Sarcopenia and Endothelial Function in Patients With Chronic Heart Failure: Results From the Studies Investigating Comorbidities Aggravating Heart Failure (SICA-HF)

Prognostic Impact of Sarcopenia Assessed Using Modified Asian Working Group for Sarcopenia 2019 Criteria in Heart Failure

BACKGROUND

Sarcopenia is a substantial therapeutic target, yet the validity of risk stratification values per the latest Asian Working Group for Sarcopenia in 2019 (AWGS 2019) remains unconfirmed in patients with heart failure. We hypothesized that using the 6-minute walk test (6MWT) to assess physical performance improves risk stratification.

METHODS

The study included 832 hospitalized patients with heart failure who could walk at discharge. Sarcopenia was diagnosed using both the original AWGS 2019 criteria (AWGS 2019 model) and an alternative method in which physical performance components were replaced with the 6MWT (modified model). An < 300 m 6MWT indicated low physical performance in the modified model. The primary outcome was 2-year mortality.

RESULTS

Sarcopenia and severe sarcopenia were identified in 45 and 150 patients with the AWGS 2019 model and in 75 and 108 patients with the modified model, respectively. Over the 2-year follow-up period, 145 (17.4%) deaths occurred. Adjusted Cox proportional hazard analysis showed both sarcopenia and severe sarcopenia were significantly associated with 2-year mortality in the modified model. In the AWGS 2019 model, only severe sarcopenia was significantly related to 2-year mortality. The modified model demonstrated significant net reclassification improvement (NRI) over the AWGS 2019 model (NRI, 0.396; 95% CI, 0.214-0.578; P < 0.001).

CONCLUSIONS

In patients with heart failure who were ambulatory at discharge, sarcopenia assessment with the modified AWGS 2019 model using the 6MWT as a physical performance component improved risk stratification compared with the original AWGS 2019 model. Reconsidering the current criteria to improve risk stratification is necessary to ensure timely, appropriate treatment.

CLINICAL TRIAL REGISTRATION

UMIN000023929.

Biological basis and treatment of frailty and sarcopenia

In an ageing society, the importance of maintaining healthy life expectancy has been emphasized. As a result of age-related decline in functional reserve, frailty is a state of increased vulnerability and susceptibility to adverse health outcomes with a serious impact on healthy life expectancy. The decline in skeletal muscle mass and function, also known as sarcopenia, is key in the development of physical frailty. Both frailty and sarcopenia are highly prevalent in patients not only with advanced age but also in patients with illnesses that exacerbate their progression like heart failure (HF), cancer, or dementia, with the prevalence of frailty and sarcopenia in HF patients reaching up to 50-75% and 19.5-47.3%, respectively, resulting in 1.5-3 times higher 1-year mortality. The biological mechanisms of frailty and sarcopenia are multifactorial, complex, and not yet fully elucidated, ranging from DNA damage, proteostasis impairment, and epigenetic changes to mitochondrial dysfunction, cellular senescence, and environmental factors, many of which are further linked to cardiac disease. Currently, there is no gold standard for the treatment of frailty and sarcopenia, however, growing evidence supports that a combination of exercise training and nutritional supplement improves skeletal muscle function and frailty, with a variety of other therapies being devised based on the underlying pathophysiology. In this review, we address the involvement of frailty and sarcopenia in cardiac disease and describe the latest insights into their biological mechanisms as well as the potential for intervention through exercise, diet, and specific therapies.

Effect of Sarcopenia on 10-Year Risk of Atherosclerotic Cardiovascular Disease in Patients with Type 2 Diabetes Mellitus

Objective

To investigate the impact of sarcopenia on the 10-year risk of atherosclerotic cardiovascular disease (ASCVD) among individuals with type 2 diabetes mellitus (T2DM).

Methods

This study included the clinical, laboratory, and body composition data of 1491 patients with T2DM who were admitted to the Department of Endocrinology and Metabolism at Tianjin Union Medical Center from July 2018 to July 2023. The China-PAR model was utilized to evaluate cardiovascular disease risk. Associations between ASCVD risk and various clinical parameters were analyzed, and the relationship between body composition parameters and ASCVD risk was assessed using logistic regression.

Results

The analysis revealed that T2DM patients with sarcopenia had a higher 10-year ASCVD risk compared to those without sarcopenia, with reduced muscle mass independently predicting an increased risk of cardiovascular disease. This association was significant among female T2DM patients, while male T2DM patients with sarcopenia showed a marginally higher median ASCVD risk compared to their non-sarcopenic counterparts. ASCVD risk inversely correlated with body muscle parameters and positively correlated with fat content parameters. Specifically, height- and weight-adjusted fat mass (FM, FM%, FMI) were identified as risk factors for ASCVD. Conversely, muscle parameters adjusted for weight and fat (ASM%, SMM%, FFM%, ASM/FM, SMM/FM, FMM/FM) were protective against ASCVD risk. These findings highlight the critical role of sarcopenia in influencing cardiovascular disease risk among Chinese patients with T2DM, as predicted by the China-PAR model.

Conclusion

This study highlights the importance of sarcopenia in T2DM patients, not only as an indicator of ASCVD risk, but possibly as an independent risk factor in this demographics.

Molecular mechanisms underlying sarcopenia in heart failure

The loss of skeletal muscle, also known as sarcopenia, is an aging-associated muscle disorder that is disproportionately present in heart failure (HF) patients. HF patients with sarcopenia have poor outcomes compared to the overall HF patient population. The prevalence of sarcopenia in HF is only expected to grow as the global population ages, and novel treatment strategies are needed to improve outcomes in this cohort. Multiple mechanistic pathways have emerged that may explain the increased prevalence of sarcopenia in the HF population, and a better understanding of these pathways may lead to the development of therapies to prevent muscle loss. This review article aims to explore the molecular mechanisms linking sarcopenia and HF, and to discuss treatment strategies aimed at addressing such molecular signals.

Cardiopulmonary Exercise Testing in Heart Failure With Preserved Ejection Fraction: Technique Principles, Current Evidence, and Future Perspectives

Heart failure with preserved ejection fraction (HFpEF) is a multifactorial clinical syndrome involving a rather complex pathophysiologic substrate and quite a challenging diagnosis. Exercise intolerance is a major feature of HFpEF, and in many cases, diagnosis is suspected in subjects presenting with exertional dyspnea. Cardiopulmonary exercise testing (CPET) is a noninvasive, dynamic technique that provides an integrative evaluation of cardiovascular, pulmonary, hematopoietic, neuropsychological, and metabolic functions during maximal or submaximal exercise. The assessment is based on the principle that system failure typically occurs when the system is under stress, and thus, CPET is currently considered to be the gold standard for identifying exercise intolerance, allowing the differential diagnosis of underlying causes. CPET is used in observational studies and clinical trials in HFpEF; however, in most cases, only a few from a wide variety of CPET parameters are examined, while the technique is largely underused in everyday cardiology practice. This article discusses the basic principles and methodology of CPET and studies that utilized CPET in patients with HFpEF, in an effort to increase awareness of CPET capabilities among practicing cardiologists.

