Elsevier

International Journal of Cardiology

Volume 222, 1 November 2016, Pages 41-46
International Journal of Cardiology

Sarcopenia in patients with heart failure with preserved ejection fraction: Impact on muscle strength, exercise capacity and quality of life

https://doi.org/10.1016/j.ijcard.2016.07.135Get rights and content

Abstract

Background

To describe the prevalence of sarcopenia in ambulatory patients with heart failure with preserved ejection fraction (HFpEF) and its relation to reduced exercise capacity, muscle strength, and quality of life (QoL).

Methods and results

A total of 117 symptomatic outpatients with HFpEF were prospectively enrolled in Germany, England, and Slovenia as part of the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF). Appendicular skeletal muscle (ASM) mass (the sum of muscle mass in both arms and legs) was assessed by DEXA. Echocardiography, 6-minute walk testing (6-MWT), muscle strength assessment, spiroergometry and QoL evaluation using EQ-5D Questionnaire were performed. Sarcopenia was defined as ASM 2 standard deviations below the mean of a healthy reference group aged 18–40 years. Patients were divided into 3 groups according to the E/e′ value: ≤ 8, 9–14, and ≥ 15. Sarcopenia was detected in 19.7% of all patients. These patients performed worse during 6-MWT (404 ± 116 vs. 307 ± 145 m, p = 0.003) and showed lower absolute peak oxygen consumption (1579 ± 474 vs. 1211 ± 442 mL/min, p < 0.05). Both ASM and muscle strength were lowest in patients with E/e′ > 15 (p < 0.05). Higher values of muscle strength/ASM were associated with a better QoL (r = 0.5, p < 0.0005). Logistic regression showed ASM to be independently associated with reduced distance walked during the 6-MWT adjusted for NYHA, height, left atrium diameter, ferritin and forced expiratory volume in 1 s (FEV1) (odds ratio 1.2, p = 0.02).

Conclusion

Sarcopenia affects a clinically relevant proportion of patients with HFpEF. Low ASM is strongly linked to reduced muscle strength, exercise capacity and QoL in these patients.

Introduction

Heart failure (HF) is a major public health problem. About 50% of all patients with HF present with preserved left ventricular ejection fraction (HFpEF) on imaging tests [1], [2]. The main symptom of these patients with HFpEF is dyspnea or early fatigue [3], [4], [5]. The underlying causes are heterogeneous and not well understood. Several mechanisms might have a role in explaining the pathophysiology, as for example reduced left ventricular (LV) longitudinal strain function [6], and higher LV filling pressures [7]. Recent studies suggest that peripheral factors such as skeletal muscle abnormalities may contribute to decreased maximal oxygen consumption (peak VO2) and may explain its improvement after exercise training [8], [9], [10], [11], [12].

After the age of 50, muscle mass declines by 1–2% annually [13] and muscle strength by about 1.5%; this process accelerates to as much as 3% per year after age 60 [14]. Such age-related loss of skeletal muscle mass and function is part of the normal aging process and has been termed sarcopenia or muscle wasting [15], and it affects about 10% of elderly healthy subjects aged 60–70 years [12], [16], [17]. The 2016 HF guidelines of the European Society of Cardiology acknowledge sarcopenia as an important co-morbidity of HF that requires particular attention [18], because wasting processes are accelerated and more pronounced in chronic diseases including HF [19]. The prevalence of sarcopenia in a mixed cohort of patients with symptomatic chronic HF was found to be 19.5% in a recently published study by our group [10]. However, its prevalence in a highly selected HFpEF cohort and its association with exercise capacity and muscle strength in these patients have not been investigated yet.

The Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF) were designed as an observational study into the co-morbidities of HF, whether with reduced or preserved ejection fraction [20]. The project was jointly funded by the European Commission and the Russian Ministry of Health. Using data from SICA-HF, the present study aimed to investigate the prevalence and clinical effects of sarcopenia in patients with HFpEF.

Section snippets

Study population

We included symptomatic out-patients with HFpEF enrolled between March 2010 and September 2013 into SICA-HF, a European observational multi-center study investigating the prevalence, incidence and impact of key co-morbidities of HF in out-patients with a clinical diagnosis of chronic HF. For this sub-study, subjects were recruited from the Departments of Cardiology at the Charité Medical School, Campus Virchow-Klinikum, Berlin, Germany (n = 61, 52.1%); Hull University Hospital, Hull, England (n = 

Results

We enrolled a total of 117 patients with HFpEF who were symptomatic with a mean New York Heart Association (NYHA) class NYHA 2.4 ± 0.5 with most patients (60.2%) being in NYHA class II (Table 1). Of all patients, 38 (32.5%) were female, and 22 were found to have E/e′ values ≤ 8, 79 had moderately elevated E/e′ between 9 and 14, and 16 had elevated values E/e′ ≥ 15. Twenty-three of all patients with HFpEF (19.7%) were found to fulfill the criteria of sarcopenia, 87% of them were males. Patients with

Discussion

The main symptom in patients with HFpEF is exercise intolerance whose etiology has been deemed multifactorial. The role of peripheral factors, such as skeletal muscle mass, strength and function, is poorly understood. This is the first multicenter European study that describes the prevalence of sarcopenia in patients with HFpEF and its impact on exercise capacity, muscle strength, and quality of life. Overall, 19.7% of the symptomatic stable HFpEF out-patients in our cohort presented with

Conclusions

This multi-center study shows that patients with HFpEF are at least as frequently affected by sarcopenia as patients in mixed cohort described previously that predominantly embraced patients with reduced ejection fraction. Patients with HFpEF and sarcopenia have worse exercise capacity as assessed in the cardiopulmonary test and in the 6-MWT as well as worse QoL.

Conflict of interest

SvH is a consultant and has received honoraria for speaking from Solartium Dietetics, Professional Dietetics, Vifor, Novartis, Chugai, Respicardia, Sorin, and Pfizer. SDA is a consultant, has received honoraria for speaking and/or attended advisory boards for Amgen Inc., Professional Dietetics, Psioxus Therapeutics, GTx, Helsinn, GSK, Sanofi, Regeneron, Novartis, Takeda, Servier, Chugai and Vifor. All other authors report no conflict of interest.

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