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

Prognostic impact of malnutrition in patients with coronary artery disease: a systematic review and meta-analysis

CONTEXT

Conflicting predictions of malnutrition for the long-term prognosis of coronary artery disease (CAD) exist.

OBJECTIVE

This study aimed to investigate the relationship between malnutrition and long-term prognosis of patients with CAD.

DATA SOURCES

Four databases were searched for articles from February 11, 1936, to September 10, 2022.

DATA EXTRACTION

Cohort studies adjusting for multiple cardiovascular risk factors with data on CAD and malnutrition were included. Malnutrition was measured and defined by different nutritional evaluation tools. The hazard ratios (HRs) and confidence intervals (CIs) for all-cause mortality and major adverse cardiovascular events (MACEs) were synthesized. Subgroup analyses were performed based on study design, assessment tools, ethnicity/race, follow-up, sample size, and types of CAD. Meta-regression was used to compare whether the effect sizes of the 2 subgroups were statistically significant.

DATA ANALYSIS

A total of 30 cohort studies were included, totaling 81 361 participants with CAD. Nutritional evaluation tools, including the Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status (CONUT), Nutritional Risk Screening 2002, Mini-Nutritional Assessment, and Prognostic Nutritional Index, were used. Malnutrition increased all-cause mortality (HR = 1.72; 95% CI: 1.53, 1.93) and MACEs (HR = 1.47; 95% CI: 1.35, 1.60) in patients with CAD. Subgroup analysis revealed the results were consistent across study design, ethnicity/race, follow-up, sample size, and types of CAD. Subgroup analyses and meta-regression revealed that malnutrition was associated with a higher risk of all-cause mortality (HR = 2.26; 95% CI: 1.91, 2.68) and MACEs (HR = 2.28; 95% CI: 1.69, 3.08) in patients with stable CAD than those with other types of CAD. Meta-regression revealed that the GNRI (HR = 2.20; 95% CI: 1.65, 2.93) was more effective than CONUT (HR = 1.47; 95% CI: 1.21, 1.78) in predicting all-cause mortality.

CONCLUSION

Malnutrition independently increased all-cause mortality by 72% and MACEs by 47% in patients with CAD, especially with stable CAD. The GNRI is a more effective nutritional evaluation tool than CONUT in predicting all-cause mortality.

Clinical outcomes of ST elevation myocardial infarction patients without standard modifiable risk factors

BACKGROUND

Standard modifiable cardiovascular risk factors (SMuRFs; hypertension, diabetes mellitus, dyslipidemia, and smoking) are widely recognized as risk factors for coronary artery disease. However, the associations between absence of SMuRFs and long-term clinical outcomes in ST-segment elevation myocardial infarction (STEMI) patients are unclear.

METHODS

Consecutive STEMI patients who underwent primary percutaneous coronary intervention (PCI) between 1999 and 2015 were retrospectively analyzed. The primary endpoint was up to 5-year all-cause mortality. Clinical characteristics and outcomes were compared between patients with at least one of the SMuRFs and those without any SMuRFs.

RESULTS

Of 1963 STEMI patients, 126 (6.4 %) did not have any SMuRFs. Patients without SMuRFs were significantly older, had lower body mass index, and were more likely to be female. During a median follow-up period of 4.9 years, the cumulative incidence of death was significantly higher in patients without SMuRFs than in those with SMuRFs (log-rank p < 0.0001). Landmark analysis showed that patients without SMuRFs had higher mortality within 30 days of STEMI onset (log-rank p = 0.0045) and >30 days after STEMI onset (log-rank p = 0.0004). Multivariable Cox hazards analysis showed that absence of SMuRFs was associated with a higher risk of mortality (hazard ratio, 1.59; 95 % confidence interval, 1.14-2.21; p = 0.006).

CONCLUSIONS

Of STEMI patients undergoing primary PCI, patients without any SMuRFs had higher mortality than those with at least one of the SMuRFs. Patients without any SMuRFs have a poor prognosis and require more attention.

Nutritional Status and Recurrent Major Cardiovascular Events Following Acute Myocardial Infarction-A Follow-Up Study in a Primary Percutaneous Coronary Intervention Center

BACKGROUND

Acute myocardial infarction is often accompanied by malnutrition, which is associated with an imbalance between catabolic and anabolic processes. This ultimately leads to cardiac cachexia, which worsens the patient's prognosis. We aimed to assess the correlation between nutritional status, assessed using the controlling nutritional status (CONUT) score, and the rate of major cardiovascular adverse events (MACE).

METHODS

The present investigation was a non-randomized, prospective, observational study in which 108 patients with acute myocardial infarction were included. Nutritional status was assessed using the CONUT score. Based on the CONUT score, the patients were divided as follows: Group 1-normal or mild nutritional status (CONUT < 3 points, n = 76), and Group 2-moderate to severe nutritional deficiency (CONUT ≥ 3 points, n = 32). Demographic, echocardiographic, and laboratory parameters were obtained for all patients, as well as the MACE rate at 1 and 3 months of follow-up.

