Background In patients with chronic heart failure (CHF), malnutrition might be related to right heart dysfunction and venous congestion, which predispose to bowel oedema and malabsorption, thereby leading to malnutrition. We explored the relation between congestion, malnutrition and mortality in a large cohort of ambulatory patients with CHF.

Methods We assessed malnutrition using the Geriatric Nutritional Risk Index (GNRI). Congestion was defined by echocardiography (raised right atrial pressure (RAP)=dilated inferior vena cava≥21 mm/raised pulmonary artery systolic pressure (PAsP)=transtricuspid gradient of ≥36 mm Hg/right ventricular systolic dysfunction (RVSD)=tricuspid annular plane systolic excursion <17 mm).

Results Of the 1058 patients enrolled, CHF was confirmed in 952 (69% males, median age 75 (IQR: 67–81) years, median N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) 1141 (IQR: 465–2562) ng/L). 39% had HF with -reduced ejection fraction (left ventricular ejection fraction, LVEF <40%) and 61% had HF with normal (HeFNEF, LVEF ≥40% and NT-pro-BNP >125 ng/L) ejection fraction. Overall, 14% of patients were malnourished (GNRI ≤98). 35% had raised RAP, 23% had raised PAsP and 38% had RVSD. Congestion was associated with malnutrition. During a median follow-up of 1683 days (IQR: 1096–2230 days), 461 (44%) patients died. Malnutrition was an independent predictor of mortality. Patients who were malnourished with both RVSD and increased RAP had much worse outcome compared with non-malnourished patients without RVSD who had normal RAP.

Conclusion Malnutrition and congestion are modestly correlated and each is independently associated with increased mortality in patients with CHF. Patients with HF with both malnutrition and congestion as evidenced by right heart dysfunction should be managed with additional vigilance.