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A Short-Form Nutrition Assessment in Patients With Advanced Heart Failure

Evaluated for Ventricular Assist Device Placement or Cardiac Transplantation.

Article  in  Nutrition in Clinical Practice · May 2014

DOI: 10.1177/0884533614535269 · Source: PubMed

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535269
research-article2014
NCPXXX10.1177/0884533614535269Nutrition in Clinical Practice X(X)Yost et al

Clinical Research
Nutrition in Clinical Practice
Volume 29 Number 5
Short-Form Nutrition Assessment in Patients With October 2014 686­–691
© 2014 American Society
Advanced Heart Failure Evaluated for Ventricular for Parenteral and Enteral Nutrition

Assist Device Placement or Cardiac Transplantation DOI: 10.1177/0884533614535269

ncp.sagepub.com
hosted at
online.sagepub.com

Gardner Yost, BS1; Mary Gregory, RD, LDN2; and Geetha Bhat, PhD, MD1

Abstract
Background: It has been shown that malnutrition affects clinical outcomes in patients with advanced heart failure and that nutrition status,
as determined by the Mini Nutritional Assessment (MNA), can be used as an independent predictor of mortality. The aim of this study
was to evaluate the prognostic utility of the short-form MNA (MNA-SF) as a surrogate to the MNA in patients with advanced heart
failure. Methods: Data retrospectively gathered from nutrition assessments of 162 patients were analyzed. Results: As defined by the
MNA, the cohort included 40 (24.7%) patients classified as malnourished, 106 (65.4%) classified as at risk, and 16 (9.9%) classified as
well nourished. The mortality for the groups was 37.3%, 47.4%, and 40.5%, respectively. A linear regression showed strong correlation
between the MNA and MNA-SF (r = 0.778, P < .0001). A significant difference was observed in survival between the undernourished
state (at risk + malnourished) and the well-nourished state, as determined by the MNA-SF (P < .001). Conclusions: The MNA-SF is a
rapid nutrition assessment that correlates strongly with the full-form MNA and is an independent predictor of mortality. (Nutr Clin Pract.
2014;29:686-691)

Keywords
heart-assist devices; nutritional status; malnutrition; nutrition assessment; heart transplantation; screening; heart failure

Although treatment of advanced heart failure (AHF) has
improved significantly in recent decades, clinical prognosis
remains poor, with half of patients dying within 4 years of
diagnosis.1 Malnutrition is known to influence the progression
of many chronic diseases, including AHF, where it has been
shown to predict adverse outcomes.2,3 Cardiac cachexia, often
characterized by weight loss, increased lipolysis, lack of appe-
tite, malabsorption, and homeostatic disruption of multiple
body systems, is known to affect prognosis.4,5
The Mini Nutritional Assessment (MNA) is a simple ques-
tionnaire-based tool that is notably sensitive (96%), specific
(98%), and predictive (97%).6 It has been substantially vali-
dated using clinical status and comprehensive nutrition assess-
ment in the setting of home care, outpatient therapy, and
general practice as well as in hospitalized and institutionalized
patients.7-9 Recently, the MNA was shown to be an indepen-
dent predictor of mortality in patients with heart failure and in
patients with heart failure who are being worked up for left
ventricular assist device (LVAD) placement or cardiac trans-
plantation (Figure 1).10
The short-form MNA (MNA-SF) is an abbreviated 6-ques-
tion subset of the full-form MNA. Use of the MNA-SF can be
instituted as a time- and cost-saving measure in the establish-
ment of clinical dietary needs. The diagnostic accuracy of the
MNA-SF has been shown to be comparable to the full-form
assessment in elderly populations (Figure 2).11,12 At this time,
the applicability of the MNA-SF in the setting of AHF has not
been studied. The aim of our research was to determine the
clinical utility of the MNA-SF in our LVAD and cardiac trans-
plantation workup population as a time- and resource-saving
surrogate for the full-form assessment.
Methods
This is a retrospective study of patients with AHF who under-
went a workup procedure for potential LVAD placement or
cardiac transplantation. Inclusion criteria for the study were (1)
diagnosis of AHF based on clinical evaluation, (2) age older
than 18 years, (3) ability to comprehend and appropriately
answer the MNA questionnaire administered by our dietician,
and (4) workup for potential LVAD placement/cardiac trans-
plantation. Exclusion criteria included incomplete data for
either the short-form or long-form MNA (n = 25).
From the 1Center for Heart Transplant and Assist Devices, Advocate
Christ Medical Center, Oak Lawn, Illinois, and 2Department of Clinical
Nutrition, Advocate Christ Medical Center, Oak Lawn, Illinois.
Financial disclosure: None declared.
This article originally appeared online on May 27, 2014.
Corresponding Author:
Geetha Bhat, PhD, MD, Medical Director Center for Heart Transplant
and Assist Devices, Advocate Christ Medical Center, 4400 West 95th St,
Oak Lawn, IL 60453, USA.
Email: geetha.bhat@advocatehealth.com
Yost et al 687

