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Malnutrition as Assessed by Nutritional Risk Index Is Associated with Worse Outcome in Patients Admitted with Acute Decompensated Heart Failure
S4 Journal of Cardiac Failure Vol. 15 No. 6S Suppl. 2009 for Adult Leukaemia, Imperial College, London, United Kingdom; 3Division of Cachexia Research, Cardiology, Charite, Berlin, Germany Background: Anemia is a prevalent and adverse comorbidity in chronic heart failure (CHF) but its origins are frequently elusive. Diffuse inflammation is also a feature of CHF and a potent trigger of impaired erythropoiesis. Hypothesis: We hypothesized that unexplained anemia in CHF may mimic the anemia of chronic disease in being subsequent to diminished erythropoiesis as a result of immune-mediated suppression of erythroid colony formation. Methods: We studied 61 CHF patients (age 66 6 1yrs, LVEF 30 6 1%, 82% male) and 20 healthy controls (63 6 2yrs, 77% male). Absolute reticulocyte counts were enumerated and the reticulocyte production index (RPI) derived. Circulating primitive hematopoietic and erythroid precursor cells were quantified by flow cytometry. Peripheral blood erythroid progenitors (BFU-E) were scored in methylcellulose cultures in the absence and presence of monocytes and sera, and with anti-tumor necrosis factor (TNF) neutralizing antibody. Results: Anemic patients (n 5 21) had significantly higher TNF and interleukin-6 concentrations than non-anemic patients (n 5 40) and healthy controls (n 5 20). Despite lower hemoglobin (Hb) and higher EPO levels (p!0.05), anemic subjects did not mount a reticulocytosis as evidenced by their lower absolute reticulocyte counts (p 5 0.01) and RPIs (p!0.001). Diminished erythropoiesis was paralleled by attenuated circulating primitive hematopoietic, erythroid progenitor and precursor cells in anemic patients (all p!0.01). Depletion from cultures of monocytes derived only from anemic patients enhanced BFU-E growth by 35 6 8% (n 5 8, p!0.05). Only monocytes and sera from anemic patients suppressed BFU-E colony formation when co-cultured with autologous anemic or allogeneic control T-cell depleted BFU-E (n 5 8, p!0.01). Higher TNF levels related to lower colony yields (r 5 -0.30, p!0.05). Anti-TNF neutralizing antibody abrogated the inhibitory effects of anemic sera on erythroid colony growth (n 5 6, p!0.05). Conclusion: Anemia of unknown origin in patients with CHF results largely from suppressed erythropoiesis and monocytes, via a direct effect of TNF on erythroid cells, orchestrate a significant degree of this suppression. Recombinant EPO with adjuvant iron therapy is a rational strategy in this cohort.
010 Malnutrition as Assessed by Nutritional Risk Index Is Associated with Worse Outcome in Patients Admitted with Acute Decompensated Heart Failure Emad Aziz, Eyal Herzog, Amjad Nader, Hari Om Sharma, Sandeep Pulimi, Manpreet Singh, Suchita Mishra, Deborah Tormey, Mina Botross, Marrick Kukin; Cardiology, St. Luke’s-Roosevelt Hospital Center, New York, NY Background: Malnutrition is common at hospital admission and tends to worsen during hospitalization. This controlled population study aimed to determine if serum albumin or moderate and severe nutritional depletion by Nutritional Risk Index (NRI) at hospital admission are associated with increased length of hospital stay (LOS) in patients admitted with acute decompensated heart failure (ADHF). Methods: Serum albumin levels and lymphocyte counts were retrospectively determined at hospital admission in 1740 consecutive patients admitted with primary and secondary diagnosis of ADHF. The Nutrition Risk Score (NRI) developed originally in AIDS and cancer populations was derived from the serum albumin concentration and the ratio of actual to usual weight, as follows: NRI 5 (1.519 serum albumin, g/L) þ (41.7 present/ideal body weight). Patients were classified into four established groups as no, mild, moderate or severe risk by NRI. Multiple logistic regressions were used to determine the association between nutritional risk category and LOS. Results: 705 Patients (40%) were at moderate or severe nutritional risk by NRI score. This cohort had lower BMI (25.4 6 5.6), albumin (2.8 6 0.5), NRI (73.5 6 9) and higher TIMI Risk Score (TRS) (3 6 1.36). NRI for this cohort, adjusted for age, was associated With LOS of 6.8 days. Using the Multiple Logistic regression module, NRI was the strongest predictor for LOS (OR 1.7, 95% CI: 1.58-1.9; p50.005), followed by TRS (OR 1.33, 95% CI: 1.03-1.71; p50.02) and the presence of coronary artery disease (OR 2.29, 95%CI: 1.03-5.1; p50.04). Moderate and severe NRI score was associated with higher Readmission rate (49% vs 37%; p50.001) and death rates (6% vs 4%; p50.02) as compared to the other two groups. Conclusions: Nutritional depletion as assessed by Nutritional Risk Index is associated with worse outcome in patients admitted with ADHF. Therefore; we recommend adding NRI to further risk stratify these patients.
010 Malnutrition as Assessed by Nutritional Risk Index Is Associated with Worse Outcome in Patients Admitted with Acute Decompensated Heart Failure Emad Aziz, Eyal Herzog, Amjad Nader, Hari Om Sharma, Sandeep Pulimi, Manpreet Singh, Suchita Mishra, Deborah Tormey, Mina Botross, Marrick Kukin; Cardiology, St. Luke’s-Roosevelt Hospital Center, New York, NY Background: Malnutrition is common at hospital admission and tends to worsen during hospitalization. This controlled population study aimed to determine if serum albumin or moderate and severe nutritional depletion by Nutritional Risk Index (NRI) at hospital admission are associated with increased length of hospital stay (LOS) in patients admitted with acute decompensated heart failure (ADHF). Methods: Serum albumin levels and lymphocyte counts were retrospectively determined at hospital admission in 1740 consecutive patients admitted with primary and secondary diagnosis of ADHF. The Nutrition Risk Score (NRI) developed originally in AIDS and cancer populations was derived from the serum albumin concentration and the ratio of actual to usual weight, as follows: NRI 5 (1.519 serum albumin, g/L) þ (41.7 present/ideal body weight). Patients were classified into four established groups as no, mild, moderate or severe risk by NRI. Multiple logistic regressions were used to determine the association between nutritional risk category and LOS. Results: 705 Patients (40%) were at moderate or severe nutritional risk by NRI score. This cohort had lower BMI (25.4 6 5.6), albumin (2.8 6 0.5), NRI (73.5 6 9) and higher TIMI Risk Score (TRS) (3 6 1.36). NRI for this cohort, adjusted for age, was associated With LOS of 6.8 days. Using the Multiple Logistic regression module, NRI was the strongest predictor for LOS (OR 1.7, 95% CI: 1.58-1.9; p50.005), followed by TRS (OR 1.33, 95% CI: 1.03-1.71; p50.02) and the presence of coronary artery disease (OR 2.29, 95%CI: 1.03-5.1; p50.04). Moderate and severe NRI score was associated with higher Readmission rate (49% vs 37%; p50.001) and death rates (6% vs 4%; p50.02) as compared to the other two groups. Conclusions: Nutritional depletion as assessed by Nutritional Risk Index is associated with worse outcome in patients admitted with ADHF. Therefore; we recommend adding NRI to further risk stratify these patients.