International Journal of Cardiology 177 (2014) 1140–1141
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
The relation between Geriatric Nutritional Risk Index and muscle mass, muscle strength, and exercise capacity in chronic heart failure patients☆ Kazuhiro P. Izawa a,i,⁎, Satoshi Watanabe b, Yasuyuki Hirano c, Shuhei Yamamoto b, Koichiro Oka d, Norio Suzuki i, Keisuke Kida i, Kengo Suzuki i, Naohiko Osada e, Kazuto Omiya f, Peter H. Brubaker g, Hiroyuki Shimizu h, Yoshihiro J. Akashi i a
Graduate School of Health Sciences, Kobe University, Kobe, Japan Department of Rehabilitation Medicine, St. Marianna University School of Medicine Hospital, Kawasaki, Japan c Department of Physical Therapy, Tokushima Bunri University, Tokushima, Japan d Faculty of Sport Sciences, Waseda University, Tokorozawa, Japan e Division of Cardiology, St. Marianna University Toyoko Hospital, Kawasaki, Japan f Department of Cardiology, St. Marianna University Yokohama City Seibu Hospital, Yokohama, Japan g Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, USA h Department of Orthopedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan i Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan b
a r t i c l e
i n f o
Article history: Received 1 August 2014 Received in revised form 5 August 2014 Accepted 9 August 2014 Available online 15 August 2014 Keywords: Geriatric Nutritional Risk Index Muscle mass Muscle strength Exercise capacity Chronic heart failure
A previous report suggested positive correlations between peak oxygen uptake (peak VO2) and measures of muscle strength such as handgrip strength (HG), knee extensor muscle strength (KEMS), inspiratory muscle pressure (MIP), and expiratory muscle pressure (MEP) in chronic heart failure (CHF) patients [1]. In addition, skeletal muscle mass independently predicts ventilator response, as measured by the regression slope relating minute ventilation to carbon dioxide output (VE/VCO2 slope), in noncachectic patients with CHF [2]. In addition, a recent report suggested that poor nutritional status as assessed by the Geriatric Nutritional Risk Index (GNRI) can predict both functional dependency at hospital discharge and dependence in activities of daily living and mortality in heart failure inpatients [3]. Thus, we hypothesized a relation between GNRI and muscle mass, muscle strength, and
☆ Work was performed in the Department of Rehabilitation Medicine, St. Marianna University School of Medicine Hospital, Kanagawa, Japan. ⁎ Corresponding author at: Graduate School of Health Sciences, Kobe University, 10-2 Tomogaoka 7-chome Suma, Kobe 654-0142, Japan. Tel.: +81 78 796 4566. E-mail address: [email protected] (K.P. Izawa).
http://dx.doi.org/10.1016/j.ijcard.2014.08.045 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
exercise capacity in CHF patients. We performed a cross-sectional study to determine a possible relation between GNRI and muscle mass, muscle strength, and exercise capacity in CHF patients. We selected 102 consecutive outpatients with stable CHF who visited St. Marianna University School of Medicine Hospital for the first-time evaluation of muscle mass, strength, and exercise capacity. Patients with neurological, peripheral vascular, orthopedic, or pulmonary disease were excluded. We evaluated participant characteristics including age, sex, body mass index, left ventricular ejection fraction, brain natriuretic peptide concentration, serum albumin level, New York Heart Association class, etiology, and medications. Average values of right- and left-side upper extremity muscle mass (UEMM) and lower extremity muscle mass (LEMM) were determined by bioelectrical impedance analysis (Muscle-α, Art Haven 9 Co. Ltd.), and VE/VCO2 slope was assessed by cardiopulmonary exercise testing using a ramp protocol cycle ergometer with an Aeromonitor AE-310S (Minato Medical Co., Ltd.) [4]. MIP and MEP were assessed by a multifunctional spirometer (HI-801; CHEST