Malnutrition in ACS patients associated with increased risk of mortality and MACE

Prevalence and Prognostic Significance of Malnutrition in Patients With Acute Coronary Syndrome

Literature - Raposeiras Roubín S, Abu Assi E, Cespón Fernandez M et al. - J Am Coll Cardiol 2020;76:828–40,

Introduction and methods

It has been demonstrated that malnutrition is associated with CVD in studies focusing on patients with heart failure, valvular heart disease or atrial fibrillation [1-3]. In patients with ACS, it is unsure what the association between malnutrition, CV events and mortality is. Therefore, in this study the prevalence, clinical associations and prognostic consequences of malnutrition were investigated in a contemporary cohort of ACS patients.

This retrospective, observational study used data from the Registry of Acute Coronary Syndrome From University Hospital of Vigo (CardioCHUVI), and enrolled 5062 ACS patients admitted

between January 2010 and September 2017 to the University Hospital Álvaro Cunqueiro, Vigo, Spain. Malnutrition was screened using 3 indexes: the Controlling Nutritional Status score (CONUT) [4], the Nutritional Risk Index (NRI) [5], the Prognostic Nutritional Index score (PNI) [6]. ]. CONUT takes into account serum albumin, cholesterol and total lymphocyte count. NRI is calculated as follows: 1.519 x serum albumin + 41.7 x (current body weight/ideal body weight). PNI is calculated as follows: 10 x serum albumin + 0.005 x total lymphocyte count. The primary endpoint was all-cause mortality. The secondary endpoint was the composite of major CV events (MACEs), including CV death, reinfarction, or ischemic stroke. Median follow-up was 3.6 years (IQR: 1.3-5.3 years).

Main results

  • 27 Patients (0.5%) were underweight, 1,139 (22.5%) were normal weight, 2,357 (46.6%) were overweight, and 1,539 (30.4%) were obese.
  • 38.5% Patients had mild malnutrition based on the CONUT score and 20.0% based on the NRI score. By CONUT, NRI, and PNI scores, 11.2%, 39.5%, and 8.9% patients had moderate to severe malnutrition, respectively. 8.9% were classified as malnourished (any degree of malnutrition) by all 3 scores, and 28.2% were not malnourished by any score.
  • Compared to those without malnutrition, those with malnutrition measured by any of the scores were older, were more likely to be women, and had worse Killip class and renal function. They also were more likely to have atrial fibrillation, anemia, and reduced LVEF (<40%).
  • Highest prevalence of malnutrition was in patients with BMI <25 kg/m². The percentage of patients with BMI >25 kg/m² who were malnourished based on CONUT, NRI and PNI were: 48.2%, 57.8% and 8.4%, respectively.
  • Worsening malnutrition status was associated with all-cause death and MACEs regardless of malnutrition indexes used (for those with severe malnutrition compared to good nutritional status, based on CONUT score: HR for mortality was 3.65, 95%CI:2.41-5.51, P<0.001, and HR for MACEs was 2.41, 95%CI: 1.53-3.80, P<0.001; based on NRI score: HR for mortality was 2.87, 95%CI:2.17-3.79, P<0.001, and HR for MACEs was 2.22, 95%CI: 1.69-2.91, P<0.001; based on PNI score: HR for mortality was 1.95, 95%CI:1.55-2.45, P<0.001, and HR for MACEs was 1.77, 95%CI: 1.39-2.25, P<0.001).
  • In the prediction of mortality and MACEs, CONUT and PNI score outperformed NRI, with CONUT having the highest sensitivity for outcomes of mortality and MACEs.
  • For mortality risk prediction, all 3 scores had a significant incremental prognostic value on the GRACE risk score.


In a contemporary cohort of ACS patients in Spain, malnutrition determined by 3 different scores was common. Malnutrition was associated with increased risk of mortality and MACE for all 3 malnutrition indexes used. Assessment of malnutrition could help to identify patients with increased risk of mortality and MACEs and who need nutritional support to improve outcomes.


1. Sze S, Pellicori P, Kazmi S, et al. Prevalence and prognostic significance of malnutrition using 3 scoring systems among outpatients with heart failure: a comparison with body mass index. J Am Coll Cardiol HF 2018;6:476–86.

2. Goldfarb M, Lauck S, Webb JG, et al. Malnutrition and mortality in frail and non-frail older

adults undergoing aortic valve replacement. Circulation 2018;138:2202–11.

3. Raposeiras-Roubin S, Abu-Assi E, Paz RC, et al. Impact of malnutrition in the embolic haemorrhagic trade-off of elderly patients with atrial fibrillation. Europace 2020;22:878–87.

4. Ignacio de Ulibarri J, Gonzalez-Madrono A, de Villar NG, et al. CONUT: a tool for controlling nutritional status. First validation in a hospital population. Nutr Hosp 2005;20:38–45.

5. Buzby GP, Williford WO, Peterson OL, et al. A randomized clinical trial of total parenteral

nutrition in malnourished surgical patients: the rationale and impact of previous clinical trials and pilot study on protocol design. Am J Clin Nutr 1988;47:357–65.

6. Buzby GP, Mullen JL, Matthews DC, Hobbs CL, Rosato EF. Prognostic nutritional index in gastrointestinal surgery. Am J Surg 1980;139:160–7.

Find this article online at J Am Coll Cardiol

Facebook Comments


We’re glad to see you’re enjoying PACE-CME…
but how about a more personalized experience?

Register for free