Predictive Value of the Hemoglobin-Geriatric Nutritional Risk Index in Patients with Heart Failure

Malnutrition prevails among patients with heart failure (HF), increasing the likelihood of functional decline. We assessed the predictive value of the Hemoglobin-Geriatric Nutritional Risk Index (H-GNRI)—combining hemoglobin and the Geriatric Nutritional Risk Index (GNRI)—on prognosis in older patients with HF. We used the JMDC multicenter database to examine the potential associations between malnutrition risk and other outcome measures. The patients were categorized as low- (H-GNRI score = 0), intermediate- (H-GNRI score = 1), or high-risk (H-GNRI score = 2) based on their H-GNRI scores. The primary outcome measure was the Barthel Index (BI) gain; the secondary outcomes included the BI at discharge, the BI efficiency, length of hospital stay, in-hospital mortality, discharge to home or a nursing home, and hospitalization-associated disability. We analyzed 3532 patients, with 244 being low-risk, 952 being intermediate-risk, and 2336 being high-risk patients. The high-risk group of patients had significantly lower BI values at discharge, lower BI gains, reduced BI efficiency values, and prolonged hospital stays compared to those in the low-risk group. The high-risk patients also had higher in-hospital mortality rates, lower rates of discharge to home or a nursing home, and greater incidences of a hospitalization-associated disability in comparison to the low-risk group. The H-GNRI may serve as a valuable tool for determining prognoses for patients with HF.


Introduction
Heart failure (HF) is a clinical condition characterized by reduced cardiac pump function resulting from cardiac dysfunction, leading to decreased exercise tolerance.The global prevalence of HF exceeds 64 million patients [1], and its incidence rises with advancing age.Consequently, the patient population with HF is expected to continue growing as the world's population ages [2].Moreover, the total HF health care costs in the United States are expected to increase from USD 20.9 billion in 2012 to USD 53.1 billion in 2030, with approximately 80% of the total health care costs being related to hospitalizations [3].The escalating medical expenses associated with prolonged hospitalization and recurrent readmissions in HF pose a serious challenge.Older patients with HF often experience a decline in Activities of Daily Living (ADL) following hospitalization, which has been linked to adverse outcomes, including mortality [4,5].In addition, the decline in ADL associated with hospitalization is a serious problem that can increase the costs of care after discharge.An early assessment of the risk of ADL decline and early intervention are needed to prevent these problems.
Malnutrition is a common issue among patients with HF and it has been associated with a lower quality of life and unfavorable prognoses [6,7].For instance, the Geriatric Nutritional Risk Index (GNRI), a tool used to assess nutritional risk status, has been evaluated for prognostic accuracy in patients with HF.Calculated based on the ratio of ideal weight and serum albumin levels, the GNRI has shown promise in predicting mortality and hospital stay duration in patients with HF [7][8][9].However, some studies have reported that the GNRI does not predict in-hospital mortality or a decline in the Barthel Index (BI) among patients with HF [9,10].Consequently, the GNRI's prognostic value in patients with HF appears to be limited.The prognostic accuracy of the GNRI for post-hospitalization HF-related mortality has been estimated at approximately 0.70 in terms of the area under the curve [11], suggesting that there is room for improved diagnostic precision.
Recently, a new nutritional risk assessment index, the Hemoglobin-GNRI (H-GNRI), emerged [12].The H-GNRI combines the GNRI with hemoglobin levels.A study published in 2021 by Wang et al. reported that the H-GNRI was an independent predictor of survival in patients with esophageal squamous cell carcinoma who underwent an esophagectomy and postoperative radiation therapy.The H-GNRI may be useful as a prognostic factor for diseases prone to malnutrition and low hemoglobin levels.
Anemia is common among patients with HF.The prevalence of anemia in patients hospitalized for HF has been reported to be about 50% [13].Anemia in HF patients is multifactorial, and the primary causes include chronic inflammation, iron deficiency, and renal dysfunction related to cardiac problems [14,15].In studies of patients with HF, lower hemoglobin levels have been reported to be associated with disease severity, re-hospitalization, and mortality in patients with HF [9,16,17].Based on these findings, the H-GNRI, a composite index incorporating hemoglobin and the GNRI, may be valuable in predicting the prognosis for patients with HF who are prone to malnutrition and hemoglobin decline.We hypothesized that a nutritional risk assessment using the H-GNRI would effectively predict the prognosis in patients with HF.The objective of this study was to investigate the utility of the H-GNRI in forecasting outcomes among older patients with HF using a multicenter database.

