In the present study, we examined the effect of
nutritional status, calculated using the CONUT
score, on the clinical presentation of patients with AF
aged 65 years and older taking oral anticoagulants.
Patients with a CONUT score of ≥5 and classified as moderate-severe malnutrition had a higher rate
of major bleeding and mortality, and no significant
difference was found in terms of ischemic stroke.
While there was no significant difference in mortality
and major bleeding according to nutritional status
in patients taking DOAC, a higher rate of major
bleeding and mortality was found in patients with moderate-to-severe malnutrition in the warfarin
group.
Elderly individuals, particularly those with
cardiovascular disease, often suffer from malnutrition.
Based on previous research, it has been found that
approximately 60 to 90% of malnourished elderly
people are below a healthy weight.[17] Around
60 to 70% of elderly people who are considered
frail are malnourished.[18] Malnutrition is not only
a consequence of chronic diseases, but can also
contribute to the progression of these diseases.
Previous studies have demonstrated a link between
malnutrition and unfavorable outcomes in patients
with coronary artery disease or heart failure.[19,20]
However, there are few studies investigating both the
incidence and predictive significance of malnutrition
in patients with AF.[21,22]
The BMI is a commonly used measure for
evaluating nutritional status. However, its use is
limited, particularly in patients with AF. This is
because 21 to 68% of patients with AF have also
heart failure.[23] In individuals with heart failure,
the retention of sodium and water in the body can
lead to weight gain, which can affect the accuracy
of BMI as a measure. In addition, BMI is unable to differentiate between muscle, fat and bone mass, and
individuals with similar BMI values may have different
metabolic profiles. The CONUT score is determined
by measuring serum albumin, total cholesterol, and
lymphocyte count. It serves as a comprehensive score
that reflects the patient's frailty.
In our study, patients with a CONUT score
of ≥5 were found to have a higher rate of major
bleeding and mortality in the patient group receiving
warfarin. However, no significant difference was
observed between the groups in patients using
DOAC. Polypharmacy often increases with age,
as the prevalence of multiple health conditions or
comorbidities increases. This situation increases the
interaction of warfarin with other medications and,
thus, it necessitates more frequent INR monitoring.
Reduced muscle strength due to malnutrition limits
physical activity and reduces hospital admissions.[24]
This prevents regular follow-up and is one reason
for the increase in the rate of major bleeding.
Albumin level, one of the parameters in the
CONUT score, is an important indicator reflecting
nutritional status in clinical practice.[25] In addition,
albumin levels also affect the efficacy of warfarin
anticoagulation. Warfarin is completely absorbed
after oral administration and subsequently binds to
albumin in plasma to a high degree. The portion
that remains unbound to albumin, about 1 to 10%,
suppresses the synthesis of vitamin K-dependent
coagulation factors in the hepatocytes, which leads
to an anticoagulant effect. Previous studies have
indicated increased anticoagulation and a higher risk
of bleeding in individuals with low serum albumin
levels receiving warfarin therapy.[26,27] These factors
may explain the higher incidence of major bleeding
and higher mortality in malnourished elderly AF
patients taking warfarin in our study.
The assessment of malnutrition in patients with
AF and the implementation of early interventions,
particularly in patients with moderate to severe
malnutrition, could have a significant impact
on patient outcomes. Some studies have shown
that the use of oral nutritional supplements
and nutritional counseling can improve clinical
outcomes in individuals with malnutrition.[28,29]
The identification of malnutrition as an isolated
risk factor for morbidity and mortality in elderly
individuals with AF is important as malnutrition
is a risk factor that can potentially be addressed
and modified. Therefore, it is of great importance to develop a multidisciplinary team approach to
reduce the negative effects of malnutrition in elderly
patients with AF treated with anticoagulants.
The recommendations of clinical nutritionists
can play a crucial role in the development of a
monitoring strategy. Incorporating oral nutritional
supplementation can prove to be a valuable resource
in preventing weight loss, enhancing nutritional
health, and lowering complications in elderly AF
patients suffering from malnutrition.
Nonetheless, there are some limitations to this
study. The study was carried out in a retrospective
manner at two centers, and the study sample size was
relatively limited. In addition, we evaluated nutritional
status exclusively at the moment of the initial hospital
admission and did not explore any fluctuations or
changes in nutritional status over the course of time.
Therefore, it is not definitively established whether
patients who had malnutrition at the beginning can
maintain the same nutritional status, when they
undergo clinical events. Finally, we only used the
CONUT score to determine nutritional status.
Therefore, we were not able to make a comparison
with other nutritional scores with proven prognostic
value.
In conclusion, the CONUT score is a critical
measure used to evaluate the nutritional status of
patients with AF. In our study, major bleeding
and mortality rates increased, particularly in AF
patients aged 65 and over who used anticoagulants
and experienced moderate to severe malnutrition.
We believe that the use of DOACs would be more
appropriate in this patient group.
Ethics Committee Approval: The study protocol
was approved by the Mardin Artuklu University Ethics
Committee (date: 06.11.2023, no: 2023/11-20). The study
was conducted in accordance with the principles of the
Declaration of Helsinki.
Patient Consent for Publication: A written informed
consent was obtained from each patient.
Data Sharing Statement: The data that support the
findings of this study are available from the corresponding
author upon reasonable request.
Author Contributions: Idea/concept, design, control/
supervision, data collection and/or processing, analysis and/or
interpretation, literature review, writing the article, critical
review, references and fundings, materials: R.K.; Design,
control/supervision, data collection and/or processing,
literature review, critical review, references and fundings,
materials: A.F.K.
Conflict of Interest: The authors declared no conflicts
of interest with respect to the authorship and/or publication
of this article.
Funding: The authors received no financial support for
the research and/or authorship of this article.