Nutritional Status Modifies the Prognostic Impact of Clinical Hemodynamic Phenotypes on Cardiorenal Outcomes in Heart Failure

Background Heart failure (HF) is a major global health burden. Hemodynamic status and nutritional status reflect important pathophysiological processes associated with clinical outcomes. Malnutrition is common in HF and may indicate metabolic and social vulnerability. We investigated whether nutritional status modified the associations between hemodynamic phenotypes and clinical outcomes in patients with HF. Methods This retrospective cohort study included 3293 adult patients with HF treated at a tertiary medical center in Taiwan. All patients had NT‐proBNP levels ≥ 125 pg/mL and complete echocardiographic data. Clinical hemodynamic phenotypes (dry–warm, wet–warm, wet–cold, and dry–cold) were classified using the Stevenson algorithm. Nutritional status was assessed using the Controlling Nutritional Status (CONUT) score; moderate‐to‐severe malnutrition was defined as a CONUT score ≥ 5. Outcomes included severe cardiovascular events, a ≥ 50% decline in estimated glomerular filtration rate, composite cardiorenal events, hospitalization for HF (HHF), all‐cause mortality (ACM), and the HHF/ACM composite endpoint. Inverse probability of treatment weighting–adjusted Cox proportional‐hazards models was used. Results After adjustment, the wet–cold phenotype and moderate‐to‐severe malnutrition were each associated with higher risks of several adverse outcomes. Among patients without moderate‐to‐severe malnutrition, both the wet–warm and wet–cold phenotypes were associated with higher risks of several adverse outcomes than the dry–warm phenotype. These associations were generally attenuated among patients with moderate‐to‐severe malnutrition. Significant interactions between nutritional status and hemodynamic phenotypes were observed for severe cardiovascular events, composite cardiorenal events, HHF, and the HHF/ACM composite endpoint. Conclusions Nutritional status modified the associations between hemodynamic phenotypes and selected clinical outcomes in HF. Malnutrition identified a vulnerable population in whom hemodynamic phenotypes provided less prognostic differentiation. Nutritional assessment may help inform clinical evaluation and care prioritization.