Study Design and Ethics
This study is a historical cohort focusing on older patients with HF, sourced from the JMDC multicenter database.The ethics committee of Mie University deemed an ethical review unnecessary, citing the database's established academic value and widespread use in research.In addition, informed consent was not required because all data obtained from the database were deidentified.

Data Source
The JMDC database contains medical reimbursement records, laboratory values, and Diagnostic Procedure Combination (DPC) data collected from multiple hospitals in all of Japan [18].Introduced in Japan in 2003, the DPC is a medical payment system [19].The DPC dataset includes a wide range of clinical information, admission and discharge statuses, diagnoses, surgeries and procedures, medications, and specialized reimbursement details pertaining to specific diseases [20].
We collected data on patients admitted for HF from January 2017 to June 2022 using the JMDC database.The database provides information on age, sex, body mass index (BMI) at admission, BI at admission and discharge, New York Heart Association (NYHA) classification, blood test values at the earliest within the first 5 days after admission, pre-admission residency information, use of ambulance services, post-discharge residency information, length of hospital stay, in-hospital mortality, the Charlson Comorbidity Index (CCI) score at admission, ventilator and vasopressor use, number of beds, and year of admission.
The patients were categorized into three age groups: pre-old (65-74 years), old (75-89 years), and oldest-old (≥90 years), as defined by the Japanese Geriatrics Society [21].BMI was calculated by dividing body weight (kg) by height (m), squared and classified into <18.5, 18.5-24.9,25.0-29.9,and ≥30 [22].The Barthel Index (BI) was used to assess the ADL in patients; the BI consists of a total of 10 items, including feeding, bathing, grooming, dressing, bowels, bladder, toilet use, transfers (from bed to a chair and back), mobility We divided the patients into low-(n = 244; 6.9%), intermediate-(n = 952; 27.0%), and high-risk (n = 2336; 66.1%) groups based on their respective H-GNRI scores.The patients' background data are presented in Table 1.The high-risk group of patients tended to be older, female, and underweight, demonstrating a lower BI and higher CCI than the lowerrisk patients.We divided the patients into low-(n = 244; 6.9%), intermediate-(n = 952; 27.0%), and high-risk (n = 2336; 66.1%) groups based on their respective H-GNRI scores.The patients' background data are presented in Table 1.The high-risk group of patients tended to be older, female, and underweight, demonstrating a lower BI and higher CCI than the lower-risk patients.
Table 2 presents our between-group comparisons.The high-risk patients had lower BI values at discharge, BI gains, BI efficiency rates, and rates of discharge to home or a nursing home, longer hospital stays, higher in-hospital mortality rates, and higher incidences of a hospitalization-associated disability than the low-or intermediate-risk patients.

