The importance of nutritional status in heart failure

Trullàs, J.C.

doi:10.1016/j.rceng.2018.01.002

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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">1</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.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">2</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">3</a>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">4</a> Nevertheless, these anthropometric measures do not help to accurately determine the body composition.<a class="elsevierStyleCrossRef" href="#bib0085">5</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">3</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">4</a> low albumin<a class="elsevierStyleCrossRef" href="#bib0090">6</a> or prealbumin readings<a class="elsevierStyleCrossRef" href="#bib0095">7</a> or by using the MNA scale<a class="elsevierStyleCrossRef" href="#bib0100">8</a>). However, there are very few studies on interventions that attempt to demonstrate the improvement in the prognosis with nutritional treatments.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">9</a>In this issue of Revista Clínica Española, 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">10</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">9</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">11,12</a> Moreover, this second analysis did not evaluate the potential changes in the baseline variables between the 2 groups.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." 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Revista Clínica Española (English Edition)

ISSN: 2254-8874

Revista Clínica Española published its first issue in 1940 and is the body of expression of the Spanish Society of Internal Medicine (SEMI).
The journal fully endorses the goals of updating knowledge and facilitating the acquisition of key developments in internal medicine applied to clinical practice. Revista Clínica Española is subject to a thorough double blind review of the received articles written in Spanish or English. Ten issues are published each year, including mostly originals, reviews and consensus documents.

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Current Contents / Clinical Medicine , JCR / SCI-Expanded, Index Medicus / Medline y Excerpta Medica / EMBASE

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Impact factor

The Impact Factor measures the average number of citations received in a particular year by papers published in the journal during the two preceding years.

© Clarivate Analytics, Journal Citation Reports 2022

Impact factor 2023

2.3

Citescore

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Citescore 2023

0.7

SJR

SRJ is a prestige metric based on the idea that not all citations are the same. SJR uses a similar algorithm as the Google page rank; it provides a quantitative and qualitative measure of the journal's impact.

SJR 2023

0.162

SNIP

SNIP measures contextual citation impact by wighting citations based on the total number of citations in a subject field.

SNIP 2023

0.211

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Vol. 218. Issue 2.

Pages 68-69 (March 2018)

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