Original Article
Clinical
Nutritional Intervention in Malnourished Hospitalized Patients with Heart Failure

https://doi.org/10.1016/j.arcmed.2016.11.005Get rights and content

Background and Aims

Hospitalized patients with heart failure who are malnourished present a worse prognosis than those with an adequate nutritional status. We undertook this study to assess whether a nutritional intervention in malnourished hospitalized patients with heart failure benefits morbidity and mortality.

Methods

A multicenter, randomized, controlled clinical trial was conducted. A total of 120 malnourished hospitalized patients due to acute heart failure were randomised to conventional heart failure treatment or conventional heart failure treatment combined with an individualized nutritional intervention. The primary endpoint of this study was a composite of all-cause death or readmission for worsening of HF, with a maximum follow-up of 12 months. Analysis was by intention to treat.

Results

Recruitment was stopped early according to the study protocol after completing the follow-up of the first 120 patients enrolled (59 in the intervention group and 61 in the control group). Both groups were homogeneous in baseline characteristics. At 12 months, the primary outcome occurred in 27.1% of patients in the intervention group and in 60.7% of patients in the control group (hazard ratio 0.45; 95% confidence interval [CI], 0.19–0.62, p = 0.0004). In total, 20.3% of patients died in the intervention group and 47.5% in the control group (hazard ratio 0.37, 95% CI, 0.19–0.72, p = 0.003). Readmission due to heart failure was also lower in the intervention group (10.2 vs. 36.1%, p = 0.001).

Conclusion

Nutritional intervention in malnourished hospitalized patients with heart failure reduces the risk of death from any cause and the risk of readmission for worsening of heart failure (ClinicalTrial.gov NCT01472237).

Introduction

Malnutrition is a prevalent disorder that affects up to 25% of patients hospitalized with heart failure (1). These patients show a worse prognosis than those with an adequate nutritional status; thus, malnutrition is associated with higher mortality (2) and with an increased risk of readmission due to heart failure (3), as well as being an independent predictor of mortality 1, 2. Despite the clinical relevance of malnutrition in these patients, it is unknown whether a nutritional intervention can modify their prognosis. Only a few studies published to date have assessed the effect of nutritional intervention in patients with heart failure, and those studies have assessed the effect on general series regardless of the baseline nutritional status of the patient, with modest aims and without assessing the effect on survival or hospital admission 4, 5, 6. The proposals and results were similar in patients with cardiac cachexia (7).

The main aim of the PICNIC study (Nutritional Intervention Program in Hospitalised Patients with Heart Failure who are Malnourished) was to assess whether a nutritional intervention in malnourished hospitalized patients with heart failure provides benefits in terms of morbidity and mortality.

Section snippets

Patients and Methods

The study design has been previously published (8). PICNIC is a multicenter, randomized controlled clinical trial in which patients >18 years old hospitalized for acute heart failure, either decompensated chronic heart failure or new onset heart failure, also presenting malnutrition, were randomly assigned to a conventional treatment for heart failure or a conventional treatment for heart failure combined with a more individualized nutritional intervention. The investigation conforms with the

Results

A total of 120 patients were included in the study: 59 in the intervention group and 61 in the control group. Follow-up data were obtained from all of these patients. Both groups were homogeneous in baseline characteristics (Table 1, Table 2). During hospitalization, three patients died: one from the control group died due to heart failure progression, and two in the intervention group died, one due to sudden death and the other due to heart failure progression. The latter died after 30 days of

Discussion

Despite the prognostic impact of malnutrition in patients with heart failure, there are currently no specific nutritional recommendations for patients with heart failure or the subgroup of malnourished patients. The PICNIC study is the first randomized study showing the prognostic benefit of a nutritional intervention in malnourished heart failure patients. Thus, this study conclusively demonstrates that an individualized nutritional intervention in the terms expressed in the protocol reduces

Acknowledgments

We would like to thank Isabel Pérez, Victoriana Santiago, María Teresa Medina, Catalina Redondo and Carlos Ráez for their work.

Funding: This work was supported by the Spanish Society of Cardiology as a Project of the Spanish Society of Cardiology for Clinical Research in Cardiology.

Disclosures: The authors declare that there is no conflict of interest.

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