Sarcopenia and cardiovascular diseases: A systematic review and meta-analysis

Sarcopenia is an age-related disease and is often accompanied by other diseases. Now, many studies have shown that cardiovascular diseases (CVDs) may raise the incidence rate of sarcopenia. Therefore, the purpose of this study was to conduct a systematic review and meta-analysis to investigate the prevalence of sarcopenia in patients with CVDs compared with the general population, defined as relatively healthy non-hospitalized subjects. The databases of PubMed, Embase, Medline and Web of Science were searched for eligible studies published up to 12 November 2022. Two assessment tools were used to evaluate study quality and the risk of bias. Statistical analysis was conducted using STATA 14.0 and R Version 4.1.2. Thirty-eight out of the 89 629 articles retrieved were included in our review. The prevalence of sarcopenia ranged from 10.1% to 68.9% in patients with CVDs, and the pooled prevalence was 35% (95% confidence interval [95% CI]: 28-42%). The pooled prevalence of sarcopenia was 32% (95% CI: 23-41%) in patients with chronic heart failure (CHF), 61% (95% CI: 49-72%) in patients with acute decompensated heart failure (ADHF), 43% (95% CI: 2-85%) in patients with coronary artery disease, 30% (95% CI: 25-35%) in patients with cardiac arrhythmia (CA), 35% (95% CI: 10-59%) in patients with congenital heart disease and 12% (95% CI: 7-17%) in patients with unclassed CVDs. However, in the general population, the prevalence of sarcopenia varied from 2.9% to 28.6% and the pooled prevalence was 13% (95% CI: 9-17%), suggesting that the prevalence of sarcopenia in patients with CVDs was about twice compared with the general population. The prevalence of sarcopenia was significantly higher only in patients with ADHF, CHF and CA compared with the general population. There is a positive correlation between CVDs and sarcopenia. The prevalence of sarcopenia is higher in patients with CVDs than that in the general population. With global aging, sarcopenia has brought a heavy burden to individuals and society. Therefore, it is important to identify the populations with high-risk or probable sarcopenia in order to do an early intervention, such as exercise, to counteract or slow down the progress of sarcopenia.

Effects of beta-hydroxy beta-methyl butyrate calcium combined with exercise therapy in patients with cardiac disease: a study protocol for clinical trial

INTRODUCTION

The current treatment for heart disease consists of exercise therapy in addition to pharmacotherapy, nutritional support and lifestyle guidance. In general, nutritional support focuses on protein, salt and energy restrictions, with no active protein or amino acid intake in cases involving moderate or higher renal failure. From this perspective, patients with cardiac disease are at high risk of frailty.Beta-hydroxy beta-methyl butyrate (HMB) is a metabolite of leucine. HMB is widely used for muscle strengthening and can be safely ingested even by patients with renal failure. The proposed study protocol will investigate the effects of HMB-calcium (HMB-Ca) administered in combination with comprehensive cardiac rehabilitation for muscle strength, muscle mass and cardiac function in patients with cardiac disease during the convalescent period. The primary outcome will be knee extensor strength. Secondary outcomes will be gross isometric limb strength and skeletal muscle mass.

METHODS AND ANALYSIS

This study will be a single-blinded, randomised, controlled trial with parallel comparisons between two groups. The study period will be 60 days from the start of outpatient cardiac rehabilitation. Participants will be randomly divided into two groups: an HMB group consuming HMB-Ca one time per day for 60 days; and a Placebo group consuming reduced maltose once one time per day for 60 days. Exercise therapy will be performed by both groups.

ETHICS AND DISSEMINATION

The study protocol will be published in a peer-reviewed journal. Ethics approval was provided by the Showa University Clinical Research Review Board.

TRIAL REGISTRATION NUMBER

jRCTs031220139; Japan Registry of Clinical Trails.

A systematic review and meta-analysis of the association between sarcopenia and myocardial infarction

BACKGROUND

Systematic review and meta-analysis of the association between sarcopenia and the development of myocardial infarction.

METHODS

PubMed, Cochrane Library, and Embase were searched for studies on the association between sarcopenia and myocardial infarction from their inception until November 26, 2022. The fixed-effects model was used to calculate the combined risk ratio (RR) of sarcopenia in patients with myocardial infarction. Sensitivity analysis was used to test the robust of the combined result, and funnel plot were used to test publication bias.

RESULTS

Five studies were included finally. There was no significant association between sarcopenia and risk of developing myocardial infarction [RR = 1.01; 95% CI = 0.94, 1.08; P = 0.317]. The sensitivity analysis showed robust of the combined result. The funnel plot showed no significant publication bias.

CONCLUSION

Limited evidence suggests no definitive association between sarcopenia and risk of myocardial infarction.

Prevalence of sarcopenia in heart failure: A systematic review

OBJECTIVE

Heart Failure (HF) is emerging as a crucial factor promoting muscle wasting and dysfunction contributing to sarcopenia. This modulates disease severity and reduces exercise capacity and leading to poorer outcomes. Therefore, we aimed to systematically investigate the overall prevalence of sarcopenia in HF.

METHODS

An electronic search was carried out in selected databases until 21st January, 2021. Data was pooled from the included articles and represented as pooled prevalence of sarcopenia. Subgroup analysis was undertaken between methods of diagnosis of sarcopenia, gender, ejection fraction, median time point and geographical region.

RESULTS

Amongst 32,643 citations imported from selected databases, 12 articles were included in final analysis. Analysis for prevalence of sarcopenia was 34%, with prevalence rates ranging from 10.1% to 68%. Subgroup analysis revealed strong associations between Dual-energy X-ray Absorptiometry (DXA) and Asian Working Group for Sarcopenia (AWGS) (chi square = 3.24; p < 0.001), with a good level of agreement (kappa = 0.76 [95% CI: 0.70-0.82]; p < 0.001). Gender wise analysis revealed higher prevalence of sarcopenia among males (66%) than females (34%).

CONCLUSION

Sarcopenia is highly prevalent among those with HF (irrespective of type of HF) and is more commonly seen in males compared to females.

Glucose-Induced Hemodynamic and Metabolic Response of Skeletal Muscle in Heart Failure Patients with Reduced vs. Preserved Ejection Fraction-A Pilot Study

(1) Background: Insulin resistance (IR) is a characteristic pathophysiologic feature in heart failure (HF). We tested the hypothesis that skeletal muscle metabolism is differently impaired in patients with reduced (HFrEF) vs. preserved (HFpEF) ejection fraction. (2) Methods: carbohydrate and lipid metabolism was studied in situ by intramuscular microdialysis in patients with HFrEF (59 ± 14y, NYHA I-III) and HFpEF (65 ± 10y, NYHA I-II) vs. healthy subjects of similar age during the oral glucose load (oGL); (3) Results: There were no difference in fasting serum and interstitial parameters between the groups. Blood and dialysate glucose increased significantly in HFpEF vs. HFrEF and controls upon oGT (both p < 0.0001), while insulin increased significantly in HFrEF vs. HFpEF and controls (p < 0.0005). Muscle tissue perfusion tended to be lower in HFrEF vs. HFpEF and controls after the oGL (p = 0.057). There were no differences in postprandial increases in dialysate lactate and pyruvate. Postprandial dialysate glycerol was higher in HFpEF vs. HFrEF and controls upon oGL (p = 0.0016); (4) Conclusion: A pattern of muscle glucose metabolism is distinctly different in patients with HFrEF vs. HFpEF. While postprandial IR was characterized by impaired tissue perfusion and higher compensatory insulin secretion in HFrEF, reduced muscle glucose uptake and a blunted antilipolytic effect of insulin were found in HFpEF.

Statins are associated with reduced likelihood of sarcopenia in a sample of heart failure outpatients: a cross-sectional study

BACKGROUND

Sarcopenia is prevalent in heart failure (HF) patients, contributing to its poor prognosis. Statin use is postulated as a probable risk for developing sarcopenia, but little is known regarding this association in HF patients. This work aims at classifying and characterising sarcopenia and at describing the association of statin use with sarcopenia in a sample of Portuguese HF outpatients.