Figure 1. Full-form Nestlé Mini Nutritional Assessment (MNA). © Nestlé, 1994, Revision 2009. N67200 12/99 10M.
688 Nutrition in Clinical Practice 29(5)

Figure 2.  Short-form Nestlé Mini Nutritional Assessment (MNA).© Nestlé, 1994, Revision 2009. N67200 12/99 10M.
Yost et al 689
The clinical records of 187 consecutive patients meeting the
inclusion criteria were initially gathered. Twenty-five patients
were removed following application of exclusion criteria, leav-
ing a final cohort of 162. Type of LVAD, date of transplanta-
tion, MNA score, MNA-SF score, and survival were collected.
Biochemical parameters, including serum urea nitrogen, cre-
atinine, B-type natriuretic peptide, serum albumin, and hemo-
globin, were collected in the preoperative and postoperative
periods.
All patients undergoing a workup for surgical intervention
completed an MNA in the first week of hospital admission fol-
lowing initial stabilization. The MNA uses an 18-item question-
naire composed of 4 sections: general status, anthropometrics,
dietary aspects, and subjective assessment (Figure 1).
Anthropometry required the measurement of patient height,
weight, calf circumference, and mid-arm circumference using
standardized protocol. All tests were administered by a single
trained dietitian. Administration of the MNA followed the same
protocol described by Aggarwal et al10 in 2012. The full-length
MNA was used to establish categorization of malnourished, at
risk of malnutrition, or well nourished based on each patient’s
cumulative score. All questions required for the MNA-SF are
included in the full MNA, allowing for simultaneous adminis-
tration of the 2 tests. The possible MNA scores range from 0 to
30. Patient categories are based on score: malnourished (<17
points), at risk of malnutrition (17–23.5 points), and well nour-
ished (≥24 points). Likewise, the MNA-SF, which scores from
0–14, was used to establish the diagnosis of malnourished (0–7
points), at risk of malnourishment (8–11 points), and well nour-
ished (12–14 points).
Statistical Analysis
The MNA and MNA-SF data were correlated using a nonpara-
metric Spearman’s ρ test. A P value less than .05 was consid-
ered significant. Nonparametric Kruskal-Wallace and
Tukey-Kramer tests were used to determine statistical differ-
ence between nutrition groups for MNA score, MNA-SF score,
length of stay, survival, and laboratory parameters. Kaplan-
Meier survival analysis was performed to compare nutrition
groups for both the MNA and the MNA-SF. Survival was ana-
lyzed within a 1000-day window following the administration
of each MNA questionnaire.
Results
A total of 162 patients were analyzed in this Advocate Christ
Medical Center institutional review board–approved study.
Using the MNA, 40 (24.7%) were classified as malnourished,
106 (65.4%) were classified as at risk, and 16 (9.9%) were
classified as well nourished. Differences in MNA between
groups were statistically significant (P < .001). Using the
MNA-SF, 50 patients (30.9%) were classified as malnourished,
77 (47.5%) were classified as at risk, and 35 (21.6%) were
Figure 3.  Shift in patient grouping from the Mini Nutritional
Assessment (MNA) to the short-form MNA (MNA-SF).
classified as well nourished. Forty-five patients were classified
differently under the MNA-SF compared with the full-form
MNA (Figure 3).
Prior to the 1000-day cutoff, 66 (40.7%) of the patients
within the cohort died: 14 in the malnourished group, 49 in the
at-risk group, and 3 in the well-nourished group as defined by
MNA-SF.
A nonparametric Spearman test indicated a strong correla-
tion between the MNA and MNA-SF (r = 0.778, P < .0001).
An all-pairs Tukey-Kramer test indicated significant difference
between the malnourished, at-risk, and well-nourished groups
based on MNA-SF scores. Kaplan-Meier survival curves dem-
onstrated increased mortality for the malnourished and at-risk
groups compared with the well-nourished group when calcu-
lated using the MNA-SF (P < .0001). A second Kaplan-Meier
model, also using the MNA-SF, by combining the at-risk and
malnourished groups into a single “undernourished” group,
increased the effect of differences in survival compared with
the well-nourished group (P < .01). This effect was observed
when the groups were defined using either the MNA or the
MNA-SF. An all-pairs Tukey-Kramer test indicated significant
difference in survival between the at-risk and well-nourished
groups and between the malnourished and well-nourished
groups but not between the at-risk and malnourished groups.
This was true whether the groups were defined based on MNA
or SF-MNA. Differences in postoperative length of stay
between groups were nonsignificant.
All-pairs Tukey-Kramer tests showed no significant differ-
ence between the groups as defined by either MNA or MNA-SF
for serum urea nitrogen, creatinine, B-type natriuretic peptide,
or hemoglobin but did show a significant difference for serum
albumin between undernourished (3.00 ± 0.43) and well-nour-
ished (3.19 ± 0.44) groups as defined by MNA-SF (P = .036).
Discussion
Our study found that more than 90% of our population was at
risk or malnourished based on the MNA. Using the MNA-SF,
more than 77% of our population was at risk or malnourished.
This finding is similar to that published by Aggarwal et al.10 The
MNA-SF is an abbreviated assessment and, in some instances,
classified patients differently than the full-form MNA. No
patient classified as malnourished by the full-form MNA was
690 Nutrition in Clinical Practice 29(5)

