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The heart is not the only muscle of importance in heart failure

Comment by Christi Deaton, Primary Care & Risk Factor Management Section

Preventive Cardiology
Heart Failure

Most patients with heart failure (HF) are older and thus subject to the effects of aging and development of geriatric syndromes like frailty. Sarcopenia is a progressive and accelerated loss of muscle mass and strength with a higher prevalence at older ages and in patients with HF [1,2]. HF may contribute to the development of sarcopenia, and the two interact to decrease physiological function and increase risk of adverse outcomes such as frailty, falls and mortality in older individuals [2,3].

In this analysis of 942 patients in the FRAGILE-HF study, patients with HF with reduced (HFrEF n = 467) and preserved ejection fraction (HFpEF, LVEF > 45%, n = 475) were evaluated for sarcopenia using assessment of appendicular skeletal muscle mass (bioelectrical impedance analysis), muscle strength (handgrip measured by dynamometer) and 4 metre walk speed. Sarcopenia was diagnosed in 18% of patients with HFpEF and 22% of those with HFrEF, with sarcopenic patients being significantly older and more likely to be male than those without sarcopenia. After adjusting for other factors, sarcopenia was associated with increased risk of all-cause mortality at one year in both groups: Hazard ratio (HR) in HFpEF was 2.42 (95% CI 1.36 – 4.32, p = 0.003) and HR in HFrEF was 2.02 (95% CI 1.08 – 3.75, p = 0.027). Sarcopenia was not however associated with the composite endpoint of death + HF hospitalisation at one year, indicating that it did not increase risk of HF hospitalisations.

One of the striking findings to me was the low BMI of the patients recruited from 15 Japanese hospitals, with a mean of 21.4 + 3.8 kg/m2, not the BMI we usually see in European populations with HF. Although patients with sarcopenia had a lower BMI than those without, it’s important to remember that sarcopenia can occur in obese patients. In their accompanying editorial Kokinidis and colleagues highlight the importance of studies like this that systematically assess sarcopenia and provide evidence of its detrimental effect on all-cause mortality in HF. However, they also note the interesting absence of an effect on HF hospitalisations and lack of data on cardiovascular mortality.

I agree with the Editorial that a main message from this paper is the importance of assessing patients with HF for sarcopenia. Grip strength and gait speed can be easily measured, and if indicative of sarcopenia, a more comprehensive evaluation including skeletal muscle mass can be conducted. Treatment for sarcopenia includes ensuring a healthy diet with recommended protein levels (and supplementation if needed) and resistance exercise, but novel therapies are being tested. Even more important may be trying to prevent sarcopenia in patients with HF through supporting and maintaining physical activity (resistance and aerobic) and ensuring that patients are eating a healthy diet. Both a Mediterranean type diet and at least three servings of fish weekly have been recommended in some studies [1].


Christi Deaton commented on this article:

Konishi M, Kagiyama N, Kayima K, et al. Impact of sarcopenia on prognosis in patients with heart failure with reduced and preserved ejection fraction. EJPC. 2021; 28: 1022 – 1029. doi:10.1093/eurjpc/zwaa117

and the accompanying editorial:

Kokkinidis DG, Afaras-Melainis A, Giannakoulas G. Sarcopenia in heart failure: ‘waste’ the appropriate time and resources, not the muscles, European Journal of Preventive Cardiology, Volume 28, Issue 9, September 2021, Pages 1019–1021,

Additional references:

1. Lena A, Anker MS, Springer J. Muscle wasting and sarcopenia in heart failure: Current state of Science. International Journal of Molecular Science. 2020; 21: doi:10.3390/ijms21186549
2. Yin J, Lu X, Qian Z, Xu W, Zhou X. New insights into the pathogenesis and treatment of sarcopenia in chronic heart failure. Theranostics. 2019; 9: 4019-4029. doi: 10.7150/thno.33000.
3. Curcio F, Testa G, Liguori I, et al. Sarcopenia and Heart Failure. Nutrients. 2020; 12: doi:10.3390/nu12010211

Notes to editor

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.