METHODS

In this cross-sectional study, a sample of 136 HF patients (median age: 59 years, 33.8% women) was recruited from an HF outpatients' clinic of a University Hospital in Portugal. Sarcopenia was defined according to the European Working Group on Sarcopenia in Older People 2. Clinical, nutritional, and dietary data were collected.

RESULTS

A total of 25 (18.4%) individuals were categorised as sarcopenic, ranging from 12.2% in younger (< 65 years) participants vs. 30.4% in older ones and from 3.3% in men vs. 47.8% in women. Severe sarcopenia accounted for 7.4% of the sample and sarcopenic obesity was identified in 5.1% of the individuals. A total of 65.4% of the participants were statin users. In multivariable analysis (n = 132, 25 sarcopenic), the use of statins was inversely associated with sarcopenia (OR = 0.03; 95% CI = 0.01, 0.30). Each additional age year was associated with a 9% increase in the likelihood of being sarcopenic (OR = 1.09; 95% CI = 1.01, 1.17), and each Kg.m^-2 increment in body mass index was associated with a 21% decrease in the likelihood of sarcopenia (OR = 0.79; 95% CI = 0.65, 0.96). The daily use of five or more medicines was also directly associated with sarcopenia (OR = 26.87; 95% CI = 2.01, 359.26). On the other hand, being a man and being physically active were inversely associated with sarcopenia (OR = 0.01; 95% CI = 0.00, 0.07 and OR = 0.09; 95% CI = 0.01, 0.65, respectively).

CONCLUSIONS

Contrary to what was expected, patients medicated with statins were less likely to be sarcopenic. Although this finding deserves further research, we hypothesise that this might be related to the pleiotropic effects of statins on endothelial function, contributing to better neuromuscular fitness.

Pharmacological treatment options for heart failure with reduced ejection fraction: A 2022 update

INTRODUCTION

Despite considerable advances in the treatment of heart failure with reduced ejection fraction (HFrEF) over the last 60 years, mortality and morbidity remains high. Fortunately, in the last years, further developments expanded the toolbox for HF treatment.

AREAS COVERED

The authors provide an overview of recent developments in HF treatment and bring the recommendations in the HF guidelines of the European Society of Cardiology into perspective.

EXPERT OPINION

Nowadays, basic pharmacological treatment of patients with HFrEF consists of a combination of angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor-neprilysin inhibitor (ARNI), beta-blockers, mineralocorticoid receptor antagonists (MRA), and the SGLT2 inhibitors dapagliflozin or empagliflozin. Treatment initiation of all four drug classes should be fast and simultaneous. In some cases, the ARNI sacubitril/valsartan may be initiated even in ACE inhibitor-naïve patients. Further HF treatment has to be individualized. Another important point is that both SGLT2 inhibitors and vericiguat can be used in patients with severely reduced kidney function. Finally, an important piece in the HF management puzzle is the treatment of its comorbidities. For instance, patients hospitalized for acute HF decompensation should be systematically screened for iron deficiency, since HF patients with proven iron deficiency benefit from intravenous ferric carboxymaltose.

Additive Effect of Sarcopenia and Anemia on the 10-Year Risk of Cardiovascular Disease in Patients with Type 2 Diabetes

OBJECTIVE

To investigate the association between sarcopenia and anemia and the 10-year cardiovascular disease risk in diabetic patients.

METHODS

A cross-sectional study was conducted involving 4673 hospitalized patients (2271 men and 2402 women) with type 2 diabetes mellitus, with an average age of 60.66 ± 11.93 years, of whom 542 were followed up for a median follow-up period of 24 months. All participants underwent body composition measurements, and they were grouped by sex and presence of sarcopenia using the Framingham risk model to assess their 10-year cardiovascular risk. According to the changes in the cardiovascular risk during follow-up, the patients were divided into four groups: low-low, low-high, high-low, and high-high.

RESULTS

The prevalence of anemia was higher in the sarcopenia group than in the nonsarcopenia group (11.5% vs. 24.1% for men, P < 0.001; 13.9% vs. 19.7% for women, P < 0.05), and the difference remained significant after adjusting for confounders. Patients with sarcopenia and without anemia had a 46.2% increased risk of high 10-year cardiovascular disease (CVD) (odds ratio (OR) = 1.462, 95% confidence interval (CI) 1.085-1.972, P = 0.013), and the risk was twofold higher in patients with sarcopenia and anemia than in those without (OR = 3.283, 95% CI 2.038-5.289, P < 0.001). In follow-up studies, sarcopenia was associated with an increased risk of CVD at 10 years, and a reduction in appendicular skeletal muscle mass index independently predicted the increased risk of CVD.

CONCLUSION

Sarcopenia is associated with an increased risk of anemia, and the presence of both has an additive effect on the 10-year CVD risk in patients with type 2 diabetes. Loss of muscle mass can independently predict an increased CVD risk in diabetic patients.

Association of endothelial dysfunction with sarcopenia and muscle function in a relatively young cohort of kidney transplant recipients

Background

Sarcopenia and endothelial dysfunction are both common among kidney transplant (KT) recipients. We aimed to evaluate the association between endothelial dysfunction and sarcopenia, as well as its individual components.

Methods

Vascular reactivity index (VRI), skeletal muscle index (SMI = skeletal muscle mass/height²), handgrip strength (HGS), and 6-meter usual gait speed (GS) were measured in 95 KT recipients. Low SMI was defined as SMI less than 10% of the sex-specific reference values from Chinese adults; low HGS as HGS < 28 kg for men and < 18 kg for women; slow GS as GS below 1.0 m/s. Sarcopenia was diagnosed based on the presence of low SMI as an essential criterion, accompanied by either low HGS or slow GS. Vascular reactivity was classified as being indicative of poor (VRI < 1.0), intermediate (1.0 ≤ VRI < 2.0), or good (VRI ≥ 2.0) vascular reactivity.

Results

Of the 95 patients, aged 45.2 ± 10.9 years, 11.6% had sarcopenia and 13.7% had poor vascular reactivity. Patients with sarcopenia were lower in body mass index (p = 0.001) and VRI (p = 0.041), and have a higher proportion of low muscle mass (p < 0.001), low HGS (p < 0.001), and slow GS (p = 0.001). Patients with poor vascular reactivity have a higher proportion of sarcopenia (p = 0.005), low HGS (p = 0.006), and slow GS (p = 0.029). Multivariate logistic regression analysis showed that patients in the poor VRI group were significantly associated with sarcopenia (odds ratio, OR = 6.17; 95% confidence interval [1.06-36.04]; p = 0.043), comparing to those with good VRI. We further analysed the effects of VRI on individual components of sarcopenia and found that VRI predicted slow GS significantly (OR = 0.41; 95% CI = [0.21-0.79]; p = 0.007), but not low SMI (OR = 1.15; 95% CI [0.53-2.49]; p = 0.718) and HGS (OR = 0.59; 95% CI [0.31-1.16]; p = 0.125).

Conclusions

We concluded that endothelial dysfunction is a key determinant of sarcopenia in KT recipients. Furthermore, endothelial dysfunction is more closely related to gait speed than muscle mass and strength.

