Sarcopenia in heart failure: mechanisms and therapeutic strategies

J-shaped relationship between serum creatinine and mortality in Korean patients with acute heart failure

BACKGROUND

Cachexia and sarcopenia are common among heart failure (HF) patients and are linked to poor outcomes. As serum creatinine levels are influenced by both renal function and muscle mass, our study aimed to investigate the relationship between serum creatinine levels and mortality in acute HF patients.

METHODS

We enrolled 5198 consecutive acute HF patients from the Korea Acute Heart Failure (KorAHF) registry, excluding those on renal replacement therapy. Patients were categorized into five groups based on their discharge serum creatinine levels: low (< 0.6 mg/dL), reference (0.6-0.89 mg/dL), upper normal (0.9-1.19 mg/dL), high (1.2-1.49 mg/dL), and very high (≥ 1.5 mg/dL). The primary endpoint was post-discharge all-cause mortality.

RESULTS

The mean creatinine level was 1.20 ± 0.88 mg/dL. Notably, 335 (6.4%) patients had serum creatinine levels < 0.6 mg/dL. These patients were younger (mean age, 67 years) and more likely to have a low BMI (< 18.5 kg/m2) compared to the reference group (15.3% vs. 6.4%). Over a median follow-up of 975 days, 1743 (34.8%) patients died. We observed a J-shaped relationship between serum creatinine levels and mortality, with both low and high levels associated with increased mortality. After adjusting for covariates, including age, sex, body mass index, diabetes, hypertension, smoking, malignancy, atrial fibrillation on electrocardiography, levels of C-reactive protein, sodium, hemoglobin, albumin, brain natriuretic peptide, de novo heart failure, use of beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists, patients with serum creatinine levels < 0.6 mg/dL had a 33% higher risk of all-cause mortality (HR, 1.33; 95% CI, 1.06 to 1.66) compared to those with levels of 0.6-0.89 mg/dL. However, BUN, which is not affected by muscle metabolism, exhibited a linear relationship with mortality.

CONCLUSIONS

Among acute HF patients, there exists a J-shaped relationship between discharge serum creatinine levels and mortality, highlighting the increased mortality risk in individuals with very low serum creatinine levels.

Association of dietary inflammatory indices with sarcopenia and all-cause mortality in COPD patients

Background

Sarcopenia frequently occurs as a comorbidity in individuals with COPD. However, research on the impact of Appendicular Skeletal Muscle Mass (ASM) on survival in COPD patients is scarce. Moreover, there is a lack of research on the association between dietary pro-inflammatory capacity and sarcopenia in COPD.

Methods

We analyzed data from the National Health and Nutrition Examination Survey (NHANES) covering the years 1999 to 2006 and 2011 to 2018. We aimed to investigate the relationship between the Dietary Inflammatory Index (DII) and sarcopenia prevalence among adults diagnosed with COPD in the United States. Furthermore, we sought to explore the relationship between sarcopenia, ASMI, and all-cause mortality. The study included a total of 1,429 eligible adult participants, divided into four groups based on quartiles of DII, with adjustments for sample weights. Methodologically, we used multivariable logistic regression analyses and to examine the association between DII and sarcopenia. Additionally, we used restricted cubic spline (RCS) tests to evaluate potential non-linear relationships. To assess the effect of sarcopenia on overall all-cause mortality, we used Kaplan-Meier models and Cox proportional hazards models. Moreover, we used RCS analyses to investigate potential non-linear relationships between ASMI and all-cause mortality. Subgroup analyses were conducted to confirm the reliability of our study findings.

Results

In our COPD participant cohort, individuals with higher DII scores were more likely to be female, unmarried, have lower educational attainment, and show lower ASMI. Using multivariable logistic regression models, we found a positive association between the highest quartile of DII levels and sarcopenia incidence [Odds Ratio (OR) 2.37; 95% Confidence Interval (CI) 1.26-4.48; p = 0.01]. However, analysis of RCS curves did not show a non-linear relationship between DII and sarcopenia. Throughout the entire follow-up period, a total of 367 deaths occurred among all COPD patients. Kaplan-Meier survival curves showed a significantly higher all-cause mortality rate among individuals with concurrent sarcopenia (p < 0.0001). Cox proportional hazards model analysis showed a 44% higher risk of all-cause mortality among COPD patients with sarcopenia compared to those without sarcopenia [Hazard Ratio (HR): 1.44; 95% CI 1.05-1.99; p < 0.05]. Additionally, our final RCS analyses revealed a significant non-linear association between ASMI levels and all-cause mortality among COPD patients, with a turning point identified at 8.32 kg/m2. Participants with ASMI levels above this inflection point had a 42% lower risk of all-cause mortality compared to those with ASMI levels below it (HR 0.58; 95% CI 0.48-0.7).

Conclusion

We observed a significant association between concurrent sarcopenia and an increased risk of all-cause mortality in COPD patients within the United States. Moreover, ASMI demonstrated a non-linear association with all-cause mortality, with a critical threshold identified at 8.32 kg/m2. Our findings also revealed an association between DII and the presence of sarcopenia. Consequently, further investigations are warranted to explore the feasibility of dietary DII adjustments as a means to mitigate muscle wasting and enhance the prognosis of COPD.

