Annually, approximately 17.9 million people die from cardiovascular disease worldwide, representing nearly 31% of global deaths.¹ In cardiac patients, the prevalence of malnutrition varies according to the cause of the disease and the malnutrition screening tool, ranging from 25 to 51.9%.² However, no study has been found in the literature over the past 10 years investigating the prevalence of malnutrition and its association with clinical outcomes in stable ischemic heart disease patients.

In hospital practice, impaired nutritional status and malnutrition are possible complications among cardiac patients^{3 , 4} leading to increased morbidity and mortality rates and impact on clinical outcomes.^{4 , 5} Studies have shown that cardiac patients with moderate or severe energy-protein malnutrition have higher mortality risks,^{3 , 6 , 7} and hospitalization, per se, is an important predictor of nutritional risk.⁸

The assessment of nutritional status of hospitalized cardiac patients is essential to diagnose nutritional disorders that may be additional risk factors for heart disease.^{3 , 5} Different parameters, such as dietary history, anthropometric measures, biochemical data, clinical history and physical examination, have been used in the nutritional assessment of hospitalized patients,^{9 , 10} and the Subjective Global Assessment (SGA) has been a widely used tool due to its practicality^{3 , 11} and sensitivity in detecting impaired nutritional status.^{3 , 7}

Identifying the nutritional profile of hospitalized cardiac patients is essential to determine the most appropriate dietary treatment and to optimize health professionals’ and institutional managers’ planning. As malnutrition is an important risk factor for clinical complications, the aim of the present study was to identify the prevalence of malnutrition and its association with the need for intensive care, with death and longer hospital stay in cardiac patients admitted to a referral center for cardiology.

Data of 130 patients were analyzed. Mean age of patients was 63 ± 13 years, most of patients was male (n = 82, 63%), and angina was the main cause of hospitalization (n = 33, 25%). The prevalence of malnutrition according to the SGA was 27% (n = 35). Table 1 describes the characteristics of the sample and SGA classification.

Table 1

Variables	N = 130
Age	63 ± 13
- elderly	56 (43.1%)
- adults	74 (56.9%)
Male	82 (63%)
Cause of hospitalization
- angina	33 (25%)
- AMI	23 (18%)
- surgery	19 (15%)
Length of hospital stay	9 (5 – 14)
Need for intensive care	59 (45%)
In-hospital death	4 (3%)
SGA classification
- A	95 (73%)
- B	32 (25%)
- C	3 (2%)

Data described as mean and standard deviation, absolute frequency and percentage. SGA: subjective global assessment; ICU: intensive care center; AMI: acute myocardial infarction;

Table 2 describes the frequency of the SGA components, and a low frequency of severe malnutrition was found. Most patients were classified as having low metabolic stress (n = 48, 37%). Weight loss in the last 6 months was identified in 15 patients (11%), and reduced food intake in 20 (15%) patients.

Table 2

SGA Variables	Frequency
Weight loss in the last 6 months	15 (11%)
Weight loss in the last 2 weeks	8 (6%)
Dietary intake change	20 (15%)
Presence of gastrointestinal symptoms	10 (7%)
Functional capacity dysfunction	12 (9%)
Underlying disease:
- heart disease	67 (51%)
- two or more	22 (17%)
Metabolic stress:
- low	48 (37%)
- moderate	2 (16%)
- high	5 (4%)
Slight fat loss	12 (9%)
Mild muscle loss	12 (9%)
Mild ankle edema	3 (2%)
Mild sacral edema	2 (1.5%)
Ascites	0 (0%)

SGA: subjective global assessment.

Table 3 shows the comparison of well-nourished patients (SGA group A) with patients grouped as SGA B + C (with some degree of malnutrition) for clinical variables and complications at admission. Patients classified as malnourished by SGA were older and had a higher frequency of hospital stay longer than 7 days.

