Inter-relation between Altered Nutritional Status and Clinical Outcomes in Patients with Acute Myocardial Infarction Admitted in a Tertiary Intensive Cardiac Care Unit

Victoria Rus 1 , Diana Opincariu 2 , 3 , Roxana Hodas 2 , 3 , Tiberiu Nyulas 2 , Marian Hintea 1 , and Theodora Benedek 2 , 3
  • 1 Department of Nutritional Diseases, University of Medicine and Pharmacy, Tîrgu Mureș, Romania
  • 2 Department of Acute Cardiac care, Clinic of Cardiology, County Clinical Emergency Hospital, , Tîrgu Mureș, Romania
  • 3 Department of Internal Medicine, Clinic of Cardiology, University of Medicine and Pharmacy, Tîrgu Mureș, Romania

Abstract

Background: The impact of nutritional status on the early outcome of subjects with acute myocardial infarction (AMI) is still not completely elucidated. This study aimed to assess the correlation between nutritional status, as expressed by the CONUT and PIN scores, and (1) clinical and laboratory characteristics, (2) complication rates, and (3) length of hospitalization, in patients with AMI.

Materials and methods: We included 56 consecutive patients with AMI who underwent primary percutaneous intervention and stenting. Evaluation of the nutritional status was comprised in the calculation of the CONUT and PNI scores. The study population was divided into 2 groups according to the calculated CONUT score, as follows: group 1 – CONUT score <3 points (normal to mildly impaired nutritional status) and group 2 – CONUT score ≥3 points (moderate to severe malnutrition). The primary end-point of the study was the rate of in-hospital complications (left ventricular free wall rupture, hemodynamic instability requiring inotropic medication, high-degree atrioventricular block, the need for temporary cardiostimulation, supraventricular and ventricular arrhythmias and in-hospital cardiac arrest). The secondary end-points included the duration of hospitalization and the length of stay in the intensive cardiac care unit.

Results: In total, 56 patients (44.64% with STEMI, 55.35% with NSTEMI) with a mean age of 61.96 ± 13.42 years, 58.92% males were included in the study. Group distribution was: group 1 – 76.78% (n = 43), group 2 – 23.21% (n = 23). There were no differences between the two groups regarding age, gender, cardiovascular risk factors, or comorbidities. PNI index in group 1 was 54.4 ± 10.4 and in group 2 41.1 ± 2.8, p <0.0001. Serum albumin was significantly lower in group 1 – 4.1 ± 0.3 vs. group 2 – 3.6 ± 0.3 (p <0.0001), similarly to total cholesterol levels (group 1 – 194.9 ± 41.5 vs. group 2 – 161.2 ± 58.2, p = 0.02). The complete blood cell count showed that group 2 presented lower levels of hematocrit (p = 0.003), hemoglobin (p = 0.002), and lymphocytes (p <0.0001) compared to group 1, but a significantly higher platelet count (p = 0.001), mean platelet volume (p = 0.03), neutrophil/lymphocyte (p <0.0001) and platelet/lymphocyte (p <0.0001) ratios, indicating enhanced blood thrombogenicity and inflammation. Regarding in-hospital complications, group 2 presented a higher rate of hemodynamic instability (group 1 – 11.6% vs. group 2 – 38.4%, p = 0.02). The overall hospitalization period was 7.7 ± 1.4 days in group 1 vs. 10.2 ± 4.8 days in group 2, p = 0.06; while the duration of stay in the intensive cardiac care unit was 2.6 ± 0.5 days in group 1 vs. 4.0 ± 2.5 days in group 2, p = 0.02.

Conclusions: This study proved that nutritional deficit in acute myocardial patients who undergo revascularization is associated with an increased rate of in-hospital complications and with a longer observation time in a tertiary intensive cardiac care unit.

If the inline PDF is not rendering correctly, you can download the PDF file here.

  • 1. Thygesen K, Alpert JS, Jaffe AS, et al. Third Universal Definition of Myocardial Infarction. Circulation. 2012;126:2020-2035. https://doi.org/10.1161/CIR.0b013e31826e1058.

