ArticlesPrognostic importance of weight loss in chronic heart failure and the effect of treatment with angiotensin-converting-enzyme inhibitors: an observational study
Introduction
Cachexia is a serious complication of several chronic diseases, including heart failure, malignant cancer, acquired immunodeficiency syndrome, thyrotoxicosis, and rheumatoid arthritis, and is suggestive of a poor outlook for patients. In a previous single-centre prospective study of 171 patients, we reported that weight loss in chronic heart failure is linked to impaired survival independent of other well recognised risk factors.1 The definition of cardiac cachexia that we used in that study (ie, >7·5% loss of bodyweight from baseline) was arbitrary, and the study was done in a sole tertiary referral centre with patients who were potentially highly selected; thus our results left several questions unanswered.
Angiotensin-converting-enzyme (ACE) inhibitors are a well studied and widely available treatment that ammeliorates symptoms, reduces morbidity, and improves survival in patients with chronic heart failure. The benefits of ACE inhibitors cannot be explained solely by a haemodynamic mode of action; other effects of ACE inhibitors include modification of the neurohormonal axis and of endothelial function.2 ACE inhibitors are most successful in preventing deaths in patients who have raised catecholamines,3, 4 which are closely related to the presence of cardiac cachexia.5
We reanalysed data from patients who participated in the SOLVD trial6 to assess the frequency of substantial weight loss in patients with chronic heart failure, to ascertain whether the degree of weight loss predicts mortality, and whether ACE inhibitors can reverse or prevent weight loss. We did similar analyses with data from the V-HeFT II database.7
Section snippets
SOLVD
The SOLVD treatment study6 was a randomised, double-blind, placebo-controlled trial investigating the effects of enalapril treatment in 2569 clinically stable patients who had a left ventricular ejection fraction (LVEF) of 35% or less and evidence of overt congestive heart failure. To avoid the confounding effect of weight loss caused by reduction of oedema, we included patients from this study who (in the opinion of the local investigator and as documented in the case report form) had been
SOLVD
We included 1929 patients from SOLVD—75% of the original trial population. Apart from oedema status, baseline clinical characteristics of these patients did not differ from those of the total study population (table 1). 993 of the included patients were randomly allocated enalapril (2·5 to 20 mg daily) and 936 patients received placebo. Mean follow-up was 35 months (SD 13), during which time 757 (39%) participants died.
During follow-up, 817 patients (42%) had weight loss of 5% or more, 549
Discussion
Our results show that substantial weight loss is a common event in patients with chronic heart failure. Spontaneous reversal of substantial weight loss was a rare event, and was noted for fewer than 2% of cases. Weight loss was independently linked to impaired survival of patients with chronic heart failure. Treatment with an ACE inhibitor, enalapril, in addition to conventional treatment reduced the risk of weight loss of 6% or more by 19%.
The development of weight loss is not a sudden event,
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