Discussion
In this study, we assessed the utility of the H-GNRI in predicting the prognosis among older patients with HF using a multicenter database.We found that the H-GNRI score was associated with BI at discharge, BI gain, BI efficiency, length of hospital stay, in-hospital mortality, discharge to home or a nursing home, and hospitalization-associated disability.A high-risk H-GNRI was independently associated with these outcomes.
Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Half of the studies included HF patients with preserved ejection as the target population.Two studies (25%) defined the age of patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.hospital mortality, discharge to home or a nursing home, and hospitalization-associated disability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Half of the studies included HF patients with preserved ejection as the target population.Two studies (25%) defined the age of patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.hospital mortality, discharge to home or a nursing home, and hospitalization-associated disability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Half of the studies included HF patients with preserved ejection as the target population.Two studies (25%) defined the age of patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.hospital mortality, discharge to home or a nursing home, and hospitalization-associated disability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Half of the studies included HF patients with preserved ejection as the target population.Two studies (25%) defined the age of patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.hospital mortality, discharge to home or a nursing home, and hospitalization-associated disability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Half of the studies included HF patients with preserved ejection as the target population.Two studies (25%) defined the age of patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.hospital mortality, discharge to home or a nursing home, and hospitalization-associated disability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Half of the studies included HF patients with preserved ejection as the target population.Two studies (25%) defined the age of patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.hospital mortality, discharge to home or a nursing home, and hospitalization-associated disability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Half of the studies included HF patients with preserved ejection as the target population.Two studies (25%) defined the age of patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients without HF risk jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients aged <65 years d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients transferred elsewhere ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients who died in hospital toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients on dialysis toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients with missing GNRI data der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients with missing GNRI data 98 patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.all-cause death with preserved ejection as the target population.Two studies (25%) defined the age of patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.GNRI in patients with HF.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Half of the studies included HF patients with preserved ejection as the target population.Two studies (25%) defined the age of patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.HFpEF/ HFrEF 451 Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients with acute coronary syndrome sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients with active malignancy sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients on dialysis spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients undergoing surgery during hospitalization spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.
Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients with missing data 92 disability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Half of the studies included HF patients with preserved ejection as the target population.Two studies (25%) defined the age of patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.in-hospital mortality hospital mortality, discharge to home or a nursing home, and hospitalization-associated disability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Half of the studies included HF patients with preserved ejection as the target population.Two studies (25%) defined the age of patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.Patients with a pre-admission Barthel Index of less than 85 8 of 13 spital mortality, discharge to home or a nursing home, and hospitalization-associated sability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the NRI in patients with HF.Table 6 shows a list of previous studies that examined the ognostic value of the GNRI in patients with HF.Half of the studies included HF patients ith preserved ejection as the target population.Two studies (25%) defined the age of tients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or der, and five studies (62.5%) did not define criteria based on age.The most common toff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis ere excluded in half of the studies.Six studies (75%) set an outcome related to death, d two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and jective nutritional risk assessment index that does not require specialized skills or user perience.These are the major advantages of the GNRI for clinical use.While prior udies examined its prognostic value and have demonstrated its independence in edicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern out the impact of edema, which is prevalent in HF patients, on the GNRI [9].We pothesized that H-GNRI may predict prognosis in older HF patients.hospital mortality, discharge to home or a nursing home, and hospitalization-associated disability.A high-risk H-GNRI was independently associated with these outcomes.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Table 6 shows a list of previous studies that examined the prognostic value of the GNRI in patients with HF.Half of the studies included HF patients with preserved ejection as the target population.Two studies (25%) defined the age of patients as 65 years or older, one study (12.5%) defined the age of patients as 80 years or older, and five studies (62.5%) did not define criteria based on age.The most common cutoff for the GNRI was 92, which was used in 75% of the studies.Patients on dialysis were excluded in half of the studies.Six studies (75%) set an outcome related to death, and two studies (25%) set an outcome related to ADLs.The GNRI is a very simple and objective nutritional risk assessment index that does not require specialized skills or user experience.These are the major advantages of the GNRI for clinical use.While prior studies examined its prognostic value and have demonstrated its independence in predicting mortality and prolonged hospital stay in patients with HF [7,8], there is concern about the impact of edema, which is prevalent in HF patients, on the GNRI [9].We hypothesized that H-GNRI may predict prognosis in older HF patients.GNRI, Geriatric Nutritional Risk Index; HF, heart failure; HFpEF, heart failure with preserved ejection; ADL, activities of daily life.