Table 1

	Well-nourished SGA A (n = 95)	Malnourished SGA B e C (n = 35)	P value
Age	60 ± 12	70 ± 13	< 0,001
Male	60 (63%)	22 (63%)	0.975
ICU admission	38 (40%)	21 (60%)	0.115
In-hospital death	1 (1%)	3 (8%)	0.075
Hospital stay > 7 days	50 (53%)	27 (77%)	0.012

Continuous data with normal distribution compared by Student's t-test and described as mean and standard deviation. Categorical data were described as absolute and percentage frequency and compared by chi-square test. SGA: global subjective assessment; ICU: intensive care unit

In table 4 consolidates the multivariate analysis by Poisson regression models, adjusted and unadjusted for age. After this adjustment, statistical significance was observed for the variables ICU stay and hospital stay longer than 7 days.

Table 4

Variables	PR (95% CI)	p	Adjusted PR* (95% CI)	p-value
ICU stay	1.48 (1.03 – 2.14)	0.034	1.55 (1.05 – 2.27)	0.026
In-hospital death	8.06 (0.87 – 74.9)	0.067	7.41 (0.49 - 112.4)	0.149
Hospital stay > 7 days	1.47 (1.13 – 1.91)	0.004	1.35 (1.01 – 1.79)	0.040

* Adjusted for age. SGA: subjective global assessment; ICU: intensive care unit; BMI: body mass index; PR: prevalence ratio; CI: confidence interval.

The present study found a low prevalence of malnutrition in the sample using SGA. Malnourished patients were older and had longer hospital stays. After age-adjusted multivariate analysis, a positive association of malnutrition with ICU transfer and length of hospital stay was observed.

Corroborating with the present study, findings in the literature indicate that malnutrition is more commonly observed in elderly patients,^{8 , 13 , 14} where the more advanced the age, the greater the risk of malnutrition. Therefore, for assessment of malnutrition using clinical outcomes, age adjustment was necessary in the multivariate analysis. This research also revealed that 73% of the sample was well-nourished, which can be justified by the fact that most patients with ischemic heart disease are overweight or obese.^{15 , 16} More severe patients and hemodynamically unstable patients were excluded to add data in the literature regarding the prevalence of malnutrition and associated clinical outcomes in patients with stable ischemic heart disease.

Malnourished patients in this study showed a higher percentage of hospitalization longer than 7 days. In the study of Karst et al.,¹⁷ which evaluated 83 cardiac patients admitted to the ICU, mean hospital stay of malnourished patients was longer than that of well-nourished patients. Kang et al.,¹⁸ evaluated 300 hospitalized patients with different diseases and identified a longer hospitalization time in the malnourished group. In contrast, the study by Veras et al.,¹⁹ performed with 45 surgical patients with various diseases, found no significant difference in the length of hospital stay between well-nourished and malnourished groups according to SGA.

In addition, in-hospital mortality was not associated with malnutrition. However, a positive association of malnutrition with in-hospital mortality in heart failure has already been demonstrated,²⁰ which is expected for this patient’s profile and which differs from ischemic heart disease. In the study by Yamauti et al.,⁷ with two groups of cardiac patients, one consisting of several etiologies and the other only with decompensated congestive heart failure, malnutrition prevalence was significantly higher in the heart failure group.

To overcome the limitation that SGA is a method originally validated for surgical patients, we used the scored version of the instrument,¹¹ which is also validated and allows minimizing possible measurement biases, inherent to any subjective assessment methods. The evaluators were previously trained for its application; however, as it was a retrospective study, intra-observer analysis was not possible. In addition, the exclusion of patients using enteral nutritional therapy may have underestimated the prevalence of malnutrition in our sample.

On the other hand, SGA allows for a consistent assessment of hospitalized patients, especially when objective measurements cannot be performed, which justifies its wide use in clinical practice.

The prevalence of malnutrition according to the SGA was 27% in hospitalized ischemic heart disease patients. There was a positive association of malnutrition with hospitalization stay longer than 7 days and referral to the intensive care unit. Studies evaluating body composition in cardiac patients can better elucidate the association of nutritional diagnosis with clinical complications and length of hospital stay.