Prognostic impact of functional decline and low muscle mass on 1-year mortality and re-hospitalization in elderly patients with heart failure

Background Sarcopenia is highly prevalent in elderly patients with heart failure (HF) and is associated with poor clinical outcomes. Recently, functional sarcopenia has been proposed as a practical marker. However, previous studies often lacked actual muscle mass data, making it unclear whether physical function or muscle mass is more important for predicting outcomes. We hypothesized that physical function is a more sensitive prognostic marker that outweighs actual muscle mass. Purpose To evaluate the impact of functional decline and low muscle mass on 1-year all-cause mortality and HF re-hospitalization, and to determine whether functional status provides sensitive prognostic information in elderly patients hospitalized for acute HF. Methods We prospectively evaluated 154 elderly patients hospitalized for acute HF. Appendicular lean mass (ALM) was measured using dual-energy X-ray absorptiometry prior to discharge. Patients were stratified into four phenotypes based on gait speed (fast: ≥0.8 m/s vs. slow: <0.8 m/s) and ALM index (high vs. low, based on sex-specific medians): Group 1 (Fast Gait/High Mass, n=37), Group 2 (Fast Gait/Low Mass, n=28), Group 3 (Slow Gait/High Mass, n=41), and Group 4 (Slow Gait/Low Mass, n=48). The primary endpoint was a composite of 1-year all-cause death or HF re-hospitalization. Results The mean age of the study population was 82 ± 7 years, and 64.9% were female. Over a 1-year follow-up, 34 clinical events (all-cause death or re-hospitalization) occurred. Kaplan-Meier analysis showed that functional decline (slow gait) led to an early increase in clinical risk, which was further worsened by low muscle mass (Group 4; log-rank P=0.021). Fast walkers (Groups 1 and 2) had similarly favourable outcomes regardless of their actual muscle mass. In the multivariable Cox model adjusted for age, sex, and left ventricular ejection fraction, preserved physical function offset the risk of low muscle mass (Group 2: Adjusted Hazard Ratio [HR] 1.06, P=0.932). In contrast, the 'Slow Gait/Low Mass' phenotype (Group 4) was a strong and independent predictor of mortality and re-hospitalization (Adjusted HR 3.49, 95% Confidence Interval 1.18–10.32, P=0.024). Conclusion In elderly patients with HF, physical function is more critical than muscle mass for predicting clinical outcomes. Preserved function offsets the risk of low muscle mass, whereas their combination drives 1-year mortality and re-hospitalization. Thus, routine functional assessment should be prioritized for optimal risk stratification.Figure 1Figure 2