Figure 4.  Reclassification of patients from the Mini Nutritional Assessment (MNA) to the short-form MNA (MNA-SF).

classified as well nourished by the MNA-SF. Likewise, no

patient classified as well nourished by the full-form MNA was
classified as malnourished by the MNA-SF. However, 45
patients were reclassified by 1 category (Figure 3). This did not
ultimately affect the predictive value of the MNA-SF.
Patients who shifted classification from malnourished
(MNA) to at risk (MNA-SF) tended to view themselves as mal-
nourished (average score question O = .714/2) and tended to
consider their health status as worse than others their age (aver-
age score question P = .5/2) (Figure 4).
Patients who shifted classification from at risk (MNA) to
malnourished (MNA-SF) tended to have lost weight in the 3
months prior to the test (average score question B = .3/3)
(Figure 4).
Finally, patients who shifted from at risk (MNA) to well
nourished (MNA-SF) tended to have had psychological stress or
acute injury within 3 months of the survey (average score ques-
tion D = .118/2) but also tended to consume enough liquids
Figure 5.  Survival for at-risk, malnourished, and well-nourished
(average score question M = 1.94/2) and have larger mid-arm groups as defined by the short-form Mini Nutritional Assessment
circumferences (average score question Q = 1.94/2) (Figure 4). (MNA-SF).
We show that the MNA-SF is a strong predictor for the full-
form MNA and that the MNA-SF exhibits strong predictive
value for patient survival. There was a significant difference in because serum albumin, although affected by nutrition intake,
survival between groups, and the Kaplan-Meier curves shown colloid oncotic pressure variations, and the presence of sys-
in Figures 5 and 6 indicate distinct survival timelines between temic inflammation, has a half life of 14–20 days in the body,
groups. In addition, the MNA-SF shows significant differences making it nontransient and therefore an effective independent
in serum albumin concentration between undernourished and predictor of mortality.10,13,14
well-nourished groups. This makes the short form a practical Kaiser et al,11 in an analysis of 2032 non–heart failure
method for assessment of nutrition risk in patients with AHF. patients, showed a strong relationship between the full-form
Aggarwal et al10 first noted in 2012 the usefulness of the MNA and the short form with a sensitivity of 0.89, specificity
MNA in evaluating patients with AHF undergoing LVAD of 0.82, and Spearman’s correlation of 0.90. This relationship
placement or cardiac transplantation. A definite survival is more robust than that which we report for patients with AHF.
advantage was observed for well-nourished patients compared We suggest our data were limited by single-center sampling,
with undernourished patients, and serum albumin was shown population size, and a relative lack of well-nourished individu-
to be significantly different between groups. We suggest this is als, leading to imbalanced grouping.
 Yost et al 691

can identify nutrition status in patients with AHF effectively

Legend
1.0
Undernourished and more rapidly than the full-form MNA.
Well Nourished

0.8
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