Abstract:

Nutritional Assessment In Advanced Heart Failure Patients

Mary Gregory, RD, Christopher Blair, Sunil Pauwaa, MD, Anup Kumar, BS, Antone J Tatooles, MD, Pat Pappas, MD, Geetha Bhat, PhD, MD

Center for Heart Transplant and Assist Devices, Advocate Christ Medical Center

Introduction: Nutrition is compromised in heart failure (HF) patients. When identified early, malnutrition can be addressed through nutritional intervention. However, no single nutritional assessment method is universally accepted.

Method: The Mini Nutritional Assessment® (MNA®), a scored screening/assessment tool for individuals over 65 years of age, was evaluated for hospitalized adult patients (age 18 or older) in severe heart failure.

Result: A retrospective review was conducted between November 2008 and April 2010. Statistical analysis included frequency, chi-square, t-tests, and logistic regression. A total of 110 MNAs® was completed. Of those, 72 met the criteria for preoperative evaluation for cardiac assist device placement or continued medical management. Final analysis was focused on the malnourished (N=26) and at risk groups (N=42); the normal group was considered insignificant (N=4) and was not included in the analysis. The MNA® effectively distinguished between malnourished and at risk (p=<0.1), regardless of age.

Conclusion: The MNA appears to successfully identify malnutrition in patients with advanced heart failure upon hospital admission. Further testing of this tool is planned with inclusion of patients in mild to moderate heart failure.

Introduction:Nutrition is compromised in heart failure (HF) patients. When identified early, malnutrition can be addressed through nutritional intervention. However, no standard clinical indicator alone is able to determine malnutrition and no single nutritional assessment method is universally accepted.

In HF patients, standard interpretation of anthropometric measures such as Body Mass Index (BMI) and nutrition-related laboratory values such as albumin is skewed because of possible fluid overload. Yet the effects of heart failure are similar to those of the aging. Sensory impairment, psychosocial changes, and decreased physical activity lead to decreased appetite. As a result of altered energy needs the diet is often lacking in essential nutrients.  The Mini Nutrition Assessment® (MNA®) is an 18-item nutritional screening and assessment tool. It was developed to identify individuals over 65 years of age who are at risk of nutritional deficiency before exhibiting weight loss and serum protein decreases. It has been tested in a variety of settings, including the acute care setting; however, it has not been tested in the HF population. We examined the use of the MNA® in hospitalized adults (age 18 or older) with HF at Advocate Christ Medical Center, a community-based tertiary hospital. 

Our objective in this pilot study is to describe and compare patients’ clinical status based upon MNA® scores

Methods:A retrospective review of records between November 2008 and April 2010 was conducted. Based on inclusion criteria, records were selected if the patient was in the preoperative period for cardiac assist device placement or being medically managed. A total of 110 records were reviewed; MNAs® scores were classified as either malnourished, at risk, and not at risk. Statistical analysis of the malnourished (N=26) and at risk (N=42) groups included frequency, chi square, t-tests, and logistic regression.

Conclusions:Malnutrition remains difficult to define using clinical indicators. No significant differences were found in clinical indicators between the malnourished and at risk groups. Despite this finding, two micronutrients – vitamin D and iron - were depleted in both groups, which suggest areas for further research in a larger HF population. Because of the lack of clinical indicators to identify malnutrition, the use of a multifactoral instrument such as the MNA® may be a viable option. Thirty-seven percent of our HF patients were identified as malnourished according to the MNA® scoring system. This percentage seems consistent with reported malnutrition in hospitals. Further studies are indicated to validate this tool in the HF population, including patients with mild to moderate HF.

References:1. Azhar G, Wei JY. Nutrition and cardiac cachexia. Curr Opin Clin Nutr Metab Care 2006;9:18-23.2. Beghetto MG, Luft VC, Mello ED, Polanczyk CA. Accuracy of nutritional assessment tools for predicting

adverse hospital outcomes. Nutr Hosp 2009;24(1):56-62.3. Guigoz Y. The mini nutrition assessment: review of the literature – what does it tell us? J of Nutr, Health &

Aging 2006;10(6):466-487.4. Lennie TA, Moser DK, Heo S, Chung ML, Zambroski CH. Factors influencing food intake in patients with

heart failure. J of Cardiovasc Nurs 2006; 21:123-129.5. Lloyd-Jones D, Adams RJ, Brown TM, et al. Heart disease and stroke statistics—2010 update. A report from

the American Heart Association statistics committee and stroke statistics subcommittee. Circulation. 2010;121:e1-e170.

6. Nestle Nutrition Institute – MNA® Elderly at http://www.mna-elderly.com/default.html. 7. Price RJG, Witham MD, McMurdo MET. Defining the nutritional status and dietary intake of older heart failure

patients. Eur J of Cardiovasc Nurs 2007; 6:178-183.8. Sabol VK. Nutrition assessment of the critically ill adult. AACN Clinical Issues. 2004:15,4;595-606.

Results:Seventy-two patients met the inclusion criteria. Twenty-six patients were classified as malnourished with a mean MNA® score of 14.2 ± 2.6. The majority of the malnourished group were male (80.8%) and Caucasian (53.8%) diagnosed with nonischemic cardiomyopathy. The mean BMI was 26.5 ± 6.6. The at-risk group numbered 42 with a mean MNA score of 20.8 ± 1.6. The majority of the at-risk group were male (66.7%) and Caucasian (59.5%) diagnosed with ischemic cardiomyopathy (59.5%). The mean BMI was 27.5 ± 6.3. The remaining patients (n=4) scored as not at risk with a mean MNA® score of 24.3 ± 0.3. There were 3 males and 1 female, 2 Caucasians and 2 Afro-Americans, 2 had ischemic cardiomyopathy and 2 nonischemic. Mean BMI was 33.0 ± 8.9. The difference among the three groups’ MNA® scores was significant (p<.05).  Since the normal group only had four patients, this group was excluded from further analysis. Overall differences of nutrition-related laboratory values were insignificant between groups. However, both groups showed depleted levels in vitamin D and iron.

