Beyond age alone: the association of malnutrition with estimated ASCVD risk in older adults without established cardiovascular disease

Introduction Age is the dominant determinant of atherosclerotic cardiovascular disease (ASCVD) risk, and the estimated 10-year ASCVD risk of nearly all individuals aged ≥70 years exceeds conventional risk thresholds. Malnutrition in older adults is a key contributor to frailty and sarcopenia and has been associated with poor prognosis in chronic diseases, as well as an increased risk of major adverse cardiovascular events. Aim Risk prediction in elderly populations remains challenging, as most ASCVD risk scores perform poorly and do not account for nutritional status. Consequently, the ability to quantify both cardiovascular and nutritional risk in individuals aged ≥70 years is limited. We therefore investigated the association between malnutrition and ASCVD risk in elderly patients without established ASCVD. Methods We enrolled 253 individuals aged ≥70 years without established ASCVD. The 10-year risk of ASCVD was estimated using the Systematic Coronary Risk Estimation 2–Older Persons (SCORE2-OP) model. Nutritional status was assessed using the Geriatric Nutritional Risk Index (GNRI). Based on GNRI values, participants were categorized into three groups: (1) normal nutritional status (GNRI >98; n=176), (2) low risk of malnutrition (GNRI 92–98; n=39), and (3) moderate-to-major risk of malnutrition (GNRI <92; n=38). Results The median 10-year ASCVD risk in the overall cohort was 23% (interquartile range 17%–32%), and the median GNRI was 105 (96–112). No participant was classified as having low ASCVD risk (<7.5%). Forty-one individuals (16.2%) were categorized as high risk, and 212 (83.8%) as very high risk. The prevalence of malnutrition increased markedly with advancing age. Although the proportion of individuals classified as very high ASCVD risk was similar across nutritional subgroups, median ASCVD risk was highest (28%) among participants at low risk of or at moderate-to-major risk of malnutrition. Multimorbidity was highly prevalent, particularly among malnourished individuals. Overweight and obesity were common across the entire cohort, including those at low risk of malnutrition (73.9%) and those at moderate-to-major risk (59.2%). SCORE2-OP demonstrated limited discriminatory ability for identifying individuals at risk of malnutrition (C-statistic 0.61; positive predictive value 25%, negative predictive value 89%; p=0.03). Conclusions Older adults without established ASCVD represent a heterogeneous population, the majority of whom are at very high estimated ASCVD risk. The risk of malnutrition increases substantially with age, and ASCVD risk was highest among individuals with low or moderate-to-major risk of malnutrition. Notably, overweight and obesity were highly prevalent even among malnourished patients. ASCVD risk modifiers, including multimorbidity, polypharmacy, and malnutrition, were common. These findings underscore the need for individualized preventive and therapeutic strategies in elderly populations.