Co., Ltd.). Average right and left HG was measured with a JAMAR hand dynamometer (Bissell Healthcare Co., Ltd.), and KEMS was measured with a System II isokinetic dynamometer (Biodex Medical Systems, Co., Ltd.). The present study was approved by the St. Marianna University School of Medicine Institutional Committee on Human Research, and informed consent was obtained from each participant. Results are expressed as mean ± standard deviation (SD). The relation between GNRI and UEMM, LEMM, MIP, MEP, HG, KEMS, and VE/VCO2 slope in all subjects was assessed by Pearson's correlation coefficients. A p value of b 0.05 was considered significant. Statistical analyses were performed with IBM SPSS 17.0 J statistical software. Clinical characteristics of the patients are shown in Table 1. Average values were as follows: GNRI, 106.7 ± 11.4; UEMM, 1.1 ± 0.4 kg; LEMM, 4.6 ± 1.6 kg; MIP, 78.5 ± 33.8 cm H2O; MEP, 100.2 ± 44.7 cm H2O; HG, 34.7 ± 10.5 kgf; KEMS, 1.7 ± 0.4 Nm/kg; and VE/VCO2 slope, 32.9 ± 7.5. There was a positive correlation between GNRI and
K.P. Izawa et al. / International Journal of Cardiology 177 (2014) 1140–1141
1141
Table 1 Clinical characteristics of the patients. No. of patients Age (years) Male sex (%) Body mass index (kg/m2) LVEF (%) Brain natriuretic peptide (pg/ml) Albumin (%) NYHA (Class I/II/III) (N) Etiology (%) Cardiomyopathy Previous myocardial infarction Arrhythmia CABG/VR Medications (%) Βeta-blockers Angiotensin receptor blocker ACEI Diuretics
102 56.4 ± 13.4 80.4 23.8 ± 4.2 32.2 ± 7.1 245.8 ± 226.9 4.1 ± 0.4 37/48/17 53.9 24.5 12.7 8.9 80.1 41.8 49.3 84.9
ACEI = angiotensin converting enzyme inhibitor; CABG = coronary artery bypass grafting; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association; VR = valve replacement.
UEMM (r = 0.50, p b 0.01), LEMM (r = 0.55, p b 0.01), MIP (r = 0.43, p b 0.01), MEP (r = 0.48, p b 0.01), HG (r = 0.45, p b 0.01), and KEMS (r = 0.38, p b 0.01) and a negative correlation between GNRI and VE/VCO2 slope (r = − 0.44, p b 0.01) in all patients (Fig. 1). The present data extend the findings of our previous study [5] on hospitalized Japanese male cardiac inpatients, which provided the first evidence that poor nutritional status may cause a reduction in physical function as assessed by HG, KEMS, gait speed, and one-leg standing time [5]. The 251 subjects (mean age: 74.7 years) of that study were divided into a low GNRI and high GNRI group for the evaluation of nutritional status by GNRI. The values of HG, KEMS, gait speed, and one-leg standing time in the low GNRI group were all significantly lower than those in the high GNRI group. We also previously reported on 235 consecutive elderly hospitalized cardiac inpatients (mean age: 73.6 years, men: 70.6%) with poor nutritional status as indicated by a low GNRI and found GNRI to be a useful predictor of step counts attained and physical activity energy expended in these patients [6]. The present study showed positive correlations between nutritional status and muscle mass, HG, and KEMS as well as with MIP and MEP, measures of respiratory muscle function. Moreover, a lower GNRI was related to a higher VE/VCO2 slope, indicating that improvement of nutritional status might also be effective in improving exercise capacity in CHF patients. The present findings suggest that poor nutritional status might affect not only upper and lower extremity muscle mass and strength but also respiratory muscle function and ventilation in CHF patients. This study was limited by the absence of longitudinal data in these CHF patients, and we did not evaluate a cause and effect relationship between GNRI and these values in CHF patients. Because nutritional status as indicated by the GNRI can either positively or negatively affect muscle mass, muscle strength, and exercise capacity in CHF patients, it must be considered when evaluating these factors. CHF patients may require additional attention to nutritional