Sarcopenia as a comorbidity of cardiovascular disease

Sarcopenia, the lowered skeletal muscle mass, weakened skeletal muscle strength, and reduced physical performance with aging, is a component of frailty and high-risk factor for falls, resulting in an increase in mortality. In cardiovascular disease (CVD) patients, systemic inflammation, oxidative stress, overactivation of ubiquitin-proteasome system, endothelial dysfunction, lowering muscle blood flow, impaired glucose tolerance, hormonal changes, and physical inactivity possibly contribute to CVD-related sarcopenia. Prevalence of sarcopenia and osteosarcopenia, which is osteopenia and sarcopenia coexisting together, seems to be higher in CVD patients than in community-dwelling adults, suggesting the necessity of early diagnosis and prevention of CVD-related sarcopenia. Atrial stiffness, coronary artery calcification score, and serum vitamin D levels may be of help as the biomarkers to suspect sarcopenia, and renin-angiotensin-aldosterone system inhibitors may play a role in the medical prevention and treatment of CVD-related sarcopenia. There are few reports to convince the efficacies of dietary and antioxidant supplementation on sarcopenia at present, whereas aerobic and resistance training exercises have been recognized as an effective strategy to prevent and treat sarcopenia.

Angiotensin II inhibition: a potential treatment to slow the progression of sarcopenia

Sarcopenia is defined as the progressive and generalized loss of skeletal muscle mass and strength, which is associated with increased likelihood of adverse outcomes including falls, fractures, physical disability, and mortality. The etiology of sarcopenia has been postulated to be multifactorial with genetics, aging, immobility, nutritional deficiencies, inflammation, stress, and endocrine factors all contributing to the imbalance of muscle anabolism and catabolism. The prevalence of sarcopenia is estimated to range from 13 to 24% in adults over 60 years of age and up to 50% in persons aged 80 and older. As the population continues to age, the prevalence of sarcopenia continues to increase and is expected to affect 500 million people by the year 2050. Sarcopenia impacts the overall health of patients through limitations in functional status, increase in hospital readmissions, poorer hospital outcomes, and increase in overall mortality. Thus, there exists a need to prevent or reduce the occurrence of sarcopenia. Here, we explore the potential mechanisms and current studies regarding angiotensin receptor blockers (ARBs) and angiotensin-converting enzyme (ACE) inhibitors on reducing the development of sarcopenia through the associated changes in cardiovascular function, renal function, muscle fiber composition, inflammation, endothelial dysfunction, metabolic efficiency, and mitochondrial function.

Effect of sacubitril valsartan on cardiac function and endothelial function in patients with chronic heart failure with reduced ejection fraction

OBJECTIVE

The aim of the present study was to observe the effect of sacubitril valsartan on cardiac function and vascular endothelial function in patients with chronic heart failure with reduced ejection fraction (HFrEF).

METHODS

A total of 80 patients with HFrEF were randomly divided into an observation group and a control group, with 40 patients in each group. Sacubitril valsartan was added to the conventional treatment in the observation group, and perindopril was added to the conventional treatment in the control group. Both groups were treated continuously for 12 weeks. The left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), flow-mediated vasodilatory function (FMD) of the brachial artery, and levels of plasma Ang II, endothelin 1 (ET-1), and calcitonin gene-related peptide (CGRP), together with the serum nitric oxide (NO) and NO synthase (NOS) were compared before and after treatment in the groups.

RESULTS

Before the treatment, the levels of LVEF, LVEDD, FMD, Ang II, ET-1, CGRP, NO, and NOS in the observation group were not significantly different from those in the control group (P > 0.05). However, the levels of LVEF, FMD, CGRP, NO, and NOS in both groups were significantly higher after the treatment than those before the treatment (P < 0.05) and significantly higher in the observation group than those in the control group. The difference was statistically significant (P < 0.05). Meanwhile, the levels of LVEDD, Ang II, and ET-1 in both groups decreased significantly after the treatment (P < 0.05) and were significantly lower in the observation group than those in the control group. The difference was statistically significant (P < 0.05).

CONCLUSION

Sacubitril valsartan might improve endothelial function while increasing cardiac function in HFrEF patients.

Does vascular endothelial dysfunction play a role in physical frailty and sarcopenia? A systematic review

BACKGROUND

Frailty is strongly associated with adverse cardiovascular outcomes; however, the underlying pathophysiological processes are largely unknown. Vascular endothelial dysfunction (VED) is the earliest stage of cardiovascular disease (CVD) progression and predicts long-term CVD outcomes. Both these conditions share an elevated inflammatory state as a common pathological factor.

OBJECTIVE

Systematic literature review was conducted to examine the evidence supporting an association between VED and physical frailty and/or sarcopenia, in electronic databases including Scopus, Ovid Medline, CINAHL, ScienceDirect, ProQuest Health & Medicine and Embase from January 1980 to August 2019.

RESULTS

A total of 18 studies met the inclusion criteria. VED is independently associated with increased frailty phenotypes and measures of sarcopenia. Several markers of VED, including higher levels of asymmetric dimethylarginine, abnormal ankle brachial index, pulse wave velocity, pulse pressure and lower levels of flow-mediated dilatation, peripheral blood flow and endothelial progenitor cell counts, have been associated with frailty/sarcopenia measurements. Some studies demonstrated the effect of inflammation on the association.

CONCLUSIONS

Recent studies, although limited, showed that VED could be one of the underlying mechanisms of frailty. It is entirely possible that inflammation-related pathological changes in the vascular endothelium are involved in the early causative mechanisms in physical frailty. The exact mechanism(s) underlying this association are still unclear and will need to be evaluated. The outcomes of these future research studies could potentially inform early preventative strategies for physical frailty and sarcopenia.

Sarcopenia in heart failure: a systematic review and meta-analysis

AIMS

Sarcopenia has been found to be frequently associated with co-morbidity among patients with heart failure (HF). However, there remain insufficient data to accurately estimate the global prevalence of sarcopenia in HF. Therefore, the purpose of this research was to conduct a systematic review and meta-analysis to estimate the current overall prevalence of sarcopenia in patients with HF.

METHODS AND RESULTS

We searched relevant databases for studies published up to 13 July 2020, assessing sarcopenia in vpatients with HF. After careful screening, data of included articles were extracted with a predesigned Excel form. Then the pooled prevalence of sarcopenia in patients with HF was calculated using the random-effects model. The Q test was used to assess the heterogeneity, and I2 statistic was calculated to quantify and evaluate the heterogeneity. Subgroup analyses were conducted to determine potential sources of heterogeneity. A total of 2852 articles were initially identified, and after removing duplicate publications and applying the selection criteria, we reviewed 79 full-text articles. Finally, 11 articles (n = 1742 patients with HF) were included in this systematic review and meta-analysis. The pooled prevalence of sarcopenia in patients with HF was 34% [95% confidence interval (CI): 22-47%, I2  = 96.59%] and ranged from 10% to 69%. However, substantial heterogeneity between studies (I2  = 96.59%, P < 0.001) was observed. There was no significant heterogeneity between subgroups by sex (P = 0.803) or the method used to define sarcopenia (P = 0.307). While the heterogeneity between subgroups by population setting was statistically significant (P < 0.001), the pooled prevalence of sarcopenia was 55% (95% CI: 43-66%) for hospitalized patients with HF and 26% (95% CI: 16-37%) for ambulatory patients.

CONCLUSIONS

Sarcopenia was a common condition in patients with HF, and the prevalence of hospitalized patients was higher than for ambulatory patients. Early detection of sarcopenia was therefore important in patients with HF, and it was important to implement interventions so that physical therapists or managerial dieticians can easily be introduced into clinical practice.

Orthostatic hypotension and age-related sarcopenia

Objectives

This study aims to determine the association of sarcopenia with orthostatic hypotension (OH) which is a significant precursor to falls and related injuries in elderly patients.

