Following the removal of duplicates, title, and abstract searches, the remaining 154 articles underwent full text review, with 31 articles accepted for final qualitative synthesis. The two most utilised frailty scores were the Fried Frailty Phenotype (n=10) and the Barthel Index (n=8). The frailty scores provide prognostic data on multiple outcomes including mortality, increased hospitalisation, and functional decline.

CONCLUSION

At the present time there is no universally applied frailty measure in a HF population. Choice of frailty score should be guided by physician experience and clinical setting, as well as tailored to a patient's functional, biological, and psycho-social circumstances. A push to adopt a single universal scoring system may help to ensure that frailty is assessed in all patients who live with HF.

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.

Prevalence and prognosis of frailty in older patients with stage B heart failure with preserved ejection fraction

AIMS

Frailty in older patients with stage B heart failure with preserved ejection fraction (HFpEF) has not been fully explored. We evaluated the prevalence and prognostic significance of frailty in older patients diagnosed with stage B HFpEF.

METHODS

Our prospective cohort study included inpatients aged ≥65 years who were followed up for 3 years. Stage B HFpEF was defined as cardiac structural or functional abnormalities with a left ventricular ejection fraction (LVEF) ≥ 50% without signs or symptoms. Frailty was assessed using the Fried phenotype. The primary outcome was 3-year all-cause mortality or readmission.

RESULTS

Overall, 520 older inpatients diagnosed with stage B HFpEF [mean ± standard deviation age: 75.5 ± 6.25 years, male: 222 (42.7%)] were included in the study. Of these, 145 (27.9%) were frail. Frail patients were older (78.5 ± 6.23 vs. 74.3 ± 6.22 years, P < 0.001), with a lower body mass index (24.6 ± 3.60 vs. 25.7 ± 3.27 kg/m² , P = 0.001), higher level of N-terminal pro-B-type natriuretic peptide [279 (interquartile range: 112.4, 596) vs. 140 (67.1, 266) pg/mL, P < 0.001], longer timed up-and-go test result (19.9 ± 9.71 vs. 13.3 ± 5.08 s, P < 0.001), and poorer performance in the short physical performance battery (4.1 ± 3.26 vs. 8.2 ± 2.62, P < 0.001), basic activities of daily living (BADL, 4.7 ± 1.71 vs. 5.7 ± 0.57, P < 0.001), and instrumental activities of daily living (IADL, 4.4 ± 2.73 vs. 7.4 ± 1.33, P < 0.001). Frail patients were more likely to have a Mini-Mental State Examination (MMSE) score <24 (55.9% vs. 28.8%, P < 0.001) and take more than five medications (64.1% vs. 47.2%, P = 0.001). Frail patients had a higher incidence of all-cause mortality or readmission (62.8% vs. 47.7%, P = 0.002), all-cause readmission (56.6% vs. 45.9%, P = 0.029), and readmission for non-heart failure (55.2% vs. 41.3%, P = 0.004) during the 3-year follow-up, with a 1.53-fold (95%CI 1.11-2.11, P = 0.009) higher risk of all-cause mortality or readmission, a 1.52-fold (95%CI 1.09-2.11, P = 0.014) higher risk of all-cause readmission, and a 1.70-fold (95%CI 1.21-2.38, P = 0.002) higher risk of readmission for non-clinical heart failure, adjusted for sex, age, polypharmacy, Athens Insomnia Scale, MMSE, LVEF, BADL, and IADL.

CONCLUSIONS

Frailty is common in elderly patients with stage B HFpEF. Physical frailty, particularly low physical activity, can independently predict the long-term prognosis in these patients.

The prognostic value of clinical frailty scale and outcomes in older patients undergoing left ventricular assist device implantation

Objectives

Heart failure impacts patients' functional capabilities, ultimately leading to frailty. The use of a left ventricular assist device (LVAD) is acceptable as both destination therapy and bridge to transplant in heart failure management. We aim to evaluate the prognostic value of the Clinical Frailty Scale (CFS) on outcomes in older patients undergoing implantation of LVAD.

Methods

We conducted a retrospective chart review of patients ≥ 60 years old that underwent LVAD implantation at our medical center from May 1, 2018, to October 30, 2020. CFS was retrospectively assigned before LVAD placement and CFS scores > 4 was considered frail. Kaplan-Meier curves and Cox regression were used to analyze 1-year survival estimates.

Results

Forty percent of the cohort was classified as frail according to CFS. Thirty-day re-admission rates were comparable between frail and non-frail patients (46% vs 35%; P = 0.419). 1-year survival was lower in the frail vs non-frail group (log rank, P = 0.017). On Cox analysis, only frailty was associated with 1-year post-intervention mortality (hazard ratio [HR] = 5.64, 95% confidence interval [CI] = 1.131-28.212; P = 0.035).

Conclusions

CFS-defined frailty was associated with increased risk of 1-year mortality after LVAD implantation. CFS may be a valuable tool in the frailty assessment for risk stratification of patients undergoing LVAD implantation. Multicenter studies are required to validate these findings.

Association between malnutrition and contrast-associated acute kidney injury in congestive heart failure patients following coronary angiography

BACKGROUND

Previous studies have shown that malnutrition is very common in patients with congestive heart failure (CHF) and is closely related to the occurrence of acute kidney injury. However, the relationship between malnutrition and contrast-associated acute kidney injury (CA-AKI) is unclear.

