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A strong association between malnutrition and worse outcomes in acute coronary syndrome (ACS) was reported in a large observational study from Spain.

Malnutrition, as assessed by various screening tools, was significantly associated with increased risk for all-cause death over a median 3.6 years after hospitalization for heart attack:

• Controlling Nutritional Status (CONUT): adjusted HR 2.02 for moderate malnutrition (95% CI 1.65 to 2.49) and 3.65 for severe nutrition (95% CI 2.41-5.51)
• Nutritional Risk Index (NRI): adjusted HR 1.40 for moderate malnutrition (95% CI 1.17-1.68) and 2.87 for severe nutrition (95% CI 2.17-3.79)
• Prognostic Nutritional Index (PNI): adjusted HR 1.71 for moderate malnutrition (95% CI 1.37-2.15) and 1.95 for severe nutrition (95% CI 1.55-2.45)

The proportion of patients deemed moderately or severely malnourished ranged from 8.9% on the PNI to 39.5% with the NRI. About 72% were at least mildly malnourished by at least one score, according to Sergio Raposeiras Roubín, MD, PhD, of Hospital Álvaro Cunqueiro in Vigo, Spain, and colleagues.

"Malnutrition, as defined by existing scores, is common in patients with ACS, and it is associated with a poor prognosis regardless of the malnutrition index used and regardless of GRACE risk score, BMI, LVEF [left ventricular ejection fraction], coronary revascularization, and other risk factors," they concluded in the .

It may be that nutritional status is a "proxy indicator of inflammation," they said. "High degrees of malnutrition correlate with high levels of inflammation, which translates into . The association between these three entities has recently been described as malnutrition-inflammation-atherosclerosis syndrome."

To improve risk stratification and guide strategies of secondary prevention, physicians are strongly encouraged to identify malnourished patients in their daily practice, according to the investigators.

"Treatment, then, of a patient at risk must include a nutritional status assessment and counseling on how to shift toward a diet that is rich in these healthier food options. In fact, many of these index hospitalizations for life-threatening events can prove valuable as teaching moments to truly affect care and change treatment trajectories," commented Andrew Freeman, MD, of National Jewish Health, Denver, and Monica Aggarwal, MD, of University of Florida, Gainesville.

Several reports have shown that most cardiologists lack knowledge in nutrition and are therefore less prepared to discuss nutrition and lifestyle measures at the bedside or in the clinic, the pair noted in an accompanying editorial.

"Paying lip service with the usual phrases, such as 'Be sure to exercise and eat right,' simply doesn't cut it. It behooves us as a profession to ensure adequate training and competency in the delivery of care in the lifestyle space," according to Freeman and Aggarwal.

Absent more widespread nutrition training, clinicians may rely on EHR tools to help with dietary assessment and counseling at the doctor's office, the American Heart Association recently suggested.

The retrospective study included 5,062 consecutive ACS patients who had been admitted to Raposeiras Roubín's center in 2010-2017. Median age was 66.2, and about three-quarters of the group were men.

Over follow-up, 16.4% patients died, and 20.7% suffered major cardiovascular events (MACE: cardiovascular mortality, reinfarction, or ischemic stroke).

Overweight and obese individuals were moderately or severely malnourished in 8.4%-36.7% of cases, depending on the index used.

"Malnutrition is often perceived as an illness due to undernutrition and, therefore, is thought to only affect people who are underweight. In fact, a large burden of malnutrition exists in the overweight and obese population because of inadequate micronutrient consumption and poor food quality," Freeman and Aggarwal noted.

All three scales assessed in the study correlated with each other, but only 8.9% of people were classified as malnourished by all three scores.

The CONUT score had the best predictive ability for both all-cause mortality and MACE, adding the greatest incremental value to the GRACE risk score. This nutritional index includes serum albumin, total cholesterol levels, and total lymphocyte count.

"There are many screening tools for malnutrition but no consensus on which to use for patients with ACS. Based on our results, we recommend the use of the CONUT score, which uses only three laboratory values and is very easy to calculate, even without specific automatic calculators," Raposeiras Roubín and colleagues said.

The NRI performed the worst out of the three tools. Unlike the CONUT and PNI scores, NRI does not include lymphocyte count as a malnutrition marker. Instead, it includes anthropometric variables such as weight and height.

Limitations of the single-center study include its retrospective nature and the enrollment of white patients only. In addition, investigators did not evaluate more comprehensive nutritional assessments, nor did they analyze results by socioeconomic characteristics of the patients.

"Clinical trials are needed to prospectively evaluate the efficacy of nutritional interventions on outcomes in patients with ACS," the authors suggested.

Such interventions may include oral nutritional supplements, food or fluid enrichment, dietary counseling, and educational intervention.

"However, relevant goals in multimodal and multidisciplinary nutritional care would not only involve the treatment of malnutrition. Maybe even more important would be the prevention of malnutrition to avoid patients with ACS -- especially elderly patients -- experiencing deterioration of their nutritional status and their general health," the investigators said.

Malnutrition has previously been tied to mortality in heart failure.

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