Patients and methods

A total of 91 outpatients (18 males, 73 females; mean age 79.3±4.0 years; range, 75 to 91 years) were prospectively enrolled and those who were eligible underwent comprehensive sarcopenia assessment including measurement of muscle mass, strength, physical performance, anthropometric measurements along with frailty tests. Patients classified as sarcopenic or non-sarcopenic based on these measurements underwent supine and standing blood pressure (BP) measurements. The frequency of OH was compared between the two groups.

Results

Of the 91 patients, 29 (31.9%) had sarcopenia. There was no statistical difference in measurements of functional tests which consisted of gait speed, timed up-and-go test and handgrip strength. However, timed sit-to-stand test values were higher in sarcopenic patients (18.2±7.9 vs. 15.0±5.1, p=0.04). Patients with sarcopenia developed OA and intolerance more often compared to the non-sarcopenic patients (n=15 [50.0%] vs. n=14 [23.0%], p<0.01 and n=13 [44.8%] vs. n=9 [15.3%], p<0.01, respectively). The adjusted odds ratio for sarcopenia was 7.80 (95% confidence interval 1.77-34.45), p=0.007.

Conclusion

Age-related sarcopenia increases the risk of OA in the elderly. This may in part explain the increased incidence of falls and also help identification of risky elderly patients for orthostatic BP drops.

Skeletal muscle (dys)function in heart failure with preserved ejection fraction

PURPOSE OF REVIEW

Skeletal muscle dysfunction contributes to exercise intolerance, which manifests as dyspnea and fatiguability in patients with heart failure with preserved ejection fraction (HFpEF). This review aims to summarize the current understanding of skeletal muscle dysfunction in HFpEF.

RECENT FINDINGS

Animal and human studies in HFpEF provide insights into the pathophysiological alterations in skeletal muscle structure and function with the identification of several molecular mechanisms. Exercise training and novel pharmacological therapies that target skeletal muscle are proposed as therapeutic interventions to treat HFpEF.

SUMMARY

There is evidence that skeletal muscle dysfunction plays a pathophysiological role in HFpEF. However, precise mechanistic insights are needed to understand the contribution of skeletal muscle dysfunction in HFpEF.

Vascular endothelial dysfunction may be an early predictor of physical frailty and sarcopenia: A meta-analysis of available data from observational studies

BACKGROUND

Physical frailty and sarcopenia (PF & S) are major public health problems in the older population and promising predictors of adverse cardiovascular outcomes. However, the underlying mechanisms linking physical frailty, sarcopenia and adverse cardiovascular outcomes are not well defined. We recently published a systematic review which highlighted early-stage vascular endothelial dysfunction (VED) as one of the potential underlying mechanisms of physical frailty and the role of inflammation in modulating this association.

OBJECTIVE AND METHOD

A meta-analysis was performed to estimate the pooled effect size of studies examining the relationship between VED and PF & S.

RESULTS

Out of 18 cross-sectional studies selected for the original review, 13 studies were excluded due to lack of available data for pooled analysis. The five remaining studies had a total of 6616 participants, of which the pooled sample size of the frail or sarcopenic cohort was 607 and robust or pre-frail or non-sarcopenic cohort was 6009. Mean age of the participants ranging from 64 to 80 years or over. In this analysis, high heterogeneity was observed among studies (99.35% of the variation between studies was due to heterogeneity). Parameters used to assess both PF & S and VED were very different across the studies.

CONCLUSION

The absence of a standardized and valid operational definition of frailty and sarcopenia is a principal limiting factors for frailty research and this is clearly reflected in our study findings. This limits the ability to interpret and define the effects of vascular endothelial dysfunction on these different parameters of frailty and sarcopenia. Similarly, assessment of vascular endothelial dysfunction was very heterogeneous with different parameters utilized across these studies.

Low muscle strength and increased arterial stiffness go hand in hand

Low handgrip strength and increased arterial stiffness are both associated with poor health outcomes, but evidence on the relationship between handgrip strength and arterial stiffness is limited. In this cross-sectional analysis of combined baseline datasets from the LipidCardio and Berlin Aging Study II cohorts we aimed to examine whether handgrip strength (HGS) is associated with arterial stiffness. 1511 participants with a median age of 68.56 (IQR 63.13–73.08) years were included. Arterial stiffness was assessed by aortal pulse wave velocity (PWV) with the Mobil-O-Graph device. Handgrip strength was assessed with a handheld dynamometer.

The mean HGS was 39.05 ± 9.07 kg in men and 26.20 ± 7.47 kg in women. According to multivariable linear regression analysis per 5 kg decrease in handgrip strength there was a mean increase in PWV of 0.08 m/s after adjustment for the confounders age, sex, coronary artery disease, systolic blood pressure, body mass index, cohort, and smoking. Thus, there was evidence that low handgrip strength and increased arterial stiffness go hand in hand. Arterial stiffness can possibly create the missing link between low handgrip strength and increased cardiovascular morbidity and mortality. Causality and direction of causality remain to be determined.

Effect of allopurinol on phosphocreatine recovery and muscle function in older people with impaired physical function: a randomised controlled trial

Background

Allopurinol has vascular antioxidant effects and participates in purinergic signalling within muscle. We tested whether allopurinol could improve skeletal muscle energetics and physical function in older people with impaired physical performance.

Methods

We conducted a randomised, double blind, parallel group, placebo-controlled trial, comparing 20 weeks of allopurinol 600 mg once daily versus placebo. We recruited community-dwelling participants aged 65 and over with baseline 6-min walk distance of <400 m and no contraindications to magnetic resonance imaging scanning. Outcomes were measured at baseline and 20 weeks. The primary outcome was post-exercise phosphocreatine (PCr) recovery rate measured using ³¹P magnetic resonance spectroscopy of the calf. Secondary outcomes included 6-min walk distance, short physical performance battery (SPPB), lean body mass measured by bioimpedance, endothelial function and quality of life.

Results

In total, 124 participants were randomised, mean age 80 (SD 6) years. A total of 59 (48%) were female, baseline 6-min walk distance was 293 m (SD 80 m) and baseline SPPB was 8.5 (SD 2.0). Allopurinol did not significantly improve PCr recovery rate (treatment effect 0.10 units [95% CI, −0.07 to 0.27], P = 0.25). No significant changes were seen in endothelial function, quality of life, lean body mass or SPPB. Allopurinol improved 6-min walk distance (treatment effect 25 m [95% 4–46, P = 0.02]). This was more pronounced in those with high baseline oxidative stress and urate.

Conclusion

Allopurinol improved 6-min walk distance but not PCr recovery rate in older people with impaired physical function. Antioxidant strategies to improve muscle function for older people may need to be targeted at subgroups with high baseline oxidative stress.

Muscle wasting as an independent predictor of survival in patients with chronic heart failure

BACKGROUND

Skeletal muscle wasting is an extremely common feature in patients with heart failure, affecting approximately 20% of ambulatory patients with even higher values during acute decompensation. Its occurrence is associated with reduced exercise capacity, muscle strength, and quality of life. We sought to investigate if the presence of muscle wasting carries prognostic information.

METHODS

Two hundred sixty-eight ambulatory patients with heart failure (age 67.1 ± 10.9 years, New York Heart Association class 2.3 ± 0.6, left ventricular ejection fraction 39 ± 13.3%, and 21% female) were prospectively enrolled as part of the Studies Investigating Co-morbidities Aggravating Heart Failure. Muscle wasting as assessed using dual-energy X-ray absorptiometry was present in 47 patients (17.5%).