Geriatric nutritional risk index as readmission predictor in older adults with heart failure irrespective of ejection fraction

OBJECTIVES

Malnutrition is associated with an increased risk of hospital readmission for heart failure in patients with acute decompensated heart failure (ADHF). Therefore, evaluation of the nutritional status in patients with ADHF may be important. The geriatric nutritional risk index (GNRI), the controlling nutritional status (CONUT) score, and the prognostic nutritional index (PNI) are widely used objective indexes for evaluation of the nutritional status. The present study was performed to determine the best nutritional index for predicting the prognosis in older adults with ADHF.

METHODS

We retrospectively studied 167 older adults (>65 years of age) who were admitted with ADHF from January 2012 to December 2015 and discharged alive. The objective nutritional status was evaluated using the GNRI, CONUT score, and PNI at admission. The endpoint of this study was unplanned hospitalization for worsening heart failure (WHF) within 1 year after discharge.

RESULTS

During the follow-up period, 58 patients were readmitted for WHF. In the multivariate Cox analysis, only the GNRI (p<0.0001) was independently associated with readmission for WHF among the three nutritional indexes. Kaplan-Meier analysis revealed that patients in the low-GNRI group (<90 as determined by receiver operating characteristic curve analysis) had a significantly greater risk of 1-year hospital readmission for WHF (p<0.0001; hazard ratio, 6.1; 95% confidence interval, 3.5-10.5).

CONCLUSION

Among the objective nutritional indexes, the GNRI is the best predictor of readmission for WHF within 1 year after discharge in older adults with ADHF.

Association between dietary inflammatory index score and muscle mass and strength in older adults: a study from National Health and Nutrition Examination Survey (NHANES) 1999-2002

PURPOSE

Chronic low-grade systemic inflammation affects muscle protein metabolism. The dietary inflammatory index (DII®) is a tool designed to assess the inflammatory potential of the diet. The available data on the association between DII and sarcopenia are limited. We aimed to investigate the association of the DII with components of sarcopenia in individuals over 50 years of age.

METHODS

This cross-sectional study used the National Health and Nutrition Examination Survey (NHANES) 1999-2002 dataset. Body composition was measured, and isokinetic strength of the knee extensors (peak force) was evaluated. Low muscle mass and strength were defined using sex-specific thresholds. Energy-adjusted DII (E-DII™) scores were calculated using 24-h dietary recall data. Regression models were fit to evaluate the association between E-DII scores and low muscle mass and low muscle strength, alone and combined.

RESULTS

Mean age of study participants was 62.1 ± 9.5 years, and 138 participants (7.4%) belonged to the combination group of low muscle mass and low muscle strength. In multivariable-adjusted regression models, higher E-DII score was associated with lower appendicular skeletal muscle index (ASMI) (β =  - 0.03, P  < 0.001, P trend <0.001), and lower peak force (β =  -2.15, P  = 0.04, P trend = 0.01) and higher likelihood for these components combined (OR = 1.12, 95% CI 1.01-1.25, P = 0.03).

CONCLUSION

Higher E-DII score is associated with lower muscle mass and muscle strength, and increased likelihood for the combination of low muscle mass and low muscle strength in older adults. This has important implications for healthy aging.

Sarcopenia and Frailty in Heart Failure: Is There a Biomarker Signature?

PURPOSE OF REVIEW

Sarcopenia and frailty are common in patients with heart failure (HF) and are strongly associated with prognosis. This review aims to examine promising biomarkers that can guide physicians in identifying sarcopenia and frailty in HF.

RECENT FINDINGS

Traditional biomarkers including C-reactive protein, aminotransaminase, myostatin, and urinary creatinine as well as novel biomarkers including microRNAs, suppression of tumorigenicity 2 (ST2), galectin-3, and procollagen type III N-terminal peptide may help in predicting the development of sarcopenia and frailty in HF patients. Among those biomarkers, aminotransferase, urinary creatinine, and ST2 predicted the prognosis in HF patients with sarcopenia and frailty. This review outlines the current knowledge of biomarkers that are considered promising for diagnosing sarcopenia and frailty in HF. The listed biomarkers might support the diagnosis, prognosis, and therapeutic decisions for sarcopenia and frailty in HF patients.

Circulating MicroRNAs as Biomarkers of Accelerated Sarcopenia in Chronic Heart Failure

Background:

Sarcopenia is a critical finding in patients with chronic heart failure (CHF). However, the search for a definitive biomarker to predict muscle and functional decline in CHF remains elusive.

Objectives:

We aimed to correlate the circulating levels of selected miRs with the indexes of sarcopenia during healthy aging and in patients with CHF.

Methods:

We analyzed the association of circulating microRNAs (miRs) levels including miR-21, miR-434-3p, miR424-5p, miR-133a, miR-455-3p and miR-181a with sarcopenia indexes in male, 61–73 years old healthy controls and patients with CHF (N = 89–92/group).

