Nutritional intervention in acute heart failure patients with undernutrition and normalbuminemia: A subgroup analysis of PICNIC study.

BACKGROUND & AIMS: Hypoalbuminemia is common in acute heart failure (HF) patients and has been associated with increased hospital mortality and long-term mortality. Undernutrition is a factor causing hypoalbuminemia. The PICNIC study results show that a nutritional intervention in undernourished acute HF patients reduces the risks of all-cause death and of readmission for HF. We aimed to investigate whether the efficacy of a nutritional intervention is consistent among the subgroups of patients with and without hypoalbuminemia. METHODS: In PICNIC study, a total of 120 malnourished hospitalized patients due to acute HF were randomized to conventional HF treatment or conventional HF treatment combined with an individualized nutritional intervention. The primary endpoint was a composite of all-cause death or readmission for worsening of HF, with a maximum follow-up of 12 months. In this post-hoc sub-analysis we assessed the interaction of the effects of a nutritional intervention among patients with and without hypoalbuminemia. Analysis was by intention to treat. RESULTS: 59 (49,2%) patients demonstrated hypoalbuminemia and 61 (50,8%) had normalbuminemia. At 12 months, the number of events for the primary endpoint in the intervention group compared with the control group was consistent among patients with hypoalbuminemia (28.6% intervention vs 61.3% control, HR 0,35, 95% CI 0,15-0,81) and those without (25.8% intervention vs 60% control, HR 0,35, 95% CI 0,15-0,79; interaction p = 0,86). CONCLUSION: There was no evidence that the relative efficacy of a nutritional intervention in undernourished acute HF patients was different between patients with normalbuminemia and those with hypoalbuminemia.

El colesterol total predice la mortalidad intrahospitalaria en pacientes de 70 años o mayores hospitalizados por insuficiencia cardiaca aguda / Total cholesterol levels predict in-hospital mortality in patients with acute heart failure aged 70 years or older

Introducción y objetivo. En insuficiencia cardiaca (IC) crónica y aguda, bajas concentraciones de colesterol total (CT) se han asociado con un incremento de la mortalidad. Este estudio pretende evaluar el impacto del CT sobre la mortalidad intrahospitalaria en pacientes de 70 años o mayores hospitalizados por IC aguda. Métodos. Los pacientes fueron divididos en 3 grupos según el valor de los cuartiles (Q) de CT (mg/dl): Q1 (CT ≤ 125), Q2-Q3 (CT: 126-174), Q4 (CT ≥ 175). Para valorar la asociación independiente de cada variable con la hipocolesterolemia y con la mortalidad intrahospitalaria se realizaron sendos análisis de regresión logística múltiple. Resultados. Se analizó a 301 pacientes. La edad media fue 79,3±5,5 años, el 51,2% presentaron una función sistólica deprimida y la etiología más frecuente fue la isquémica (40,9%). Se asociaron de forma independiente con la hipocolesterolemia una mayor proteína C reactiva, cifras menores de albúmina sérica y de hemoglobina y una menor fracción de eyección del ventrículo izquierdo. Durante el ingreso fallecieron 26 pacientes (8,6%). La mortalidad intrahospitalaria decreció progresivamente en cada cuartil del CT: Q1 14,3%, Q2-Q3 8,7% y Q4 2,7% (p=0,04), y se asoció de forma independiente con cifras mayores de creatinina sérica y menores de albúmina sérica y de CT. Conclusión. Cifras más bajas de CT predicen de forma independiente un incremento de la mortalidad intrahospitalaria en pacientes ancianos hospitalizados por IC aguda. Una mayor actividad inflamatoria, asociada a la hipocolesterolemia en este contexto clínico, podría explicar la asociación inversa entre colesterol y mortalidad (AU)

Introduction and purpose. Lower total cholesterol (TC) levels have been associated with increased mortality In both acute and chronic heart failure (HF) patients. The present study sought to evaluate the impact of TC levels on in-hospital mortality in patients with acute HF aged 70 years or older. Methods. Patients were divided into 3 groups based on TC (mg/dL) quartiles (Q) as follow: Q1 (CT≤125), Q2-Q3 (CT 126-174), Q4 (CT≥175). Multivariate logistic regression analysis was performed to assess the association of each variable with hypocholesterolaemia and in-hospital mortality. Results. The analysis included 301 patients with acute HF. The mean age was 79.3±5.5 years, and 51.2% of patients had HF with depressed systolic function, and the most frequent aetiology was ischaemic heart disease (40.9%). Higher C-reactive protein levels, lower levels of serum albumin and haemoglobin, and lower left ventricle ejection fraction were independently associated with hypocholesterolaemia. There 26 deaths (8.6% of the series) during hospitalization. In-hospital mortality decreased in a stepwise fashion with increasing quartile of TC: Q1 14.3%, Q2-Q3 8.7% and Q4 2.7% (P=.04), and was independently associated with higher serum creatinine levels and lower serum albumin and TC levels. Conclusions. Lower TC levels independently predict increased in-hospital mortality risk in older patients with acute HF. A higher inflammatory activity, associated with a lower total cholesterol in this clinical setting may explain the inverse relationship between cholesterol and mortality (AU)