RESULTS

During a mean follow-up of 67.2 ± 28.02 months, 95 patients (35.4%) died from any cause. After adjusting for age, New York Heart Association class, left ventricular ejection fraction, creatinine, N-terminal pro-B-type natriuretic peptide, and iron deficiency, muscle wasting remained an independent predictor of death (hazard ratio 1.80, 95% confidence interval 1.01-3.19, P = 0.04). This effect was more pronounced in patients with heart failure with reduced than in heart failure with preserved ejection fraction.

CONCLUSIONS

Muscle wasting is an independent predictor of death in ambulatory patients with heart failure. Clinical trials are needed to identify treatment approaches to this co-morbidity.

Association of Body Mass Index with Endothelial Function in Asian Men

BACKGROUND

The association of body weight with cardiovascular events is still controversial. We evaluated the relationship between body mass index (BMI) and endothelial function.

METHODS

We measured flow-mediated vasodilation (FMD) and BMI in 7682 men. All participants were divided into four groups by BMI: underweight (<18.5 kg/m²), normal weight (18.5 to 24.9 kg/m²), overweight (25.0 to 29.9 kg/m²), and obesity (≥30.0 kg/m²).

RESULTS

Multiple logistic regression analysis revealed that overweight (OR: 1.30, 95% CI: 1.14-1.47; P < 0.001) and obesity (OR: 1.40, 95% CI: 1.09-1.80; P = 0.009) were associated with an increased risk of a low quartile of FMD. In 5571 younger adults (<60 years), overweight (OR: 1.34, 95% CI: 1.16-1.55; P < 0.001) and obesity (OR: 1.37, 95% CI: 1.04-1.81; P = 0.03) were associated with an increased risk of a low quartile of FMD, and underweight (OR: 0.56, 95% CI: 0.35-0.89; P = 0.01) was associated with a reduced risk of a low quartile of FMD. In 2111 older adults (≥60 years), underweight (OR: 2.16, 95% CI: 1.22-3.80; P = 0.008) was associated with an increased risk of a low quartile of FMD, and overweight and obesity were not associated with a risk of a low quartile of FMD.

CONCLUSIONS

In Asian men, endothelial function was impaired in the overweight and obesity groups compared with that in the normal weight group. The risk for endothelial dysfunction was higher in obese younger adults than in obese older adults. The association of BMI with endothelial function may be different in young and elderly men.

CLINICAL TRIAL REGISTRATION INFORMATION

http://www.umin.ac.jp (University Hospital Medical Information Network Clinical Trials Registry) (UMIN000012952).

Muscle mass, muscle strength, and functional capacity in patients with heart failure of Chagas disease and other aetiologies

Aims

Patients with Chagas disease and heart failure (HF) have a poor prognosis similar to that of patients with ischaemic or dilated cardiomyopathy. However, the impact of body composition and muscle strength changes in these aetiologies is still unknown. We aimed to evaluate these parameters across aetiologies in two distinct cohort studies [TESTOsterone‐Heart Failure trial (TESTO‐HF; Brazil) and Studies Investigating Co‐morbidities Aggravating Heart Failure (SICA‐HF; Germany)].

Methods and results

A total of 64 male patients with left ventricular ejection fraction ≤40% were matched for body mass index and New York Heart Association class, including 22 patients with Chagas disease (TESTO‐HF; Brazil), and 20 patients with dilated cardiomyopathy and 22 patients with ischaemic heart disease (SICA‐HF; Germany). Lean body mass (LBM), appendicular lean mass (ALM), and fat mass were assessed by dual energy X‐ray absorptiometry. Sarcopenia was defined as ALM divided by height in metres squared <7.0 kg/m² (ALM/height²) and handgrip strength cut‐off for men according to the European Working Group on Sarcopenia in Older People. All patients performed maximal cardiopulmonary exercise testing. Forearm blood flow (FBF) was measured by venous occlusion plethysmography. Chagasic and ischaemic patients had lower total fat mass (16.3 ± 8.1 vs. 19.3 ± 8.0 vs. 27.6 ± 9.4 kg; P < 0.05) and reduced peak oxygen consumption (VO₂) (1.17 ± 0.36 vs. 1.15 ± 0.36 vs. 1.50 ± 0.45 L/min; P < 0.05) than patients with dilated cardiomyopathy, respectively. Chagasic patients showed a trend towards decreased LBM when compared with ischaemic patients (48.3 ± 7.6 vs. 54.2 ± 6.3 kg; P = 0.09). Chagasic patients showed lower handgrip strength (27 ± 8 vs. 37 ± 11 vs. 36 ± 14 kg; P < 0.05) and FBF (1.84 ± 0.54 vs. 2.75 ± 0.76 vs. 3.42 ± 1.21 mL/min/100 mL; P < 0.01) than ischaemic and dilated cardiomyopathy patients, respectively. There was no statistical difference in the distribution of sarcopenia between groups (P = 0.87). In addition, FBF correlated positively with LBM (r = 0.31; P = 0.012), ALM (r = 0.25; P = 0.046), and handgrip strength (r = 0.36; P = 0.004). In a logistic regression model using peak VO₂ as the dependent variable, haemoglobin (odds ratio, 1.506; 95% confidence interval, 1.043–2.177; P = 0.029) and ALM (odds ratio, 1.179; 95% confidence interval, 1.011–1.374; P = 0.035) were independent predictors for peak VO₂ adjusted by age, left ventricular ejection fraction, New York Heart Association, creatinine, and FBF.

Conclusions

Patients with Chagas disease and HF have decreased fat mass and exhibit reduced peripheral blood flow and impaired muscle strength compared with ischaemic HF patients. In addition, patients with Chagas disease and HF show a tendency to have greater reduction in total LBM, with ALM remaining an independent predictor of reduced functional capacity in these patients. The percentage of patients affected by sarcopenia was equal between groups.

Correlation between sarcopenia and left ventricular myocardial mass in chronic heart failure patients

Sarcopenia is defined as a progressive age-related syndrome of reduced whole-body muscle mass, muscle strength, and muscle function. Patients with heart failure (HF) and sarcopenia are inclined to have decreased muscle strength. The current research suggests that skeletal muscle changes are the main manifestations of sarcopenia, but myocardium is not mentioned as skeletal muscle. The myocardium changes significantly with the progression of HF. Measuring myocardial quality has become an important and accessible way to assess HF by detecting changes in myocardial quality in patients with sarcopenia. Due to its economical, simple, and effective advantages in measuring myocardial quality, real-time three-dimensional echocardiography provides a convenient and reliable method for clinical diagnosis of HF and sarcopenia. This will be conducive to the screening of sarcopenia in people with chronic HF to better guide clinical treatments. This review describes the definition and diagnostic criteria of sarcopenia, the characteristics of HF with sarcopenia, and the related study of myocardial quality.

Peripheral endothelial dysfunction in myalgic encephalomyelitis/chronic fatigue syndrome

AIMS

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex multisystem disease. Evidence for disturbed vascular regulation comes from various studies showing cerebral hypoperfusion and orthostatic intolerance. The peripheral endothelial dysfunction (ED) has not been sufficiently investigated in patients with ME/CFS. The aim of the present study was to examine peripheral endothelial function in patients with ME/CFS.

