Comorbidities, Fragility, and Quality of Life in Heart Failure Patients With Midrange Ejection Fraction

Differences in Health-Related Quality of Life among Patients with Heart Failure

Heart failure (HF) is characterized by a progressive clinical course marked by frequent exacerbations and repeated hospitalizations, leading to considerably high morbidity and mortality rates. Patients with HF present with a constellation of bothersome symptoms, which range from physical to psychological and mental manifestations. With the transition to more advanced HF stages, symptoms become increasingly more debilitating, interfere with activities of daily living and disrupt multiple domains of life, including physical functioning, psychological status, emotional state, cognitive function, intimate relationships, lifestyle status, usual role activities, social contact and support. By inflicting profuse limitations in numerous aspects of life, HF exerts a profoundly negative impact on health-related quality of life (HRQOL). It is therefore not surprising that patients with HF display lower levels of HRQOL compared not only to the general healthy population but also to patients suffering from other chronic diseases. On top of this, poor HRQOL in patients with HF becomes an even greater concern considering that it has been associated with unfavorable long-term outcomes and poor prognosis. Nevertheless, HRQOL may differ significantly among patients with HF. Indeed, it has consistently been reported that women with HF display poorer HRQOL compared to men, while younger patients with HF tend to exhibit lower levels of HRQOL than their older counterparts. Moreover, patients presenting with higher New York Heart Association (NYHA) functional class (III-IV) have significantly more impaired HRQOL than those in a better NYHA class (I-II). Furthermore, most studies report worse levels of HRQOL in patients suffering from HF with preserved ejection fraction (HFpEF) compared to patients with HF with reduced ejection fraction (HFrEF) or HF with mildly reduced ejection fraction (HFmrEF). Last, but not least, differences in HRQOL have been noted depending on geographic location, with lower HRQOL levels having been recorded in Africa and Eastern Europe and higher in Western Europe in a recent large global study. Based on the observed disparities that have been invariably reported in the literature, this review article aims to provide insight into the underlying differences in HRQOL among patients with HF. Through an overview of currently existing evidence, fundamental differences in HRQOL among patients with HF are analyzed based on sex, age, NYHA functional class, ejection fraction and geographic location or ethnicity.

Respiratory Muscle Strength and Quality of Life in Patients With Heart Failure and Their Main Correlated Factors: A Cross-sectional Study

BACKGROUND

Heart failure may cause peripheral and respiratory muscle alterations, dyspnea, fatigue, and exercise intolerance, worsening the quality of life of patients.

OBJECTIVES

The aims of this study were to analyze respiratory muscle strength and quality of life of patients with heart failure and correlate them with clinical variables and functional classification.

METHODS

This cross-sectional study involved patients with heart failure. A manovacuometer assessed maximum inspiratory and expiratory pressures, and quality of life was assessed using the Minnesota Living with Heart Failure Questionnaire. Functional classification was categorized according to the New York Heart Association (NYHA) class in I, II, III, or IV.

RESULTS

We included 60 patients (66.7% male) with a mean age of 62.0 years and mean left ventricular ejection fraction of 42.0%. Maximum inspiratory pressure and maximum expiratory pressure were close to normal (>70% of predicted) in most patients; however, a subgroup composed mostly of patients with dilated heart failure and NYHA class III (n = 21) presented low maximum inspiratory pressure values (59.2%; 95% confidence interval, 55.7%-62.8%). The mean total score of the Minnesota Living with Heart Failure Questionnaire was 44.4 points, being negatively correlated with left ventricular ejection fraction (r = -0.29, P = .02). Patients with NYHA class III and disease duration longer than 120 months presented higher total (P < .01) and physical dimension scores.

CONCLUSIONS

Most patients had respiratory muscle strength close to normal; however, those with dilated heart failure and NYHA class III presented low maximum inspiratory pressure values. Quality of life was moderately compromised, mainly because of long disease duration, NYHA class III, and low left ventricular ejection fraction.