[Total cholesterol levels predict in-hospital mortality in patients with acute heart failure aged 70 years or older]. / El colesterol total predice la mortalidad intrahospitalaria en pacientes de 70 años o mayores hospitalizados por insuficiencia cardiaca aguda.

INTRODUCTION AND PURPOSE: Lower total cholesterol (TC) levels have been associated with increased mortality In both acute and chronic heart failure (HF) patients. The present study sought to evaluate the impact of TC levels on in-hospital mortality in patients with acute HF aged 70 years or older. METHODS: Patients were divided into 3 groups based on TC (mg/dL) quartiles (Q) as follow: Q1 (CT≤125), Q2-Q3 (CT 126-174), Q4 (CT≥175). Multivariate logistic regression analysis was performed to assess the association of each variable with hypocholesterolaemia and in-hospital mortality. RESULTS: The analysis included 301 patients with acute HF. The mean age was 79.3±5.5 years, and 51.2% of patients had HF with depressed systolic function, and the most frequent aetiology was ischaemic heart disease (40.9%). Higher C-reactive protein levels, lower levels of serum albumin and haemoglobin, and lower left ventricle ejection fraction were independently associated with hypocholesterolaemia. There 26 deaths (8.6% of the series) during hospitalization. In-hospital mortality decreased in a stepwise fashion with increasing quartile of TC: Q1 14.3%, Q2-Q3 8.7% and Q4 2.7% (P=.04), and was independently associated with higher serum creatinine levels and lower serum albumin and TC levels. CONCLUSIONS: Lower TC levels independently predict increased in-hospital mortality risk in older patients with acute HF. A higher inflammatory activity, associated with a lower total cholesterol in this clinical setting may explain the inverse relationship between cholesterol and mortality.

Nutritional Intervention in Malnourished Hospitalized Patients with Heart Failure.

BACKGROUND AND AIMS: Hospitalized patients with heart failure who are malnourished present a worse prognosis than those with an adequate nutritional status. We undertook this study to assess whether a nutritional intervention in malnourished hospitalized patients with heart failure benefits morbidity and mortality. METHODS: A multicenter, randomized, controlled clinical trial was conducted. A total of 120 malnourished hospitalized patients due to acute heart failure were randomised to conventional heart failure treatment or conventional heart failure treatment combined with an individualized nutritional intervention. The primary endpoint of this study was a composite of all-cause death or readmission for worsening of HF, with a maximum follow-up of 12 months. Analysis was by intention to treat. RESULTS: Recruitment was stopped early according to the study protocol after completing the follow-up of the first 120 patients enrolled (59 in the intervention group and 61 in the control group). Both groups were homogeneous in baseline characteristics. At 12 months, the primary outcome occurred in 27.1% of patients in the intervention group and in 60.7% of patients in the control group (hazard ratio 0.45; 95% confidence interval [CI], 0.19-0.62, p = 0.0004). In total, 20.3% of patients died in the intervention group and 47.5% in the control group (hazard ratio 0.37, 95% CI, 0.19-0.72, p = 0.003). Readmission due to heart failure was also lower in the intervention group (10.2 vs. 36.1%, p = 0.001). CONCLUSION: Nutritional intervention in malnourished hospitalized patients with heart failure reduces the risk of death from any cause and the risk of readmission for worsening of heart failure (ClinicalTrial.govNCT01472237).

Rationale and design of PICNIC study: nutritional intervention program in hospitalized patients with heart failure who are malnourished.

