Cardiovascular Outcomes in Acute Coronary Syndrome and Malnutrition: A Meta-Analysis of Nutritional Assessment Tools

Angeline Rx Lai; Manish Warrier; Ethel Zx Ng; Chaoxing Lin; Yip Han Chin; Gwyneth Kong; Vickram V Anand; Ethan Cz Lee; Haoxing Lai; Hung Wei Ng; Rachel Sj Goh; Bryan Chong; Mark D Muthiah; Chin Meng Khoo; Jiong-Wei Wang; Gary Tse; Poay Huan Loh; Anurag Mehta; Adrian Brown; Georgios K Dimitriadis; Mark Y Chan; Nicholas W S Chew

doi:10.1016/j.jacadv.2023.100635

Cardiovascular Outcomes in Acute Coronary Syndrome and Malnutrition: A Meta-Analysis of Nutritional Assessment Tools

JACC Adv. 2023 Sep 28;2(8):100635. doi: 10.1016/j.jacadv.2023.100635. eCollection 2023 Oct.

Authors

Angeline Rx Lai¹, Manish Warrier¹, Ethel Zx Ng¹, Chaoxing Lin¹, Yip Han Chin¹, Gwyneth Kong¹, Vickram V Anand², Ethan Cz Lee², Haoxing Lai¹, Hung Wei Ng¹, Rachel Sj Goh¹, Bryan Chong¹, Mark D Muthiah^{1

3

4}, Chin Meng Khoo^{1

5}, Jiong-Wei Wang^{1

6

7}, Gary Tse^{8

9}, Poay Huan Loh^{1

10}, Anurag Mehta¹¹, Adrian Brown^{12

13

14}, Georgios K Dimitriadis^{15

16}, Mark Y Chan^{1

10}, Nicholas W S Chew¹⁰

Affiliations

¹ Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
² Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
³ Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore.
⁴ National University Centre for Organ Transplantation, National University Health System, Singapore, Singapore.
⁵ Division of Endocrinology, Department of Medicine, National University Hospital, Singapore, Singapore.
⁶ Department of Surgery, Cardiovascular Research Institute, National University Heart Centre, Singapore, Singapore.
⁷ Nanomedicine Translational Research Program, Centre for NanoMedicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
⁸ Department of Cardiology, Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China.
⁹ School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China.
¹⁰ Department of Cardiology, National University Heart Centre, National University Health System, Singapore, Singapore.
¹¹ Division of Cardiology, Department of Internal Medicine, VCU Health Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA.
¹² UCL Centre for Obesity Research, University College London, London, Greater London, United Kingdom.
¹³ Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital NHS Trust, London, Greater London, United Kingdom.
¹⁴ National Institute of Health Research, UCLH Biomedical Research Centre, London, Greater London, United Kingdom.
¹⁵ Department of Endocrinology ASO/EASO COM, King's College Hospital NHS Foundation Trust, London, United Kingdom.
¹⁶ Faculty of Cardiovascular Medicine & Sciences, Department of Diabetes, Obesity, Type 2 Diabetes and Immunometabolism Research Group, School of Life Course Sciences, King's College London, London, United Kingdom.

Abstract

Background: There is emerging evidence that malnutrition is associated with poor prognosis among patients with acute coronary syndrome (ACS).

Objectives: This study seeks to elucidate the prognostic impact of malnutrition in patients with ACS and provide a quantitative review of most commonly used nutritional assessment tools.

Methods: Medline and Embase were searched for studies reporting outcomes in patients with malnutrition and ACS. Nutritional screening tools of interest included the Prognostic Nutrition Index, Geriatric Nutritional Risk Index, and Controlling Nutritional Status. A comparative meta-analysis was used to estimate the risk of all-cause mortality and cardiovascular events based on the presence of malnutrition and stratified according to ACS type, ACS intervention, ethnicity, and income.

Results: Thirty studies comprising 37,303 patients with ACS were included, of whom 33.5% had malnutrition. In the population with malnutrition, the pooled mortality rate was 20.59% (95% CI: 14.95%-27.67%). Malnutrition was significantly associated with all-cause mortality risk after adjusting for confounders including age and left ventricular ejection fraction (adjusted HR: 2.66, 95% CI: 1.78-3.96, P = 0.004). There was excess mortality in the group with malnutrition regardless of ACS type (P = 0.132), ethnicity (P = 0.245), and income status (P = 0.058). Subgroup analysis demonstrated no statistically significant difference in mortality risk between individuals with and without malnutrition (P = 0.499) when using Controlling Nutritional Status (OR: 7.80, 95% CI: 2.17-28.07, P = 0.011), Geriatric Nutritional Risk Index (OR: 4.30, 95% CI: 2.78-6.66, P < 0.001), and Prognostic Nutrition Index (OR: 4.67, 95% CI: 2.38-9.17, P = 0.023).

Conclusions: Malnutrition was significantly associated with all-cause mortality risk following ACS, regardless of ACS type, ethnicity, and income status, underscoring the importance of screening and interventional strategies for patients with malnutrition.

Keywords: acute coronary syndrome; coronary artery disease; malnutrition; nutritional assessment tools; prognosis; systematic review and meta-analysis.