Clinical Characteristics and Prognostic Impact of Short Physical Performance Battery in Hospitalized Patients with Acute Heart Failure-Results of the PROFUND-IC Registry

BACKGROUND

Most patients diagnosed with heart failure (HF) are older adults with multiple comorbidities. Multipathological patients constitute a population with common characteristics: greater clinical complexity and vulnerability, frailty, mortality, functional deterioration, polypharmacy, and poorer health-related quality of life with more dependency.

OBJECTIVES

To evaluate the clinical characteristics of hospitalized patients with acute heart failure and to determine the prognosis of patients with acute heart failure according to the Short Physical Performance Battery (SPPB) scale.

METHODS

Observational, prospective, and multicenter cohort study conducted from September 2020 to May 2022 in patients with acute heart failure as the main diagnosis and NT-ProBNP > 300 pg. The cohort included patients admitted to internal medicine departments in 18 hospitals in Spain. Epidemiological variables, comorbidities, cardiovascular risk factors, cardiovascular history, analytical parameters, and treatment during admission and discharge of the patients were collected. Level of frailty was assessed by the SPPB scale, and dependence, through the Barthel index. A descriptive analysis of all the variables was carried out, expressed as frequencies and percentages. A bivariate analysis of the SPPB was performed based on the score obtained (SPPB ≤ 5 and SPPB > 5). For the overall analysis of mortality, HF mortality, and readmission of patients at 30 days, 6 months, and 1 year, Kaplan-Meier survival curves were used, in which the survival experience among patients with an SPPB > 5 and SPPB ≤ 5 was compared.

RESULTS

A total of 482 patients were divided into two groups according to the SPPB with a cut-off point of an SPPB < 5. In the sample, 349 patients (77.7%) had an SPPB ≤ 5 and 100 patients (22.30%) had an SPPB > 5. Females (61%) predominated in the group with an SPPB ≤ 5 and males (61%) in those with an SPPB > 5. The mean age was higher in patients with an SPPB ≤ 5 (85.63 years). Anemia was more frequent in patients with an SPPB ≤ 5 (39.5%) than in patients with an SPPB ≥ 5 (29%). This was also seen with osteoarthritis (32.7%, p = 0.000), diabetes (49.6%, p = 0.001), and dyslipidemia (69.6%, p = 0.011). Patients with an SPPB score > 5 had a Barthel index < 60 in only 4% (n = 4) of cases; the remainder of the patients (96%, n = 96) had a Barthel index > 60. Patients with an SPPB > 5 showed a higher probability of survival at 30 days (p = 0.029), 6 months (p = 0.031), and 1 year (p = 0.007) with (OR = 7.07; 95%CI (1.60-29.80); OR: 3.9; 95%CI (1.30-11.60); OR: 6.01; 95%CI (1.90-18.30)), respectively. No statistically significant differences were obtained in the probability of readmission at 30 days, 6 months, and 1 year (p > 0.05).

CONCLUSIONS

Patients admitted with acute heart failure showed a high frequency of frailty as assessed by the SPPB. Patients with an SPPB ≤ 5 had greater comorbidities and greater functional limitations than patients with an SPPB > 5. Patients with heart failure and a Barthel index > 60 frequently presented an SPPB < 5. In daily clinical practice, priority should be given to performing the SPPB in patients with a Barthel index > 60 to assess frailty. Patients with an SPPB ≤ 5 had a higher risk of mortality at 30 days, 6 months, and 1 year than patients with an SPPB ≤ 5. The SPPB is a valid tool for identifying frailty in acute heart failure patients and predicting 30-day, 6-month, and 1-year mortality.

Effects of a multidisciplinary management program on symptom burden and medication adherence in heart failure patients with comorbidities: A randomized controlled trial

BACKGROUND

Comorbidities in heart failure (HF) are a complex clinical challenge. There is little data on the benefits of multidisciplinary postdischarge management programs in such patients. This study aimed to examine the effects of a multidisciplinary management program (MMP) on symptom burden and medication adherence in HF patients with comorbidities.