METHODS AND RESULTS

Thirty-five patients [median age 40 (range 18-70) years, mean body mass index 23.8 ± 4.2 kg/m² , 31% male] with ME/CFS were studied for peripheral endothelial function assessed by peripheral arterial tonometry (EndoPAT2000). Clinical diagnosis of ME/CFS was based on Canadian Criteria. Nine of these patients with elevated antibodies against β2-adrenergic receptor underwent immunoadsorption, and endothelial function was measured at baseline and 3, 6, and 12 months follow-up. ED was defined by reactive hyperaemia index ≤1.81. Twenty healthy subjects of similar age and body mass index were used as a control group. Peripheral ED was found in 18 of 35 patients (51%) with ME/CFS and in 4 healthy subjects (20%, P < 0.05). Patients with ED, in contrast to patients with normal endothelial function, reported more severe disease according to Bell score (31 ± 12 vs. 40 ± 16, P = 0.04), as well as more severe fatigue-related symptoms (8.62 ± 0.87 vs. 7.75 ± 1.40, P = 0.04) including a higher demand for breaks [9.0 (interquartile range 7.0-10.0) vs. 7.5 (interquartile range 6.0-9.25), P = 0.04]. Peripheral ED showed correlations with more severe immune-associated symptoms (r = -0.41, P = 0.026), such as sore throat (r = -0.38, P = 0.038) and painful lymph nodes (r = -0.37, P = 0.042), as well as more severe disease according to Bell score (r = 0.41, P = 0.008) and symptom score (r = -0.59, P = 0.005). There were no differences between the patient group with ED and the patient group with normal endothelial function regarding demographic, metabolic, and laboratory parameters. Further, there was no difference in soluble vascular cell adhesion molecule and soluble intercellular adhesion molecule levels. At baseline, peripheral ED was observed in six patients who underwent immunoadsorption. After 12 months, endothelial function had improved in five of these six patients (reactive hyperaemia index 1.58 ± 0.15 vs. 2.02 ± 0.46, P = 0.06).

CONCLUSIONS

Peripheral ED is frequent in patients with ME/CFS and associated with disease severity and severity of immune symptoms. As ED is a risk factor for cardiovascular disease, it is important to elucidate if peripheral ED is associated with increased cardiovascular morbidity and mortality in ME/CFS.

Sarcopenia and Heart Failure

Modifications of lean mass are a frequent critical determinant in the pathophysiology and progression of heart failure (HF). Sarcopenia may be considered one of the most important causes of low physical performance and reduced cardiorespiratory fitness in older patients with HF. Sarcopenia is frequently misdiagnosed as cachexia. However, muscle wasting in HF has different pathogenetic features in sarcopenic and cachectic conditions. HF may induce sarcopenia through common pathogenetic pathways such as hormonal changes, malnutrition, and physical inactivity; mechanisms that influence each other. In the opposite way, sarcopenia may favor HF development by different mechanisms, including pathological ergoreflex. Paradoxically, sarcopenia is not associated with a sarcopenic cardiac muscle, but the cardiac muscle shows a hypertrophy which seems to be “not-functional.” First-line agents for the treatment of HF, physical activity and nutritional interventions, may offer a therapeutic advantage in sarcopenic patients irrespective of HF. Thus, sarcopenia is highly prevalent in patients with HF, contributing to its poor prognosis, and both conditions could benefit from common treatment strategies based on pharmacological, physical activity, and nutritional approaches.

Sarcopaenia complicating heart failure

Sarcopaenia is defined as reduced skeletal muscle mass associated with either a decline in muscle strength or low physical performance. It has been shown to affect 17.5% of people worldwide, with a prevalence of 20% or higher in patients with heart failure (HF). Sarcopaenia has severe impact on mortality, physical capacity, and quality of life. Even though several mechanisms, such as autonomic imbalance, reduced muscle blood flow, increased inflammation, hormonal alterations, increased apoptosis, and autophagy have been proposed to fuel the pathogenesis of sarcopaenia, additional studies assessing the interaction of these conditions need to be conducted to elucidate how the presence of sarcopaenia can exacerbate the progression of HF and vice-versa. Resistance training combined with nutritional protein intake seems to be effective in the treatment of sarcopaenia, although current pharmacotherapies have not been extensively studied with this endpoint in mind. In conclusion, sarcopaenia is interwoven with HF and leads to worse exercise capacity in these patients. The mechanisms associated with this bilateral relationship between sarcopaenia and HF are still to be elucidated, leading to effective treatment, not only for the heart, but also for the skeletal muscle.

PREDICTORS OF WEIGHT LOSS IN PATIENTS WITH CHRONIC HEART FAILURE AND REDUSED LEFT VENTRICULAR EJECTION FRACTION

Chronic heart failure (CHF) is a heterogeneous syndrome with a poor prognosis. Aim of the work – to define predictors of body weight (BW) loss in patients with CHF and a reduced left ventricular ejection fraction (LVEF). Materials and methods. 120 patients with stable CHF and LVEF ≤35 %, II-IV NYHA class were examined. Patients were divided into two groups according to the value of BW loss for 6 months: the first group - loss of BW <6 %, the second - ≥ 6 %. Results. Out of the 120 patients who were studied, a BW loss of ≥ 6 % occurred in 59 (49.2 %) patients. According to the results of binary logistic regression, predictors of BW loss of ≥6 % in patients with CHF and LVEF ≤ 35 % were: age, coronary heart disease, anaemia, and the number of hospitalizations over the last year. People with poorer quality of life, bigger number of points on the Beck depression scale and DEFS, with lower levels of physical activity and worse endothelium-dependent vasodilator response; higher sizes of the right atrium, right ventricle, and pulmonary artery systolic pressure, E / E '. Higher levels of C-reactive protein (CRP), uric acid are associated with a risk of losing BW≥6 %. Conclusions. Weight loss ≥ 6 % is observed in 49.2 % of patients with CHF and LVEF≤35 %. According to multivariate analysis, independent predictors of BW loss of ≥6 % in patients with CHF and LVEF≤35 % are age, CRP level, III-IV NYHA class, lower cholesterol levels, as well as lower rates of flow-dependent vasodilator response and hip circumference.

Exercise benefits in cardiovascular disease: beyond attenuation of traditional risk factors

Despite strong scientific evidence supporting the benefits of regular exercise for the prevention and management of cardiovascular disease (CVD), physical inactivity is highly prevalent worldwide. In addition to merely changing well-known risk factors for systemic CVD, regular exercise can also improve cardiovascular health through non-traditional mechanisms. Understanding the pathways through which exercise influences different physiological systems is important and might yield new therapeutic strategies to target pathophysiological mechanisms in CVD. This Review includes a critical discussion of how regular exercise can have antiatherogenic effects in the vasculature, improve autonomic balance (thereby reducing the risk of malignant arrhythmias), and induce cardioprotection against ischaemia-reperfusion injury, independent of effects on traditional CVD risk factors. This Review also describes how exercise promotes a healthy anti-inflammatory milieu (largely through the release of muscle-derived myokines), stimulates myocardial regeneration, and ameliorates age-related loss of muscle mass and strength, a frequently overlooked non-traditional CVD risk factor. Finally, we discuss how the benefits of exercise might also occur via promotion of a healthy gut microbiota. We argue, therefore, that a holistic view of all body systems is necessary and useful when analysing the role of exercise in cardiovascular health.

New insights into the pathogenesis and treatment of sarcopenia in chronic heart failure

Sarcopenia is an age-related geriatric syndrome that is characterized by a progressive loss of muscle mass, strength and function. Chronic heart failure (CHF), the final stage of various cardiovascular diseases, may be closely correlated with the occurrence of sarcopenia. Accumulating evidence has demonstrated that CHF can promote the development of sarcopenia through multiple pathophysiological mechanisms, including malnutrition, inflammation, hormonal changes, oxidative stress, autophagy, and apoptosis. Additionally, CHF can aggravate the adverse outcomes associated with sarcopenia, including falls, osteoporosis, frailty, cachexia, hospitalization, and mortality. Sarcopenia and CHF are mutually interacting clinical syndromes. Patients with these two syndromes seem to endure a double burden, with no particularly effective way to hinder their progression. However, the combination of physical exercise, nutritional supplements, and drug therapy may counteract the development of these maladies. In this review, we will summarize the latest progress in the pathogenesis and treatment of sarcopenia in patients with CHF.