(r= -0.44, P
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
The relation between Geriatric Nutritional Risk Index and muscle mass, muscle strength, and exercise capacity in chronic heart failure patients☆ Kazuhiro P. Izawa a,i,⁎, Satoshi Watanabe b, Yasuyuki Hirano c, Shuhei Yamamoto b, Koichiro Oka d, Norio Suzuki i, Keisuke Kida i, Kengo Suzuki i, Naohiko Osada e, Kazuto Omiya f, Peter H. Brubaker g, Hiroyuki Shimizu h, Yoshihiro J. Akashi i a
Graduate School of Health Sciences, Kobe University, Kobe, Japan Department of Rehabilitation Medicine, St. Marianna University School of Medicine Hospital, Kawasaki, Japan c Department of Physical Therapy, Tokushima Bunri University, Tokushima, Japan d Faculty of Sport Sciences, Waseda University, Tokorozawa, Japan e Division of Cardiology, St. Marianna University Toyoko Hospital, Kawasaki, Japan f Department of Cardiology, St. Marianna University Yokohama City Seibu Hospital, Yokohama, Japan g Department of Health and Exercise Science, Wake Forest University, Winston-Salem, NC, USA h Department of Orthopedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan i Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan b
a r t i c l e
i n f o
Article history: Received 1 August 2014 Received in revised form 5 August 2014 Accepted 9 August 2014 Available online 15 August 2014 Keywords: Geriatric Nutritional Risk Index Muscle mass Muscle strength Exercise capacity Chronic heart failure
A previous report suggested positive correlations between peak oxygen uptake (peak VO2) and measures of muscle strength such as handgrip strength (HG), knee extensor muscle strength (KEMS), inspiratory muscle pressure (MIP), and expiratory muscle pressure (MEP) in chronic heart failure (CHF) patients [1]. In addition, skeletal muscle mass independently predicts ventilator response, as measured by the regression slope relating minute ventilation to carbon dioxide output (VE/VCO2 slope), in noncachectic patients with CHF [2]. In addition, a recent report suggested that poor nutritional status as assessed by the Geriatric Nutritional Risk Index (GNRI) can predict both functional dependency at hospital discharge and dependence in activities of daily living and mortality in heart failure inpatients [3]. Thus, we hypothesized a relation between GNRI and muscle mass, muscle strength, and
☆ Work was performed in the Department of Rehabilitation Medicine, St. Marianna University School of Medicine Hospital, Kanagawa, Japan. ⁎ Corresponding author at: Graduate School of Health Sciences, Kobe University, 10-2 Tomogaoka 7-chome Suma, Kobe 654-0142, Japan. Tel.: +81 78 796 4566. E-mail address: [email protected] (K.P. Izawa).
http://dx.doi.org/10.1016/j.ijcard.2014.08.045 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
exercise capacity in CHF patients. We performed a cross-sectional study to determine a possible relation between GNRI and muscle mass, muscle strength, and exercise capacity in CHF patients. We selected 102 consecutive outpatients with stable CHF who visited St. Marianna University School of Medicine Hospital for the first-time evaluation of muscle mass, strength, and exercise capacity. Patients with neurological, peripheral vascular, orthopedic, or pulmonary disease were excluded. We evaluated participant characteristics including age, sex, body mass index, left ventricular ejection fraction, brain natriuretic peptide concentration, serum albumin level, New York Heart Association class, etiology, and medications. Average values of right- and left-side upper extremity muscle mass (UEMM) and lower extremity muscle mass (LEMM) were determined by bioelectrical impedance analysis (Muscle-α, Art Haven 9 Co. Ltd.), and VE/VCO2 slope was assessed by cardiopulmonary exercise testing using a ramp protocol cycle ergometer with an Aeromonitor AE-310S (Minato Medical Co., Ltd.) [4]. MIP and MEP were assessed by a multifunctional spirometer (HI-801; CHEST Co., Ltd.). Average