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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Chronic severe heart failure

  • Nonedematous, unintentional body weight loss of > 5% in < 12 months

  • Decrease in muscle strength, fatigue, anorexia, low fat-free muscle index, abnormal biochemistry (inflammation, anemia, low serum albumin)

GENERAL CONSIDERATIONS

  • Affects up to 10% of symptomatic patients with chronic heart failure (CHF)

  • Associated with very poor survival

  • Pathophysiology of wasting is not certain, but likely involve mediators of altered appetite and food intake, abnormal lipid and glucose metabolism, or anabolic or catabolic regulators

  • Treatment involves medical optimization of CHF and replacement of detectable vitamin deficiencies

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Patient with CHF

  • Early fatigue with exercise

  • Muscle weakness

  • Loss of appetite

  • Preserved or deteriorating appetite

  • Muscle wasting/atrophy

  • Loss of adipose tissue

DIFFERENTIAL DIAGNOSIS

  • Malignancy

  • Hyperthyroidism

  • Acquired immunodeficiency syndrome

  • Intentional weight loss or starvation

  • Diuresis

  • Infection

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Hyponatremia

  • Elevated serum uric acid

  • Elevated C-reactive protein and erythrocyte sedimentation rate

  • Elevated serum creatinine

  • Elevated triglycerides

  • Low serum albumin

  • Anemia

ELECTROCARDIOGRAPHY

  • Sinus rhythm/sinus tachycardia

  • Atrial fibrillation

  • Low-voltage QRS or evidence of ventricular hypertrophy

IMAGING STUDIES

  • Chest x-ray: normal or enlarged cardiac silhouette, pulmonary vascular congestion and/or curly B lines; osteopenia with or without vertebral body compression fractures

  • Echocardiography: biventricular and/or right ventricular enlargement and reduced contractility; atrial enlargement; color Doppler evidence of valvular regurgitation due to annular dilatation; mitral, pulmonary venous, and tissue Doppler evidence of left ventricular diastolic dysfunction with elevated filling pressures; elevated Doppler tricuspid regurgitant peak velocity indicating pulmonary hypertension; plethoric inferior vena cava

  • Other diagnostic tests directed at excluding malignancy and other noncardiac causes of cachexia

DIAGNOSTIC PROCEDURES

  • No specific diagnostic procedures

TREATMENT

CARDIOLOGY REFERRAL

  • Most patients with chronic heart failure should be followed up by a cardiologist

HOSPITALIZATION CRITERIA

  • Syncope

  • Decompensated CHF

  • Severe or symptomatic hypotension

MEDICATIONS

  • Optimization of goal-directed medical therapy for CHF

  • Omega-3 polyunsaturated fatty acids

  • Antioxidants (vitamins C and E)

  • Protein supplementation of 1.0–1.2 g per kg body weight

  • Anabolic steroids and recombinant human growth hormone can be considered

  • Avoid drugs that worsen anorexia

MONITORING

  • Weight

  • Fluid and nutritional intake

DIET AND ACTIVITY

  • Nutritional support (40–50 kcal/m2 of body surface per hour including 1.0–1.2 g/kg body weight protein)

  • Two-gram dietary sodium restriction

  • Exercise training for CHF patients in New York Heart Association (NYHA) functional classes I–III

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Adequate nutritional intake

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