No Mortality Benefit for Mediterranean Diet After Acute Heart Failure

Fran Lowry

December 15, 2017

BARCELONA, SPAIN — In elderly patients who have had an episode of acute heart failure (AHF), adherence to the Mediterranean diet had no influence on their risk of death in the long term, according to results of the Mediterranean Diet in Acute Heart Failure (MEDIT-AHF) study[1].

While the study failed to meet its primary end point, patients who were adherent to the diet had reduced rates of rehospitalization for heart failure compared with those who were not adherent (hazard ratio [HR] 0.74, P=0.003).

The finding remained significant after adjustment for baseline variables (HR 0.76, P =0.008) and further adjustment for imputation of missing values (HR 0.76, P =0.007).

"After a decompensation of heart failure, those patients who are adherent to the Mediterranean diet will experience fewer hospitalizations, irrespective of other risk factors or how evolved their myocardiopathy," lead author Dr Òscar Miró (University of Barcelona, Spain) told | Medscape Cardiology.

"My message to physicians would be to please put your heart-failure patients on a Mediterranean diet after a decompensation and the patient will avoid a number of hospitalizations. Be more aggressive in giving diet instructions to patients with acute heart failure after discharge and during follow-up," Miró said.

The Mediterranean diet, which emphasizes the consumption of fruits and vegetables, whole grains, legumes, nuts, and healthy fats such as olive oil, has previously been shown to be beneficial in the primary prevention of cardiovascular disease and in reducing cardiovascular risk factors, such as type 2 diabetes.

The diet also enhances the function of HDL cholesterol, as recently reported in the PREDIMED study.

To determine whether the benefits of the Mediterranean diet could extend to patients with a prior AHF episode, Miró and his fellow investigators prospectively enrolled 991 consecutive patients diagnosed with AHF in seven Spanish emergency departments.

Their mean age was 80 years (range 70 to 90 years), and 57.8% were women. They had a high number of comorbidities (prior HF episode 54.4%), were on multiple medications, and most had functional limitations (Barthel Index <100 points in 58.6%).

Patients were divided into two groups depending on whether they were adherent (scoring ≥9 points) or not adherent (scoring ≤8 points) to the Mediterranean diet, based on responses to the validated food questionnaire used in the PREDIMED study.

Patients who were adherent (n=523) were significantly younger, had more frequent hypertension, less frequent peripheral artery disease, and showed higher pulse oximetry values at admission compared with patients who were not adherent (n=468).

After a mean follow-up of 2.1 years, all-cause mortality was not significantly different between adherent vs nonadherent patients (HR 0.86, P =0.08).

Similarly, at the 1-year follow-up, there were no significant differences between the two groups in emergency-department revisits for AHF (HR 1.11, P=0.49), all-cause mortality (HR 1.04, P=0.71), or the combination of these variables (HR 0.89, P=0.13). The results remained in adjusted analyses.

Too Late for a Mortality Benefit

It's good to keep patients with AHF out of the hospital, but ultimately, the expectation that diet can alter the course of heart failure, a disease with such a dire prognosis, is perhaps misguided, Dr Valentin Fuster (Icahn School of Medicine at Mount Sinai, New York, NY) senior author of a related editorial[2], told | Medscape Cardiology.

"Diet can certainly be very meaningful for primary prevention or for cardiac disease that is stable, but the people in this study had acute heart failure, they were very old, they had many comorbidities, so how can you expect you are going to have an impact that is positive with the Mediterranean diet in a population with this prognosis?" Fuster said in an email.

He continued, "The Mediterranean diet has been found to be of significant help in the primary prevention of cardiovascular disease, but once the disease is very advanced, diet may not be sufficient to counteract this bad prognosis, although, as this study shows, it may still play a role in reducing rehospitalization.

"When we talk about diets, we have to be sure that we are talking about their utility in a group of individuals in whom the prognosis is not overwhelmingly bad."

An Outcome Not to Be Discounted

The editorial, led by Dr Sumeet Mitter (Icahn School of Medicine at Mount Sinai, New York, NY), notes there is a biological plausibility for the Mediterranean diet tempering the clinical syndrome of heart failure, "namely, that the consumption of foods high in polyphenol and monosaturated fat content could increase plasma nitric oxide and also act as antioxidants and anti-inflammatory agents that could have led to a decrease in admissions for heart failure."

Although mortality benefit remains the gold-standard outcome in cardiovascular studies, the editorialists write, "The finding of fewer heart-failure admissions is not insignificant. In an elderly population afflicted with heart failure, reducing heart-failure admissions so that further time is spent at home or with family may be associated with improved quality of life—a goal that should not be underestimated for this population."

The study was supported by grants from the Instituto de Salud Carlos III, the Spanish Ministry of Health and FEDER, Fundació La Maratóo de TV3, and the Catalonia Govern for Consolidated Groups of Investigation. The ICA-SEMES Research Group has received unrestricted support from Orion Pharma and Novartis. The authors report they have no relevant financial relationships, as do the editorialists.

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