Results:

Patients with CHF had lower hand-grip strength (HGS), appendicular skeletal mass index (ASMI) and physical capacity than healthy controls. Circulating miR-21 levels were higher and miR-181a, miR-133a, miR-434-3p and miR-455-3p levels were lower in patients with CHF than healthy controls. Among the sarcopenia indexes, HGS showed the strongest correlation with miR-133a while ASMI showed the strongest correlations with miR-133a, miR-434-3p and miR-455-3p. Among the miRs, miR-434-3p showed the highest area under the curve in testing for sensitivity and specificity for CHF. These changes were associated with higher expressions of the markers of inflammation, oxidative stress and muscle damage in CHF patients.

Conclusion:

Taken together, our data show that circulating miRs can be useful markers of muscle health and physical capacity in the sarcopenic elderly with CHF.

Sarcopenia-derived exosomal micro-RNA 16-5p disturbs cardio-repair via a pro-apoptotic mechanism in myocardial infarction in mice

Sarcopenia is a pathophysiological malfunction induced by skeletal muscle atrophy. Several studies reported an association between sarcopenia-induced cardiac cachexia and poor prognosis in heart disease. However, due to lack of an established animal models, the underlying mechanism of disturbed cardiac repair accompanied with sarcopenia remains poorly understood. Here, we developed a novel sarcopenia-induced cardiac repair disturbance mouse model induced by tail suspension (TS) after cardiac ischemia and reperfusion (I/R). Importantly, we identified a specific exosomal-microRNA marker, miR-16-5p, in the circulating exosomes of I/R-TS mice. Of note, sarcopenia after I/R disturbed cardiac repair and raised the level of circulating-exosomal-miR-16-5p secreting from both the atrophic limbs and heart of TS mice. Likewise, miR-16-5p mimic plasmid disturbed cardiac repair in I/R mice directly. Additionally, in neonatal rat ventricular myocytes (NRVMs) cultured in vitro under hypoxic conditions in the presence of a miR-16-5p mimic, we observed increased apoptosis through p53 and Caspase3 upregulation, and also clarified that autophagosomes were decreased in NRVMs via SESN1 transcript interference-mediated mTOR activation. In conclusion, we show the pro-apoptotic effect of sarcopenia-derived miR-16-5p, which may be behind the exacerbation of myocardial infarction. Therefore, miR-16-5p can be a novel therapeutic target in the context of cardiac repair disturbances in sarcopenia-cachexia.

Frailty in Acute and Chronic Coronary Syndrome Patients Entering Cardiac Rehabilitation

Worldwide population ageing is partly due to advanced standard of care, leading to increased incidence and prevalence of geriatric syndromes such as frailty and disability. Hence, the age at the onset of acute coronary syndromes (ACS) keeps growing as well. Moreover, ageing is a risk factor for both frailty and cardiovascular disease (CVD). Frailty and CVD in the elderly share pathophysiological mechanisms and associated conditions, such as malnutrition, sarcopenia, anemia, polypharmacy and both increased bleeding/thrombotic risk, leading to a negative impact on outcomes. In geriatric populations ACS is associated with an increased frailty degree that has a negative effect on re-hospitalization and mortality outcomes. Frail elderly patients are increasingly referred to cardiac rehabilitation (CR) programs after ACS; however, plans of care must be tailored on individual's clinical complexity in terms of functional capacity, nutritional status and comorbidities, cognitive status, socio-economic support. Completing rehabilitative intervention with a reduced frailty degree, disability prevention, improvement in functional state and quality of life and reduction of re-hospitalization are the goals of CR program. Tools for detecting frailty and guidelines for management of frail elderly patients post-ACS are still debated. This review focused on the need of an early identification of frail patients in elderly with ACS and at elaborating personalized plans of care and secondary prevention in CR setting.

Vitamin D Deficiency in Older Patients-Problems of Sarcopenia, Drug Interactions, Management in Deficiency

Vitamin D deficiency frequently occurs in older people, especially in individuals with comorbidity and polypharmacotherapy. In this group, low vitamin D plasma concentration is related to osteoporosis, osteomalacia, sarcopenia and myalgia. Vitamin D levels in humans is an effect of the joint interaction of all vitamin D metabolic pathways. Therefore, all factors interfering with individual metabolic stages may affect 25-hydroxyvitamin D plasma concentration. The known factors affecting vitamin D metabolism interfere with cytochrome CYP3A4 activity. There is another group of factors that impairs intestinal vitamin D absorption. The phenomenon of drugs and vitamin D interactions is observed first and foremost in patients with comorbidity. This is a typical situation, where the absence of "hard evidence" is not synonymous with the possible lack of adverse effects. Osteoporosis and sarcopenia (generalized and progressive decrease of skeletal muscle mass and strength) are some of the musculoskeletal consequences of hypovitaminosis D. These consequences are related to an increased risk of adverse outcomes, including bone fractures, physical disabilities, and a lower quality of life. This can lead not only to an increased risk of falls and fractures but is also one of the main causes of frailty syndrome in the aging population. Generally, Vitamin D plasma concentration is significantly lower in subjects with osteoporosis and muscle deterioration. In some observational and uncontrolled treatment studies, vitamin D supplementation resulted in a reduction of proximal myopathy and muscle pain. The most conclusive results were found in subjects with severe vitamin D deficiency and in patients avoiding large doses of vitamin D. However, the role of vitamin D in muscle pathologies is not clear and research has provided conflicting results. This is plausibly due to the heterogeneity of the subjects, vitamin D doses and environmental factors. This report presents data on some problems with vitamin D deficiency in the elderly population and the management of vitamin D deficiency D in successful or unsuccessful aging.

