535269
research-article2014
NCPXXX10.1177/0884533614535269Nutrition in Clinical Practice X(X)Yost et al
Clinical Research
Short-Form Nutrition Assessment in Patients With Advanced Heart Failure Evaluated for Ventricular Assist Device Placement or Cardiac Transplantation
Nutrition in Clinical Practice Volume 29 Number 5 October 2014 686–691 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614535269 ncp.sagepub.com hosted at online.sagepub.com
Gardner Yost, BS1; Mary Gregory, RD, LDN2; and Geetha Bhat, PhD, MD1
Abstract Background: It has been shown that malnutrition affects clinical outcomes in patients with advanced heart failure and that nutrition status, as determined by the Mini Nutritional Assessment (MNA), can be used as an independent predictor of mortality. The aim of this study was to evaluate the prognostic utility of the short-form MNA (MNA-SF) as a surrogate to the MNA in patients with advanced heart failure. Methods: Data retrospectively gathered from nutrition assessments of 162 patients were analyzed. Results: As defined by the MNA, the cohort included 40 (24.7%) patients classified as malnourished, 106 (65.4%) classified as at risk, and 16 (9.9%) classified as well nourished. The mortality for the groups was 37.3%, 47.4%, and 40.5%, respectively. A linear regression showed strong correlation between the MNA and MNA-SF (r = 0.778, P < .0001). A significant difference was observed in survival between the undernourished state (at risk + malnourished) and the well-nourished state, as determined by the MNA-SF (P < .001). Conclusions: The MNA-SF is a rapid nutrition assessment that correlates strongly with the full-form MNA and is an independent predictor of mortality. (Nutr Clin Pract. 2014;29:686-691)
Keywords heart-assist devices; nutritional status; malnutrition; nutrition assessment; heart transplantation; screening; heart failure
Although treatment of advanced heart failure (AHF) has improved significantly in recent decades, clinical prognosis remains poor, with half of patients dying within 4 years of diagnosis.1 Malnutrition is known to influence the progression of many chronic diseases, including AHF, where it has been shown to predict adverse outcomes.2,3 Cardiac cachexia, often characterized by weight loss, increased lipolysis, lack of appetite, malabsorption, and homeostatic disruption of multiple body systems, is known to affect prognosis.4,5 The Mini Nutritional Assessment (MNA) is a simple questionnaire-based tool that is notably sensitive (96%), specific (98%), and predictive (97%).6 It has been substantially validated using clinical status and comprehensive nutrition assessment in the setting of home care, outpatient therapy, and general practice as well as in hospitalized and institutionalized patients.7-9 Recently, the MNA was shown to be an independent predictor of mortality in patients with heart failure and in patients with heart failure who are being worked up for left ventricular assist device (LVAD) placement or cardiac transplantation (Figure 1).10 The short-form MNA (MNA-SF) is an abbreviated 6-question subset of the full-form MNA. Use of the MNA-SF can be instituted as a time- and cost-saving measure in the establishment of clinical dietary needs. The diagnostic accuracy of the MNA-SF has been shown to be comparable to the full-form assessment in elderly populations (Figure 2).11,12 At this time, the applicability of the MNA-SF in the setting of AHF has not
been studied. The aim of our research was to determine the clinical utility of the MNA-SF in our LVAD and cardiac transplantation workup population as a time- and resource-saving surrogate for the full-form assessment.
Methods This is a retrospective study of patients with AHF who underwent a workup procedure for potential LVAD placement or cardiac transplantation. Inclusion criteria for the study were (1) diagnosis of AHF based on clinical evaluation, (2) age older than 18 years, (3) ability to comprehend and appropriately answer the MNA questionnaire administered by our dietician, and (4) workup for potential LVAD placement/cardiac transplantation. Exclusion criteria included incomplete data for either the short-form or long-form MNA (n = 25). From the 1Center for Heart Transplant and Assist Devices, Advocate Christ Medical Center, Oak Lawn, Illinois, and 2Department of Clinical Nutrition, Advocate Christ Medical Center, Oak Lawn, Illinois. Financial disclosure: None declared. This article originally appeared online on May 27, 2014. Corresponding Author: Geetha Bhat, PhD, MD, Medical Director Center for Heart Transplant and Assist Devices, Advocate Christ Medical Center, 4400 West 95th St, Oak Lawn, IL 60453, USA. Email: [email protected]
Downloaded from ncp.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 1, 2015
Yost et al
687
Figure 1. Full-form Nestlé Mini Nutritional Assessment (MNA). © Nestlé, 1994, Revision 2009. N67200 12/99 10M.
