More than muscle loss: sarcopenia as a marker of disease severity in ambulatory heart failure

Introduction

Sarcopenia is common in older adults and is associated with increased morbidity and mortality. Patients with heart failure (HF) are particularly vulnerable; however, data on the prevalence of sarcopenia and its clinical correlates in ambulatory HF populations are limited. This study aimed to assess the prevalence of probable sarcopenia in HF outpatients and its association with geriatric and cardiac-related factors.

Methods

A retrospective observational study was conducted including patients diagnosed with HF and followed at a multidisciplinary Heart Failure Unit in a tertiary care hospital between December 2023 and February 2025. Sarcopenia screening was performed using the SARC-F questionnaire combined with muscle strength assessment (handgrip dynamometry and/or five-times sit-to-stand test). Probable sarcopenia was defined as a positive SARC-F score plus impaired muscle strength. Clinical, functional, cognitive, frailty, nutritional, laboratory and HF-related variables were collected. Patients were compared according to sarcopenia status, and multivariable logistic regression was used to identify independent associations.

Results

A total of 150 patients were included, with a mean age of 83.03±9.32 years, and 62% were male. A positive SARC-F screening was observed in 55.3% of patients, and probable sarcopenia was diagnosed in 81 (54.0%). Patients with sarcopenia were significantly older and showed greater functional dependence, poorer cognitive status, higher levels of frailty and worse nutritional status (all p<0.05). They also presented higher levels of inflammatory and cardiac biomarkers, including C-reactive protein, NT-proBNP, troponin T and CA-125, together with lower concentrations of albumin, cholesterol, haemoglobin and potassium.

From a cardiological perspective, sarcopenia was significantly associated with atrial fibrillation, worse NYHA functional class and higher NT-proBNP levels, while no differences were observed in left ventricular ejection fraction or HF aetiology. Patients with sarcopenia were less frequently treated with statins and SGLT2 inhibitors, and more frequently received loop diuretics and direct oral anticoagulants. In multivariable analysis, atrial fibrillation [OR=3.07, 95%CI(1.11-8.53); p=0.031] and NT-proBNP levels [OR=1.00, 95%CI(1.00-1.00); p=0.047] were independently associated with sarcopenia, whereas NYHA class I–II was inversely associated [OR=0.36, 95%CI(0.15-0.88); p=0.025]. During six months of follow-up, sarcopenic patients showed a non-significant trend towards higher rates of hospitalisation and mortality.

Conclusion

Sarcopenia affects more than half of outpatients with HF and is strongly associated with functional and cognitive impairment, frailty, malnutrition and markers of greater cardiac disease severity. These findings support the need for systematic screening and multidisciplinary interventions targeting muscle health within comprehensive HF management strategies.