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.

Risk factors of poor prognosis and impairment of activities of daily living in patients with hemorrhagic gastroduodenal ulcers

Background

Impairment of activities of daily living (ADL) due to hemorrhagic gastroduodenal ulcers (HGU) has rarely been evaluated. We analyzed the risk factors of poor prognosis, including mortality and impairment of ADL, in patients with HGU.

Methods

In total, 582 patients diagnosed with HGU were retrospectively analyzed. Admission to a care facility or the need for home adaptations during hospitalization were defined as ADL decline. The clinical factors were evaluated: endoscopic features, need for interventional endoscopic procedures, comorbidities, symptoms, and medications. The risk factors of outcomes were examined with multivariate analysis.

Results

Advanced age (> 75 years) was a significant predictor of poor prognosis, including impairment of ADL. Additional significant risk factors were renal disease (odds ratio [OR] 3.43; 95% confidence interval [CI] 1.44–8.14) for overall mortality, proton pump inhibitor (PPIs) usage prior to hemorrhage (OR 5.80; 95% CI 2.08–16.2), and heart disease (OR 3.05; 95% CI 1.11–8.43) for the impairment of ADL. Analysis of elderly (> 75 years) subjects alone also revealed that use of PPIs prior to hemorrhage was a significant predictor for the impairment of ADL (OR 8.24; 95% CI 2.36–28.7).

Conclusion

In addition to advanced age, the presence of comorbidities was a risk of poor outcomes in patients with HGU. PPI use prior to hemorrhage was a significant risk factor for the impairment of ADL, both in overall HGU patients and in elderly patients alone. These findings suggest that the current strategy for PPI use needs reconsideration.

Exercise as a Therapeutic Strategy for Sarcopenia in Heart Failure: Insights into Underlying Mechanisms

Sarcopenia, a syndrome commonly seen in elderly populations, is often characterized by a gradual loss of skeletal muscle, leading to the decline of muscle strength and physical performance. Growing evidence suggests that the prevalence of sarcopenia increases in patients with heart failure (HF), which is a dominant pathogenesis in the aging heart. HF causes diverse metabolic complications that may result in sarcopenia. Therefore, sarcopenia may act as a strong predictor of frailty, disability, and mortality associated with HF. Currently, standard treatments for slowing muscle loss in patients with HF are not available. Therefore, here, we review the pathophysiological mechanisms underlying sarcopenia in HF as well as current knowledge regarding the beneficial effects of exercise on sarcopenia in HF and related mechanisms, including hormonal changes, myostatin, oxidative stress, inflammation, apoptosis, autophagy, the ubiquitin-proteasome system, and insulin resistance.

Clinical significance of nutritional status in patients with chronic heart failure-a systematic review

Chronic heart failure (CHF) and nutritional disorders are recognized as major challenges for contemporary medicine. This study aims to estimate the role of nutritional disorders as risk factors for CHF development and prognostic factors for CHF patients and the outcome of nutritional intervention in CHF. Full-text English articles published between January 2013 and February 2019 available in the PubMed and Scopus databases were considered. Seventy-five prospective, retrospective, and cross-sectional studies as well as meta-analyses on patients with CHF, reporting correlation of their nutritional status with the risk and prognosis of CHF and the outcome of nutritional interventions in CHF were all included. Higher BMI increases the risk of CHF by 15-70%, especially when associated with severe, long-lasting and abdominal obesity. Overweight and obesity are associated with the reduction of mortality in CHF by 24-59% and 15-65%, respectively, and do not affect the outcome of invasive CHF treatment. Malnutrition increases the risk of mortality (by 2- to 10-fold) and the risk of hospitalization (by 1.2- to 1.7-fold). Favorable outcome of nutritional support in CHF patients was reported in a few studies. Nutritional disorders are prevalent in patients with CHF and play a significant role in the incidence, course, and prognosis of the disease. The existence of an "obesity paradox" in patients with CHF was confirmed. Further studies on the effect of nutritional support and body weight reduction in patients with CHF are necessary.