METHOD AND RESULTS

We obtained data from 842 patients who were diagnosed with CHF following coronary angiography (CAG) or percutaneous coronary angiography (PCI) and had follow-up information from January 2013 to February 2016. The patients were divided into 3 groups according to the Controlling Nutritional Status Score before CAG or PCI procedure (Group 1: Normal; Group 2: Mild Malnutrition; Group 3: Moderate to Severe Malnutrition). The main endpoint was CA-AKI. Univariate and multivariable logistic regression analyses were performed. 556 (60.0%) patients suffered from malnutrition before CAG or PCI. During a median follow-up of 2.1 years, A total of 49 (5.82%) patients developed CA-AKI. Additionally, 5 (1.75%), 26 (6.27%) and 18 (12.77%) events were documented in patients with normal, mild and moderate or severe malnutrition, respectively (p < 0.01). In multivariable-adjusted models, patients with malnutrition showed a significantly higher incidence of CA-AKI than those in the normal group.

CONCLUSION

Malnutrition is an independent risk factor for CA-AKI in CHF patients following CAG.

Characteristics and outcomes of patients with heart failure discharged from different speciality units in Australia: an observational study

BACKGROUND

Previous studies have reported differing clinical outcomes among hospitalized heart failure (HF) patients admitted under cardiology and general medicine (GM) without consideration of patients' frailty.

AIMS

To explore outcomes in patients admitted under the two specialities after taking into account their frailty and other characteristics.

METHODS

This retrospective study included all HF patients ≥18 years admitted between 1 January 2013 and 31 December 2019 at two Australian tertiary hospitals. Frailty was determined by use of the Hospital Frailty Risk Score (HFRS) and patients with HFRS ≥ 5 were classified as frail. Propensity score matching (PSM) was used to match 11 variables between the two specialities. The primary outcomes included the days-alive-and-out-of-hospital (DAOH90) at 90 days of discharge, 30-day mortality and readmissions.

RESULTS

Of 4913 HF patients, mean age 76.2 (14.1) years, 51% males, 2653 (54%) were admitted under cardiology compared to 2260 (46%) under GM. Patients admitted under GM were more likely to be older females, with a higher Charlson index and poor renal function than those admitted under cardiology. Overall, 23.8% patients were frail and frail patients were more likely to be admitted under GM than cardiology (33.6% vs. 15.3%, P < 0.001). PSM created 1532 well-matched patients in each group. After PSM, the DAOH90 was not significantly different among patients admitted in GM when compared to cardiology (coefficient -5.36, 95% confidence interval -11.73 to 1.01, P = 0.099). Other clinical outcomes were also similar between the two specialities.

CONCLUSIONS

Clinical characteristics of HF patients differ between GM and cardiology; however, clinical outcomes were not significantly different after taking into account frailty and other variables.

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.

Benefits of heart failure-specific pharmacotherapy in frail hospitalised patients: a cross-sectional study

OBJECTIVES

Up to 50% of heart failure (HF) patients may be frail and have worse clinical outcomes than non-frail patients. The benefits of HF-specific pharmacotherapy (beta-blockers, ACE-inhibitors/angiotensin-receptor-blockers and mineralocorticoid-receptor-antagonist) in this population are unclear. This study explored whether HF-specific pharmacotherapy improves outcomes in frail hospitalised HF patients.

DESIGN

Observational, multicentre, cross-sectional study.

SETTINGS

Tertiary care hospitals.

PARTICIPANTS

One thousand four hundred and six hospitalised frail HF patients admitted between 1 January 2013 and 31 December 2020.

MEASURES

The Hospital Frailty Risk Score (HFRS) determined frailty status and patients with HFRS ≥5 were classified as frail. The primary outcomes included the days alive and out of hospital (DAOH) at 90 days following discharge, 30-day and 180-day mortality, length of hospital stay (LOS) and 30-day readmissions. Propensity score matching (PSM) compared clinical outcomes depending on the receipt of HF-specific pharmacotherapy.

RESULTS

Of 5734 HF patients admitted over a period of 8 years, 1406 (24.5%) were identified as frail according to the HFRS and were included in this study. Of 1406 frail HF patients, 1025 (72.9%) received HF-specific pharmacotherapy compared with 381 (27.1%) who did not receive any of these medications. Frail HF patients who did not receive HF-specific pharmacotherapy were significantly older, with higher creatinine and brain natriuretic peptide but with lower haemoglobin and albumin levels (p<0.05) when compared with those frail patients who received HF medications. After PSM frail patients on treatment were more likely to have an increased DAOH (coefficient 16.18, 95% CI 6.32 to 26.04, p=0.001) than those who were not on treatment. Both 30-day (OR 0.30, 95% CI 0.23 to 0.39, p<0.001) and 180-day mortality (OR 0.43, 95% CI 0.33 to 0.54, p<0.001) were significantly lower in frail patients on HF treatment but, there were no significant differences in LOS and 30-day readmissions (p>0.05).

CONCLUSION

This study found an association between the use of HF-specific pharmacotherapy and improved clinical outcomes in frail HF hospitalised patients when compared to those who were not on treatment.

TRIAL REGISTRATION NUMBER

ANZCTRN383195.

