title: Nutritional Risk Index predicts mortality in hospitalized advanced heart failure patients.
abstract: BACKGROUND
  Hospitalized advanced heart failure (HF) patients are at high risk for malnutrition and death. The Nutritional Risk Index (NRI) is a simple, well-validated tool for identifying patients at risk for nutrition-related complications. We hypothesized that, in advanced HF patients from the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) trial, the NRI would improve risk discrimination for 6-month all-cause mortality.
  
  
  METHODS
  We analyzed the 160 ESCAPE index admission survivors with complete follow-up and NRI data, calculated as follows: NRI = (1.519 × discharge serum albumin [in g/dl]) + (41.7 × discharge weight [in kg] / ideal body weight [in kg]); as in previous studies, if discharge weight is greater than ideal body weight (IBW), this ratio was set to 1. The previously developed ESCAPE mortality model includes: age; 6-minute walk distance; cardiopulmonary resuscitation/mechanical ventilation; discharge β-blocker prescription and diuretic dose; and discharge serum sodium, blood urea nitrogen and brain natriuretic peptide levels. We used Cox proportional hazards modeling for the outcome of 6-month all-cause mortality.
  
  
  RESULTS
  Thirty of 160 patients died within 6 months of hospital discharge. The median NRI was 96 (IQR 91 to 102), reflecting mild-to-moderate nutritional risk. The NRI independently predicted 6-month mortality, with adjusted HR 0.60 (95% CI 0.39 to 0.93, p = 0.02) per 10 units, and increased Harrell's c-index from 0.74 to 0.76 when added to the ESCAPE model. Body mass index and NRI at hospital admission did not predict 6-month mortality. The discharge NRI was most helpful in patients with high (≥ 20%) predicted mortality by the ESCAPE model, where observed 6-month mortality was 38% in patients with NRI < 100 and 14% in those with NRI > 100 (p = 0.04).
  
  
  CONCLUSIONS
  The NRI is a simple tool that can improve mortality risk stratification at hospital discharge in hospitalized patients with advanced HF.
authors.affiliation: Frankel Cardiovascular Center, University of Michigan Health System, Ann Arbor.
authors.forename: Oluwayemisi L
authors.initials: OL
authors.lastname: Adejumo
authors.affiliation: Frankel Cardiovascular Center, University of Michigan Health System, Ann Arbor.
authors.forename: Todd M
authors.initials: TM
authors.lastname: Koelling
authors.affiliation: Frankel Cardiovascular Center, University of Michigan Health System, Ann Arbor; Ann Arbor Veterans Affairs Health System, Ann Arbor, Michigan. Electronic address: scothumm@med.umich.edu.
authors.forename: Scott L
authors.initials: SL
authors.lastname: Hummel
mesh_terms: D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D002170:Canada / Q000453:epidemiology; D002423:Cause of Death / Q000639:trends; D004232:Diuretics / Q000627:therapeutic use; D005081:Exercise Therapy; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000150:complications / Q000401:mortality* / Q000628:therapy; D006760:Hospitalization; D006801:Humans; D015994:Incidence; D008297:Male; D044342:Malnutrition / Q000453:epidemiology / Q000209:etiology / Q000628:therapy*; D008875:Middle Aged; D015596:Nutrition Assessment; D009752:Nutritional Status; D011379:Prognosis; D018570:Risk Assessment; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D014481:United States / Q000453:epidemiology
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D004232:Diuretics
keywords: cachexia; heart failure; mortality; nutrition; risk model