High Serum Aspartate Aminotransferase, Underweight, and Weight Loss in Older People: Results of the KITCHEN-4

Background: Reduced muscle mass is frequently observed in older people and can lead to being underweight and/or weight loss (WL), but prediction and screening systems utilizing hematological biochemical parameters are limited. High serum aspartatSe aminotransferase in conjunction with normal serum alanine aminotransferase (HASNAL) can reflect systemic muscle damage. HASNAL and the incidence of being underweight concomitant with WL (UWWL) were investigated in the present 6-year community-based cohort study. Methods: Clinical parameters, lifestyle, the incidence of being underweight, ≥ 5% WL, and UWWL were investigated in 238,536 Japanese people aged 40-68 years who had normal serum alanine aminotransferase. HASNAL was defined as serum aspartate aminotransferase ≥ 30 U/L and serum alanine aminotransferase < 30 U/L. The subjects were divided into a younger group (< 55 years) and an older group (≥ 55 years). Results: After 6 years, overall body weight had increased by 0.4% in the younger group and decreased by 0.4% in the older group. In logistic regression analysis, in the younger group ≥ 5% WL was significantly associated with baseline HASNAL compared to baseline low serum aspartate aminotransferase (< 20 U/L). In the older group, baseline HASNAL was significantly associated with being underweight, ≥ 5% WL, and UWWL, even after adjustment for potential confounders, and UWWL was inversely associated with regular exercise and daily alcohol consumption-both of which modified the aforementioned associations. Conclusions: Older subjects with HASNAL were at an increased risk of UWWL, possibly via skeletal muscle damage, which may be affected by common lifestyles.

Axial Muscle Size as a Strong Predictor of Death in Subjects With and Without Heart Failure

Background

The impact of skeletal muscle size, quantified using simple noninvasive images routinely obtained during cardiac magnetic resonance imaging studies on mortality in the heart failure (HF) population is currently unknown.

Methods and Results

We prospectively enrolled 567 subjects without HF (n=364), with HF with reduced ejection fraction (n=111), or with HF with preserved ejection fraction (n=92), who underwent a cardiac magnetic resonance imaging. Skeletal muscle cross‐sectional area was assessed with manual tracing of major thoracic muscle groups on axial chest magnetic resonance images. Factor analysis was used to identify a latent factor underlying the shared variability in thoracic muscle cross‐sectional area. Cox regression was used to assess the relationship between these measurements and all‐cause mortality (median follow up, 36.4 months). A higher overall thoracic muscle area factor assessed with principal component analysis was independently associated with lower mortality (standardized hazard ratio, 0.51; P<0.0001). The thoracic muscle area factor was predictive of death in subjects with HF with preserved ejection fraction, HF with reduced ejection fraction, and those without HF. Among all muscle groups, the pectoralis major cross‐sectional area was the most representative of overall muscle area and was also the most robust predictor of death. A higher pectoralis major cross‐sectional area predicted a lower mortality (standardized hazard ratio, 0.49; P<0.0001), which persisted after adjustment for various confounders (standardized hazard ratio, 0.55; P=0.0017).

Conclusions

Axial muscle size, and in particular smaller size of the pectoralis major, is independently associated with higher risk of mortality in patients with and without HF. Further work should clarify the role of muscle wasting as a therapeutic target in patients with HF.

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.

Angiotensin-II Drives Human Satellite Cells Toward Hypertrophy and Myofibroblast Trans-Differentiation by Two Independent Pathways

Skeletal muscle regeneration is ensured by satellite cells (SC), which upon activation undergo self-renewal and myogenesis. The correct sequence of healing events may be offset by inflammatory and/or fibrotic factors able to promote fibrosis and consequent muscle wasting. Angiotensin-II (Ang) is an effector peptide of the renin angiotensin system (RAS), of which the direct role in human SCs (hSCs) is still controversial. Based on the hypertrophic and fibrogenic effects of Ang via transient receptor potential canonical (TRPC) channels in cardiac and renal tissues, we hypothesized a similar axis in hSCs. Toward this aim, we demonstrated that hSCs respond to acute Ang stimulation, dose-dependently enhancing p-mTOR, p-AKT, p-ERK1/2 and p-P38. Additionally, sub-acute Ang conditioning increased cell size and promoted trans-differentiation into myofibroblasts. To provide a mechanistic hypothesis on TRPC channel involvement in the processes, we proved that TRPC channels mediate a basal calcium entry into hSCs that is stimulated by acute Ang and strongly amplified by sub-chronic Ang conditioning. Altogether, these findings demonstrate that Ang induces a fate shift of hSCs into myofibroblasts and provide a basis to support a benefit of RAS and TRPC channel blockade to oppose muscle fibrosis.

The Heart Failure "Pandemic" in Japan: Reconstruction of Health Care System in the Highly Aged Society

An increase in the number of patients with heart failure is an international health-related problem. In advanced countries, the number of such patients has rapidly increased since the beginning of the 21^st century, raising an important issue regarding medical practice and public health. In 2010, the concept of “heart failure pandemic” was proposed, and it has been recognized as a global social/economic issue. In particular, the number of elderly patients with heart failure has increased with the rapid aging of society and a decrease in the number of children in Japan. A rapid increase in the number of heart failure patients increases stress and social disease-related/medical economic burdens on individuals and their families. The prognosis of patients with chronic heart failure is unfavorable, and the quality of life markedly reduces. To improve the prognosis of elderly patients with heart failure and reduce the readmission rate, the innovation of a medical-care-providing system for heart failure is required. In addition to the provision of medical practice based on a potent heart failure disease control program, manifold strategies, such as lifestyle improvements, self-care practice, cardiac rehabilitation, and environmental intervention, are essential. It is necessary to innovate hospital-based medical practice to a regional-care-system-based medical care system. In addition, to efficiently promote future heart failure strategies, an investigational study with disease registration must be conducted. Recently a new basic act on countermeasures to cardiovascular diseases has been established which may help the reform for this purpose.