The Clinical Frailty Scale (CFS) employment in the frailty assessment of patients suffering from Non-Communicable Diseases (NCDs): A systematic review

Background

The Clinical Frailty Scale (CFS) is a well-established tool that has been widely employed to assess patients' frailty status and to predict clinical outcomes in the acute phase of a disease, but more information is needed to define the implications that this tool have when dealing with Non-Communicable Diseases (NCDs).

Methods

An electronic literature search was performed on PubMed, Scopus, EMBASE, Web of Science, and EBSCO databases to identify studies employing the CFS to assess frailty in patients with NCDs.

Findings

After database searching, article suitability evaluation, and studies' quality assessment, 43 studies were included in the systematic review. Researches were conducted mostly in Japan (37.5%), and half of the studies were focused on cardiovascular diseases (46.42%), followed by cancer (25.00%), and diabetes (10.71%). Simplicity (39.29%), efficacy (37.5%), and rapidity (16.07%) were the CFS characteristics mostly appreciated by the authors of the studies. The CFS-related results indicated that its scores were associated with patients' clinical outcomes (33.92%), with the presence of the disease (12.5%) and, with clinical decision making (10.71%). Furthermore, CFS resulted as a predictor of life expectancy in 23 studies (41.07%), clinical outcomes in 12 studies (21.43%), and hospital admissions/readmissions in 6 studies (10.71%).

Discussion

CFS was found to be a well-established and useful tool to assess frailty in NCDs, too. It resulted to be related to the most important disease-related clinical characteristics and, thus, it should be always considered as an important step in the multidisciplinary evaluation of frail and chronic patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.asp? PROSPERO 2021, ID: CRD42021224214.

Assessment of Malnutrition in Heart Failure and Its Relationship with Clinical Problems in Brazilian Health Services

Malnutrition in heart failure (HF) is frequent and associated with a worse prognosis. Due to differences in investment and the profile of those assisted, the objective of this study was to evaluate the frequency of malnutrition in hospitalized patients with HF and its association with clinical outcomes in the public and private health systems. Methodology: A cross-sectional study, with 247 volunteers hospitalized with HF in three public hospitals and one private hospital in Aracaju, SE, Brazil. A subjective global nutritional assessment (SGA) and mini nutritional assessment (MNA) were performed. Results: Sample with 72.5% users of the public health system and 75.3% with malnutrition (public = 74.9%; private = 76.5%; p = 0.793). Regardless of the healthcare system, hospital stay (>14 days) was longer (p = 0.020) among those with malnutrition (48.4%) than well-nourished patients (29.5%). Malnutrition in the public system had higher mortality (7.5%; 5.8%; p < 0.001) and hospital transfer rate (21.1%; 0.0%; p < 0.001) than those in the private system. Death after discharge was observed only in the public system (p = 0.039). Conclusion: Malnutrition was frequent in both systems and was associated with longer hospital stays and, in the public hospital, in-hospital death and transfers.

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.

Preoperative malnutrition as an independent risk factor for the postoperative mortality in elderly Chinese individuals undergoing hip surgery: a single-center observational study

Objective:

Malnutrition is prevalent in elderly with hip fracture and higher than in community-dwelling older adults. Scarce studies have examined the association between preoperative malnutrition and postoperative mortality in elderly Chinese individuals with hip fracture. This study was designed to explore the effect of preoperative malnutrition on the postoperative long-term mortality in elderly Chinese individuals undergoing hip surgery.

Methods:

As a single-center observational study, this study included 263 consecutive patients above 70 years old with hip fracture and elective surgery. Preoperative nutritional status was evaluated by prognostic nutritional index (PNI). Patients were divided into one group with malnutrition (26 patients with PNI ⩽ 38) and the other group without malnutrition (169 patients with PNI > 38), respectively.

Results:

The overall malnutrition rate was 13.3% (26 patients). The postoperative long-term mortality rates of patients with and without malnutrition had statistically significant difference [10 patients (38.5%) and 32 patients (18.9%), p < 0.05]. Cox regression analysis showed that malnutrition (hazard ratio: 0.269, 95% confidence interval: 0.085–0.859, p < 0.05) and partial pressure of carbon dioxide (hazard ratio: 0.873, 95% confidence interval: 0.790–0.964, p < 0.05) were independent risk factors for the postoperative long-term mortality.

Conclusion:

This study demonstrated that preoperative malnutrition was an independent risk factor for the postoperative long-term mortality and resulted in a more than 2.5-fold increase of the postoperative long-term mortality in elderly Chinese individuals undergoing hip surgery.

Association Between Prognostic Nutritional Index and Prognosis in Patients With Heart Failure: A Meta-Analysis

Background

The prognostic nutritional index (PNI) has been proposed as a marker of malnutrition and associated with the prognosis of cardiovascular disease. However, whether PNI can serve as a potential biomarker for the prognosis of heart failure (HF) upon those established risk factors were still controversial. This meta-analysis aimed to generate comprehensive evidence on the prognostic value of PNI in patients with HF.

Methods

Multiple databases (PubMed, Embase, the Cochrane Library, and Google Scholar) were searched for related studies up to January 31, 2022. Observational studies accessed associations between PNI levels and the prognosis in patients with HF were included for meta-analysis. The hazard ratios (HRs) and 95% confidence intervals (CI) were calculated.