right and left HG was measured with a JAMAR hand dynamometer (Bissell Healthcare Co., Ltd.), and KEMS was measured with a System II isokinetic dynamometer (Biodex Medical Systems, Co., Ltd.). The present study was approved by the St. Marianna University School of Medicine Institutional Committee on Human Research, and informed consent was obtained from each participant. Results are expressed as mean ± standard deviation (SD). The relation between GNRI and UEMM, LEMM, MIP, MEP, HG, KEMS, and VE/VCO2 slope in all subjects was assessed by Pearson's correlation coefficients. A p value of b 0.05 was considered significant. Statistical analyses were performed with IBM SPSS 17.0 J statistical software. Clinical characteristics of the patients are shown in Table 1. Average values were as follows: GNRI, 106.7 ± 11.4; UEMM, 1.1 ± 0.4 kg; LEMM, 4.6 ± 1.6 kg; MIP, 78.5 ± 33.8 cm H2O; MEP, 100.2 ± 44.7 cm H2O; HG, 34.7 ± 10.5 kgf; KEMS, 1.7 ± 0.4 Nm/kg; and VE/VCO2 slope, 32.9 ± 7.5. There was a positive correlation between GNRI and
K.P. Izawa et al. / International Journal of Cardiology 177 (2014) 1140–1141
1141
Table 1 Clinical characteristics of the patients. No. of patients Age (years) Male sex (%) Body mass index (kg/m2) LVEF (%) Brain natriuretic peptide (pg/ml) Albumin (%) NYHA (Class I/II/III) (N) Etiology (%) Cardiomyopathy Previous myocardial infarction Arrhythmia CABG/VR Medications (%) Βeta-blockers Angiotensin receptor blocker ACEI Diuretics
102 56.4 ± 13.4 80.4 23.8 ± 4.2 32.2 ± 7.1 245.8 ± 226.9 4.1 ± 0.4 37/48/17 53.9 24.5 12.7 8.9 80.1 41.8 49.3 84.9
ACEI = angiotensin converting enzyme inhibitor; CABG = coronary artery bypass grafting; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association; VR = valve replacement.
UEMM (r = 0.50, p b 0.01), LEMM (r = 0.55, p b 0.01), MIP (r = 0.43, p b 0.01), MEP (r = 0.48, p b 0.01), HG (r = 0.45, p b 0.01), and KEMS (r = 0.38, p b 0.01) and a negative correlation between GNRI and VE/VCO2 slope (r = − 0.44, p b 0.01) in all patients (Fig. 1). The present data extend the findings of our previous study [5] on hospitalized Japanese male cardiac inpatients, which provided the first evidence that poor nutritional status may cause a reduction in physical function as assessed by HG, KEMS, gait speed, and one-leg standing time [5]. The 251 subjects (mean age: 74.7 years) of that study were divided into a low GNRI and high GNRI group for the evaluation of nutritional status by GNRI. The values of HG, KEMS, gait speed, and one-leg standing time in the low GNRI group were all significantly lower than those in the high GNRI group. We also previously reported on 235 consecutive elderly hospitalized cardiac inpatients (mean age: 73.6 years, men: 70.6%) with poor nutritional status as indicated by a low GNRI and found GNRI to be a useful predictor of step counts attained and physical activity energy expended in these patients [6]. The present study showed positive correlations between nutritional status and muscle mass, HG, and KEMS as well as with MIP and MEP, measures of respiratory muscle function. Moreover, a lower GNRI was related to a higher VE/VCO2 slope, indicating that improvement of nutritional status might also be effective in improving exercise capacity in CHF patients. The present findings suggest that poor nutritional status might affect not only upper and lower extremity muscle mass and strength but also respiratory muscle function and ventilation in CHF patients. This study was limited by the absence of longitudinal data in these CHF patients, and we did not evaluate a cause and effect relationship between GNRI and these values in CHF patients. Because nutritional status as indicated by the GNRI can either positively or negatively affect muscle mass, muscle strength, and exercise capacity in CHF patients, it must be considered when evaluating these factors. CHF patients may require additional attention to nutritional
(r= -0.44, P