  • 2. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39:119-177. doi: 10.1093/eurheartj/ehx393.

  • 3. Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37:267-315. doi: 10.1093/eurheartj/ehv320.

  • 4. Kolh P, Windecker S, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg. 2014;46:517-592. doi: 10.1093/ejcts/ezu366.

  • 5. Chan D, Ng LL. Biomarkers in acute myocardial infarction. BMC Medicine. 2010;8:34. doi:10.1186/1741-7015-8-34.

  • 6. Waxman S, Ishibashi F, Muller JE. Detection and Treatment of Vulnerable Plaques and Vulnerable Patients Novel Approaches to Prevention of Coronary Events. Circulation. 2006;114:2390-2411. doi: 10.1161/CIRCULATIONAHA.105.540013.

  • 7. Narain VS, Gupta N, Sethi R, et al. Clinical correlation of multiple biomarkers for risk assessment in patients with acute coronary syndrome. Indian Heart J. 2008;60:536-542.

  • 8. Naghavi M, Libby P, Falk E, et al. From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part II. Circulation. 2003;108:1772-1778. doi: 10.1161/01.CIR.0000087481.55887.C9.

  • 9. Tello-Montoliu A, Marín F, Roldán V, et al. A multimarker risk stratification approach to non-ST elevation acute coronary syndrome: implications of troponin T, CRP, NT pro-BNP and fibrin D-dimer levels. J Intern Med. 2007;262:651-658. doi: 10.1111/j.1365-2796.2007.01871.x.

  • 10. Naghavi M, Libby P, Falk E, et al. From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part I. Circulation. 2003;108:1664-1672. doi: 10.1161/01.CIR.0000087480.94275.97.

  • 11. Hess K, Marx N, Lehrke M. Cardiovascular disease and diabetes: the vulnerable patient. Eur Heart J Supplements. 2012;14:B4-B13. doi:10.1093/eurheartj/sus002.

  • 12. Danesh J, Collins R, Appleby P, Peto R. Association of fibrinogen, C-reactive protein, albumin, or leukocyte count with coronary heart disease: meta-analyses of prospective studies. JAMA. 1998; 279:1477-1482.

  • 13. Chien SC, Chen CY, Lin CF, Yeh HI. Critical appraisal of the role of serum albumin in cardiovascular disease. Biomarker Research. 2017;5:31. doi:10.1186/s40364-017-0111-x.

  • 14. Don BR, Kaysen G. Serum albumin: relationship to inflammation and nutrition. Semin Dial. 2004;17:432-437. doi: 10.1111/j.0894-0959.2004.17603.x.

  • 15. Ignacio de Ulibarri J, Gonzalez-Madrono A, de Villar NG, et al. CONUT: a tool for controlling nutritional status. First validation in a hospital population. Nutr Hosp. 2005;20:38-45.

  • 16. Iwakami N, Nagai T, Furukawa TA, et al. Prognostic value of malnutrition assessed by Controlling Nutritional Status score for long-term mortality in patients with acute heart failure. Int J Cardiol. 2017;230:529-536. doi: 10.1016/j.ijcard.2016.12.064.

  • 17. Toyokawa T, Kubo N, Tamura T, et al. The pretreatment Controlling Nutritional Status (CONUT) score is an independent prognostic factor in patients with resectable thoracic esophageal squamous cell carcinoma: results from a retrospective study. BMC Cancer. 2016;16:722. doi:10.1186/s12885-016-2696-0.

  • 18. Sun X, Luo L, Zhao X, Ye P. Controlling Nutritional Status (CONUT) score as a predictor of all-cause mortality in elderly hypertensive patients: a prospective follow-up study. BMJ Open. 2017;7:e015649. doi: 10.1136/bmjopen-2016-015649.

  • 19. Keskin M, Hayıroğlu Mİ, Keskin T, et al. A novel and useful predictive indicator of prognosis in ST-segment elevation myocardial infarction; prognostic nutritional index. Nutr Metab Cardiovasc Dis. 2017;27:438-446. doi: 10.1016/j.numecd.2017.01.005.

