Malnutrition Surprisingly Common in ACS, Transcends BMI

Patrice Wendling

August 11, 2020

Malnutrition is common in hospitalized acute coronary syndrome (ACS) patients, regardless of weight, and increases the chance of major cardiac events and death years later, new research suggests.

Investigators followed 5062 consecutive ACS patients (median age, 66.2 years) for an average of 3.6 years and assessed three nutritional biomarker indexes: the Controlling Nutritional Status (CONUT) score; the Nutritional Risk Index (NRI); and the Prognostic Nutritional Index (PNI).

Results show that up to 59.5% of patients had some degree of malnutrition, and between 8.9% and 39.5% were moderately or severely malnourished.

Although malnutrition was more common in underweight patients, a substantial proportion of patients with a body mass index (BMI) above 25 kg/m2 were also malnourished (48.2% according to CONUT and 57.8% according to NRI).

"In the underweight [patient], you can maybe think it's possible but, of course, in normal weight and overweight, it is very difficult to understand. This was the most surprising thing to us," Sergio Raposeiras Roubín, MD, PhD, University Hospital Álvaro Cunqueiro, Vigo, Spain, told theheart.org | Medscape Cardiology.

Malnutrition is associated with poor prognosis in heart failure, valvular disease, and atrial fibrillation, but it's role in ACS has been limited to a few small studies, he noted. Recently, however, a study showed that malnutrition is an independent predictor of all-cause mortality in elderly ACS patients.

Malnutrition in the present study was associated with poor prognosis, regardless of Global Registry of Acute Coronary Events (GRACE) risk score, BMI, left ventricular function, coronary revascularization, or other risk factors, the authors report in the August 18 issue of the Journal of the American College of Cardiology.

Compared with good nutritional status, the adjusted risk for all-cause death was increased with moderate and severe malnutrition on each index respectively:

  • CONUT, 2.02 (95% CI, 1.65 - 2.49) and 3.65 (95% CI, 2.41 - 5.51)

  • NRI, 1.40 (95% CI, 1.17 - 1.68) and 2.87 (95% CI, 2.17 - 3.79)

  • PNI, 1.71 (95% CI, 1.37 - 2.15) and 1.95 (95% CI, 1.55 - 2.45).

The risk for major adverse cardiovascular events with moderate and severe malnutrition followed a similar pattern on each index:

  • CONUT, 1.69 (95% CI, 1.40 - 2.04) and 2.41 (95% CI, 1.53 - 3.80)

  • NRI, 1.11 (95% CI, 0.96 - 1.30) and 2.22 (95% CI, 1.69 - 2.91)

  • PNI, 1.68 (95% CI, 1.34 - 2.12) and 1.77 (95% CI, 1.39 - 2.25).

One possible explanation is that nutritional status may be a "proxy indicator of inflammation" and that high degrees of malnutrition may translate into increased atherosclerotic burden and higher risk for plaque rupture. "But ours is an observational study, so we cannot say," said Raposeiras Roubín.

"The take-home message is that when you see a patient with acute coronary syndrome, you have to think about the nutritional status. And if the patient has malnutrition, you have to improve the nutritional status in order to improve prognosis," he said.

No More Lip Service

Although the study failed to assess dietary intake or quality, "what I think is great is that it brought to the fore the connection between aspects of nutrition and cardiovascular outcomes," commented Stephen Devries, MD, executive director of the Gaples Institute for Integrative Cardiology, Deerfield, Illinois, who was not involved with the study.

"We're so much on the hunt for a new drug or a better procedure that will improve prognosis in patients with acute coronary syndromes and here we've got a tool that potentially could be used with such power and yet nutritional interventions are certainly not sufficiently utilized in practice," said Devries, who is also a cardiologist at Northwestern University, Chicago.

Although time constraints are often cited for underutilization, 90% of cardiologists surveyed in 2017 by Devries and colleagues reported receiving either no or minimal education in nutrition.

"There's just too little attention paid to this area, which is so sad, especially now; even in the COVID era, it is coming back to haunt us," he said. "Some of the most important comorbidities that put people at risk of developing COVID and of making the condition more serious once it develops are obesity, heart disease, and hypertension, and all of these are very strongly diet-related and variable."

Devries was struck by the fact that the prevalence of malnutrition in normal-weight patients was on par with those who were overweight or obese (49.4% vs 54.9% and 46.2%, according to CONUT).

"It's not only an issue of the number of calories consumed but the quality of calories consumed. I think most clinicians, if looking at a person of normal weight, may not be as tuned to the fact that this person can be poorly nourished" and should undergo dietary assessment, he said.

In a related editorial, Andrew M. Freeman, MD, National Jewish Health, Denver, and Monica Aggarwal, MD, University of Florida, Gainesville, also note that cardiologists and cardiology care teams are less prepared to discuss nutrition and lifestyle because of a lack of education and knowledge about nutrition.

"Paying lip service with the usual phrases, such as 'Be sure to exercise and eat right,' simply doesn't cut it. It behooves us as a profession to ensure adequate training and competency in the delivery of care in the lifestyle space," they write.

The study findings should alert clinicians to recognize and assess malnutrition and then ensure patients receive adequate education and coaching on fundamental nutrition concepts to help reduce their mortality risk, Freeman and Aggarwal suggest.

"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," the editorialists conclude.

The authors and Aggarwal reported having no relevant relationships to disclose. Devries reported that the nonprofit Gaples Institute offers nutrition courses for physicians. Freeman has provided nonpromotional speaking for Boehringer Ingelheim, consulted for Actelion and Boehringer Ingelheim, and served on the advisory boards for Regeneron and The Medicines Company.

J Am Coll Cardiol. 2020;76:828-840, 841-843. Abstract, Editorial

Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org | Medscape Cardiology, join us on Twitter and Facebook.

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