METHODS

In this clinical trial study, 94 HF patients with comorbidities were assigned to intervention (n = 47) and control (n = 47) groups by the stratified-random method. The intervention group underwent MMP supervised by a nurse for two months after discharge, including multi-professional visits, telephone follow-ups, and an educational booklet. Medication adherence and symptom burden were assessed using Morisky Medication Adherence Scale (MMAS) and Edmonton Symptom Assessment Scale (ESAS), respectively, on three occasions: Before discharge, six weeks, and eight weeks after discharge.

RESULTS

Both groups almost matched at the baseline, and the most frequent comorbidities included myocardial infarction (MI), hypertension, peptic ulcer, and depression, respectively. The interactive effect of time in groups showed that mean changes in total scores of symptom burden and medication adherence were significantly different (P < 0.001) at other time points. A significant increase in medication adherence (P < 0.001) and a significant reduction in the burden of all symptoms were observed in the intervention group compared to the control group from Time 1 to Time 3.

CONCLUSIONS

The MMP (targeting comorbidity) is a promising strategy for managing symptoms and medication adherence in HF patients with comorbidities.

Quality of life in patients with heart failure and improved ejection fraction: one-year changes and prognosis

AIMS

The criteria for patients with heart failure (HF) and improved ejection fraction (HFimpEF) are a baseline left ventricular ejection fraction (LVEF) ≤40%, a ≥10-point increase from baseline LVEF, and a second LVEF measurement >40%. We aimed to (i) assess patients with HF and reduced LVEF (HFrEF) at baseline and compare quality of life (QoL) changes between those that fulfilled and those that did not fulfil the HFimpEF criteria 1 year later and (ii) assess the prognostic role of QoL in patients with HFimpEF.

METHODS

We reviewed data from a prospective registry of real-world outpatients with HF that were assessed for LVEF and QoL at a first visit to the HF clinic and 1 year later. QoL was evaluated with the Minnesota Living with Heart Failure Questionnaire (MLWHFQ). The primary prognostic endpoint was the composite of all-cause death or HF hospitalization.

RESULTS

Baseline and 1-year LVEF and MLWFQ scores were available for 1040 patients with an initial LVEF ≤40% (mean age, 65.2 ± 11.7 years; 75.9% men). The main aetiology was ischaemic heart disease (52.9%), and patients were mostly in New York heart Association Classes II (71.1%) and III (21.6%). At baseline, the mean LVEF was 28.5% ± 7.3, and the mean MLWHFQ score was 30.2 ± 19.5. After 1 year, the mean LVEF increased to 38.0% ± 12.2, and the MLWHFQ scores improved to 17.4 ± 16.0. In 361 patients that fulfilled the HFimpEF criteria (34.7%), significant improvements were observed in both LVEF (from 28.7% ± 6.6 to 50.9% ± 7.6, P < 0.001) and QoL (from 32.9 ± 20.6 to 16.9 ± 16.0, P < 0.001). Patients that did not fulfil the HFimpEF criteria also showed significant improvements in LVEF (from 28.4% ± 7.6 to 31.1% ± 7.9, P < 0.001) and QoL (from 28.7 ± 18.8 to 17.6 ± 15.9, P < 0.001). However, the QoL improvement was significantly higher in the HFimpEF group (-16.0 ± 23.8 vs. -11.1 ± 20.3, P = 0.001), despite the worse mean baseline MLWHFQ score, compared with the non-HFimpEF group (P = 0.001). The 1-year QoL was similar between groups (P = 0.50). The 1-year MLWHFQ score was independently associated with outcomes; the hazard ratio for the composite endpoint was 1.02 (95% CI: 1.01-1.03, P = 0.006). In contrast, the QoL improvement (with a cut-off ≥5 points) was not independently associated with the composite outcome.

CONCLUSIONS

Patients with HFrEF showed improved QoL after 1 year, regardless of whether they met the HFimpEF criteria. The similar 1-year QoL perception between groups suggested that factors other than LVEF influenced QoL perception. The 1-year QoL was superior to the QoL change from baseline for predicting prognosis in patients with HFimpEF.

