Geriatric patients who did not get their nutrition on track after transcatheter aortic valve replacement (TAVR) suffered worse long-term outcomes, a single center study from Spain showed.
Before TAVR, 61.4% of 433 elderly patients scored as nutritional risk (or malnourished) on the geriatric nutritional risk index (GNRI), Diego López Otero, MD, PhD, of Hospital Clínico Universitario de Santiago de Compostela, Spain, and colleagues reported online in Circulation: Cardiovascular Interventions.
Remaining malnourished from day of TAVR to 3 months later was an independent predictor of death and heart failure events over follow-up averaging 2.7 years from the 3-month mark:
- All-cause mortality: HR 2.10, 95% CI 1.30-3.39
- Heart failure hospitalization: HR 1.97, 95% CI 1.26-3.06
- Composite of both: HR 2.0, 95% CI 1.37-2.91
On the other hand, moving out of the malnourished category was associated with better long-term outcomes than staying that way for the 3 months:
- All-cause mortality: HR 0.48, 95% CI 0.30-0.78
- Heart failure hospitalization: HR 0.50, 95% CI 0.34-0.74
- Composite of both: HR 0.44, 95% CI 0.32-0.62
“From our perspective, these results are interesting as it can raise concerns about whether pre-TAVR and post-TAVR nutritional interventions could improve the prognosis of TAVR patients. In addition, this makes it important to emphasize that it is necessary to incorporate the nutritional screening as a component of frailty assessment in the selection of patients who are candidates for TAVR,” López Otero’s group said.
Nutrition generally improved in the study: mean GNRI improved from 97.9 to 104.0 points, and just 25.2% of people were malnourished at 3 months post-TAVR. A full 68.4% of patients with baseline malnutrition had improved their nutrition after the procedure.
Study authors noted that nutritional status is a marker of frailty, but acknowledged that they did not perform a formal frailty assessment among patients.
The GNRI, “as part of a comprehensive geriatric evaluation, could indicate which patients at nutritional risk would require close clinical monitoring, as well as nutritional intervention program, to improve their nutritional and functional status, and ultimately their prognosis,” they suggested.
“Nutrition, or more appropriately malnutrition, is appearing to be another piece of the puzzle in our quest for continued progress [for patients with severe symptomatic aortic stenosis]. The mandate is clear; we must evaluate nutritional status and pursue the rigorous evaluation of potential interventions to evaluate whether we can further improve patient outcomes,” commented Paul Ohayon, MD, and Anita Asgar, MD, MSc, both of the Montreal Heart Institute in Quebec.
“Malnutrition is highly prevalent in the geriatric population, reported in up to 50% of older adults and is associated with decreased food intake, as well as increased energy needs in the setting of acute or chronic illness,” they noted in an accompanying editorial.
The observational study was conducted at López Otero’s institution. Included were 433 consecutive patients with severe symptomatic aortic stenosis who received TAVR from 2008 to 2019.
This was an elderly population (average age around 82 years) with increased surgical risk. Roughly half of participants were women.
GNRI was calculated using serum albumin, actual body weight, and ideal body weight.
People with baseline nutritional risk were particularly likely to have a history of stroke, a low estimated glomerular filtration rate (eGFR), and left ventricular ejection fraction below 50%.
Those who stayed malnourished after TAVR tended to have comorbid conditions such as chronic obstructive pulmonary disease, a low eGFR, and high surgical risk.
Change in status in the other direction — from not malnourished to malnourished — was observed in 15% of those without baseline GNRI risk. These individuals were more likely, compared with peers not changing nutrition status, to have had an in-hospital stroke and require percutaneous coronary intervention before TAVR.
Over follow-up, a total of 36.3% patients died and 39.7% were hospitalized due to heart failure.
López Otero’s group cautioned that the report was not powered to detect differences in adverse event rates between nutritional risk subgroups. The observational nature of the data also precluded any causal inferences from being drawn.
“In fact, some of these findings may in fact be related to the presence of patient frailty which is already known to have an impact on outcomes,” wrote Ohayon and Asgar.
“This does not, however, take away from the important recurring message from this study and others; malnutrition is associated with poor outcomes. The evaluation of geriatric patients undergoing cardiac procedures, including TAVR, would likely benefit from the addition of a nutritional screening, such as the Mini Nutritional Assessment or GNRI,” according to the editorialists.
Randomized trials are still needed to show that nutritional interventions really improve outcomes after TAVR.
According to Ohayon and Asgar, the ongoing PERFORM-TAVR trial may provide some answers, as investigators are planning to randomize 200 patients to usual lifestyle counseling or a multi-faceted intervention consisting of a home-based exercise program and a protein-rich oral nutritional supplement.
López Otero, Ohayon, and Asgar had no disclosures.
A study coauthor reported proctoring for Medtronic.