RESULTS

The MACE occurred more frequently in patients with impaired nutritional status at both 1-month follow-up (46.9% versus 9.2%; p < 0.0001) and 3-month follow-up (68.8% versus 10.5%; p < 0.0001). In terms of cardiovascular events, patients with poor nutritional status, with a CONUT score ≥ 3, presented more frequent non-fatal myocardial infarction, stroke, revascularization procedure, and ventricular arrhythmia. Also, the number of cardiovascular deaths was higher in the undernourished group.

CONCLUSIONS

This study found that patients with poor nutritional status experienced inflammatory status, frailty, and cardiovascular events more often than those with normal nutritional status at 1-month and 3-month follow-up after an acute myocardial infarction.

Living alone predicts poor prognosis among patients with acute myocardial infarction

BACKGROUND

Living alone as a proxy for social isolation has been considered to increase the risk of cardiovascular disease. We thus investigated the impact of living alone on mortality in acute myocardial infarction (AMI) patients.

METHODS

Subjects comprised 277 AMI patients who underwent percutaneous coronary intervention (PCI). Associations between all-cause and cardiac deaths after PCI and baseline characteristics including living alone and Global Registry of Acute Coronary Events (GRACE) risk score were assessed.

RESULTS

Eighty-three patients (30%) were living alone. Thirty patients died after PCI, including 20 cardiac deaths. Patients living alone showed higher incidences of both all-cause and cardiac deaths compared with patients not living alone (18% vs. 8%, P  = 0.019 and 14% vs. 4%, P  = 0.004). Multivariate Cox proportional hazards regression analysis models showed living alone [hazard ratio (HR), 2.60; 95% confidence interval (CI), 1.20-5.62; P  = 0.016 and HR, 4.17; 95% CI, 1.60-10.84; P  = 0.003] and GRACE risk score (HR, 1.02; 95% CI, 1.01-1.03; P  = 0.003 and HR, 1.03; 95% CI, 1.01-1.04; P  < 0.001) correlated significantly with all-cause and cardiac deaths. Cox proportional hazards modeling revealed that patients living alone with GRACE risk score ≥162 derived from the receiver-operating characteristic curve showed a significantly greater risk of all-cause death than patients not living alone with GRACE risk score <162 (HR 16.57; 95% CI 6.67-41.21; P  < 0.001).

CONCLUSION

Among AMI patients, living alone represents an independent risk factor for all-cause and cardiac deaths after PCI, separate from GRACE risk score. Furthermore, AMI patients living alone with high GRACE risk scores may experience an additively increased risk of mortality after PCI.

Association of Malnutrition and High Bleeding Risk with Long-Term Prognosis in Patients with Acute Coronary Syndrome following Percutaneous Coronary Intervention

BACKGROUND

Malnutrition in cardiovascular disease is associated with poor prognosis, especially in patients with heart failure and acute coronary syndrome (ACS). High bleeding risk is also linked to coronary artery disease prognosis, including ACS. However, whether the extent of malnutrition and high bleeding risk have a cumulative impact on the long-term prognosis of patients with ACS who undergo percutaneous coronary intervention remains unclear.

METHODS

We analyzed 275 patients with ACS treated with percutaneous coronary intervention. The Controlling Nutritional Status score and Japanese version of the Academic Research Consortium for High Bleeding Risk criteria (J-HBR) were retrospectively evaluated. The primary and secondary outcomes were adjusted using the inverse probability treatment weighting method.

RESULTS

The prevalence of moderate or severe malnutrition in this cohort was 16%. Kaplan-Meier analysis showed a significantly higher incidence of major adverse cardiovascular and cerebrovascular events in patients who were moderately or severely malnourished than in those who were not. Notably, the incidence of these major events was similar between severely malnourished patients with J-HBR and those without.

CONCLUSION

Moderate or severe malnutrition has a significant impact on the long-term prognosis of patients with ACS who undergo percutaneous coronary intervention.

Appetite Predicts Long-Term Clinical Outcomes in Patients with Acute Myocardial Infarction

BACKGROUND

Recently, the nutritional status of patients has drawn attention in an aging society. Early studies have reported that nutritional status is related to long-term outcomes in patients with acute myocardial infarction (AMI). However, it is not necessarily simple to evaluate the nutritional status of patients with AMI. We hypothesized that appetite before discharge can be a predictor for long-term adverse cardiovascular events in patients with AMI. This retrospective study aimed to investigate whether appetite is related to long-term adverse outcomes in patients with AMI.

METHODS

This study included 1006 patients with AMI, and divided them into the good appetite group (n = 860) and the poor appetite group (n = 146) according to the percentage of the dietary intake on the day before discharge. Major adverse cardiac events (MACE), which were defined as a composite of all-cause death, non-fatal MI, and re-admission for heart failure, were set as the primary outcome.

RESULTS

The median follow-up duration was 996 days, and a total of 243 MACE was observed during the study period. MACE was more frequently observed in the poor appetite group than in the good appetite group (42.5% versus 21.0%, p < 0.001). In the multivariate COX hazard model, poor appetite was significantly associated with MACE (Hazard ratio 1.698, 95% confidence interval 1.243-2.319, p < 0.001) after controlling for multiple confounding factors.