Relationship of spiritual wellbeing with life expectancy and quality of life for patients living with heart failure

Aim: Spirituality is a crucial dimension in human health. However, it is often overlooked in patients with heart failure (HF) in Iran. Thus, the purpose of this study was to determine the relationship between spiritual wellbeing, life expectancy and quality-of-life (QOL) in patients with HF. Methods: This cross-sectional study was performed with 150 HF patients, who were enrolled through convenience sampling. Data were collected using a questionnaire comprising four parts: the Minnesota Living with Heart Failure Questionnaire, Schneider's life expectancy instrument, Ellison's and Paulotzin's (1982) Spiritual Well-Being Scale, and a demographic checklist. SPSS software was used for data analysis. Results: In this study, mean and standard deviation of QOL, life expectancy and spiritual wellbeing were 41.82±19.17, 30.20±4.58 and 87.80±5.28 respectively. There was a significant relationship between spiritual wellbeing and quality of life (r=-0.633, P<0.001) and also life expectancy (r=0.544, P<0.001). Quality of life and life expectancy were significantly higher in men than in women. Linear regression tests showed that the existential and religious dimensions of spirituality could influence 44.9% of the QOL variance (F=54.54, P<0.001) and increased values of existential spirituality would improve QOL by an average of 3.45 units. Improving life expectancy also raised QOL by 14.0% (F=21.26, P<0.001). This study also demonstrated that life expectancy is impacted by spiritual health, with a variance of 34.2%, in which the role of existential-spiritual health is of particular significance (t=7.10, P<0.001). Conclusion: The results revealed that spiritual wellbeing, especially the existential type, enhances life expectancy and quality-of-life among HF patients. Therefore, it is recommended that healthcare professionals design a comprehensive and supportive care model for the promotion of spiritual wellbeing in HF patients.

Depressive Symptoms, Cardiac Structure and Function, and Risk of Incident Heart Failure With Preserved Ejection Fraction and Heart Failure With Reduced Ejection Fraction in Late Life

Background Depressive symptoms are associated with heightened risk of heart failure (HF), but their association with cardiac function and with HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF) in late life is unclear. We aimed to determine the prevalence of depression in HFpEF and in HFrEF in late life, and the association of depressive symptoms with cardiac function and incident HFpEF and HFrEF. Methods and Results We studied 6025 participants (age, 75.3±5.1 years; 59% women; 20% Black race) in the ARIC (Atherosclerosis Risk in Communities) study at visit 5 who underwent echocardiography and completed the Center for Epidemiologic Studies Depression Scale questionnaire. Among HF-free participants (n=5086), associations of Center for Epidemiologic Studies Depression Scale score with echocardiography and incident adjudicated HFpEF and HFrEF were assessed using multivariable linear and Cox proportional hazards regression. Prevalent HFpEF, but not HFrEF, was associated with a higher prevalence of depression compared with HF-free participants (P<0.001 and P=0.59, respectively). Among HF-free participants, Center for Epidemiologic Studies Depression Scale score was not associated with cardiac structure and function after adjusting for demographics and comorbidities (all P>0.05). Over 5.5-year follow-up, higher Center for Epidemiologic Studies Depression Scale score was associated with heightened risk of incident HFpEF (hazard ratio [HR] [95% CI], 1.06 [1.04-1.12]; P=0.02), but not HFrEF (HR [95% CI], 1.02 [0.96-1.08]; P=0.54), independent of echocardiographic measures, NT-proBNP (N-terminal pro-B-type natriuretic peptide), troponin, and hs-CRP (high-sensitivity C-reactive protein) (HR [95% CI], 1.06 [1.00-1.12]; P=0.04). Conclusions Worse depressive symptoms predict incident HFpEF in late life, independent of common comorbidities, cardiac structure and function, and prognostic biomarkers. Further studies are necessary to understand the mechanisms linking depression to risk of HFpEF.

