Verification of the impact of the improvement and worsening of anemia after discharge of heart failure on cardiorenal nutrition and the prognosis of HFpEF from the PURSUIT-HFpEF registry
Authors: Kitao T , Tamaki S , Yano M , Hayashi T , Yamada T , Yasumura Y , Hikoso S , Sotomi Y , Sakata Y 
Published: October 2022

Abstract

Background
Anemia has been reported as poor prognostic factor on heart failure with preserved ejection fraction (HFpEF) in past reports.

Aim
The aim of this study is to evaluate the impact of the improvement or worsening of anemia from discharge of heart failure to 1 year after discharge on the prognosis of HFpEF and evaluate the effects of those changes on cardiorenal nutrition.

Objective
The subjects were 547 PURSUIT-HFpEF enrolled patients whose hemoglobin (Hb) and Controlling Nutrition Status (CONUT) were evaluated both at discharge and 1 year after discharge.

Method
First, 547 cases were divided into two groups, anemia (n=218) and non anemia (n=329), by Hb at discharge. Next, the anemia group (n=218) at discharge was divided into anemia group (G1, n=113) and non anemia group (G2, n=105) by Hb at 1 year later. Similarly, the non anemia group (n=329) at discharge was divided into anemia group (G3, n=66) and no anemia group (G4, n=263). Major Adverse Cardiovascular Event (MACE) was defined as composite of all-cause death, heart failure readmission, and cerebrovascular events. Anemia was defined as Hb &lt;11.0 g/dl based on the ROC curve that predicted MACE by Hb. We examined incidence rate of MACE between G1 and G2 and between G3 and G4 and examined changes in eGFR, NT-proBNP, CONUT and CRP at discharge and at 1 year later in each group.

Result
All-cause death was significantly higher in G1 maintained with anemia than in G2 with improved anemia (G1: 28.3%, G2: 13.3%, p=0.0078), but there was no significant difference in MACE and heart failure readmission. MACE, all-cause death and heart failure readmission were significantly higher in G3 with worsened anemia than in G4 maintained without anemia (MACE; G3: 54.5%, G4: 32.3%, p=0.0010, All-cause mortality; G3: 24.2%, G4: 9.1%, p=0.0024, Heart failure readmission; G3: 45.5%, G4: 24.3%, p=0.0012). In G2 with improved anemia, CONUT significantly decreased (4.3±2.1 → 1.8±1.4, p&lt;0.001)and CRP significantly decreased (1.01±1.63 mg/dl → 0.33±0.69 mg/dl, p&lt;0.001). In G2, ΔCONUT and ΔCRP were significantly greater than those in G4 maintained without anemia (ΔCONUT; G2: −2.5±2.1, G4: −0.9±1.9, p&lt;0.001, ΔCRP; G2: −0.68±1.77mg/dl, G4: −0.11±1.58 mg/dl, p=0.0027). In G3 with worsened anemia, eGFR, NT-proBNP, CONUT and CRP did not show significant change. In multivariate analysis of data at discharge, Self-rating Depression Scale (SDS) score were independent predictor of worsening of anemia at 1 year later (the adjusted hazard ratio 1.07, 95% confidential interval 1.00–1.13, p=0.0426).

Conclusion
Post-discharge anemia management might be important to prevent worsening of the prognosis of HFpEF. The improvement of anemia after discharge of heart failure was accompanied by that of nutritional status and inflammation. The worsening of anemia after discharge might be associated with the SDS score at discharge.

Funding Acknowledgement
Type of funding sources: None.