Implications of Sarcopenia and Obesity in Patients across the Spectrum of Heart Failure with Preserved Ejection Fraction

Paula Sagmeister (Leipzig)1, M. Mueller (Leipzig)1, A. Schöber (Leipzig)1, K.-P. Kresoja (Leipzig)1, S. Rosch (Leipzig)1, M. Scholz (Leipzig)2, S. Henger (Leipzig)2, H. Thiele (Leipzig)1, P. Lurz (Mainz)3, K.-P. Rommel (Leipzig)1

1Herzzentrum Leipzig - Universität Leipzig Klinik für Innere Medizin/Kardiologie Leipzig, Deutschland; 2Institute of Medical Informatics Statistic and Epidemiology, University of Leipzig Leipzig, Deutschland; 3Universitätsmedizin der Johannes Gutenberg-Universität Mainz Kardiologie 1, Zentrum für Kardiologie Mainz, Deutschland


BACKGROUND: While it has been shown that sarcopenia (S) and obesity (O) have synergistic detrimental implications for cardiorespiratory fitness in patients with heart failure with reduced ejection fraction, their interaction in patients with heart failure with preserved ejection fraction (HFpEF) is less well defined. In particular, the association of these peripheral abnormalities with cardiac abnormalities remain elusive.
We aimed at characterizing clinical profiles, everyday physical activity and cardiac function according to the presence of sarcopenia and obesity in patients at risk for and with overt HFpEF.

METHODS: A total of 780 patients with elevated cardiovascular risk (mean age 67 ± 9 years, 31% female) were prospectively included, underwent thorough clinical examination and were classified as having HFpEF according to ESC consensus criteria. Body composition was assessed by means of bioelectrical impendence analysis (BIA) with determination of sarcopenia, defined as skeletal muscle mass index (SMI) < median and obesity as defined by percentage body fat (PBF) > median. Data on daily physical activity was aquired using a wrist worn accelerometer for five consecutive days. Cardiac function was assessed by echocardiography, including generation of single-beat pressure volume loops (PVL).
RESULTS: Overall, median SMI was 8.6 (8.1-9.2) kg/m2 for male and 7.0 (6.4-7.6) kg/m2 for female patients with no significant difference between patients with HFpEF and without heart failure (p=0.998). Median PBF over all patients was 29.5 ± 7.5 % for male and 39.1 ± 7.6 % for female patients, whereas the PBF in male patients with HFpEF was higher than in the control group (32.2 ± 8.0 % vs. 28.9 ± 7.3 %, p<0.001). 63 patients (8%) had a sarcopenic obesity, 255 patients (33%) were sarcopenic without acompanying obesity, 132 patients (17%) were solely obese, and 298 patients fulfilled neither the criteria for sarcopenia nor obesity. 
Patients with sarcopenia were more likely to have a coronary artery disease (CAD) (p=0.004), and displayed a smaller left ventricular (LV) enddiastolic volume (p<0.001) and LV stroke volume (LV-SV) (p<0.001). The effective arterial elestance (Ea), as well as end-systolic pressure volume relationship (ESPVR) were more pronounced in patients with sarcopenia (Ea: p<0.001, ESPVR: p<0.001). Patients with obesity were most symptomatic (NYHA ≥II: p<0.001, edema: p<0.001), more likely to have arterial hypertension (p<0.001) and diabetes mellitus (p<0.001), and less physically active (steps per day: p<0.001).  Furthermore, patients with adipositas showed higher blood concentrations of C-reactive protein (p<0.001), and bigger interventricular septal thickness at end-diastole (IVSD; p<0.001). The combination of both sarcopenia and obesity lead to the biggest risk of developing a HFpEF (p<0.001). 

CONCLUSIONS: Sarcopenia is associated with small LV- volumes and LV-SV, CAD, and heightened Ea and Es. Patients with obesity exhibited greater symptoms, a more pronounced cardiovascular risk profil, LV hypertrophy and lower activity levels. The combined impact of both conditions synergistically contributes to the onset of HFpEF.  These findings suggest that body composition significantly influences HFpEF development and advocate for addressing both peripheral and cardiac abnormalities concurrently, rather than in isolation. 
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