Mortality rates 1 year after transcatheter or surgical aortic valve replacement are approximately three times higher among older adults with signs and symptoms of malnutrition, according to new data published in Circulation.
“In addition to the prognostic value of identifying malnutrition, there is potentially actionable therapeutic value for implementing nutritional interventions that have been shown to be effective in preventing morbidity and mortality,” Michael Goldfarb, MD, from the Azrieli Heart Center, Jewish General Hospital at McGill University in Montreal, and colleagues wrote in the study background. “While nutritional guidelines recommend screening for nutrition risk in all hospitalized older adults, they acknowledge that this is based on low levels of evidence stemming from small uncontrolled studies. Likewise, an international consensus statement on nutrition in cardiac surgery concluded that ‘valid and reliable data are urgently needed to improve the so-far non-standardized clinical practice of nutrition screening.’”
To assess the prevalence and prognostic association between malnutrition screening and mortality after AVR, the researchers conducted the FRAILTY-AVR prospective multicenter international cohort study.
The study was conducted in 14 centers in three countries between 2012 and 2017 and included patients aged at least 70 years who underwent TAVR or surgical AVR.
Trained observers assessed the Mini Nutritional Assessment-Short Form (MNA-SF) before the procedure, with scores of 7 or less considered malnourished and 8 to 11 considered at-risk for malnutrition.
The researchers simultaneously assessed the Short Performance Physical Battery (SPPB) to measure physical frailty, with scores of 5 or less considered severely frail and 6 to 8 considered mildly frail.
The primary outcome was 1-year all-cause mortality and the secondary outcome was 30-day composite mortality or major morbidity. Goldfarb and colleagues used multivariable regression models to adjust for potential confounders.
Malnutrition and mortality
Of the 1,158 patients included in the study (mean age, 81 years; 45% women), 8.7% were classified as malnourished and 32.8% were at-risk for malnutrition.
According to the results of the study, MNA-SF scores were moderately correlated with SPPB scores (Spearman rank correlation = 0.31; P < .001).
Among the TAVR cohort, there were 126 deaths during the study period (19.1 per 100 patient-years), and in the surgical AVR group, there were 30 deaths (7.5 per 100 patient-years).
Malnourished patients had a nearly threefold higher crude risk for 1-year mortality compared with those with normal nutritional status (28% vs. 10%, P < .001).
After adjusting for frailty, Society of Thoracic Surgeons Predicted Risk of Mortality score and procedure type, preprocedural nutritional status was a significant predictor of 1-year mortality (OR = 1.08 per MNA-SF point; 95% CI, 1.01-1.16) and of the 30-day composite safety endpoint (OR = 1.06 per MNA-SF point; 95% CI, 1-1.12).
Support may be needed
“Given the evidence available at this time, preoperative nutritional support may be considered in the malnourished patient when elective surgery can be safely postponed for one week or more. In addition, there may be a role for more intensive postoperative nutritional support in the malnourished or at-risk patient,” the researchers wrote. “An ongoing clinical trial is investigating the feasibility and value of a multidisciplinary strategy involving nutritional support for preprocedural optimization (‘prehab’) in older adults prior to elective cardiac surgery.” – by Dave Quaile
Disclosures: The authors report no relevant financial disclosures.