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von Haehling S, Ebner N, Dos Santos MR, Springer J, Anker SD. Muscle wasting and cachexia in heart failure: mechanisms and therapies. Nat Rev Cardiol 2017; 14:323-341. [PMID: 28436486 DOI: 10.1038/nrcardio.2017.51] [Citation(s) in RCA: 215] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Body wasting is a serious complication that affects a large proportion of patients with heart failure. Muscle wasting, also known as sarcopenia, is the loss of muscle mass and strength, whereas cachexia describes loss of weight. After reaching guideline-recommended doses of heart failure therapies, the most promising approach to treating body wasting seems to be combined therapy that includes exercise, nutritional counselling, and drug treatment. Nutritional considerations include avoiding excessive salt and fluid intake, and replenishment of deficiencies in trace elements. Administration of omega-3 polyunsaturated fatty acids is beneficial in selected patients. High-calorific nutritional supplements can also be useful. The prescription of aerobic exercise training that provokes mild or moderate breathlessness has good scientific support. Drugs with potential benefit in the treatment of body wasting that have been tested in clinical studies in patients with heart failure include testosterone, ghrelin, recombinant human growth hormone, essential amino acids, and β2-adrenergic receptor agonists. In this Review, we summarize the pathophysiological mechanisms of muscle wasting and cachexia in heart failure, and highlight the potential treatment strategies. We aim to provide clinicians with the relevant information on body wasting to understand and treat these conditions in patients with heart failure.
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Affiliation(s)
- Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Centre and DZHK (German Centre for Cardiovascular Research), Robert-Koch-Strasse 40, D-37075 Göttingen, Germany
| | - Nicole Ebner
- Department of Cardiology and Pneumology, University of Göttingen Medical Centre and DZHK (German Centre for Cardiovascular Research), Robert-Koch-Strasse 40, D-37075 Göttingen, Germany
| | - Marcelo R Dos Santos
- Department of Cardiology and Pneumology, University of Göttingen Medical Centre and DZHK (German Centre for Cardiovascular Research), Robert-Koch-Strasse 40, D-37075 Göttingen, Germany.,Heart Institute (InCor), University of Sao Paulo Medical School, Dr. Arnaldo Avenue, 455 Cerqueira César, 01246903 Sao Paulo, Brazil
| | - Jochen Springer
- Department of Cardiology and Pneumology, University of Göttingen Medical Centre and DZHK (German Centre for Cardiovascular Research), Robert-Koch-Strasse 40, D-37075 Göttingen, Germany
| | - Stefan D Anker
- Department of Cardiology and Pneumology, University of Göttingen Medical Centre and DZHK (German Centre for Cardiovascular Research), Robert-Koch-Strasse 40, D-37075 Göttingen, Germany.,Division of Cardiology and Metabolism: Heart Failure, Cachexia and Sarcopenia, Department of Internal Medicine and Cardiology, Berlin-Brandenburg Centre for Regenerative Therapies, Charité Medical School, Augustenburger Platz 1, 13353 Berlin, Germany
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152
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Carbone S, Lavie CJ, Arena R. Obesity and Heart Failure: Focus on the Obesity Paradox. Mayo Clin Proc 2017; 92:266-279. [PMID: 28109619 DOI: 10.1016/j.mayocp.2016.11.001] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 10/14/2016] [Accepted: 11/01/2016] [Indexed: 12/17/2022]
Abstract
The escalating prevalence of obesity has been linked to substantial increases in both metabolic and cardiovascular disease. Nevertheless, the direct effects of obesity on cardiovascular health and function require further exploration. In particular, the relationship between obesity and cardiac function has received intense scrutiny. Although obesity increases the risk for development of heart failure (HF), it appears to exert a protective effect in patients in whom HF has already been diagnosed (the "obesity paradox"). The protective effects of obesity in patients with previously diagnosed HF are the focus of particularly intense research. Several explanations have been proposed, but most studies are limited by the use of body mass index to classify obesity. Because body mass index does not distinguish between fat mass, fat-free mass, and lean mass, individuals with similar body mass indices may have vastly different body composition. This article discusses the roles of body composition, diet, cardiorespiratory fitness, and weight loss in the development of cardiac dysfunction and HF and the potential protective role that body composition compartments might play in improving HF prognosis. Based on an intensive literature search (Pubmed, Google Scholar) and critical review of the literature, we also discuss how a multidisciplinary approach including a nutritional intervention targeted to reduce systemic inflammation and lean mass-targeted exercise training could potentially exert beneficial effects for patients with HF.