CONCLUSION

Appetite at the time of discharge was significantly associated with long-term clinical outcomes in patients with AMI. Patients with poor appetite should be carefully followed up after discharge from AMI.

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

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

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.

Prognosis and risk factors of chronic kidney disease progression in patients with diabetic kidney disease and non-diabetic kidney disease: a prospective cohort CKD-ROUTE study

Diabetic kidney disease (DKD) is emerging rapidly as the leading cause of chronic kidney disease (CKD) worldwide. In this 3-year prospective, multicenter cohort study, a total of 1138 pre-dialysis CKD patients were recruited. Patients were categorized into two groups according to the etiologies of DKD and non-diabetic kidney disease (NDKD). Propensity score matching was performed to adjust for confounding factors, resulting in 197 patients being assigned to DKD and NDKD groups, respectively. The primary endpoints were 50% estimated glomerular filtration rate (eGFR) decline and initiation of kidney replacement therapy (KRT). The secondary endpoints were all-cause death and the development of cardiovascular disease (CVD) events. We found that DKD patients have a higher risk to develop 50% eGFR decline endpoint (HR:2.30, 95%CI [1.48-3.58], p < 0.001) and KRT endpoint (HR:1.64, 95%CI [1.13-2.37], p < 0.05) than NDKD patients. The 3-year cumulative incidence of 50% eGFR decline and KRT endpoint was significantly higher in DKD patients (26.90% vs.13.71% and 35.03% vs. 22.34%, respectively). The Cox regression analyses showed that the increased systolic blood pressure (SBP), DKD, decreased serum albumin (Alb), and higher CKD stages were risk factors for the 50% eGFR decline endpoint; the increased SBP, DKD, decreased serum Alb, serum creatinine (Scr), higher CKD stages, presence of proteinuria and CVD were risk factors for KRT endpoint; the increased age, decreased hemoglobin (Hb), decreased serum Alb were risk factors for all-cause death endpoint; the increased age, decreased serum Alb were risk factors for CVD events endpoint. Appropriate preventive or therapeutic interventions should be taken to control these predictive factors to delay the development of CKD complications, thereby improving the prognosis and reducing the disease burden of the high-risk populations.

Meta-Analysis of the Effects of Recombinant Human Brain Natriuretic Peptides on Left Ventricular Remodeling in Patients with Acute Myocardial Infarction

Objective

Systematic evaluation of the efficacy of natriuretic recombination in human brain on disease myocardial infarction, left ventricular heart failure, and the efficacy and safety of long-term left ventricular remodeling.

Methods

Computerized search of CNKI, Wanfang database, Wipro Chinese Technology Publications (VIP) numerical database, Chinese Biomedical Literature Database (CBM), Medline Cochrane Library, clinical Trail.Gov clinical collection, and other documents. Randomized controlled trials (RCT) of recombinant human brain natriuretic peptide in the treatment of acute myocardial infarction from inception to December 2021 were searched. Based on the Jadad scale, inclusion-exclusion data for diseases were collected and elaborated by meta by RevMan 5.3 simulation software. In a total of 23 randomized controlled trials, 2 024 cases were used as the basic data, the control group was routinely treated for 1 012 cases, and 1 012 cases in the experimental group were also treated with natriuretic peptide in the recombinant human brain on the previous basis.

Results

In terms of overall efficacy, the experimental group was better than the control group, statistically significant (OR = 4.30, 95% CI (3.26, 5.67), P < 0.000 01), left ventricular ejection fraction in the experimental group than the control group (OR = 1.58, 95% CI (1.27, 1.90), P < 0.000 01). In terms of a myocardial strain in the left ventricle, the experimental group was superior to the control group. The difference was significant (OR = −0.91, 95% CI (-1.50, -0.33), P = 0.002). In terms of the cardiac output volume, the experimental group was superior to the control group (OR = 1.24, 95% CI (0.55, 1.94), P = 0.0005). Regarding brain natriuretic peptide precursors, the experimental group was superior to the control group (OR = −4.37, 95% CI (-6.21, -3.25), P < 0.00001). In terms of the heart rate, the experimental group was superior to the control group. Measurement of differential significance is as follows: OR = −13.70, 95% CI (-14.95, -12.46), P < 0.00001. In terms of contraction, the experimental group was superior to the comparison group (OR = −12.38, 95% CI (-17.98, -6.79), P < 0.00001). The experimental group outperformed the control group (OR = −7.42, 95% CI (-8.53, -6.30), P < 0.00001). In terms of bad influence, the measurement is as follows: OR = 0.95, 95% CI (0.29, 3.16), P = 0.94.

Conclusion

In patients with acute myocardial infarction and left ventricular remodeling, if treated with a heavy treatment of the group of cerebral natriuretic peptide mode, it can increase clinical treatment, improve the cardiac effect, inhibit ventricular remodeling, improve blood pressure and heart rhythm, and have greater clinical treatment and safety.