Impact of heart failure on functional recovery after hip fracture

[Purpose] Heart failure has been identified as a risk factor for reduced physical function and falls; however, the impact of heart failure on functional recovery after a hip fracture is unclear. This study aimed to examine how heart failure and pre-fracture physical function affect recovery after a hip fracture. [Participants and Methods] The study population consisted of 122 patients with sub-acute hip fracture (mean age 81.7 ± 9.7 years, 18.9% male) who were divided into two groups: heart failure and non-heart failure. The outcome measurement was the functional independence measure effectiveness. A two-way analysis of variance was performed to investigate how heart failure and ambulatory ability prior to hip fracture were related to the functional independence measure effectiveness. [Results] Seventeen patients (13.9%) had a history of heart failure. The two-way analysis of variance showed the two independent variables (heart failure and ambulatory ability before fracture) had significant main effects; however, their interaction effect was not significant. [Conclusion] Heart failure affects functional recovery after hip fracture independent of the pre-fracture physical function, and vice versa. Further research on rehabilitation in hip fracture patients with heart failure is required to develop strategies to overcome poor functional recovery in such patients.

Combating frailty and sarcopenia in aging populations: Switching to a more positive paradigm

Frailty may be used as a public health indicator of aging well for projection of health and social care resource allocation. Frailty assessments have been adopted by various medical as well as surgical specialties as part of prognosis in influencing choice of therapy, although the assessment tools are even more heterogeneous than those in the gerontological fields. Recently, the World Health Organization called for a life course approach to healthy aging, placing the emphasis on function, expressed as intrinsic capacity, which would address concerns with the negative image of frailty and with the overemphasis on deficits. The impact of social and physical environments is taken into account in the concept of resilience. These are all related concepts that differ in the setting in which they are used. Frailty may be more useful in clinical management in hospitals and residential care homes, as well as in community models of care. Intrinsic capacity could be used for development of health-promotion policies and service models across the life course; mainly primary care with low resource needs, using a step-care approach. Resilience could be considered an overarching holistic concept covering physical, psychological, and environmental domains, which is still in the research arena.

Low skeletal muscle mass is associated with low aerobic capacity and increased mortality risk in patients with coronary heart disease - a CARE CR study

BACKGROUND

In patients with chronic heart failure, there is a positive linear relationship between skeletal muscle mass (SMM) and peak oxygen consumption ( V ˙ O_2peak ); an independent predictor of all-cause mortality_. We investigated the association between SMM and V ˙ O_2peak in patients with coronary heart disease (CHD) without a diagnosis of heart failure.

METHODS

Male patients with CHD underwent maximal cardiopulmonary exercise testing and dual X-ray absorptiometry assessment. V ˙ O_2peak, the ventilatory anaerobic threshold and peak oxygen pulse were calculated. SMM was expressed as appendicular lean mass (lean mass in both arms and legs) and reported as skeletal muscle index (SMI; kg m^-2 ), and as a proportion of total body mass (appendicular skeletal mass [ASM%]). Low SMM was defined as a SMI <7·26 kg m^-2 , or ASM% <25·72%. Five-year all-cause mortality risk was calculated using the Calibre 5-year all-cause mortality risk score.

RESULTS

Sixty patients were assessed. Thirteen (21·7%) had low SMM. SMI and ASM% correlated positively with V ˙ O_2peak (r = 0·431 and 0·473, respectively; P<0·001 for both). SMI and ASM% predicted 16·3% and 12·9% of the variance in V ˙ O_2peak , respectively. SMI correlated most closely with peak oxygen pulse (r = 0·58; P<0·001). SMI predicted 40·3% of peak V ˙ O₂ /HR variance. ASM% was inversely associated with 5-year all-cause mortality risk (r = -0·365; P = 0·006).

CONCLUSION

Skeletal muscle mass was positively correlated with V ˙ O_2peak in patients with CHD. Peak oxygen pulse had the strongest association with SMM. Low ASM% was associated with a higher risk of all-cause mortality. The effects of exercise and nutritional strategies aimed at improving SMM and function in CHD patients should be investigated.

Muscle mass, BMI, and mortality among adults in the United States: A population-based cohort study

Background

The level of body-mass index (BMI) associated with the lowest risk of death remains unclear. Although differences in muscle mass limit the utility of BMI as a measure of adiposity, no study has directly examined the effect of muscle mass on the BMI-mortality relationship.

Methods

Body composition was measured by dual-energy x-ray absorptiometry in 11,687 participants of the National Health and Nutrition Examination Survey 1999–2004. Low muscle mass was defined using sex-specific thresholds of the appendicular skeletal muscle mass index (ASMI). Proportional hazards models were created to model associations with all-cause mortality.

