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Nutritional risk screening is fundamental to prevent undesirable outcomes in heart failure (HF). Current reviews of nutritional screening tools encompass both hospitalized and outpatient settings, which may not be suitable because of different clinical manifestations. We hypothesize that multidimensional tools would better identify prognosis of decompensated patients because the tools assess more than isolated aspects. This systematic review aims to explore the association of multidimensional nutritional risk screening tools and prognosis in patients hospitalized with decompensated HF. Five databases were searched for studies that assessed nutritional risk through multidimensional screening tools and its association with prognosis in adults hospitalized with decompensated HF. The 95% confidence interval and relative risk were computed using a random-effects model. Inverse variance method was used. Thirty-eight studies were included. Most studies demonstrated higher nutritional risk was significantly associated with worse prognosis. Quantitative analysis identified higher nutritional risk by using the Mini Nutritional Assessment Short Form (MNA-SF), Controlling Nutritional Status, Geriatric Nutritional Risk Index, and Prognostic Nutritional Index to be associated with all-cause mortality. The MNA-SF demonstrated greater magnitude of association with all-cause mortality in older subjects (relative risk, 4.85; 95% confidence interval, 2.0-11.75). Higher nutritional risk was associated with poor prognosis and higher mortality in patients hospitalized with decompensated HF, especially when screened by MNA-SF. Tools were not directly compared. That might reinforce the importance of evaluating multiple aspects when screening hospitalized HF patients once symptoms associated with decompensation frequently mask the underlying nutritional status and risk. PROSPERO registration number (CRD42021256271)., Competing Interests: Author Declarations None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic raised awareness of the need to better understand where and how patient-level costs are incurred in health care organizations, as health managers and other decision-makers need to plan and quickly adapt to the increasing demand for health care services to meet patients' care needs. Time-driven activity-based costing offers a better understanding of the drivers of cost throughout the care pathway, providing information that can guide decisions on process improvement and resource optimization. This study aims to estimate COVID-19 patient-level hospital costs and to evaluate cost variability considering the in-hospital care pathways of COVID-19 management and the patient clinical classification., Methods: This is a prospective cohort study that applied time-driven activity-based costing (TDABC) in a Brazilian reference center for COVID-19. Patients hospitalized during the first wave of the disease were selected for their data to be analyzed to estimate in-hospital costs. The cost information was calculated at the patient level and stratified by hospital care pathway and Ordinal Scale for Clinical Improvement (OSCI) category. Multivariable analyses were applied to identify predictors of cost variability in the care pathways that were evaluated., Results: A total of 208 patients were included in the study. Patients followed five different care pathways, of which Emergency + Ward was the most followed (n = 118, 57%). Pathways which included the intensive care unit presented a statistically significant influence on costs per patient (p <  0.001) when compared to Emergency + Ward. The median cost per patient was I$2879 (IQR 1215; 8140) and mean cost per patient was I$6818 (SD 9043). The most expensive care pathway was the ICU only, registering a median cost per patient of I$13,519 (IQR 5637; 23,373) and mean cost per patient of I$17,709 (SD 16,020). All care pathways that included the ICU unit registered a higher cost per patient., Conclusions: This is one of the first microcosting study for COVID-19 that applied the TDABC methodology and demonstrated how patient-level costs vary as a function of the care pathways followed by patients. These findings can be used to develop value reimbursement strategies that will inform sustainable health policies in middle-income countries such as Brazil., (© 2023. The Author(s).)

Frailty commonly coexists with heart failure and although both have been associated with neurohormonal dysregulation, inflammation, catabolism, and skeletal muscle dysfunction, there are still no defined biomarkers to assess frailty, especially from the perspective of populations with cardiovascular diseases. This is a cross-sectional study with 106 outpatients with heart failure, aged ≥60 years, which aimed to assess frailty through a physical (frailty phenotype) and multidimensional (Tilburg Frailty Indicator) approach and to analyze its association with inflammatory and humoral biomarkers (high sensitivity C-reactive protein [hs-CRP], interleukin 6, tumor necrosis factor-α, insulin-like growth factor-1, and total testosterone), clinical characteristics, and functional capacity. In univariate analysis, hs-CRP was associated with frailty in both phenotype and Tilburg Frailty Indicator assessment (PR = 1.005, 95% confidence interval [CI] 1.001 to 1.009, p = 0.027 and PR = 1.015, 95% CI 1.006 to 1.024, p = 0.001, respectively), which remained significant in the final multivariate model in the frailty assessment by the phenotype (PR = 1.004, 95% CI 1.001 to 1.008, p = 0.025). There was no statistically significant difference between the groups for other biomarkers analyzed. Frailty was also associated with worse functional capacity, nonoptimized pharmacological treatment and a greater number of drugs in use, age, female gender, and a greater number of comorbidities. In conclusion, frailty is associated with higher levels of hs-CRP, which can indicate it is a promising frailty biomarker., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background/objectives: The phase angle, expressed through bioelectrical impedance, has been studied as a prognostic marker in several health conditions. As this issue is still conflicting, the question whether this parameter correlates with mortality in the most diverse clinical situations remains. Therefore, this study aimed to evaluate the relationship between phase angle and mortality through a systematic review of the literature., Subjects/methods: This research was conducted in electronic databases (Pubmed, Embase, Cochrane, Lilacs, Scielo, e Scopus), and included studies that had phase angle as a variable of interest and mortality/survival as an outcome. Data were extracted independently by two reviewers and disagreements were assessed by a third reviewer., Results: Forty-eight of 455 papers were assessed and an amount of 42 showed a correlation between phase angle and mortality., Conclusions: Phase angle seems to be a good indicator for mortality in many clinical situations and can be used in screening individuals prone to this outcome.

