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* From the Department of Cardiac Medicine (Dr. Anker and Mr. Coats), National Heart & Lung Institute, London, UK; and the Franz-Volhard-Klinik am Max Delbrück Centrum (Dr. Anker), Charité, Campus Berlin-Buch, Berlin, Germany.
Chronic heart failure (CHF) is a complex syndrome
affecting many body systems. Body wasting (ie, cardiac
cachexia) is a serious complication of CHF long known but little
investigated. Although no specific diagnostic criteria have been
established, we have suggested that cardiac cachexia be defined on the
basis of the presence of documented nonintentional and nonedematous
weight loss > 7.5% of the premorbid normal weight, occurring over a
time period of > 6 months. Using this definition, 16% of an
unselected CHF outpatient population was found to be cachectic. The
cachectic state is predictive of impaired prognosis independently of
age, functional disease classification, left ventricular ejection
fraction, and peak oxygen consumption. The mortality in the cachectic
cohort is 50% at 18 months. Analyzing body composition
in detail, it has been found that patients with cardiac cachexia suffer
from a general loss of fat tissue (ie, energy reserves),
lean tissue (ie, skeletal muscle), and bone tissue
(ie, osteoporosis). Cachectic CHF patients are weaker
and fatigue earlier, which is due to both reduced skeletal muscle mass
and impaired muscle quality. The pathophysiologic alterations leading
to cardiac cachexia remain unclear, but initial cross-sectional studies
have suggested that humoral neuroendocrine and immunologic
abnormalities are linked, independently of established heart failure
severity markers, to the presence of body wasting. Comparing the
features of cachectic and noncachectic CHF patients with those of
healthy control subjects, it is mainly the cachectic CHF patients who
show raised plasma levels of epinephrine, norepinephrine, and cortisol;
the highest plasma renin activity and aldosterone plasma
concentrations; and the lowest plasma sodium level. Several studies
have shown that cardiac cachexia is linked to raised plasma levels of
tumor necrosis factor-
. The degree of body wasting is strongly
correlated with neurohormonal and immune abnormalities.
The available evidence suggests that cardiac cachexia is a
multifactorial neuroendocrine and metabolic disorder with a poor
prognosis. A complex imbalance of different body systems may cause the
development of body wasting.
Key Words: body wasting • chronic heart failure • cytokines • immune activation • neurohormonal activation • neurohormones • weight loss
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