Downloaded from ncp.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 1, 2015
688
Nutrition in Clinical Practice 29(5)
Figure 2. Short-form Nestlé Mini Nutritional Assessment (MNA).© Nestlé, 1994, Revision 2009. N67200 12/99 10M.
Downloaded from ncp.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 1, 2015
Yost et al
689
The clinical records of 187 consecutive patients meeting the inclusion criteria were initially gathered. Twenty-five patients were removed following application of exclusion criteria, leaving a final cohort of 162. Type of LVAD, date of transplantation, MNA score, MNA-SF score, and survival were collected. Biochemical parameters, including serum urea nitrogen, creatinine, B-type natriuretic peptide, serum albumin, and hemoglobin, were collected in the preoperative and postoperative periods. All patients undergoing a workup for surgical intervention completed an MNA in the first week of hospital admission following initial stabilization. The MNA uses an 18-item questionnaire composed of 4 sections: general status, anthropometrics, dietary aspects, and subjective assessment (Figure 1). Anthropometry required the measurement of patient height, weight, calf circumference, and mid-arm circumference using standardized protocol. All tests were administered by a single trained dietitian. Administration of the MNA followed the same protocol described by Aggarwal et al10 in 2012. The full-length MNA was used to establish categorization of malnourished, at risk of malnutrition, or well nourished based on each patient’s cumulative score. All questions required for the MNA-SF are included in the full MNA, allowing for simultaneous administration of the 2 tests. The possible MNA scores range from 0 to 30. Patient categories are based on score: malnourished (
research-article2014
NCPXXX10.1177/0884533614535269Nutrition in Clinical Practice X(X)Yost et al
Clinical Research
Short-Form Nutrition Assessment in Patients With Advanced Heart Failure Evaluated for Ventricular Assist Device Placement or Cardiac Transplantation
Nutrition in Clinical Practice Volume 29 Number 5 October 2014 686–691 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614535269 ncp.sagepub.com hosted at online.sagepub.com
Gardner Yost, BS1; Mary Gregory, RD, LDN2; and Geetha Bhat, PhD, MD1
Abstract Background: It has been shown that malnutrition affects clinical outcomes in patients with advanced heart failure and that nutrition status, as determined by the Mini Nutritional Assessment (MNA), can be used as an independent predictor of mortality. The aim of this study was to evaluate the prognostic utility of the short-form MNA (MNA-SF) as a surrogate to the MNA in patients with advanced heart failure. Methods: Data retrospectively gathered from nutrition assessments of 162 patients were analyzed. Results: As defined by the MNA, the cohort included 40 (24.7%) patients classified as malnourished, 106 (65.4%) classified as at risk, and 16 (9.9%) classified as well nourished. The mortality for the groups was 37.3%, 47.4%, and 40.5%, respectively. A linear regression showed strong correlation between the MNA and MNA-SF (r = 0.778, P < .0001). A significant difference was observed in survival between the undernourished state (at risk + malnourished) and the well-nourished state, as determined by the MNA-SF (P < .001). Conclusions: The MNA-SF is a rapid nutrition assessment that correlates strongly with the full-form MNA and is an independent predictor of mortality. (Nutr Clin Pract. 2014;29:686-691)
Keywords heart-assist devices; nutritional status; malnutrition; nutrition assessment; heart transplantation; screening; heart failure
