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It may be important to consider the potential prognostic value of malnutrition in heart failure, researchers suggested.

Heart failure patients at a community heart failure clinic in England had moderate-to-severe malnutrition at rates ranging from 6.7% to 10.0% depending on the definition used -- geriatric nutritional risk index (GNRI), controlling nutritional status (CONUT) score, or prognostic nutritional index (PNI) -- according to Shirley Sze, MBBS, of Castle Hill Hospital in Cottingham, England, and colleagues.

Notably, 57% were at least mildly malnourished by one score, they wrote in .

One-year mortality was more likely among the moderately or severely malnourished. Adding one of the three nutritional indices slightly improved the fit of a base model predicting 1-year survival (C-statistic up to 0.724 from 0.719, P<0.001), yet BMI added nothing to the model's performance, the researchers pointed out.

"Malnutrition, as defined by existing scores, is common in outpatients with chronic heart failure and is associated with a poor prognosis regardless of the screening tools used and regardless of left ventricular systolic function, circulating levels of natriuretic peptides, or BMI," they said.

Moreover, the findings suggest that BMI is no ideal measure of body size and composition and therefore shouldn't be used as surrogate of nutritional status in patients with heart failure, the researchers stated.

"Although we found that indices of malnutrition increased the prognostic value of the models we constructed, the modest increase in Harrell's concordance index is of little value for the individual patient," Sze's group said. "Given the effect in a substantial population of patients, however, the increase in C-statistic does emphasize that there is some component of 'malnutrition' that is related to prognosis above and beyond the usual clinical variables taken into account when constructing prognostic models."

The study included 4,021 patients who were screened in 2000-2016, of which heart failure was confirmed in 3,386 (61% men, median age 75). Half died over a median follow-up of 4.3 years.

Besides being a single-center study, the analysis also failed to take into account changes in nutritional status over time, the investigators acknowledged. They also said that groups were imbalanced, as patients with malnutrition per any of the three scales were more likely to be older and men with worse symptoms and more comorbidities.

Shintaro Kinugawa, MD, PhD, and Arata Fukushima, MD, PhD, both of Hokkaido University in Japan, highlighted the latter point in an accompanying editorial.

"This clearly indicates the clinical feature of frailty in older patients with heart failure, suggesting that malnutrition is closely linked to the process of [the] frail cycle," they wrote.

The editorialists also suggested that they weren't ready to let go of the BMI as a predictor of clinical outcomes.

"Although the GNRI, PNI, and CONUT scores each identified the malnourished patients with heart failure who have worse clinical outcomes, the GNRI showed the greatest incremental value in predicting mortality. This finding suggests that the combination of serum albumin, which is an objective value reflecting a protein reserve, and BMI, a body composition calculation used as a conventional surrogate for nutritional status, is a superior nutritional index for the prediction of clinical outcomes," Kinugawa and Fukushima wrote.

"Furthermore, this may remind us of the relevance of including BMI in assessing nutritional status," they said.

In the end, they agreed that malnutrition appears to be prevalent in outpatients with heart failure and provides a critical clue for how to stratify higher-risk patients. "Further research is warranted to verify whether nutrition-oriented management and intervention could reduce mortality and improve quality of life in patients with heart failure living in the era of an aging society," they stated.