Results

Fourteen studies, comprising 19,605 patients with HF were included for meta-analysis. The median follow-up duration was 18.5 months. Compared with those with higher PNI (normal nutritional status), patients with HF with lower PNI (malnourished) were associated with a higher risk of all-cause mortality (HR 1.53, 95% CI 1.27–1.85) and composite major adverse cardiac outcomes (MACEs; HR 2.26, 95% CI 1.54–3.31) in the multivariable-adjusted model. Furthermore, when PNI was defined as per 1 increment as a continuous metric, higher PNI was associated with a decrease in all-cause mortality (per 1 increment of PNI: HR 0.94, 95% CI 0.88–0.96) and MACEs (per 1 increment of PNI: HR 0.97, 95% CI 0.95–0.98).

Conclusions

The PNI can serve as an easily calculated bedside “malnutrition-inflammation” biomarker in HF. Lower PNI was associated with a worse prognosis in patients with HF.

Responders to Sodium-Glucose Cotransporter 2 Inhibitors in Improving Left Ventricular Function

Sodium-glucose cotransporter 2 inhibitor (SGLT2i)-incorporated medical therapy is associated with cardiac function improvement in patients with heart failure. However, the factors associated with such an improvement remain unknown.This study included patients with heart failure and type 2 diabetes mellitus who received SGLT2i-incorporated medical therapy in our institute. Transthoracic echocardiography was performed at baseline and 3-18 months later. The factors associated with cardiac function improvement were investigated.A total of 47 patients (median age, 69 years old; 35 men) were included in this study. SGLT2i was administered for median 284 days (range: 86-730 days). The left ventricular ejection fraction increased from 39.0% to 54.0% (P < 0.001), and the E/e' ratio decreased from 14.0 to 10.4 (P = 0.002). Younger age, higher serum albumin level, and lower serum sodium level were independently associated with an improvement in systolic function, defined as an increase in the ejection fraction of ≥ 35% among patients with systolic heart failure (P = 0.018). Male sex and impaired renal function tended to be associated with an improvement in diastolic function, defined as a decrease in the E/e' ratio of ≥ 20% among the overall cohort.Several factors were associated with improvements in systolic and diastolic functions during the SGLT2i-incorporated medical therapy.

Potential association with malnutrition and allocation of combination medical therapies in hospitalized heart failure patients with reduced ejection fraction

Malnutrition is common in patients with heart failure with reduced ejection fraction (HFrEF) and may influence the long-term prognosis and allocation of combination medical therapy. We reviewed 1231 consecutive patient-level records from a multicenter Japanese registry of hospitalized HFrEF patients. Nutritional status was assessed using geriatric nutritional risk index (GNRI). Combination medical therapy were categorized based on the use of beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists. The composite outcome of all-cause death and HF rehospitalization was assessed. The mean age was 72.0 ± 14.2 years and 42.6% patients were malnourished (GNRI < 92). At discharge, 43.6% and 33.4% of patients were receiving two and three agents, respectively. Malnourished patients had lower rates of combination medical therapy use. The standardized GNRI score was independently associated with the occurrence of adverse events (hazard ratio [HR]: 0.88, 95% confidence interval [CI] 0.79-0.98). Regardless of the GNRI score, referenced to patients receiving single agent, risk of adverse events were lower with those receiving three (HR: 0.70, 95% CI 0.55-0.91) or two agents (HR: 0.70, 95% CI 0.56-0.89). Malnutrition assessed by GNRI score predicts long-term adverse outcomes among hospitalized HFrEF patients. However, its prognosis may be modified with combination medical therapy.

The Association of Nutritional Risk Screening 2002 With 1-Year Re-hospitalization and the Length of Initial Hospital Stay in Patients With Heart Failure

Backgrounds and Aims

Nutritional Risk Screening 2002 (NRS-2002) has been widely recommended for identifying the nutritional risk. However, the association between NRS-2002 and the prognosis of heart failure has not been fully addressed. This study aimed to explore the association of NRS-2002 with 1-year re-hospitalization and the length of initial hospital stay in heart failure patients.

Methods

This retrospective study included 2,830 heart failure patients. The primary endpoint was 1-year re-hospitalization for heart failure. The secondary endpoint was the length of initial hospital stay. The Log-binomial regression analysis was performed to determine the association between NRS-2002 and re-hospitalization. The Cox regression model was fitted to estimate hazard of discharge. The cumulative incidence curves of discharge were plotted using Kaplan–Meier method and log-rank test was performed. Exploratory analysis was also conducted according to the classification of heart failure and the level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) fold-elevation.

Results

Among 2,830 heart failure patients, the mean age was 64.3 years and 66.4% were male. A total of 122 (4.3%) patients were considered at high nutritional risk. Log-binomial regression analysis demonstrated that higher NRS-2002 score was an independent risk factor of re-hospitalization ([1 vs. 0]: relative risks [RR] = 1.383, 95% CI = 1.152 to 1.660; [2 vs. 0]: RR = 1.425, 95% CI = 1.108 to 1.832; [3–7 vs. 0]: RR = 1.770, 95% CI = 1.310 to 2.393). Kaplan–Meier curve showed that the cumulative incidence of discharge was lower in high nutritional risk group (Log rank p &lt; 0.001). Cox regression analysis also found that higher NRS-2002 score (2 or ≥3) was strongly associated with longer length of initial hospital stay ([2 vs. 0]: Hazard ratios [HR] = 0.854, 95% CI = 0.748 to 0.976; [3–7 vs. 0]: HR = 0.609, 95% CI = 0.503 to 0.737). Exploratory analysis showed that such association still remained irrespective of NT-proBNP fold-elevation, but only existed in patients with heart failure with preserved ejection fraction (HFpEF).