Although treatment of advanced heart failure (AHF) has improved significantly in recent decades, clinical prognosis remains poor, with half of patients dying within 4 years of diagnosis.1 Malnutrition is known to influence the progression of many chronic diseases, including AHF, where it has been shown to predict adverse outcomes.2,3 Cardiac cachexia, often characterized by weight loss, increased lipolysis, lack of appetite, malabsorption, and homeostatic disruption of multiple body systems, is known to affect prognosis.4,5 The Mini Nutritional Assessment (MNA) is a simple questionnaire-based tool that is notably sensitive (96%), specific (98%), and predictive (97%).6 It has been substantially validated using clinical status and comprehensive nutrition assessment in the setting of home care, outpatient therapy, and general practice as well as in hospitalized and institutionalized patients.7-9 Recently, the MNA was shown to be an independent predictor of mortality in patients with heart failure and in patients with heart failure who are being worked up for left ventricular assist device (LVAD) placement or cardiac transplantation (Figure 1).10 The short-form MNA (MNA-SF) is an abbreviated 6-question subset of the full-form MNA. Use of the MNA-SF can be instituted as a time- and cost-saving measure in the establishment of clinical dietary needs. The diagnostic accuracy of the MNA-SF has been shown to be comparable to the full-form assessment in elderly populations (Figure 2).11,12 At this time, the applicability of the MNA-SF in the setting of AHF has not
been studied. The aim of our research was to determine the clinical utility of the MNA-SF in our LVAD and cardiac transplantation workup population as a time- and resource-saving surrogate for the full-form assessment.
Methods This is a retrospective study of patients with AHF who underwent a workup procedure for potential LVAD placement or cardiac transplantation. Inclusion criteria for the study were (1) diagnosis of AHF based on clinical evaluation, (2) age older than 18 years, (3) ability to comprehend and appropriately answer the MNA questionnaire administered by our dietician, and (4) workup for potential LVAD placement/cardiac transplantation. Exclusion criteria included incomplete data for either the short-form or long-form MNA (n = 25). From the 1Center for Heart Transplant and Assist Devices, Advocate Christ Medical Center, Oak Lawn, Illinois, and 2Department of Clinical Nutrition, Advocate Christ Medical Center, Oak Lawn, Illinois. Financial disclosure: None declared. This article originally appeared online on May 27, 2014. Corresponding Author: Geetha Bhat, PhD, MD, Medical Director Center for Heart Transplant and Assist Devices, Advocate Christ Medical Center, 4400 West 95th St, Oak Lawn, IL 60453, USA. Email: [email protected]
Downloaded from ncp.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 1, 2015
Yost et al
687
Figure 1. Full-form Nestlé Mini Nutritional Assessment (MNA). © Nestlé, 1994, Revision 2009. N67200 12/99 10M.
Downloaded from ncp.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 1, 2015
688
Nutrition in Clinical Practice 29(5)
Figure 2. Short-form Nestlé Mini Nutritional Assessment (MNA).© Nestlé, 1994, Revision 2009. N67200 12/99 10M.
Downloaded from ncp.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 1, 2015
Yost et al
689
The clinical records of 187 consecutive patients meeting the inclusion criteria were initially gathered. Twenty-five patients were removed following application of exclusion criteria, leaving a final cohort of 162. Type of LVAD, date of transplantation, MNA score, MNA-SF score, and survival were collected. Biochemical parameters, including serum urea nitrogen, creatinine, B-type natriuretic peptide, serum albumin, and hemoglobin, were collected in the preoperative and postoperative periods. All patients undergoing a workup for surgical intervention completed an MNA in the first week of hospital admission following initial stabilization. The MNA uses an 18-item questionnaire composed of 4 sections: general status, anthropometrics, dietary aspects, and subjective assessment (Figure 1). Anthropometry required the measurement of patient height, weight, calf circumference, and mid-arm circumference using standardized protocol. All tests were administered by a single trained dietitian. Administration of the MNA followed the same protocol described by Aggarwal et al10 in 2012. The full-length MNA was used to establish categorization of malnourished, at risk of malnutrition, or well nourished based on each patient’s cumulative score. All questions required for the MNA-SF are included in the full MNA, allowing for simultaneous administration of the 2 tests. The possible MNA scores range from 0 to 30. Patient categories are based on score: malnourished (
