Nutritional markers and prognosis in cardiac cachexia José Paulo Araújo ⁎, Patrícia Lourenço, Francisco Rocha-Gonçalves, António Ferreira, Paulo Bettencourt Heart Failure Clinic, Serviço de Medicina Interna, Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, Portugal abstract article info Article history: Received 12 April 2009 Received in revised form 10 July 2009 Accepted 19 July 2009 Available online 23 August 2009 Keywords: Heart failure Cardiac cachexia Nutrition Inflammation Catabolism Background: Cachexia frequently complicates chronic heart failure (CHF) and predicts an ominous prognosis. Hormonal and inflammatory environment differ between cachectic and non-cachectic patients. Nutritional markers of cardiac cachexia and prognostic predictors in this context are not completely understood. Objectives: To study biochemical markers of nutritional status in cardiac cachexia and to investigate variables associated with worse prognosis. Methods: A total of 94 ambulatory patients — 38 cachectics and 56 non-cachectics — were recruited. Cardiac cachexia was defined as a weight loss of ≥7.5%. An anthropometric evaluation was performed in all patients and blood was collected for several laboratory determinations: haemoglobin, lymphocytes, albumin, transferrin, pre-albumin, cholesterol and triglycerides. Patients were included in a prospective cohort study. Results: Cachectics had lower albumin and pre-albumin levels. They also had lower haemoglobin, lymphocytes and triglycerides. Levels of high-sensitivity C-reactive protein, and catabolic hormones were higher in the cachectic group. Low pre-albumin was the only nutritional marker independently associated with cardiac cachexia. (OR = 1.08, CI: 1.01–1.17). During a follow-up of 16.2 ± 5.2 months, 15 (39.4%) cachectic patients and 6 (10.7%) non-cachectics died. In the cachectic group, lower cholesterol was independently associated with worse outcome (HR = 1.32, CI: 1.11–1.57). Conclusions: Pre-albumin seems to be the best laboratory marker of undernutrition in CHF. Low cholesterol independently associates with worse outcome in cardiac cachexia. © 2009 Elsevier Ireland Ltd. All rights reserved. 1. Introduction Chronic heart failure (CHF) is a major public health problem in western countries [1]. Cardiac cachexia, i.e. body wasting, is a serious complication of CHF, which is associated with poor prognosis, independently of age, New York Heart Association (NYHA) class, peak oxygen consumption and left ventricular ejection fraction (LVEF) [2]. Approximately 15% of CHF patients develop cachexia [3]. The development of cachexia in CHF patients is not well understood. Several mechanisms have been implicated in this pathophysiologic process: pro-inflammatory cytokines [4], imbalance between anabolic and catabolic hormones [5] and changes in the hormonal environment that regulates energy metabolism, lean/fat body composition and appetite — leptin, adiponectin and ghrelin [6–8]. Decrease in food intake [9] and gut malabsorption resulting from bowel oedema and reduced perfusion [10] may also be important factors contributing for this process of losing weight. Cardiac cachexia has been recognised for centuries [11], but only recently became a growing field of investigation. Catabolic and anabolic abnormalities characteristic of cachexia have already been described [5,12,13] and several studies [4,14] consistently reported increased levels of inflammatory cytokines. Not yet investigated is the possible association between cardiac cachexia and biochemical markers of undernutrition. Although cachexia is recognised as a condition associated with worse prognosis, little is known about factors predicting worse outcome in cachectic patients. We compared the biochemical markers of undernutrition in CHF patients with or without cachexia in order to investigate cachexia predictors. We also aimed to assess variables associated with worse outcome in the subgroup of patients with established cardiac cachexia. 2. Methods 2.1. Study design We screened clinical records of patients attending our heart failure clinic (Hospital S. João, Porto, Portugal) and identified all cachectic patients. They were contacted by phone or mail and scheduled to a recruitment visit. The control group consisted of patients without weight loss, attending the clinic during the recruitment time. Chronic heart failure diagnosis was based on the European Society of Cardiology criteria [15]. Cardiac cachexia was defined as a non-intentional, non-oedematous, weight loss of ≥7.5% of the previous normal, non-oedematous weight over a period of at least 6 months [2]. Inclusion criteria were body mass index (BMI) b 30 Kg/m 2 and clinical stability for at least 2 months, with no hospital admissions, no changes in NYHA class and no diuretic dose adjustments during that period. Additional conditions for study recruitment were absence of any recent (≤1 month) clinically significant infectious or inflammatory International Journal of Cardiology 146 (2011) 359–363 ⁎ Corresponding author. Heart Failure Clinic, Serviço de Medicina Interna, Hospital S. João, Alameda Professor Hernâni Monteiro, 4202-451 Porto. Tel.: +351 225512200; fax: +351 225512332. E-mail address: pauloaraujo@iol.pt (J.P. Araújo). 0167-5273/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2009.07.042 Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard