Prevalence, Pathophysiology, and Prognostic Importance of Malnutrition Risk in Early-Stage Patients With Heart Failure and Preserved Ejection Fraction

Background and Objectives: Malnutrition is common and is associated with poor clinical outcomes in clinically overt patients with heart failure and preserved ejection fraction (HFpEF). However, its prevalence and pathophysiologic and prognostic relevance remain unclear in early-stage HFpEF. This study sought to assess the association between malnutrition risk, exercise capacity, cardiac and peripheral reserve limitations, and clinical outcomes in patients with early HFpEF, defined as those without a history of HF hospitalization. Methods: Patients with symptomatic HFpEF without previous HF hospitalization (n=341) underwent exercise stress echocardiography. Simultaneous expired gas analysis was conducted in 296 (87%) participants to measure peak oxygen consumption (VO₂). Nutritional status was evaluated using the Geriatric Nutritional Risk Index (GNRI). Results: At least mild malnutrition risk (GNRI ≤98) was identified in 125 patients with HFpEF (36.6%). Compared to HFpEF patients without malnutrition risk (n=216), those at risk (n=125) showed reduced exercise capacity (lower peak VO₂) and lower cardiac output and arteriovenous oxygen content difference during exercise. During a median follow-up of 435 days, 52 patients experienced a composite outcome of all-cause mortality or worsening HF events. Patients with malnutrition risk had a nearly 3-fold increased risk of this outcome compared to those without risk (hazard ratio, 3.07; 95% confidence interval, 1.73–5.44; p<0.001). Conclusions: Malnutrition risk is common in early-stage HFpEF and correlates with exercise intolerance, reduced cardiac output and oxygen uptake, and worse outcomes. Further research is needed to determine management strategies.