Association between a pre-admission limitation in walking ability and post-discharge adverse outcomes among hospitalized patients with heart failure: Report from a multicenter prospective cohort study

BACKGROUND

Although limited walking ability at discharge is a known risk factor for adverse outcomes in older patients with heart failure (HF), the association between pre-admission limitations and adverse outcomes is unknown. Therefore, we evaluated the prevalence of a pre-admission limitation in walking ability and its relationship with post-discharge outcomes among patients with HF with reduced, mid-range, and preserved left-ventricular ejection fraction (HFrEF, HFmrEF, and HFpEF).

METHODS

We followed 2042 patients aged ≥65 years (HFrEF, n = 668; HFmrEF, n = 360; HFpEF, n = 1014) from a multicenter cohort study in Japan. A limitation in walking ability was defined as the necessity of any assistance or a walking aid. Adverse outcomes were defined as the composite of HF rehospitalization and all-cause death within 2 years after discharge.

RESULTS

During 2978.0 person-years of follow-up, 563 patients were rehospitalized due to HF exacerbation and 103 patients died. In HFrEF, HFmrEF, and HFpEF groups, the prevalence of a pre-admission limitation in walking ability was 12.1%, 18.6%, and 21.1%, respectively, the crude hazard ratios [95% confidence interval] of a pre-admission limitation in walking ability were 2.46 [1.79-3.39], 1.34 [0.87-2.06], and 1.94 [1.53-2.47], and the adjusted hazard ratios were 2.21 [1.58-3.16], 1.19 [0.75-1.89], and 1.39 [1.06-1.82], respectively.

CONCLUSIONS

A pre-admission limitation in walking ability is a predictor of post-discharge HF rehospitalization or all-cause death among patients with HFrEF and HFpEF, but not among patients with HFmrEF. Shortly after admission, information regarding pre-admission functional limitations should be obtained to better understand the risk of post-discharge adverse outcomes.

Individualized Nutritional Support for Hospitalized Patients With Chronic Heart Failure

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Moving the Dial on Heart Failure Patient Adherence Rates

INTRODUCTION

Heart failure remains a substantive contributor to patient morbidity and mortality rates worldwide and represents a significant burden on the healthcare ecosystem. Faced with persistent physical symptoms and debilitating social consequences, patients follow complex treatment regimens and often have difficulty adhering to them.

PURPOSE

In this manuscript, we review factors which contribute to low adherence rates and advance potential single- and multi-factor-based interventions. It is hoped that these observations can lead to improvements in managed care of this vulnerable population of patients.

METHODS

A narrative review of the primary literature was performed on contributing factors with primary focus on the period 2015-2020 using available databases and search engines. Adherence pain points identified were mapped against a series of potential solutions which are presented.

RESULTS

Enhancement of treatment adherence relies on two approaches viz. single-factor and multi-factor solutions. Single factors identified include electronic reminders, enhanced health education, financial incentives, gamification strategies, community drivers, persona-based modeling, and burden relief of poly pharmacy. Multi-factor solutions combine two or more of the seven approaches offering the potential for flexible interventions tailored to the individual.

DISCUSSION AND CONCLUSION

Heart failure patients with poor adherence have increased mortality, hospitalization needs, and healthcare costs. This review highlights current single-factor and multi-factor adherence methods. Against a backdrop of diversity of approaches, multi-factor solutions cast the widest net for positively influencing adherent behaviors. A key enabler lies in the development and leveraging of patient personas in the synthesis of successful intervention methods. Deployable solutions can also be envisioned in clinical trials where adherence tracking represents an essential component.

Prehospital Shock Precautions on Triage (PSPoT) score to assess in-hospital mortality for septic shock

CONTEXT

In the prehospital setting, early identification of septic shock (SS) with high risk of poor outcome is a daily issue. There is a need for a simple tool aiming to early assess outcome in order to decide delivery unit (emergency department (ED) or intensive care unit (ICU)). In France, prehospital emergencies are managed by the Service d'Aide Médicale d'Urgence (SAMU). The SAMU physician decides the destination ward either to the ICU or to the ED after on scene severity assessment. We report the association between The Prehospital Shock Precautions on Triage (PSPoT) score, and in-hospital mortality of SS patients initially cared for in the prehospital setting by a mobile ICU (MICU).

