August 10, 2020
3 min read
The authors of the study and Aggarwal report no relevant financial disclosures. Freeman reports he spoke for Boehringer Ingelheim, consulted for Actelion and Boehringer Ingelheim and served on the advisory board for Regeneron and The Medicines Company.
Malnutrition, a common risk factor in patients with ACS, was strongly linked to increased CV events and mortality, researchers found.
“Screening for malnutrition scores may be an easy way to determine which ACS patients are at high risk of adverse outcomes and has the added benefit of being a very simple calculation, as many of the variables are taken through routine testing in the emergency setting,” Sergio Raposeiras–Roubín, MD, PhD, clinical cardiologist at the University Hospital Álvaro Cunqueiro in Vigo, Spain, and researcher at the Centro Nacional de Investigaciones Cardiovasculares in Madrid, said in a press release. “Malnutrition is also a potentially modifiable risk factor for these patients, as clinicians could start nutritional interventions during hospitalization and continue after discharge by coordinating with rehabilitation centers and programs.”
Assessing malnutrition in ACS
In this retrospective observational study published in the Journal of the American College of Cardiology, researchers analyzed data from 5,062 patients (median age, 66 years; 26% women) with ACS who were admitted to the hospital between 2010 and September 2017. ACS was defined as non-STEMI (n = 2,482), STEMI (n = 2,043) and unstable angina (n = 537). Malnutrition was screened in all patients using three indexes: the Controlling Nutritional Status score, the Nutritional Risk Index score and the Prognostic Nutritional Index score.
The primary endpoint for this study was all-cause mortality. The secondary endpoint included a composite of major CV events such as reinfarction, CV death or ischemic stroke.
Moderate to severe malnutrition was identified in 11.2% using the Controlling Nutritional Status score, 39.5% with the Nutritional Risk Index score and 8.9% using the Prognostic Nutritional Index score. Mild malnutrition was seen in 71.8% of patients using at least one of the scores.
Despite the fact that worse scores were most strongly linked to lower BMI, 8.4% to 36.7% of patients who had a BMI of at least 25 kg/m2 were moderately or severely malnourished. This depended on the nutritional index that was used.
Mortality occurred in 16.4% of patients and major adverse CV events were observed in 20.7% of patients during a median follow-up of 3.6 years.
Patients with moderate and severe degrees of malnutrition had a significantly increased risk for all-cause death compared with patients with good nutritional status:
- Controlling Nutritional Status score (moderate: adjusted HR = 2.02; 95% CI, 1.65-2.49; severe: adjusted HR = 3.65; 95% CI, 2.41-5.51);
- Nutritional Risk Index score (moderate: adjusted HR = 1.4; 95% CI, 1.17-1.68; severe: adjusted HR = 2.87; 95% CI, 2.17-3.79); and
- Prognostic Nutritional Index score (moderate: adjusted HR = 1.71; 95% CI, 1.37-2.15; severe: adjusted HR = 1.95; 95% CI, 1.55-2.45).
Results were similar for the Controlling Nutritional Status and Prognostic Nutritional Index scores for major adverse CV events.
All three risk scores improved the predictive ability of the Global Registry of Acute Coronary Events risk score for all-cause mortality and major adverse CV events.
“All these findings strongly support the need for physicians to integrate in their daily practice the identification of malnutrition,” Raposeiras-Roubín and colleagues wrote. “This may improve the risk stratification and may guide subsequent interventions of secondary prevention. Assessing silent conditions, such as malnutrition in the ACS setting, has always been considered difficult because of the lack of time in the emergency context and the absence of a universal definition of these potential risk factors. However, with those easily calculable indexes, malnutrition might be systematically screened.”
‘Urgent call to action’
Andrew M. Freeman
In a related editorial, Andrew M. Freeman, MD, FACC, FACP, associate professor, director of cardiovascular prevention and wellness and director of clinical cardiology and operations at National Jewish Health in Denver and Cardiology Today Next Gen Innovator, and Monica Aggarwal, MD, FACC, associate professor of medicine in the division of cardiovascular medicine at University of Florida College of Medicine in Gainesville and Cardiology Today Next Gen Innovator, wrote: “These findings should alert clinicians to recognize and assess malnutrition in patients who are overweight/obese. Then, helping these identified patients receive adequate education and coaching on fundamental nutrition concepts will help decrease their mortality risk. Furthermore, this paper is yet another urgent call to action: It is time for the CVD profession to arm itself with the most cost-effective and powerful tool in the battle against CVD: nutrition and lifestyle medicine.”