AimTo investigate if cardiac/pulmonary functional tests and variables obtained from clinical practice (body mass index, dyspnea, functional class, clinical judgment of disability to perform an exercise test and previous hospitalization rate) are related to mortality in patients with overlap chronic obstructive pulmonary disease (COPD) and chronic heart failure (CHF). BACKGROUND: Although the coexistence of COPD and CHF has been growingly reported, description of survival predictors considering the presence of both conditions is still scarce. METHODS: Using a cohort design, outpatients with the previous diagnosis of COPD and/or CHF that performed both spirometry and echocardiography in the same year were followed-up during a mean of 20.9±8.5 months.FindingsOf the 550 patients initially evaluated, 301 had both spirometry and echocardiography: 160 (53%) with COPD on isolation; 100 (33%) with CHF on isolation; and 41 (14%) with overlap. All groups presented similar mortality: COPD 17/160 (11%); CHF 12/100 (12%); and overlap 7/41 (17%) (P=0.73). In the overlap group (n=41), inability to exercise and hospitalization rate were the unique parameters associated with higher mortality (seven events) in univariate analyses. In conclusion, inability to exercise and hospitalization rate emerged as the unique parameters associated with mortality in our sample.

Reduction in inspiratory capacity (IC) during exercise has been reported in chronic heart failure (CHF). Since inspiratory muscle dysfunction may be present to a variable degree, the assumption that IC reduction during exercise represents an increase in end-expiratory lung volume must be made with caution. This interpretation is flawed if patients develop dynamic inspiratory muscle strength reduction, i.e., progressively lower esophageal (Pes) pressures as the IC maneuvers are repeated. Sixteen CHF patients and 9 age-matched controls performed an incremental exercise test with serial IC and respiratory pressure measurements. Regardless whether IC decreased or not with exercise (N = 4 and N = 12, respectively), Pes,IC remained stable. This was confirmed by similar Pes,sniff immediately upon exercise cessation (p > .05). No association was found between changes in IC and related Pes from rest to peak exercise. Owing to the lack of dynamic inspiratory muscle weakness, non-invasive indexes of lung mechanics can be reliably obtained from exercise IC in CHF., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The main objective was to assess the effects of abdominal breathing (AB) versus subject's own breathing on femoral venous blood flow (Qfv) and their repercussions on central hemodynamics at rest and during exercise contrasting healthy subjects versus heart failure (HF) patients. We measured esophageal and gastric pressure (PGA), Qfv and parameters of central hemodynamics in eight healthy subjects and nine HF patients, under four conditions: subject's own breathing and AB ( ∆: PGA ≥ 6 cmH2O) at rest and during knee extension exercises (15% of 1 repetition maximum) until exhaustion. Qfv and parameters of central hemodynamics [stroke volume (SV), cardiac output (CO)] were measured using Doppler ultrasound and impedance cardiography, respectively. At rest, healthy subjects Qfv, SV, and CO were higher during AB than subject's breathing (0.11 ± 0.02 vs. 0.06 ± 0.00 L·min(-1), 58.7 ± 3.4 vs. 50.1 ± 4.1 mL and 4.4 ± 0.2 vs. 3.8 ± 0.1 L·min(-1), respectively, P ≤ 0.05). ∆SV correlated with ∆PGA during AB (r = 0.89, P ≤ 0.05). This same pattern of findings induced by AB was observed during exercise (SV: 71.1 ± 4.1 vs. 65.5 ± 4.1 mL and CO: 6.3 ± 0.4 vs. 5.2 ± 0.4 L·min(-1); P ≤ 0.05); however, Qfv did not reach statistical significance. The HF group tended to increase their Qfv during AB (0.09 ± 0.01 vs. 0.07 ± 0.03 L·min(-1), P = 0.09). On the other hand, unlike the healthy subjects, AB did not improve SV or CO neither at rest nor during exercise (P > 0.05). In healthy subjects, abdominal pump modulated venous return improved SV and CO at rest and during exercise. In HF patients, with elevated right atrial and vena caval system pressures, these findings were not observed., (© 2014 The Authors. Physiological Reports published by Wiley Periodicals, Inc. on behalf of the American Physiological Society and The Physiological Society.)

Background: Most reports regarding the obesity paradox have focused on body mass index (BMI) to classify obesity and the prognostic values of other indirect measurements of body composition remain poorly examined in heart failure (HF)., Objective: To evaluate the association between BMI and other indirect, but easily accessible, body composition measurements associated with the risk of all-cause mortality in HF., Methods: Anthropometric parameters of body composition were assessed in 344 outpatients with a left ventricular ejection fraction (LVEF) of <50% from a prospective HF cohort that was followed-up for 30 ± 8.2 months. Survival was evaluated using the Kaplan-Meier method and Cox proportional hazard regression analysis., Results: HF patients were predominantly male, of non-ischemic etiology, and had moderate to severe LV systolic dysfunction (mean LVEF = 32 ± 9%). Triceps skinfold (TSF) was the only anthropometric index that was associated with HF prognosis and had significantly lower values in patients who died (p = 0.047). A TSF > 20 mm was present in 9% of patients that died and 22% of those who survived (p = 0.027). Univariate analysis showed that serum creatinine level, LVEF, and NYHA class were associated with the risk of death, while Cox proportional hazard regression analysis showed that TSF > 20 was a strong independent predictor of all-cause mortality (hazard ratio = 0.36; 95% confidence interval = 0.13-0.97, p = 0.03)., Conclusion: Although BMI is the most widely used anthropometric parameter in clinical practice, our results suggested that TSF is a better predictive marker of mortality in HF outpatients.