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Affiliation(s)
- Salvatore Carbone
- Pauley Heart Center, Victoria Johnson Research Laboratories, Virginia Commonwealth University, Richmond, VA; Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy.
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA
| | - Ross Arena
- Department of Physical Therapy and Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL
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153
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Abstract
With aging and other muscle wasting diseases, men and women undergo similar pathological changes in skeletal muscle: increased inflammation, enhanced oxidative stress, mitochondrial dysfunction, satellite cell senescence, elevated apoptosis and proteasome activity, and suppressed protein synthesis and myocyte regeneration. Decreased food intake and physical activity also indirectly contribute to muscle wasting. Sex hormones also play important roles in maintaining skeletal muscle homeostasis. Testosterone is a potent anabolic factor promoting muscle protein synthesis and muscular regeneration. Estrogens have a protective effect on skeletal muscle by attenuating inflammation; however, the mechanisms of estrogen action in skeletal muscle are less well characterized than those of testosterone. Age- and/or disease-induced alterations in sex hormones are major contributors to muscle wasting. Hence, men and women may respond differently to catabolic conditions because of their hormonal profiles. Here we review the similarities and differences between men and women with common wasting conditions including sarcopenia and cachexia due to cancer, end-stage renal disease/chronic kidney disease, liver disease, chronic heart failure, and chronic obstructive pulmonary disease based on the literature in clinical studies. In addition, the responses in men and women to the commonly used therapeutic agents and their efficacy to improve muscle mass and function are also reviewed.
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154
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Springer J, Anker SD. Publication trends in cachexia and sarcopenia in elderly heart failure patients. Wien Klin Wochenschr 2016; 128:446-454. [PMID: 27885423 DOI: 10.1007/s00508-016-1126-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 10/26/2016] [Indexed: 12/11/2022]
Abstract
The loss of skeletal mass - sarcopenia and cachexia - is considered to be a major contributor to morbidity and mortality in chronic heart failure (CHF). Unfortunately, sarcopenia is generally considered to be a geriatric syndrome, but not necessarily seen as a comorbidity in CHF, even though it has a wide range of adverse health outcomes. While there were 15,574 publication with the title word "heart failure" in PubMed in the 5‑year period from 1 June 2011 to 31 May 2016, only 22 or 71 publications were found with the search combination "sarcopenia" or "cachexia" (title word) and "heart failure" (all fields), respectively. This shows very clearly that loss of muscle quality and function due to heart failure is still an underappreciated problem in the medical field.
