Clinical utility of the modified controlling nutritional status score for predicting atherosclerotic severity and prognosis in statin-treated patients with atherosclerotic cardiovascular disease

Background and Objective Malnutrition is associated with adverse outcomes in atherosclerotic cardiovascular disease (ASCVD). The Controlling Nutritional Status (CONUT) score is a widely used laboratory-based nutritional index; however inclusion of total cholesterol allows statin-induced cholesterol lowering to confound nutritional classification and attenuate risk stratification in statin-treated patients. The present study evaluated the recently proposed modified CONUT (M-CONUT) score and compared M-CONUT with CONUT, Geriatric Nutritional Risk Index (GNRI), and the Prognostic Nutritional Index (PNI) for predicting atherosclerotic severity and 1-year major adverse cardiovascular events (MACE) in statin-treated ASCVD. Methods A retrospective analysis was conducted in 288 statin-treated ASCVD patients (age 73±10.7 years; 71.2% male; LDL cholesterol 78.12±29.19 mg/dL): ischemic heart disease (n=203), peripheral artery disease (n=45), and prior stroke (n=40). M-CONUT replaced the total cholesterol component with hemoglobin while retaining serum albumin and total lymphocyte count. Hemoglobin scoring (g/dL) was: 0 (male ≥13/female ≥12), 1 (male 10.0–12.9/female 10.0–11.9), 2 (8.0–9.9), 3 (<8). Malnutrition was defined as M-CONUT ≥2. Atherosclerotic severity was assessed by arterial stiffness (high pulse wave velocity [PWV] ≥1800) and polyvascular disease score (≥2). The primary endpoint was 1-year MACE (all-cause death, heart failure hospitalization, nonfatal myocardial infarction, ischemic stroke). Prognostic performance was assessed using Kaplan–Meier analysis and Cox proportional hazards models adjusted for age, sex, and estimated glomerular filtration rate (eGFR). Results Over 1-year follow-up, MACE occurred in 26 patients (9.4%). M-CONUT–defined malnutrition was associated with arterial stiffness (OR 1.84, 95% CI 1.09–3.12; p=0.022) and showed the strongest association with polyvascular disease (OR 2.44, 95% CI 1.40–4.32; p=0.002). In contrast, PNI showed an association with arterial stiffness, whereas CONUT and GNRI showed no significant associations with atherosclerotic severity. Kaplan–Meier analysis demonstrated lower 1-year event-free survival in M-CONUT malnutrition (log-rank p=0.018), whereas CONUT did not discriminate risk (p=0.478). In adjusted Cox models, M-CONUT malnutrition independently predicted 1-year MACE (HR 2.62, 95% CI 1.06–6.49; p=0.038), with prognostic performance comparable to GNRI (HR 2.77, 95% CI 1.17–6.60; p=0.021) and PNI (HR 2.43, 95% CI 1.04–5.66; p=0.04), whereas conventional CONUT was not significant (HR 1.19, 95% CI 0.46–3.08; p=0.71). Conclusions In statin-treated ASCVD patients, M-CONUT was associated with atherosclerotic severity and provided prognostic stratification for 1-year MACE. M-CONUT demonstrated clearer risk discrimination than conventional CONUT and prognostic performance comparable to GNRI and PNI, supporting clinical utility for risk assessment in statin-treated populations.