Acknowledgement:

A special thanks to Cheryl LeFaiver, Professional Nurse Researcher/Educator, at Advocate Christ Medical Center.

Nutrition-Related Clinical Indicators

LAB VALUE NORMAL RANGE MALNUTRITION AT RISK P VALUE MACRONUTRIENTS PROTEIN MARKERS ALBUMIN 3.5-5.0 3.058 ± 0.46 (n=26) 3.152 ± 0.49 (n=42) 0.985 PREALBUMIN 16-35 20.8 ±8.7 (n=20) 19.6 ± 19.5 (n=36) 0.731 TOTAL LYMPHOCYTES

>2.0 1.415 ± .77 (n=26) 1.559 ± 1.25 (n=42) 0.394

FAT MARKERS TOTAL CHOLESTEROL 120-210 138.5 ± 33.3 (n=20) 119.5 ± 34.4 (n=40) 0.611 LDL <100 78.71 ± 25.821 (n=21) 69.45 ± 27.216 (n=38) 0.579 HDL >40 33.86 ± 13.85 (n=21) 31.21 ± 10.893 (n=38) 0.294 TRIGLYCERIDE <150 89.14 ± 47.476 (n=21) 87.47 ± 46.123 (n=38) 0.867 CARBOHYDRATE MARKER A1C <6.0 6.13 ± 0.9 (n=22) 6.57 ± 1.1 (n=39) 0.187 MICRONUTRIENTS IRON 65-175 39 ± 22 (n=13) 54 ± 25 (n=25) 0.787 MAGNESIUM 1.8-3.0 2.05 ± 0.23 (n=26) 2.2 2.05 ± 1.04 (n=42) 0.283 VITAMIN D 30-74 18.26 ± 10.2 (n=20) 21.2 ± 17.03 (n=34) 0.124 FERRITIN >20 217.5 ± 29.2 (n=12) 437.4 ± 73.6 (n=20) 0.277 HEMOGLOBIN 12-17 10.79 ±2.469 (n=26) 14.12 ± 15.743 (n=42) 0.278

Mini Nutritional Assessment® Form

Figure 2. Serum markers for macronutrient and micronutrients showed no significant difference between the Malnourished and At Risk groups.

Iron

0

20

40

60

80

100

120

Malnutrition At Risk

Vitamin D

0

10

20

30

40

50

60

70

80

90

Malnutrition At Risk

Albumin

1

2

3

4

5

Malnutrition At Risk

Figure 3. The mean Albumin was mildly depleted at 3.058 ± 0.46 and 3.152 ± for the Malnutrition and At Risk groups, respectively.

Lymphocytes

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Malnutrition At Risk

Figure 4. The mean Absolute Lymphocytes was moderately depleted at 1.415 ± .77 in the Malnutrition group and mildly depleted at 1.559 ± 1.25 in the At Risk group.

Figure 5. The mean Iron level was below the normal range at 39 ± 22 in the Malnutrition group and also below normal at 54 ± 25 in the At Risk group. However, no significant difference between the two was noted.

Figure 6. Depleted levels of Vitamin D were found in both the Malnutrition and At Risk groups, Mean Vitamin D level was 18.26 ± 10.2 in the Malnutrition group and 21.2 ± 17.03 in the At Risk group.

Comparison of Select Clinical Indicators To Normal Ranges

Figure 1. The only significant finding among groups was the MNA.

Characteristics of Study Population

VARIABLES MALNOURISHED

(n = 26) AT RISK (n = 42)

NORMAL (n = 4)

p-value

Age 57.0 ± 12.8 64.8 ± 13.0 50.3 ± 7.5 .129 Sex

Male 21 (80.8) 28 (66.7) 3 (75) .208 Female 5 (19.2) 14 (33.3) 1 (25)

Race African American

9 (34.6) 14 (33.3) 2 (50) .761

Arabic 1 (3.8) 1 (2.4) 0 (0) Asian 1 (3.8) 0 (0) 0 (0) Caucasian 14 (53.8) 25 (59.5) 2 (50) Hispanic 1 (3.8) 2 (4.8) 0 (0)

Cardiomyopathy Ischemic 12 (46.2) 25 (59.5) 2 (50) .282 Non-Ischemic 14 (53.8) 17 (40.5) 2 (50)

Statin .964 Yes 15 (57.7) 24 (57.1) 1 (25) No 11 (42.3) 18 (42.9) 3 (75)

LVEF 17.0 ± 6.0 19.8 ± 7.0 21.3 ± 15.1 .116 Height (cm) 174.3 ± 11.2 170.9 ± 9.7 178.8 ± 12.8 .185 Weight (kg) 80.4 ± 24.3 80.4 ± 20.0 105.9 ± 33.2 .994 BSA 1.95 ± 0.28 1.92 ± 0.25 2.22 ± 0.35 .708 BMI 26.5 ± 6.6 27.5 ± 6.3 33.0 ± 8.9 .542 MNA 14.2 ± 2.6 20.8 ± 1.6 24.3 ± 0.3 <.01