Nutritional Status in Patients with Acute heart failure: A systematic review and meta-analysis with trial sequential analysis
Authors: Belayachi Jihane , Katir Imane , Bennis Rhita Nechba , Madani Naoufel , Abouqal Redouane 
Published: January 2021

A critical review of the prognosis impact of malnutrition in patients admitted with acute heart failure (AHF) has never been performed. We systematically reviewed the observational epidemiology literature to determine the all-cause mortality (ACM) in undernourished patients with acute heart failure or at risk of malnutrition through a meta-analysis of observational studies.

A systemic search using PubMed, Scopus, and Web of Science was done for articles reporting an association between malnutrition and mortality in patient with acute heart failure published before December 2019. Original data from observational cohort studies in patients with acute heart failure at baseline, and with nutritional state evaluation at admission using screening, or assessment tools. The outcome of interest was mortality independent of the timeframe for follow up. The characteristics of the included study were collected. Data quality assessment using the Newcastle Ottawa Quality Assessment Scale. The hazard ratios (HRs) and corresponding 95% confidence intervals (CIs) were extracted. For the meta-analysis, a random-effects model was considered.

Heterogeneity between studies was assessed using Cochran Q statistics and I2 statistics. Subgroup analyses were used to identify the source of heterogeneity. A sensitive analysis was performed to reflect the influence of the individual data set on the pooled HR. Publication bias was detected using the Doi plot and Luis Furuya-Kanamori asymmetry index (LFK index). The influence of potential publication bias on results was explored by using the trim-and-fill procedure. To assess the risks of random errors, trial sequential analysis (TSA) was performed.

Seven studies were eligible for review and meta-analysis. There were 9053 participants and over 1536 events occurred. The prevalence of malnutrition varied from 33% to 78.8%. Mean follow-up varied between 189 and 951 days. ACM rates varied between 7% and 42.6%. Nutritional status is significantly associated with mortality in patients with AHF (Pooled HR=1.15;95%CI[1.08-1.23]). Considerable between-study heterogeneity was observed (I2=83%, P=0.001). Heterogeneity was partially explained by the different tools used to screen malnutrition risk, and follow-up durations used by the included studies. There was evidence of major publication bias regarding the risk of malnutrition-related to ACM. The obtained LFK index was 6.12 and suggests major asymmetry. The recalculated pooled HR that incorporates the hypothetical missing studies is 1.15; 95%CI (1.08-1.22). However, the accumulating number of participants and the required information size has not yet been achieved. Then, the trial sequential monitoring boundary is inconclusive.

This first meta-analysis of the association between nutritional status in patients with acute heart failure and all-cause mortality indicated that malnutrition risk in a patient with acute heart failure was associated with increased all-cause mortality. The prognosis impact of malnutrition is real despite heterogeneity in tools and cut off for defining malnutrition and mean follow up duration. This review underlines the peremptory need for multicenter studies, for uniform guidelines for assessing nutritional status, and for reporting guidelines for prognostic studies in an acute cardiovascular setting. Better nutritional practice to improve patient care is emphasized in international and national health care guidelines.