The high-risk H-GNRI group exhibited a significantly lower BI gain than the other risk groups.After adjusting for confounders, the H-GNRI remained independently associated with BI gain.Furthermore, the mean BI gain (13.1) was greater than the minimal clinically important difference in BI for acute stroke (9.8 point) [33] and femoral neck fracture (9.25 point) [34], indicating a clinically meaningful change in the BI in this study.Regardless of the nutritional risk, the BI increased with general condition recovery from the inpatient treatment, although the high-risk H-GNRI group had a smaller BI gain than the other groups.
Previous research has shown a positive correlation between hemoglobin levels and ADL recovery in older hospitalized patients [35].Anemia is also associated with reduced ADL in patients with HF [36,37].Hemoglobin, a key component of red blood cells, is pivotal in oxygen transport.Reduced hemoglobin levels can lead to symptoms such as dizziness, palpitations, fatigue, and limited physical activity [38,39].Patients in the highrisk H-GNRI group are more likely to have anemia, which may hinder ADL recovery due to the associated physical limitations.
Furthermore, GNRI-a component of the H-GNRI-is a nutritional risk assessment index calculated using BMI and albumin.Previous studies have highlighted that malnutrition poses a risk for hospitalization-associated disability in older hospitalized patients, with chronic-disease-related malnutrition linked to a lower BI at discharge [40,41].A low BMI is also associated with post-discharge functional decline [42].These findings suggest that malnutrition risk can impede rehabilitation effectiveness and negatively impact ADL recovery.In addition, malnutrition is a risk for complications such as infections [43].Although this study could not be verified because it was not possible to detect all infective complications, higher-nutritional-risk patients may be at a higher risk for complications, which may have inhibited the recovery of ADLs.
The high-risk H-GNRI group had a higher incidence of hospitalization-associated disability than the other groups.After adjusting for confounders, hospitalization-associated disability was still independently associated with the H-GNRI score, suggesting that the H-GNRI may predict ADL decline during hospitalization.This could be explained for the same reason that the BI gains were smaller in the high-risk group, the effects of anemia, undernutrition, and comorbidities on ADLs.However, the GNRI alone was insufficient to predict BI decline in the HF patients [10].One possible explanation is that the nutritional risk assessment via the GNRI relies on body weight.Fluid retention and edema are common symptoms in patients with HF [44].In cases in which patients have fluid retention, an assessment via body weight is not appropriate.Therefore, the GNRI may underestimate the nutritional risk of HF patients.Combining the GNRI with hemoglobin may address this underestimation, potentially enhancing the prognostic accuracy in older patients with HF.
The results of the subgroup analyses by age showed that high-risk H-GNRI was independently associated with BI at discharge in the 75-89 and >90 years old age categories.However, no association was found between the H-GNRI and BI at discharge in the 65-74 age group.This finding could be due to various reasons.First, the sample size decreased by dividing the sample into subgroups.Smaller sample sizes make it more difficult to detect statistically significant differences because the p-values are affected by the sample size.Second, the higher mean BI at discharge in the 65-74 age category may have caused a ceiling effect.
Assessments using a bioelectrical impedance analysis and dual energy X-ray absorptiometry have been reported to be associated with clinical outcomes in HF patients [45,46].However, the use of a bioelectrical impedance analysis and dual-energy X-ray absorptiometry requires special equipment and much labor, and there is a high cost of installing the equipment.The H-GNRI is a simple nutritional risk assessment index suitable for clinical use that can be calculated using only the height, weight, and routinely measured blood test data of hospitalized patients without the need for special equipment, much expense, or labor.
This has limitations, including a lack of post-discharge information due to limits on retrospective data acquisition and potential selection bias, as the data were drawn from hospitals that submitted inpatient data.These hospitals may provide different care to patients compared to those that did not.Consequently, we cannot draw assumptions about the utility of the H-GNRI for long-term prognostication.In addition, we could not assess biomarkers such as natriuretic peptide, adipocytokines, and galectin 3, nor could we assess information on patient lifestyle habits such as alcohol and smoking.Additionally, we were unable to obtain data on indicators such as the bioelectrical impedance analysis, Subjective Global Assessment, and Nutritional Risk Screening 2002; thus, we were unable to make comparisons with the H-GNRI.Furthermore, this study demonstrated an association between the H-GNRI and clinical outcomes in patients with HF.However, it is not possible to determine these causal associations.
This study revealed the potential utility of the H-GNRI in predicting the prognosis of older patients with HF; however, long-term prognosis could not be validated.Thus, further research is still needed.A subsequent study is required to include extended follow-up periods to assess the long-term prognostic value of the H-GNRI in HF patients.It is possible to determine the most effective method to identify HF patients with or at risk of malnutrition by clarifying the utility of the H-GNRI and comparing it with other nutritional risk assessment indexes.In addition, interventions for high-risk patients based on nutritional risk assessment using the H-GNRI and their effectiveness need to be investigated.