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Affiliation(s)
- Jochen Springer
- Institute of Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Centre Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
| | - Stefan D Anker
- Institute of Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Centre Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
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155
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Nutritional status and its effects on muscle wasting in patients with chronic heart failure: insights from Studies Investigating Co-morbidities Aggravating Heart Failure. Wien Klin Wochenschr 2016; 128:497-504. [DOI: 10.1007/s00508-016-1112-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 10/12/2016] [Indexed: 12/20/2022]
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156
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Dos Santos MR, Saitoh M, Ebner N, Valentova M, Konishi M, Ishida J, Emami A, Springer J, Sandek A, Doehner W, Anker SD, von Haehling S. Sarcopenia and Endothelial Function in Patients With Chronic Heart Failure: Results From the Studies Investigating Comorbidities Aggravating Heart Failure (SICA-HF). J Am Med Dir Assoc 2016; 18:240-245. [PMID: 27816483 DOI: 10.1016/j.jamda.2016.09.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 09/12/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Skeletal muscle wasting, also known as sarcopenia, has recently been identified as a serious comorbidity in patients with heart failure (HF). We aimed to assess the impact of sarcopenia on endothelial dysfunction in patients with HF with reduced ejection fraction (HFrEF) and with preserved ejection fraction (HFpEF). DESIGN Cross-sectional study. SETTING Ambulatory patients with HF were recruited at Charité Medical School, Campus Virchow-Klinikum, Berlin, Germany. PARTICIPANTS We assessed peripheral blood flow (arm and leg) in 228 patients with HF and 32 controls who participated in the Studies Investigating Comorbidities Aggravating HF (SICA-HF). MEASUREMENTS The appendicular skeletal muscle mass of the arms and the legs combined was assessed by dual energy x-ray absorptiometry (DEXA). Sarcopenia was defined as the appendicular muscle mass two standard deviations below the mean of a healthy reference group of adults aged 18 to 40 years, as suggested for the diagnosis of muscle wasting in healthy aging. All patients underwent a 6-minute walk test and spiroergometry testing. Forearm and leg blood flow were measured by venous occlusion plethysmography. Peak blood flow was assessed after a period of ischemia in the limbs to test endothelial function. RESULTS Sarcopenia was identified in 37 patients (19.5%). Patients with sarcopenia presented with lower baseline forearm blood flow (2.30 ± 1.21 vs. 3.06 ± 1.49 vs. 4.00 ± 1.66 mL min-1 100 mL-1; P = .02) than those without sarcopenia or controls. The group of patients with sarcopenia showed similar baseline leg blood flow (2.06 ± 1.62 vs. 2.39 ± 1.39 mL min-1 100 mL-1; P = .11) to those without but lower values when compared to controls (2.06 ± 1.62 vs. 2.99 ± 1.28 mL min-1 100 mL-1; P = .03). In addition, patients with and without sarcopenia presented with lower peak flow in the forearm when compared to controls (18.37 ± 7.07 vs. 22.19 ± 8.64 vs. 33.63 ± 8.57 mL min-1 100 mL-1; P < .001). A similar result was observed in the leg (10.89 ± 5.61 vs. 14.66 ± 7.19 vs. 21.37 ± 13.16 mL min-1 100 mL-1; P < .001). Peak flow in the forearm showed a significant correlation with exercise capacity (relative peak VO2: R = 0.47; P < .001; absolute peak VO2: R = 0.35; P < .001; and 6-min walk distance: R = 0.20; P < .01). Similar correlations were observed between peak flow in the leg and exercise capacity (absolute peak VO2: R = 0.42, P < .001; relative peak VO2: R = 0.41, P < .001; and 6-min walk test: R = 0.33; P < .001). Logistic regression showed peak flow in the leg to be independently associated with the 6-min walk distance adjusted for age, hemoglobin level, albumin, creatinine, presence of sarcopenia, and coronary artery disease (hazard ratio, 0.903; 95% confidence interval, 0.835-0.976; P = .01). CONCLUSION Patients with HF associated with sarcopenia have impaired endothelial function. Lower vasodilatation had a negative impact on exercise capacity, particularly prevalent in patients with sarcopenia.
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Affiliation(s)
- Marcelo R Dos Santos
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University of Göttingen Medical School, Göttingen, Germany; Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil
| | - Masakazu Saitoh
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University of Göttingen Medical School, Göttingen, Germany
| | - Nicole Ebner
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University of Göttingen Medical School, Göttingen, Germany
| | - Miroslava Valentova
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University of Göttingen Medical School, Göttingen, Germany
| | - Masaaki Konishi
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University of Göttingen Medical School, Göttingen, Germany
| | - Junichi Ishida
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University of Göttingen Medical School, Göttingen, Germany
| | - Amir Emami
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University of Göttingen Medical School, Göttingen, Germany
| | - Jochen Springer
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University of Göttingen Medical School, Göttingen, Germany
| | - Anja Sandek
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University of Göttingen Medical School, Göttingen, Germany
| | - Wolfram Doehner
- Center for Stroke Research Berlin, Charité Medical School, Berlin, Germany
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University of Göttingen Medical School, Göttingen, Germany
| | - Stephan von Haehling
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University of Göttingen Medical School, Göttingen, Germany.