  • 20. Yang L, Xia L, Wang Y, et al. Low Prognostic Nutritional Index (PNI) Predicts Unfavorable Distant Metastasis-Free Survival in Nasopharyngeal Carcinoma: A Propensity Score-Matched Analysis. PLoS One. 2016;11:e0158853. doi: 10.1371/journal.pone.0158853.

  • 21. Narumi T, Arimoto T, Funayama A, et al. Prognostic importance of objective nutritional indexes in patients with chronic heart failure. J Cardiol. 2013;62:307-313. doi: 10.1016/j.jjcc.2013.05.007.

  • 22. Basta G, Chatzianagnostou K, Paradossi U, et al. The prognostic impact of objective nutritional indices in elderly patients with ST-elevation myocardial infarction undergoing primary coronary intervention. Int J Cardiol. 2016;221:987-992. doi: 10.1016/j.ijcard.2016.07.039.

  • 23. Shirakabe A, Hata N, Kobayashi N, et al. The prognostic impact of malnutrition in patients with severely decompensated acute heart failure, as assessed using the Prognostic Nutritional Index (PNI) and Controlling Nutritional Status (CONUT) score. Heart Vessels. 2018;33:134-144. doi: 10.1007/s00380-017-1034-z.

  • 24. Wada H, Dohi T, Miyauchi K, et al. Prognostic impact of nutritional status assessed by the Controlling Nutritional Status score in patients with stable coronary artery disease undergoing percutaneous coronary intervention. Clin Res Cardiol. 2017;106:875-883. doi: 10.1007/s00392-017-1132-z.

  • 25. Bourdel-Marchasson I, Emeriau JP. Nutritional strategy in the management of heart failure in adults. Am J Cardiovasc Drugs. 2001;1:363-373.

  • 26. Broqvist M, Arnqvist H, Dahlström U, Larsson J, Nylander E, Permert J. Nutritional assessment and muscle energy metabolism in severe chronic congestive heart failure – effects of long-term dietary supplementation. Eur Heart J. 1994;15:1641-1650.

  • 27. Iseki K, Yamazato M, Tozawa M, Takishita S. Hypocholesterolemia is a significant predictor of death in a cohort of chronic hemodialysis patients. Kidney Int. 2002;61:1887-1893. doi: 10.1046/j.1523-1755.2002.00324.x.

  • 28. Tuikkala P, Hartikainen S, Korhonen MJ, et al. Serum total cholesterol levels and all-cause mortality in a home-dwelling elderly population: a six-year follow-up. Scandinavian Journal of Primary Health Care. 2010;28:121-127. doi: 10.3109/02813432.2010.487371.

  • 29. Pekkanen J, Nissinen A, Vartiainen E, Salonen JT, Punsar S, Karvonen MJ. Changes in serum cholesterol level and mortality: a 30-year follow-up. The Finnish cohorts of the seven countries study. Am J Epidemiol. 1994;139:155-165.

  • 30. Shiyovich A, Gilutz H, Plakht Y. White Blood Cell Subtypes Are Associated with a Greater Long-Term Risk of Death after Acute Myocardial Infarction. Texas Heart Institute Journal. 2017;44:176-188. doi:10.14503/THIJ-16-5768.

  • 31. Kunimura A, Ishii H, Uetani T, et al. Impact of nutritional assessment and body mass index on cardiovascular outcomes in patients with stable coronary artery disease. Int J Cardiol. 2017;230:653-658. doi:10.1016/j.ijcard.2017.01.008.

  • 32. Kang MC, Kim JH, Ryu SW, et al. Prevalence of Malnutrition in Hospitalized Patients: a Multicenter Cross-sectional Study. Journal of Korean Medical Science. 2018;33:e10. doi:10.3346/jkms.2018.33.e10.

  • 33. Agarwal E, Ferguson M, Banks M, et al. Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: results from the Nutrition Care Day Survey 2010. Clin Nutr. 2013;32:737-475. doi: 10.1016/j.clnu.2012.11.021.

OPEN ACCESS

Journal + Issues

Search