INTRODUCTION AND OBJECTIVES: Hospitalized patients with heart failure who are malnourished present a worse prognosis than those with an adequate nutritional status. It is unknown whether a nutritional intervention can modify the prognosis of these patients. The aim of this study is to assess the efficacy of a nutritional intervention on morbidity and mortality in hospitalized patients with heart failure who are malnourished. METHODS: PICNIC is a multicentre, randomized, controlled trial in which hospitalized patients with heart failure and malnutrition, as defined by the Mini Nutritional Assessment, are randomly assigned to conventional management of heart failure or conventional management of heart failure and an individualized nutritional intervention consisting of 3 points: optimization of diet, specific recommendations, and prescription, if deemed necessary, of nutritional supplements. A sample size of 182 patients for a maximum follow-up of 12 months has been estimated. The primary endpoint is time to death from any cause or rehospitalization because of heart failure. Analysis is by intention to treat. CONCLUSIONS: PICNIC study will determine the prognostic impact of a nutritional intervention in hospitalized patients with heart failure who are malnourished.

Justificación y diseño del estudio PICNIC: Programa de Intervención Nutricional en pacientes hospitalizados por Insuficiencia Cardiaca desnutridos / Rationale and Design of PICNIC Study: Nutritional Intervention Program in Hospitalized Patients With Heart Failure Who Are Malnourished

Introducción y objetivos: Los pacientes hospitalizados por insuficiencia cardiaca en estado de desnutrición tienen un pronóstico más desfavorable que los que están en adecuado estado nutricional. Se desconoce si una intervención nutricional puede modificar el pronóstico de estos pacientes. El objetivo de este estudio es evaluar si una intervención nutricional sobre pacientes hospitalizados con insuficiencia cardiaca desnutridos produce beneficio en su morbimortalidad. Métodos: PICNIC es un ensayo clínico multicéntrico, aleatorizado y controlado, en el que se asigna aleatoriamente a los pacientes hospitalizados por insuficiencia cardiaca aguda que además estén en estado de desnutrición, definido según la puntuación de la encuesta Mini Nutritional Assessment, a tratamiento convencional de la insuficiencia cardiaca o a tratamiento convencional de la insuficiencia cardiaca más una intervención nutricional individualizada que consta de tres puntos: optimización de la dieta, recomendaciones específicas y prescripción, si se estima necesario, de suplementos nutricionales. Se ha estimado un tamaño muestral de 182 pacientes para un periodo máximo de seguimiento de 12 meses. La variable principal del estudio será el tiempo hasta la muerte por cualquier causa o reingreso por insuficiencia cardiaca. El análisis se realiza por intención de tratar. Conclusiones: El estudio PICNIC determinará el impacto pronóstico de una intervención nutricional en pacientes hospitalizados con insuficiencia cardiaca desnutridos (AU)

Introduction and objectives: Hospitalized patients with heart failure who are malnourished present a worse prognosis than those with an adequate nutritional status. It is unknown whether a nutritional intervention can modify the prognosis of these patients. The aim of this study is to assess the efficacy of a nutritional intervention on morbidity and mortality in hospitalized patients with heart failure who are malnourished. Methods: PICNIC is a multicentre, randomized, controlled trial in which hospitalized patients with heart failure and malnutrition, as defined by the Mini Nutritional Assessment, are randomly assigned to conventional management of heart failure or conventional management of heart failure and an individualized nutritional intervention consisting of 3 points: optimization of diet, specific recommendations, and prescription, if deemed necessary, of nutritional supplements. A sample size of 182 patients for a maximum follow-up of 12 months has been estimated. The primary endpoint is time to death from any cause or rehospitalization because of heart failure. Analysis is by intention to treat. Conclusions: PICNIC study will determine the prognostic impact of a nutritional intervention in hospitalized patients with heart failure who are malnourished (AU)

Desnutrición e insuficiencia cardiaca. Apostillas / Malnutrition and Heart Failure: comments

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¿Cuándo deberíamos iniciar el tratamiento enzimático sustitutivo de la enfermedad de Pompe infantil con miocardiopatía severa? / When should we start enzyme replacement therapy for infantile pompe disease with severe cardiomyopathy?

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Influencia de la desnutrición en la mortalidad a largo plazo de pacientes hospitalizados por insuficiencia cardiaca / Impact of malnutrition on long-term mortality in hospitalized patients with heart failure