Conclusion

In patients with heart failure, high NRS-2002 score was strongly and independently associated with the incidence of 1-year re-hospitalization and the length of initial hospital stay.

Association of wound, ischemia, and foot infection clinical stage with frailty and malnutrition in chronic limb-threatening ischemia patients undergoing endovascular intervention

OBJECTIVE

The Wound, Ischemia, and foot Infection (WIfI) clinical stage has been thought to have a prognostic value in Chronic limb-threatening ischemia (CLTI) patients, and frailty and nutritional status appear to represent pivotal factor affecting prognosis among CLTI patients. The purpose of this study was to examine clinical factors (including frailty and nutritional status) relevant to WIfI clinical stage.

METHODS

This retrospective study investigated 200 consecutive CLTI patients. We individually assessed WIfI clinical stage, frailty according to the Clinical Frailty Scale (CFS) score, and malnutrition according to Geriatric Nutritional Risk Index (GNRI). We then compared mortality after endovascular intervention between a WIfI stage 1, 2 group and a stage 3, 4 group, and investigated associations between baseline characteristics (including CFS and GNRI) and WIfI clinical stage.

RESULTS

Among 200 patients, 123 patients (62%) showed WIfI stage 1 or 2, and the remaining 77 patients (38%) had WIfI stage 3 or 4. CFS score was significantly higher in the WIfI stage 3, 4 group [median 6.0, interquartile range (IQR) 5.5-7.0] compared with the WIfI stage 1, 2 group (median 5.0, IQR 4.0-6.0, p < 0.001), and GNRI was significantly lower in the WIfI stage 3, 4 group (median 88, IQR 80-97) than in the WIfI stage 1, 2 (median 103, IQR 94-111, p < 0.001). Forty patients (20%) died after endovascular intervention. Incidences of all-cause and cardiac deaths were higher in the WIfI stage 3, 4 group than in the WIfI stage 1, 2 group (27% vs. 15%, p = 0.047 and 12% vs. 3%, p = 0.040, respectively). Kaplan-Meier analysis showed a significantly lower survival rate in the WIfI stage 3, 4 group than in the WIfI stage 1, 2 group (p = 0.002 by log-rank test). Multivariate logistic regression analysis using relevant factors from univariate analysis showed CFS score [odds ratio (OR) 2.06, 95% confidence interval (CI) 1.41-3.13, p < 0.001), diabetes mellitus (OR 3.17, 95%CI 1.17-8.61, p = 0.023) and GNRI (OR 0.93, 95%CI 0.89-0.97, p = 0.002) significantly associated with WIfI stage 3 or 4. In addition, multivariate ordinal logistic regression analysis for WIfI clinical stage showed CFS score (OR 1.43, 95%CI 1.09-1.89, p = 0.011), diabetes mellitus (OR 1.77, 95%CI 1.26-2.54, p < 0.001), and high-sensitivity C-reactive protein (OR 1.14, 95%CI 1.02-1.28, p = 0.041) were positively associated with WIfI clinical stage, and GNRI correlated negatively with WIfI clinical stage (OR 0.95, 95%CI 0.91-0.97, p < 0.001).

CONCLUSIONS

These results indicate that CLTI patients with high WIfI clinical stage may be more frail and malnourished, and be associated with poor prognosis after endovascular intervention.

Association of nutritional status and mortality risk in patients with primary pulmonary hypertension

Malnutrition plays a crucial role in pulmonary hypertension (PH). The prognostic nutritional index (PNI) is a reliable indicator for nutritional status assessment. However, its relationship with mortality risk in PH patients has not yet been investigated. This study analyzed data from the Patient Registry for Primary PH. PNI was calculated through albumin and lymphocyte counts. Subjects with missing data for PNI calculation were excluded. The primary endpoint was all‐cause mortality. Cox proportional hazard model was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs). Of the 317 patients records available in the registry, we finally included 136 patients. The average age of the included subjects was 40.56 (14.91) years and 63.24% (86/136) were female. In our analysis of Cox regression, per 1‐point increment of PNI was associated with 4% decreased risk of mortality in PH patients (age‐ and sex‐adjusted HR: 0.96, 95% CI: 0.93–0.98, p = 0.002). We further categorized these subjects by quartiles of PNI. Compared to quartile 4, the age‐ and sex‐adjusted HRs of death for quartiles 1, 2, and 3 were 2.39 (95% CI: 1.21–4.72, p = 0.01), 2.25 (95% CI: 1.15–4.39, p = 0.02), and 1.72 (95% CI: 0.84–3.52, p = 0.14). In addition, logistic regression analyses suggested a positive correlation of PNI with total lung capacity (β = 0.98, p = 0.002) and forced expiratory volume in 1 min (β = 1.53, p = 0.03). This study demonstrates that low PNI was associated with an increased risk of death in PH patients. These findings help to enlighten our understanding of the nutritional status and adverse outcomes in PH patients.