Sympatho-Vagal Imbalance is Associated with Sarcopenia in Male Patients with Heart Failure

Background

Resting sympathetic hyperactivity and impaired parasympathetic reactivation after exercise have been described in patients with heart failure (HF). However, the association of these autonomic changes in patients with HF and sarcopenia is unknown.

Objective

The aim of this study was to evaluate the impact of autonomic modulation on sarcopenia in male patients with HF.

Methods

We enrolled 116 male patients with HF and left ventricular ejection fraction < 40%. All patients underwent a maximal cardiopulmonary exercise testing. Maximal heart rate was recorded and delta heart rate recovery (∆HRR) was assessed at 1^st and 2^nd minutes after exercise. Muscle sympathetic nerve activity (MSNA) was recorded by microneurography. Dual-energy X-ray absorptiometry was used to measure body composition and sarcopenia was defined by the sum of appendicular lean muscle mass (ALM) divided by height in meters squared and handgrip strength.

Results

Sarcopenia was identified in 33 patients (28%). Patients with sarcopenia had higher MSNA than those without (47 [41-52] vs. 40 [34-48] bursts/min, p = 0.028). Sarcopenic patients showed lower ∆HRR at 1^st (15 [10-21] vs. 22 [16-30] beats/min, p < 0.001) and 2^nd min (25 [19-39] vs. 35 [24-48] beats/min, p = 0.017) than non-sarcopenic. There was a positive correlation between ALM and ∆HRR at 1^st (r = 0.26, p = 0.008) and 2^nd min (r = 0.25, p = 0.012). We observed a negative correlation between ALM and MSNA (r = -0.29, p = 0.003).

Conclusion

Sympatho-vagal imbalance seems to be associated with sarcopenia in male patients with HF. These results highlight the importance of a therapeutic approach in patients with muscle wasting and increased peripheral sympathetic outflow.

Abdominal skeletal muscle mass as a predictor of mortality in Japanese patients undergoing left ventricular assist device implantation

Aims

We assessed preoperative muscle wasting in patients undergoing left ventricular assist device (LVAD) implantations using abdominal skeletal muscle images on computed tomography (CT) and explored the associations between the preoperative muscle wasting and clinical outcomes after LVAD implantation.

Methods and results

We retrospectively examined the records of 111 patients who underwent continuous‐flow LVAD implantations as bridge‐to‐transplant therapy from January 2010 to December 2016 at our institution. After 33 patients were excluded, the study cohort consisted of 78 individuals. CT images used to calculate the skeletal muscle index (SMI) at the third lumbar vertebra level were obtained before the LVAD implantation procedures. Patients were classified as having muscle wasting if their SMI fell into the lowest gender‐based tertile. The median SMI for the study patients was 37.6 cm²/m². The SMI cut‐off values for the lowest tertiles were 36.7 cm²/m² for men and 28.2 cm²/m² for women, resulting in 26 patients (33.3%) with muscle wasting in this study. During the mean follow‐up of 738 ± 379 days, there were 10 deaths (12.8% mortality). Seven of the 26 patients with muscle wasting (26.9%) died, and 3 of the 52 patients without muscle wasting (5.8%) died. The times to all‐cause mortality were significantly different between patients with and without muscle wasting (P = 0.0094). Muscle wasting was found to be associated with mortality in univariate and multivariate Cox analyses (hazard ratio: 4.32; 95% CI: 1.19–20.2).

Conclusions

Preoperative muscle wasting was associated with a higher mortality in patients with LVAD. Assessment of the abdominal skeletal muscle area on CT prior to LVAD implantation can help predict mortality.

Associations of pre-existing co-morbidities with skeletal muscle mass and radiodensity in patients with non-metastatic colorectal cancer

BACKGROUND AND AIM

Co-morbidities and computerized tomography-measured muscle abnormalities are both common in cancer patients and independently adversely influence clinical outcomes. Muscle abnormalities are also evident in other diseases, such as diabetes and obesity. This study examined for the first time the association between co-morbidities and muscle abnormalities in patients diagnosed with colorectal cancer (CRC).

METHODS

This cross-sectional study included 3051 non-metastatic patients with Stages I-III CRC. Muscle abnormalities, measured at diagnosis, were defined as low skeletal muscle mass index (SMI) or low skeletal muscle radiodensity (SMD) quantified using computerized tomography images using optimal stratification. Co-morbidities included in the Charlson index were ascertained. χ2 tests were used to compare the prevalence of co-morbidities by the presence or absence of each muscle abnormality. Logistic regressions were performed to evaluate which co-morbidities predicted muscle abnormalities adjusting for age, sex, body mass index, weight change, cancer stage, cancer site, race/ethnicity, and smoking.

RESULTS

Mean age was 63 years; 50% of patients were male. The prevalence of low SMI and low SMD were 43.1% and 30.2%, respectively. Co-morbidities examined were more prevalent in patients with low SMD than in those with normal SMD, and most remained independent predictors of low SMD after adjustment for covariates. Co-morbidities associated with higher odds of low SMD included myocardial infarction [odds ratio (OR) = 1.77, P = 0.023], congestive heart failure (OR = 3.27, P < 0.001), peripheral vascular disease (OR = 2.15, P = 0.002), diabetes with or without complications (OR = 1.61, P = 0.008; OR = 1.46, P = 0.003, respectively), and renal disease (OR = 2.21, P < 0.001). By contrast, only diabetes with complications was associated with lower odds of low SMI (OR = 0.64, P = 0.007).

CONCLUSIONS

Prevalence of muscle abnormalities was high in patients with non-metastatic CRC. Pre-existing co-morbidities were associated with low SMD, suggestive of a potential shared mechanism between fat infiltration into muscle and each of these co-morbidities.

An exploratory study on the efficacy and safety of a BCAA preparation used in combination with cardiac rehabilitation for patients with chronic heart failure

Background

Sarcopenia is generally complicated with patients with chronic heart failure (CHF) and its presence negatively affects the course of heart failure, however effective nutritional intervention had not been elucidated yet. The primary objective of this study is to explore whether the addition of a branched-chain amino acid (BCAA) preparation for cardiac rehabilitation (CR) of patients with CHF further improves cardiopulmonary functions, skeletal muscle functions, and metabolism in comparison with conventional CR.

Methods

This is a randomized, parallel-group comparative study. The elderly patients that were participated in CR and complicated with left ventricular systolic or diastolic dysfunction are randomized into two groups, CR + BCAA and CR. 20 weeks later, the second randomization is performed, which divide subjects into two groups with and without BCAA intervention without CR. Primary outcome measure is the rate of change of the anaerobic threshold workload from baseline to post-intervention. Secondary outcome include parameters of exercise capacity, cardiac function and psychological status.

Discussion

In the current study the effect of a promising new intervention, BCAA, will be assessed to determine whether its addition to CR improve exercise capacity in patients with heart failure, who are generally complicated with sarcopenia.

Trial registration

This clinical trial was registered with the University Hospital Medical Information Network—Clinical Trials Registry (UMIN–CTR; JPRN–UMIN R000022440).