Prevalence, Pathophysiology, and Prognostic Importance of Malnutrition Risk in Early-Stage Patients With Heart Failure and Preserved Ejection Fraction

Figure 1. Patient flow. Consecutive 981 patients who underwent exercise stress echocardiography for the evaluation of exertional dyspnea were retrospectively identified. After excluding 640 patients, 341 were selected for cross-sectional analysis. The diagnosis of HFpEF was made based on the Heart Failure Association Pre-test Assessment, Echocardiography and Natriuretic Peptides, Functional Testing, Final Etiology algorithm, which includes resting assessments of comprehensive echocardiography and natriuretic peptides (step 2) and subsequent exercise stress echocardiography (step 3). The diagnosis of HFpEF was made if patients had a combined score of ≥ 5 points from steps 2 and 3. Patients with elevated pulmonary capillary wedge pressure (≥15 mmHg at rest and/or ≥25 mmHg during exercise) on exercise RHC were also diagnosed as HFpEF. Of the 341 patients with HFpEF, 229 had a Step 2 score ≥5 points (i.e., HFpEF). An additional 87 and 25 were diagnosed with HFpEF based on exercise stress echocardiography and exercise RHC, respectively. HFpEF = heart failure with preserved ejection; RHC = right heart catheterization.

Figure 2. Prevalence of malnutrition. The prevalence of at least mild malnutrition risk (GNRI ≤98) was 36.6% in patients with heart failure with preserved ejection. GNRI = geriatric nutritional risk index.

Figure 3. Comparisons of exercise capacity. (A-C) Compared to patients with HFpEF and absent malnutrition risk, those with malnutrition risk had lower peak oxygen consumption (VO2), lower peak workload achieved, and shorter exercise duration. Peak VO2 data were available in 296 subjects. GNRI = geriatric nutritional risk index; HFpEF = heart failure with preserved ejection.

Figure 4. Peripheral and ventilatory reserve during peak exercise. (A-C) Arteriovenous oxygen content difference (AVO2 diff), mitochondrial oxidative phosphorylation capacity (Vmax), and ventilatory efficiency (minute ventilation to carbon dioxide production ratio; VE) were lower in patients with HFpEF at risk for malnutrition than those without. Data were available for 292, 296, and 293 subjects for peak AVO2 diff, peak Vmax, and VE vs VCO2 slope, respectively. GNRI = geriatric nutritional risk index; HFpEF = heart failure with preserved ejection.

Figure 5. Malnutrition risk and clinical outcomes. Patients with HFpEF at risk for malnutrition had higher rates of a composite outcome of all-cause mortality, heart failure hospitalization, unplanned visits requiring intravenous diuretic treatment, or intensification of oral diuretics than those without. GNRI = geriatric nutritional risk index; HFpEF = heart failure with preserved ejection.