Impact of nutritional status on prognosis in acute myocardial infarction patients undergoing percutaneous coronary intervention

BACKGROUND

Malnutrition affects the prognosis of cardiovascular disease. Acute myocardial infarction (AMI) has been a major cause of death around the world. Thus, we investigated the impact of malnutrition as defined by Geriatric Nutritional Risk Index (GNRI) on mortality in AMI patients.

METHODS

In 268 consecutive AMI patients who underwent percutaneous coronary intervention (PCI), associations between all-cause death and baseline characteristics including malnutrition (GNRI < 92.0) and Global Registry of Acute Coronary Events (GRACE) risk score were assessed.

RESULTS

Thirty-three patients died after PCI. Mortality was higher in the 51 malnourished patients than in the 217 non-malnourished patients, both within 1 month after PCI (p < 0.001) and beyond 1 month after PCI (p = 0.017). Multivariate Cox proportional hazards regression modelling using age, left ventricular ejection fraction and GRACE risk score showed malnutrition correlated significantly with all-cause death within 1 month after PCI (hazard ratio [HR] 7.04; 95% confidence interval [CI] 2.30-21.51; p < 0.001) and beyond 1 month after PCI (HR 3.10; 95% CI 1.70-8.96; p = 0.037). There were no significant differences in area under the receiver-operating characteristic (ROC) curve between GRACE risk score and GNRI for predicting all-cause death within 1 month after PCI (0.90 vs. 0.81; p = 0.074) or beyond 1 month after PCI (0.69 vs. 0.71; p = 0.87). Calibration plots comparing actual and predicted mortality confirmed that GNRI (p = 0.006) was more predictive of outcome than GRACE risk score (p = 0.85) beyond 1 month after PCI. Furthermore, comparison of p-value for interaction of malnutrition and GRACE risk score for all-cause death within 1 month after PCI, beyond 1 month after PCI, and the full follow-up period after PCI were p = 0.62, p = 0.64 and p = 0.38, respectively.

CONCLUSIONS

GNRI may have a potential for predicting the mortality in AMI patients especially in beyond 1 month after PCI, separate from GRACE risk score. Assessment of nutritional status may help stratify the risk of AMI mortality.

Clinical Characteristics of Older Heart Failure Patients With Hospital-Acquired Disability: A Preliminary, Single-Center, Observational Study

Background

This study investigated the clinical factors related to hospital-acquired disability (HAD) among 70 patients (median age, 78 years; interquartile range (IQR), 78 - 83) who were hospitalized for heart failure (HF) at Ayase Heart Hospital between December 2019 and October 2020.

Methods

HAD was defined as a ≥ 5-point decrease in Barthel Index (BI) scores from admission to discharge. Twenty-nine HF patients (41%) developed HAD after admission.

Results

Compared to the non-HAD group, the HAD group had higher Kihon Checklist scores (14 points (IQR, 11 - 17) vs. 9 points (IQR, 6 - 13); P < 0.01) and prevalence of multi-faceted frailty (90% vs. 29%; P < 0.01), a longer urinary-catheter-placement period (3 days (IQR, 1 - 5] vs. 1 day (IQR, 0 - 2), P < 0.05), less daily number of steps (457 steps (IQR, 301 - 997) vs. 1,692 steps (IQR, 1,227 - 2,418); P < 0.01), and moderate-intensity physical activity time (0 min (IQR, 0 - 2] vs. 1 min (IQR, 0 - 3); P < 0.05).

Conclusion

In conclusion, lower physical function and general physical activity and longer urinary-catheter-placement are associated with HAD.

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%.

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 objective nutritional indexes for the prediction of in-hospital mortality among elderly patients with acute heart failure

OBJECTIVES

The association between objective nutritional indexes and prognosis in patients with acute heart failure have not been well studied. Therefore, we aimed to compare the prognostic value of modified Glasgow prognostic score, prognostic nutritional index, controlling nutritional status score, and geriatric nutritional risk index for the prediction of in-hospital mortality in patients with acute heart failure.

METHODS

All consecutive elderly patients (aged ≥65 years) who had tests for C-reactive protein, total lymphocyte count, total cholesterol, and albumin levels at admission, and hospitalized due to acute heart failure were retrospectively included. The primary endpoint of the study was in-hospital mortality. We used a base model for the prediction of in-hospital mortality, including age, gender, log N-terminal pro-B-type natriuretic peptide, and the presence of coronary artery disease. We added each of the malnutrition scores, in turn, to the base model and used C-statistics to evaluate model discrimination in survival analysis.

RESULTS

A total of 628 patients were included, and 80 (12.7%) of the patients died during the hospital stay. Multivariate analysis showed that older age, prognostic nutritional index < 41.2, controlling nutritional status score > 5, geriatric nutritional risk index <92, and modified Glasgow prognostic score were independent predictors of in-hospital mortality. Among the malnutrition scores, geriatric nutritional risk index increased model performance most compared with base model.

CONCLUSION

Though all objective nutritional indexes were associated with prognosis in elderly patients with acute heart failure, geriatric nutritional risk index was superior to other scores in predicting in-hospital mortality.

Gender differences in the prevalence of frailty in heart failure: A systematic review and meta-analysis

OBJECTIVES

This study quantitatively synthesized literature to identify gender differences in the prevalence of frailty in heart failure (HF).