Results

At any level of BMI ≥22, participants with low muscle mass had higher body fat percentage (%TBF), an increased likelihood of diabetes, and higher adjusted mortality than other participants. Increases in %TBF manifested as 30–40% smaller changes in BMI than were observed in participants with preserved muscle mass. Excluding participants with low muscle mass or adjustment for ASMI attenuated the risk associated with low BMI, magnified the risk associated with high BMI, and shifted downward the level of BMI associated with the lowest risk of death. Higher ASMI was independently associated with lower mortality. Effects were similar in never-smokers and ever-smokers. Additional adjustment for waist circumference eliminated the risk associated with higher BMI. Results were unchanged after excluding unintentional weight loss, chronic illness, early mortality, and participants performing muscle-strengthening exercises or recommended levels of physical activity.

Conclusions

Muscle mass mediates associations of BMI with adiposity and mortality and is inversely associated with the risk of death. After accounting for muscle mass, the BMI associated with the greatest survival shifts downward toward the normal range. These results provide a concrete explanation for the obesity paradox.

The association of sarcopenia, telomere length, and mortality: data from the NHANES 1999-2002

BACKGROUND/OBJECTIVES

Sarcopenia is defined as the loss of muscle mass or function with aging and is associated with adverse outcomes. Telomere shortening is associated with mortality, yet its relationship with sarcopenia is unknown.

SUBJECTS/METHODS

Adults ≥60 years from the 1999-2002 NHANES with body composition measures were identified. Sarcopenia was defined using the two Foundation for the National Institute of Health definitions: appendicular lean mass (ALM) (men <19.75; women <15.02 kg); or ALM divided by body mass index (BMI) (ALM:BMI, men <0.789; women <0.512). Telomere length was assessed using quantitative PCR. Regression models predicted telomere length with sarcopenia (referent = no sarcopenia).

RESULTS

We identified 2672 subjects. Mean age was 70.9 years (55.5% female). Prevalence of ALM and ALM:BMI sarcopenia was 29.2 and 22.1%. Deaths were higher in persons with sarcopenia as compared to those without sarcopenia (ALM: 46.4 vs. 33.4%, p < 0.001; ALM:BMI: 46.7 vs. 33.2%, p < 0.001). No adjusted differences were observed in telomere length in those with/without sarcopenia (ALM: 0.90 vs. 0.92, p = 0.74, ALM:BMI 0.89 vs. 0.92, p = 0.24). In men with ALM:BMI-defined sarcopenia, adjusted telomere length was significantly lower compared to men without sarcopenia (0.85 vs. 0.91, p = 0.013). With sarcopenia, we did not observe a significant association between telomere length and mortality (ALM: HR 1.11 [0.64,1.82], p = 0.68; ALM:BMI: HR 0.97 [0.53,1.77], p = 0.91), but noted significance in those without sarcopenia with mortality (ALM: HR 0.59 [0.40,0.86], p = 0.007; ALM:BMI: HR 0.62 [0.42,0.91]; p = 0.01).

CONCLUSIONS

We observed a potentially inverse relationship between telomere length and mortality in those without sarcopenia but did not observe a significant relationship between telomere length and mortality in the presence of sarcopenia.

Sarcopenia: a chronic complication of type 2 diabetes mellitus

BACKGROUND

Diabetics are at increased risk for impaired mobility and strength, frequently related to the disease control. Sarcopenia is the reduction of muscle mass associated with the decrease in muscle strength and/or performance, resulting in worse morbidity in chronic diseases.

METHODS

The objectives of this paper was to assess the prevalence of sarcopenia in patients with type 2 diabetes mellitus (T2DM) and determine its association with diabetes characteristics, progression, and complications, as well as changes in bone mineral density. The sample consisted of patients with T2DM followed at the outpatient clinics of the Serviço de Endocrinologia e Metabologia do Hospital de Clínicas da Universidade Federal do Paraná, from March to August 2016. Participants were men and women above 18 years with T2DM diagnosed at least 1 year earlier. Individuals with chronic diseases, users of any drug that modifies body composition, patients with body mass index (BMI) > 35 or < 18 kg/m², and users of illicit drugs or hormonal or nutritional supplementation were excluded. The selected patients answered questionnaires about demographics, eating habits, and disease characteristics, and performed a bone densitometry exam in a dual energy absorptiometry (total body; spine and femur (total and neck)), a handgrip test by manual dynamometer, and an evaluation of the abdominal circumference (AC). The medical records were reviewed seeking diabetes data and laboratory test results. Patients were matched for sex, age, and race with healthy controls [Control Group (CG)]. The diagnosis of sarcopenia was conducted according to the criteria of the Foundation for National Institute of Health.