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157
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Saitoh M, Rodrigues Dos Santos M, von Haehling S. Muscle wasting in heart failure : The role of nutrition. Wien Klin Wochenschr 2016; 128:455-465. [PMID: 27761739 DOI: 10.1007/s00508-016-1100-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 09/14/2016] [Indexed: 12/25/2022]
Abstract
Muscle wasting and malnutrition are common complications in patients with advanced heart failure (HF); however, both remain underdiagnosed and undertreated although they both play relevant roles in the progression of HF. The risk of muscle wasting in patients with HF increases in those patients with malnutrition or at risk of malnutrition. Muscle wasting and malnutrition are thought to be positively influenced by adequate therapeutic interventions such as physical activity and nutritional support. Consequently, early detection of malnutrition in patients with HF is recommended. This review discusses muscle wasting and nutritional status, describing the effects of malnutrition on muscle wasting in patients with HF. We review specific issues related to muscle wasting and nutritional status in patients with HF; however, no established strategies currently exist to focus on patients suffering from muscle wasting with malnutrition.
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Affiliation(s)
- Masakazu Saitoh
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.
| | - Marcelo Rodrigues Dos Santos
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany.,Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Stephan von Haehling
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
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158
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Fernández-Solà J, Planavila Porta A. New Treatment Strategies for Alcohol-Induced Heart Damage. Int J Mol Sci 2016; 17:E1651. [PMID: 27690014 PMCID: PMC5085684 DOI: 10.3390/ijms17101651] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/15/2016] [Accepted: 09/16/2016] [Indexed: 02/07/2023] Open
Abstract
High-dose alcohol misuse induces multiple noxious cardiac effects, including myocyte hypertrophy and necrosis, interstitial fibrosis, decreased ventricular contraction and ventricle enlargement. These effects produce diastolic and systolic ventricular dysfunction leading to congestive heart failure, arrhythmias and an increased death rate. There are multiple, dose-dependent, synchronic and synergistic mechanisms of alcohol-induced cardiac damage. Ethanol alters membrane permeability and composition, interferes with receptors and intracellular transients, induces oxidative, metabolic and energy damage, decreases protein synthesis, excitation-contraction coupling and increases cell apoptosis. In addition, ethanol decreases myocyte protective and repair mechanisms and their regeneration. Although there are diverse different strategies to directly target alcohol-induced heart damage, they are partially effective, and can only be used as support medication in a multidisciplinary approach. Alcohol abstinence is the preferred goal, but control drinking is useful in alcohol-addicted subjects not able to abstain. Correction of nutrition, ionic and vitamin deficiencies and control of alcohol-related systemic organ damage are compulsory. Recently, several growth factors (myostatin, IGF-1, leptin, ghrelin, miRNA, and ROCK inhibitors) and new cardiomyokines such as FGF21 have been described to regulate cardiac plasticity and decrease cardiac damage, improving cardiac repair mechanisms, and they are promising agents in this field. New potential therapeutic targets aim to control oxidative damage, myocyte hypertrophy, interstitial fibrosis and persistent apoptosis In addition, stem-cell therapy may improve myocyte regeneration. However, these strategies are not yet approved for clinical use.
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Affiliation(s)
- Joaquim Fernández-Solà
- Alcohol Unit, Department of Internal Medicine, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain.
| | - Ana Planavila Porta
- Departament of Biochemistry and Molecular Biomedicine, Faculty of Biology, Avda Diagonal 643, Universitat de Barcelona, 08028 Barcelona, Spain.
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