BACKGROUND

The intersection of frailty and HF continues to garner interest. Almost half of patients with HF are frail; however, gender differences in frailty in HF are poorly understood.

METHODS

We performed a literature search to identify studies that reported prevalence of frailty by gender in HF. Random-effects meta-analysis was used to quantify the relative and absolute risk of frailty in women compared with men with HF, overall, and by Physical and Multidimensional Frailty measures. Meta-regression was performed to examine the influence of study age and functional class on relative risk in HF.

RESULTS

Twenty-nine studies involving 8854 adults with HF were included. Overall in HF, women had a 26% higher relative risk of being frail compared with men (95% CI = 1.14-1.38, z = 4.69, p < 0.001, I2 = 76.5%). The overall absolute risk for women compared to men with HF being frail was 10% (95% CI = 0.06-0.15, z = 4.41, p < 0.001). The relative risk of frailty was slightly higher among studies that used Physical measures (relative risk = 1.27, p < 0.001) compared with studies that used Multidimensional measures (relative risk = 1.24, p = 0.024). There were no significant relationships between relative risk and either study age or functional class.

CONCLUSIONS

In HF, frailty affects women significantly more than men. Future work should focus on elucidating potential causes of gender differences in frailty in HF.

Derivation of an electronic frailty index for predicting short-term mortality in heart failure: a machine learning approach

Aims

Frailty may be found in heart failure patients especially in the elderly and is associated with a poor prognosis. However, assessment of frailty status is time‐consuming, and the electronic frailty indices developed using health records have served as useful surrogates. We hypothesized that an electronic frailty index developed using machine learning can improve short‐term mortality prediction in patients with heart failure.

Methods and results

This was a retrospective observational study that included patients admitted to nine public hospitals for heart failure from Hong Kong between 2013 and 2017. Age, sex, variables in the modified frailty index, Deyo's Charlson co‐morbidity index (≥2), neutrophil‐to‐lymphocyte ratio (NLR), and prognostic nutritional index at baseline were analysed. Gradient boosting, which is a supervised sequential ensemble learning algorithm with weak prediction submodels (typically decision trees), was applied to predict mortality. Variables were ranked in the order of importance with a total score of 100 and used to build the frailty models. Comparisons were made with decision tree and multivariable logistic regression. A total of 8893 patients (median: age 81, Q1–Q3: 71–87 years old) were included, in whom 9% had 30 day mortality and 17% had 90 day mortality. Prognostic nutritional index, age, and NLR were the most important variables predicting 30 day mortality (importance score: 37.4, 32.1, and 20.5, respectively) and 90 day mortality (importance score: 35.3, 36.3, and 14.6, respectively). Gradient boosting significantly outperformed decision tree and multivariable logistic regression. The area under the curve from a five‐fold cross validation was 0.90 for gradient boosting and 0.87 and 0.86 for decision tree and logistic regression in predicting 30 day mortality. For the prediction of 90 day mortality, the area under the curve was 0.92, 0.89, and 0.86 for gradient boosting, decision tree, and logistic regression, respectively.

Conclusions

The electronic frailty index based on co‐morbidities, inflammation, and nutrition information can readily predict mortality outcomes. Their predictive performances were significantly improved by gradient boosting techniques.

Screening Community-Living Older Adults for Protein Energy Malnutrition and Frailty: Update and Next Steps

Protein-energy malnutrition (PEM)/undernutrition and frailty are prevalent, overlapping conditions impacting on functional and health outcomes of older adults, but are frequently unidentified and untreated in community settings in the United States. Using the World Health Organization criteria for effective screening programs, we reviewed validity, reliability, and feasibility of data-driven screening tools for identifying PEM and frailty risk among community-dwelling older adults. The SCREEN II is recommended for PEM screening and the FRAIL scale is recommended as the most promising frailty screening tool, based on test characteristics, cost, and ease of use, but more research on both tools is needed, particularly on predictive validity of favorable outcomes after nutritional/physical activity interventions. The Malnutrition Screening Tool (MST) has been recommended by one expert group as a screening tool for all adults, regardless of age/care setting. However, it has not been tested in US community settings, likely yields large numbers of false positives (particularly in community settings), and its predictive validity of favorable outcomes after nutritional interventions is unknown. Community subgroups at highest priority for screening are those at increased risk due to prior illness, certain demographics and/or domiciliary characteristics, and those with BMI < 20 kg/m² or < 22 if > 70 years or recent unintentional weight loss > 10% (who are likely already malnourished). Community-based health professionals can better support healthy aging by increasing their awareness/use of PEM and frailty screening tools, prioritizing high-risk populations for systematic screening, following screening with more definitive diagnoses and appropriate interventions, and re-evaluating and revising screening protocols and measures as more data become available.

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.

The impact of frailty according to Clinical Frailty Scale on clinical outcome in patients with heart failure

AIMS

There is currently no gold standard in evaluating frailty in patients with heart failure (HF), and the prognostic value of frailty according to the Canadian Study of Health and Aging Clinical Frailty Scale (CFS) on mortality in patients with HF is still unknown.

