Editorial
The importance of nutritional status in heart failure
La importancia del estado nutricional en la insuficiencia cardiaca
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Trullàs" "autores" => array:1 [ 0 => array:4 [ "nombre" => "J.C." "apellidos" => "Trullàs" "email" => array:1 [ 0 => "jctv5153@comg.cat" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital de Olot, Olot, Girona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departament de Ciències Mèdiques, Universitat de Girona, Girona, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La importancia del estado nutricional en la insuficiencia cardiaca" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure (HF) is a progressively increasing syndrome of epidemic proportions. In the last 20 years, disease-modifying drugs (angiotensin-converting enzyme inhibitors, beta-blockers, aldosterone antagonists and, more recently, neprilysin inhibitors) have markedly improved the prognosis, when the left ventricular ejection fraction (LVEF) is reduced. Despite the benefits demonstrated by these drugs, mortality due to heart failure remains high. There is still no intervention that has been shown to improve the prognosis of heart failure with preserved LVEF, whose mortality is very similar to that of HF with reduced LVEF.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a> For this reason, there is considerable interest in identifying variables that affect the prognosis of HF and whose change can provide an additional benefit to drug treatment. One of these variables is the nutritional state.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Malnutrition is common in patients with HF and is often part of a vicious cycle in which inflammation and cardiac cachexia also participate. When cardiac cachexia occurs, the prognosis worsens and mortality is high. One of the therapeutic objectives should therefore be to prevent or reverse the nutritional disorders.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> The assessment of the nutritional state in early phases of the disease allows for early intervention and possibly avoiding this deterioration, contributing to a better prognosis.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">To assess the nutritional state, anthropometric or biochemical parameters can be used, but all have limitations and are not sufficiently reliable in isolation. The body mass index (BMI) is used as an estimate of the body fat content, and its inverse relationship with the prognosis of HF is well known (the obesity paradox).<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> Nevertheless, these anthropometric measures do not help to accurately determine the body composition.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a> Therefore, the assessment should be completed with tools such as the Mini Nutritional Assessment (MNA) scale, which is currently considered the gold standard for the nutritional assessment of HF.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> Most observational studies of patients with HF have identified malnutrition as a factor of poor prognosis, regardless of how it was diagnosed (low weight by BMI,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> low albumin<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> or prealbumin readings<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> or by using the MNA scale<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a>). However, there are very few studies on interventions that attempt to demonstrate the improvement in the prognosis with nutritional treatments.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The Program of Nutritional Intervention in Malnourished Patients Hospitalized for Heart Failure (PICNIC) is a prospective study that included 120 patients hospitalized for decompensated HF and malnutrition (diagnosed using the MNA scale). During admission, the patients were randomized to conventional treatment or conventional treatment plus an individualized nutritional intervention. This intervention was maintained for up to 6 months after the hospital discharge. The main finding was a significant reduction in all-cause mortality and hospitalizations for HF in the patients of the intervention group, after 12 months of follow-up.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In this issue of <span class="elsevierStyleSmallCaps">Revista Clínica Española</span>, a new analysis of the PICNIC study after 2 years of follow-up was published. The beneficial effects of the nutritional intervention implemented during the first 6 months remained.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">10</span></a> The strength of this study lies in the intervention's randomized design. Nevertheless, there are a number of limitations worth mentioning. Although it is true that the 2 treatment groups of the PICNIC study showed no significant differences in any of their baseline characteristics, these did not include the patients’ functional assessment.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a> This is a relevant consideration, given that functional impairment (measured by the Barthel index) is one of the variables with a major effect on the mortality of patients with HF.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">11,12</span></a> Moreover, this second analysis did not evaluate the potential changes in the baseline variables between the 2 groups.</p><p id="par0030" class="elsevierStylePara elsevierViewall">HF is a complex and heterogeneous syndrome, with numerous variables that influence the onset and prognosis of HF. Therefore, a global, comprehensive and multidisciplinary assessment is increasingly necessary and needs to include a nutritional evaluation. The early detection of and subsequent intervention for malnutrition can provide significant benefits for patients with HF.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Trullàs JC. La importancia del estado nutricional en la insuficiencia cardiaca. Rev Clin Esp. 2018;218:68–69.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of heart failure with preserved ejection fraction" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "S.M. Dunlay" 1 => "V.L. Roger" 2 => "M.M. 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