RESULTS

The final sample consisted of 83 patients in the DG and 83 in the CG. The DG had higher BMI, WC, past history of fractures and lower calcium and healthy diet intake (p < 0.005), compared to the CG. The DG presented a higher frequency of abnormal BMD (osteopenia in 45 (53%), and osteoporosis in 14 (19%)) and comorbidities than the CG (p < 0.005). Pre-sarcopenia was not different between groups, but muscle weakness was present in 25 diabetics (18 women) and only in 5 controls (4 men) (p = 0.00036). Sarcopenia was diagnosed in 13 (16.2%) patients in the DG and 2 (2.4%) in the CG (p = 0.01168). Pre-sarcopenia and sarcopenia were associated with altered BMD (p < 0.005), with no association with diabetes duration or control. Body mass index and osteoporosis increased the likelihood to have sarcopenia, but hypertension and healthy diet decreased it.

CONCLUSION

The DG had altered BMD associated with worse glycemic control, and a higher prevalence of sarcopenia, suggesting the need to look for their presence in diabetics.

Pre-Liver Transplant Muscle Loss Is a Risk Factor for Post-Liver Transplantation Left Ventricular Systolic Dysfunction

BACKGROUND The development of left ventricular systolic dysfunction (LVSD) after liver transplant (LT) can result in increased morbidity and mortality in the immediate period following liver transplant. The aim of this study was to evaluate low muscle mass due to chronic liver disease, as a potential risk factor for LVSD after LT. MATERIAL AND METHODS A retrospective chart review was completed for all adult patients who received a liver transplant between January 2002 and January 2015 at a single academic LT center. Collected data included patient demographics, medical history, laboratory data, radiology results, and pathology. Echocardiograms were reviewed for patients identified as having LVSD diagnosed within 1 year after LT (left ventricular ejection fraction <55%). The total psoas area (TPA), a marker of low muscle mass, was determined by measuring the average cross-sectional area of the psoas muscle on MRI or CT scans before transplant at the level of L4 vertebra. RESULTS Of the 503 post-LT patients reviewed, 144 (28.6%) had pre-and post-LT echocardiograms. Of these 144 patients, 17 developed LVSD, of which 15 (88.2%) occurred within 1 year after LT. The average age at transplant of those with LVSD was 58.9±6 years, with a mean MELD score of 30.7±6. The mean TPA normalized for height for patients with LVSD was 297.68±86.99 mm²/m² compared to 382.1±104.2 mm²/m² for those with normal EF (p= 0.002). BMI, MELD score, and etiology of cirrhosis were not significant risk factors for post-LT LVSD in our study population. During the study period, 35.2% (n=6) of LVSD patients died within 1 year after LT. CONCLUSIONS Although LVSD is thought to be a rare complication after LT, those with muscle loss as predicted by mean TPA measurements normalized for height may be at highest risk.

The mortality determinants of sarcopenia and comorbidities in hospitalized geriatric patients

Objectives:

Determine the influence of muscle mass, muscle strength, physical performance, nutritional status and certain comorbidities on the four years mortality risk of hospitalized geriatric patients.

Design:

Retrospective cohort study.

Setting:

During hospitalization of the included geriatric patients, the determinants of sarcopenia and nutritional status were obtained.

Participants:

A total of 302 patients hospitalized at the geriatric department of the Saint-Elisabeth hospital in Antwerp (Belgium) from 01/08/2012 until 31/01/2013.

Measurements:

Muscle mass was measured using a CT scan. The muscle strength was obtained by measuring the handgrip strength using a Jamar dynamometer. The physical performance was measured by performing the SPPB. The nutritional status was surveyed by using the MNA-SF. Comorbidities were obtained through medical records.

Results:

The variables gender (HR= 0.609; 95% CI 0.442-0.838), nutritional status (HR= 2.953; 95% CI 1.924-4.531), muscle mass (HR= 0.443; 95% CI 0.251-0.780), muscle strength (HR= 0.215; CI 95% 0.079-0.587), physical performance (HR= 0.407; 95% CI 0.237-0.702) and heart failure (HR= 1.440; 95% CI 1.022-2.029) have been shown to be significant.

Conclusion:

The determinants gender, nutritional status and physical performance have the greatest prognostic value.

Clinical relevance of sarcopenia in chronic kidney disease

PURPOSE OF REVIEW

In this article, we review sarcopenia in chronic kidney disease (CKD). We aim to present how definitions of sarcopenia from the general population may pertain to those with CKD, its assessment by clinicians and emerging therapies for sarcopenia in CKD. For this review, we limit our description and recommendations to patients with CKD who are not on dialysis.

RECENT FINDINGS

Poorer parameters of lean mass, strength and physical function are associated with worsening patient-centered outcomes such as limiting mobility, falls and mortality in CKD; however, the magnitude of these associations are different in those with and without CKD. Sarcopenia in CKD is a balance between skeletal muscle regeneration and catabolism, which are both altered in the uremic environment. Multiple pathways are involved in these derangements, which are briefly reviewed. Differences between commonly used terms cachexia, frailty, protein-energy wasting, dynapenia and sarcopenia are described. Therapeutic options in predialysis CKD are not well studied; therefore, we review exercise options and emerging pharmacological therapies.

SUMMARY

Sarcopenia, now with its own International Classification of Diseases, 10th Revision (ICD-10) code, is of importance clinically and should be accounted for in research studies in patients with CKD. Multiple therapies for sarcopenia are in development and will hopefully be available for our patients in the future.