METHODS AND RESULTS

Among consecutive 596 patients after their discharge from HF in Kokura Memorial Hospital (Kitakyushu, Japan) during 2015, their frailty at discharge was assessed according to CFS. Patients were classified into three groups: low (N = 232, 38.9%), intermediate (N = 230, 38.6%), and high (N = 134, 22.5%). The primary endpoint was defined as 2 year all-cause death. The mean age was 76.6 ± 10.1 years, and 55.3% were men in entire cohort. There were significant differences in age, living environment, and dementia among low, intermediate, and high CFS groups. Left ventricular ejection fraction (LVEF) and co-morbidities such as severe renal failure and severe anaemia tended to increase with frailty severity, while body mass index (BMI) and albumin level tended to decrease with frailty severity. Two year cumulative incidences of all-cause death for the three groups were 12.8%, 25.4%, and 52.7% (P < 0.001), respectively. This significant difference in the risk for all-cause death among the CFS groups was driven by the risk for cardiac (8.6%, 14.2%, and 31.0%, respectively, P < 0.001) and non-cardiac death (4.6%, 13.0%, and 31.4%, respectively, P < 0.001). The multivariate analysis showed that high frailty was independently associated with all-cause death (intermediate CFS group: adjusted hazard ratio, 1.43, 95% confidence interval, 0.86-2.36, P = 0.16; high CFS group: adjusted hazard ratio, 3.90, 95% confidence interval, 2.32-6.55, P < 0.001), and this result was consistent, irrespective of stratification based on age, sex, BMI, and LVEF without significant interaction.

CONCLUSIONS

The simple CFS tool was successful in predicting the risk for all-cause death in patients with HF, and frailty according to CFS was independently associated with all-cause death irrespective of stratification based on age, sex, BMI, and LVEF without significant interaction. The CFS is a valuable prognostic tool in clinical settings.

Frailty related all-cause mortality or hospital readmission among adults aged 65 and older with stage-B heart failure inpatients

BACKGROUND

Frailty increases the adverse outcomes of clinical heart failure; however, the relationship between frailty and stage-B heart failure (SBHF) remains unknown. We aimed to explore the epidemiology and predictive value of frailty in older adults with SBHF.

METHODS

A prospective cohort of SBHF inpatients aged 65 years or older who were hospitalized between September 2018 and February 2019 and were followed up for 6 months were included. SBHF was defined as systolic abnormality, structural abnormality (left ventricular enlargement, left ventricular hypertrophy, wall motion abnormalities, valvular heart disease), or prior myocardial infarction. Frailty was assessed by the Fried frailty phenotype. Multivariable Cox proportional hazards regression was used to explore the independent risk and prognostic factors.

RESULTS

Data of 443 participants (age: 76.1 ± 6.79 years, LVEF: 62.8 ± 4.92%, men: 225 [50.8%], frailty: 109 [24.6%]) were analyzed. During the 6-month follow-up, 83 (18.7%) older SBHF inpatients experienced all-cause mortality or readmission, and 29 (6.5%) of them developed clinical HF. Frail individuals had a 1.78-fold (95%CI: 1.02-3.10, P = 0.041) higher risk of 6-month mortality or readmission and a 2.83-fold (95%CI 1.24-6.47, P = 0.014) higher risk of developing clinical HF, independent of age, sex, left ventricular ejection fraction, and N-terminal pro-B-type natriuretic peptide level.

CONCLUSIONS

Frailty is common in older SBHF inpatients and should be considered to help identify individuals with an increased risk of mortality or readmission, and developing clinical HF.

TRIAL REGISTRATION

ChiCTR1800017204 .

Frailty and the risk of all-cause mortality and hospitalization in chronic heart failure: a meta-analysis

To estimate the risk of all-cause mortality and hospitalization in frail patients with chronic heart failure (HF), a systematic search and meta-analysis was carried out to identify all prospective cohort studies conducted among adults with HF where frailty was quantified and related to the primary endpoints of all-cause mortality and/or hospitalization. Twenty-nine studies reporting the link between frailty and all-cause mortality in 18 757 patients were available for the meta-analysis, along with 11 studies, with 13 525 patients, reporting the association between frailty and hospitalization. Frailty was a predictor of all-cause mortality and hospitalization with summary hazard ratios (HRs) of 1.48 [95% confidence interval (CI): 1.31-1.65, P < 0.001] and 1.40 (95% CI: 1.27-1.54, P < 0.001), respectively. Summary HRs for all-cause mortality among frail inpatients undergoing ventricular assist device implantation, inpatients hospitalized for HF, and outpatients were 1.46 (95% CI: 1.18-1.73, P < 0.001), 1.58 (95% CI: 0.94-2.22, P = not significant), and 1.53 (95% CI: 1.28-1.78, P < 0.001), respectively. Summary HRs for all-cause mortality and frailty based on Fried's phenotype were 1.48 (95% CI: 1.03-1.93, P < 0.001) and 1.42 (95% CI: 1.05-1.79, P < 0.001) for inpatients and outpatients, respectively, and based on other frailty measures were 1.42 (95% CI: 1.12-1.72, P < 0.001) and 1.60 (95% CI: 1.43-1.77, P < 0.001) for inpatients and outpatients, respectively. Across clinical contexts, frailty in chronic HF is associated with an average of 48% and 40% increase in the hazard of all-cause mortality and hospitalization, respectively. The relationship between frailty and all-cause mortality is similar across clinical settings and comparing measurement using Fried's phenotype or other measures.