Introducción y objetivos. Actualmente se desconoce la prevalencia de desnutrición entre los pacientes con insuficiencia cardiaca y el papel que este estado pudiera tener en su pronóstico. El objetivo de este estudio es analizar la prevalencia y riesgo de desnutrición y su posible influencia en la mortalidad a largo plazo de los pacientes con insuficiencia cardiaca. Métodos. Se analizó prospectivamente a 208 pacientes dados de alta consecutivamente desde nuestro centro entre enero de 2007 y marzo de 2008 tras un ingreso por insuficiencia cardiaca. Antes del alta, se realizó una completa valoración nutricional y se realizó el diagnóstico de desnutrición y riesgo de desnutrición mediante la encuesta Mini Nutritional Assessment. Su posible asociación independiente con la mortalidad se valoró mediante un análisis multivariable de Cox. Resultados. La media de edad fue 73±10 años, el 46% eran mujeres y la etiología más frecuente de la insuficiencia cardiaca fue la isquémica (41%). El 13% de los pacientes fueron clasificados como desnutridos; el 59,5%, en riesgo de desnutrición y el 27,5%, bien nutridos. A los 25 meses (mediana de seguimiento), la mortalidad en los tres grupos fue del 76, el 35,9 y el 18,9% respectivamente (log-rank test, p<0,001). En el análisis multivariable de Cox, el estado de desnutrición resultó ser un predictor independiente de mortalidad (hazard ratio=3,75; intervalo de confianza del 95%, 1,75-8,02; p=0,001). Conclusiones. La desnutrición y el de riesgo de desnutrición alcanzan una prevalencia elevada en pacientes hospitalizados por insuficiencia cardiaca. Además, hemos encontrado que el estado de desnutrición definido mediante el Mini Nutritional Assessment es un predictor independiente de mortalidad en estos pacientes (AU)

Introduction and objectives. The prevalence of malnutrition among patients with heart failure and the role it might play in prognosis is not currently known. The aim of this study was to analyse the prevalence and risk of malnutrition as well as its possible influence on long-term mortality in patients with heart failure. Methods. A prospective analysis was conducted on 208 patients discharged consecutively from our centre between January 2007 and March 2008 after being hospitalised with heart failure. Before discharge, a complete nutritional assessment was performed and diagnosis of malnutrition and risk of malnutrition was done with the Mini Nutritional Assessment. Its possible independent association with mortality was assessed by a Cox multivariate analysis. Results. The mean age of the patients was 73±10 years, with 46% women; the most common aetiology of heart failure was ischaemia (41%). In addition, 13% were classified as malnourished, 59.5% at risk of malnutrition and 27.5% were well-nourished. At a median follow-up of 25 months, mortality in the three groups was 76%, 35.9% and 18.9%, respectively (log-rank, P<.001). In the Cox multivariate analysis, the malnutrition state was an independent predictor of mortality (hazard ratio 3.75, 95% confidence interval, 1.75-8.02, P=.001). Conclusions. Malnutrition and the risk of malnutrition are highly prevalent in patients hospitalised for heart failure. Furthermore, we found that the state of malnutrition as defined by the Mini Nutritional Assessment survey is an independent predictor of mortality in these patients (AU)

[Impact of malnutrition on long-term mortality in hospitalized patients with heart failure]. / Influencia de la desnutrición en la mortalidad a largo plazo de pacientes hospitalizados por insuficiencia cardiaca.

INTRODUCTION AND OBJECTIVES: The prevalence of malnutrition among patients with heart failure and the role it might play in prognosis is not currently known. The aim of this study was to analyse the prevalence and risk of malnutrition as well as its possible influence on long-term mortality in patients with heart failure. METHODS: A prospective analysis was conducted on 208 patients discharged consecutively from our centre between January 2007 and March 2008 after being hospitalised with heart failure. Before discharge, a complete nutritional assessment was performed and diagnosis of malnutrition and risk of malnutrition was done with the Mini Nutritional Assessment. Its possible independent association with mortality was assessed by a Cox multivariate analysis. RESULTS: The mean age of the patients was 73 ± 10 years, with 46% women; the most common aetiology of heart failure was ischaemia (41%). In addition, 13% were classified as malnourished, 59.5% at risk of malnutrition and 27.5% were well-nourished. At a median follow-up of 25 months, mortality in the three groups was 76%, 35.9% and 18.9%, respectively (log-rank, P<.001). In the Cox multivariate analysis, the malnutrition state was an independent predictor of mortality (hazard ratio 3.75, 95% confidence interval, 1.75-8.02, P=.001). CONCLUSIONS: Malnutrition and the risk of malnutrition are highly prevalent in patients hospitalised for heart failure. Furthermore, we found that the state of malnutrition as defined by the Mini Nutritional Assessment survey is an independent predictor of mortality in these patients.

Insuficiencia cardiaca derecha grave debida a la conjunción de una anomalía de Ebstein y una constricción pericárdica / Severe right heart failure due to the combination of Ebstein's anomaly and pericardial constriction

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Endocarditis con verruga estenosante sobre homoinjerto pulmonar / No disponible

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