METHODS

SS patients cared for by MICU were prospectively included between February 2017 and July 2019. The PSPoT score was established by adding shock index>1 and criterion based on past medical history: age >65 years and at least 1 previous comorbidity (chronic cardiac failure, chronic renal failure, chronic obstructive pulmonary disease, previous or actual history of cancer, institutionalization, hospitalisation within previous 3 months. A threshold of ≥2, was arbitrarily chosen for clinical relevance and usefulness in clinical practice.

RESULTS

One-hundred and sixty-nine with a median age of 72 [20-93] years were analysed. SS origin was mainly pulmonary (54%), abdominal (19%) and urinary (15%). The median PSPoT score was 2 [1-2]. PSPoT score and PSPoT score ≥ 2 were associated with in-hospital mortality: OR = 1.24 [0.77-2.05] and OR = 2.19 [1.09-4.59] respectively.

CONCLUSION

We report an association between PSPoT score, and in-hospital mortality of SS patients cared for by a MICU. A PSPoT score ≥ 2 early identifies poorer outcome.

Mini Nutritional Assessment Short Form is a morbi-mortality predictor in outpatients with heart failure and mid-range left ventricular ejection fraction

BACKGROUND & AIMS

Nutritional status is an important prognostic factor in patients with heart failure (HF). In a pilot study we previously observed that the Mini Nutritional Assessment Short Form tool (MNA-SF) was the best approach for the screening of nutritional status in HF outpatients over other screening tools. The current study aimed to determine whether the MNA-SF has prognostic value in outpatients with HF and whether the impact of malnutrition differs depending on left ventricular ejection fraction (LVEF).

METHODS

Prospective study performed in outpatients attending a HF clinic at a university hospital. All subjects completed the MNA-SF at study entry. The primary endpoint was all-cause mortality. Secondary end-points were the number of recurrent HF-related hospitalizations and the composite end-point of all-cause death or HF-related hospitalizations. Patients with malnutrition and at risk of malnutrition were merged and considered as having abnormal nutritional status for statistical analysis.

RESULTS

From October 2016 to November 2017, 555 patients were included (age 69 ± 11.5 years, 71% male, LVEF 44.6 ± 13.2). Abnormal nutritional status was identified in 103 (18.6%) subjects. HF patients with preserved LVEF had a higher proportion of abnormal nutritional status (23%) than patients with HF and mid-range LVEF (HFmrEF) (16.4%) or those with HF with reduced LVEF (HFrEF) (15.9%.). During a mean follow-up of 23.8 ± 6.6 months, 99 patients died (17.8%), 74 were hospitalized due to HF (13.3%) and the composite end-point was observed in 181 (32.6%). In the univariate analysis, abnormal nutritional status was significantly associated with all-cause mortality (p = 0.02) and the composite end-point (p = 0.02) in the total cohort. However, in the multivariate analysis including age, sex, NYHA functional class, BMI, ischemic aetiology, diabetes, hypertension and HF duration, abnormal nutritional status remained significantly associated with all-cause mortality (HR 3.32 [95%CI 1.47-7.52], p = 0.004), and the composite end-point (HR 2.53 [95%CI 1.30-4.94], p = 0.006) only in HFmrEF patients. Patients with abnormal nutritional status suffered double the crude number of recurrent HF-related hospitalizations (16.4 vs. 8.4 per 100 patients-years, p < 0.001).

CONCLUSIONS

The implementation of MNA-SF as a routine screening tool allowed the detection of abnormal nutritional status in almost one out of five ambulatory HF patients. Nutritional status assessed by the MNA-SF was an independent predictor of all-cause death and the composite end-point of all-cause death or HF-related hospitalization in outpatients with HFmrEF. Furthermore, abnormal nutritional status was significantly related to recurrent hospitalizations across the HF spectrum.