Conclusions
Among older patients with HF, the H-GNRI scores were associated with the BI at discharge, BI gain, BI efficiency, length of hospital stay, in-hospital mortality, discharge to home or a nursing home, and hospitalization-associated disability.Thus, the H-GNRI may be useful for prognostication in patients with HF.However, further research is necessary to validate its utility in predicting long-term prognosis and assess interventions' effectiveness for high-risk patients with HF, as indicated by the H-GNRI score.

ble 6 .
Previous studies of GNRI in patients with heart failure.mortality ･HF re-hospitalization ･ADL at discharge GNRI may be a useful index for predicting functional dependency and mortality Kinugasa et al.

ble 6 .
Previous studies of GNRI in patients with heart failure.mortality ･HF re-hospitalization ･ADL at discharge GNRI may be a useful index for predicting functional dependency and mortality Kinugasa et al.Patients with missing for GNRI data 92 Nutrients 2023, 15, x FOR PEER REVIEW 8 of 13

Table 2 .
Comparison of outcomes among the three groups.

Table 3 .
Association between H-GNRI and multiple linear regression analysis outcomes.
Models adjusted for age, sex, New York Heart Association class, Barthel Index at admission, Charlson Comorbidity Index, ventilator use at admission, vasodilator use at admission, use of ambulance service, number of beds, and year of admission.

Table 4 .
Association between H-GNRI and multiple logistic regression analysis outcomes.
Models adjusted for age, sex, New York Heart Association class, Barthel Index at admission, Charlson Comorbidity Index, ventilator use at admission, vasodilator use at admission, use of ambulance service, number of beds, and year of admission.

Table 5 .
Multiple logistic regression analysis for Barthel Index at discharge based on age.
Models adjusted for sex, New York Heart Association class, Barthel Index at admission, Charlson Comorbidity Index, ventilator use at admission, vasodilator use at admission, use of ambulance service, number of beds, and year of admission.

Table 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.
g for GNRI data 92 ･all-cause death ･cardiovascular death ･non-cardiovascular death GNRI is helpful for risk stratification Honda et al. [11] risk 107.1 ･cardiovascular events GNRI may be useful for predicting cardiovascular events Minamisawa et al. [29]

ble 6 .
Previous studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.

ble 6. Previous
studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.
･Patients with cancer ･Patients with liver cirrhosis ･Patients on dialysis ･Patients with missing data 92 ･all-cause mortality ･HF re-hospitalization ･ADL at discharge GNRI may be a useful index for predicting functional dependency and mortality Kinugasa et al. [28] Acute HF 490 ･Patients with acute coronary syndrome ･Patients aged <65 ･Patients with missing for GNRI data 92 ･all-cause death ･cardiovascular death ･non-cardiovascular death GNRI is helpful for risk stratification Honda et al. [11] At risk of 1823 ･Patients without HF risk 107.1 ･cardiovascular events GNRI may be useful for predicting cardiovascular Minamisawa et al. all-cause death Nutrients 2023, 15, x FOR PEER REVIEW 8 of 13

Table 6 .
Previous studies of GNRI in patients with heart failure.
･Patients with cancer ･Patients with liver cirrhosis ･Patients on dialysis ･Patients with missing data 92 ･all-cause mortality ･HF re-hospitalization ･ADL at discharge GNRI may be a useful index for predicting functional dependency and mortality Kinugasa et al. [28] Acute HF 490 ･Patients with acute coronary syndrome ･Patients aged <65 ･Patients with missing for GNRI data 92 ･all-cause death ･cardiovascular death ･non-cardiovascular death GNRI is helpful for risk stratification Honda et al. [11] GNRI may be useful for cardiovascular death Nutrients 2023, 15, x FOR PEER REVIEW 8 of 13

Table 6 .
Previous studies of GNRI in patients with heart failure.
[11]ients with cancer ･Patients with liver cirrhosis ･Patients on dialysis ･Patients with missing data 92 ･all-cause mortality ･HF re-hospitalization ･ADL at discharge GNRI may be a useful index for predicting functional dependency and mortality Kinugasa et al. [28] Acute HF 490 ･Patients with acute coronary syndrome ･Patients aged <65 ･Patients with missing for GNRI data 92 ･all-cause death ･cardiovascular death ･non-cardiovascular death GNRI is helpful for risk stratification Honda et al. [11]non-cardiovascular death GNRI is helpful for risk stratification Honda et al.[11]

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

ble 6 .
Previous studies of GNRI in patients with heart failure.

Table 6 .
Previous studies of GNRI in patients with heart failure.