Poor Nutrition Status Linked With Survival After MitraClip

PHOENIX -- Poor nutrition status was associated with mortality risk in heart failure patients with secondary mitral regurgitation but didn't undermine the benefits of getting a MitraClip to treat it, post hoc analysis of the COAPT trial showed.

Among the 17% of trial participants who had a combination of low serum albumin and low BMI pointing to malnutrition, 68.3% had died within 4 years compared with 52.8% of those without malnutrition (P=0.001), reported researchers led by Andrea Scotti, MD, of the Cardiovascular Research Foundation and Montefiore Medical Center in New York City.

Reductions in all-cause mortality and heart failure hospitalization seen with mitral transcatheter edge-to-edge repair (TEER) were similar regardless of nutrition status, in the findings presented at the annual TVT conference hosted by the Cardiovascular Research Foundation. The results also were published in the Journal of the American College of Cardiology.

"Malnutrition should not be a reason to restrict patients from the potential benefit of TEER," Scotti told attendees, "and actually, we should perform the procedure as soon as possible before severe malnutrition and cardiac cachexia develop."

Session discussant Saurabh Sanon, MD, of HCA Florida Heart Institute in Largo, called the findings somewhat surprising in not finding a heart failure hospitalization link, in contrast with results from the nearly 900-patient MIVNUT registry. It showed more than two-fold risk of mortality and a 60% increased risk of heart failure admission with moderate-to-severe malnutrition. While TEER procedural success was similar across nutritional status groups, the likelihood of moderate or greater mitral regurgitation afterward rose with worse malnutrition.

Sanon suggested that screening heart failure patients for malnutrition, and maybe nutrition assessment, as part of the evaluation for TEER might be reasonable. "If we can change things at baseline, maybe we can provide additional benefit to patients."

Notably, the findings largely reflected the effects of mild malnutrition. Moderate or severe malnutrition was uncommon in the trial population.

Session moderator Nino Mihatov, MD, of NewYork-Presbyterian Brooklyn Methodist Hospital in New York City, agreed that malnutrition should be on operators' radar. "Many times our decision to offer therapy is influenced by the 'eyeball test,'" he said, "and malnutrition probably factors into that."

Scotti's group looked at the COAPT trial patients for geriatric nutritional risk index (GNRI), which is calculated as a product serum albumin and body weight divided by ideal body weight, with a score of 98 as the cutoff for malnutrition in the study.

Of the trial's 614 patients with heart failure and moderate-to-severe or severe secondary mitral regurgitation, 552 had sufficient data to calculate GNRI. The two groups randomly assigned to medical therapy with or without mitral TEER had similar GNRI at baseline.

Prevalence of malnutrition was 36.9% in the patients of normal or low BMI and just 3.4% among those with a BMI over 25. It was more common in heart failure with low ejection fraction than when ejection fraction was 40% or greater (20.3% vs 8.7%). Malnourished patients were also significantly older (75.1 vs 71.5 on average).

Malnourished patients had significantly lower 4-year all-cause mortality with TEER than with medical therapy alone (adjusted HR 0.55, 95% CI 0.32-0.94), as did those without malnutrition (aHR 0.67, 95% CI 0.51-0.88). The effects were independent of age, sex, chronic kidney disease, chronic obstructive pulmonary disease, and treatment.

While heart failure hospitalizations weren't more common for the malnourished patients, overall hospitalizations were, driven by non-cardiovascular causes, Scotti noted. Heart failure hospitalization was less common with TEER in both malnourished and non-malnourished groups (aHR 0.39 and 0.47, respectively, P=0.67 for interaction).

Limitations of the analysis included that malnutrition was not prespecified as a subgroup, that the findings might not generalize to a non-COAPT-like population, and that repeat albumin levels were not available for enough patients to assess.

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