Nutrition and cardiac cachexia Gohar Azhar and Jeanne Y. Wei Purpose of review Congestive heart failure is a leading cause of morbidity and mortality, especially in older persons. In advanced stages of the disease, congestive heart failure can be associated with serious complications such as cardiac cachexia (defined here as weight loss of more than 6% in 6 months). This review will discuss recent insights into the pathophysiology, anthropometric predictors and potential management of cardiac cachexia. Recent findings Cardiac cachexia and the associated progressive weight loss are sometimes overlooked by care providers. A delay in diagnosis often results in further loss of vital tissues, progressive weakness, fall-related injuries and potentially long-term care institutionalization and/or death. Emerging data suggest that congestive heart failure is a dynamic disorder of many organ systems, including the myocardial, neurohormonal, immune, vascular, gastrointestinal, renal and musculoskeletal systems. It is becoming more widely appreciated that it is the deterioration of this interactive multisystem complex that results in the systemic inflammation and progressive wasting and atrophy of muscle and other organ tissues, which is the hallmark of cardiac cachexia. Summary Cardiac cachexia in congestive heart failure patients may be associated with a low level of physical activity. A high systemic inflammatory state is another marker of cardiac cachexia. Prudent anti-inflammatory nutrition, dietary supplements and exercise can serve to ameliorate and/or potentially prevent progressive wasting. A better understanding of factors contributing to the development of cardiac cachexia will enable us to design preventive strategies and provide improved care for individuals with this debilitating condition. Keywords cachexia, gut, heart failure, inflammation, muscle atrophy, nutrition Curr Opin Clin Nutr Metab Care 9:18–23. ß 2006 Lippincott Williams & Wilkins. Geriatric Research Education and Clinical Center (GRECC), Central Arkansas Veterans Healthcare System (CAVHS) and Reynolds Department of Geriatrics, University of Arkansas for Medical Sciences (UAMS), Little Rock, Arkansas, USA Correspondence to Jeanne Y. Wei, MD, PhD, Reynolds Department of Geriatrics, 4301 W. Markham St., #748, Little Rock, AR 72205, USA Tel: +1 501 603 1261; fax: +1 501 686 5884; e-mail: jwei@uams.edu Current Opinion in Clinical Nutrition and Metabolic Care 2006, 9:18–23 Abbreviations CHF congestive heart failure TNFa tumor necrosis factor a ß 2006 Lippincott Williams & Wilkins 1363-1950 Introduction Congestive heart failure (CHF) remains the leading cause of acute hospitalization among older individuals (aged 65 years and over) in the USA [1–4]. It has long been appreciated that advanced CHF may be associated with progressive tissue wasting, unintentional weight loss and a poor prognosis. In the first reported observational study of cachexia on the island of Cos, Hippocrates (460–377 BC) observed that in patients with advanced CHF ‘the flesh is consumed and becomes water, ...the abdomen fills with water, the feet and legs swell, the shoulders, clavicles, chest and thighs melt away. ...This illness is fatal’. Although this condition has been known to exist for over 2300 years, it has been relatively under- studied, and until recently a definition had not been clearly established [5  ,6  ]. Definition In the literature, the term cachexia in patients with CHF has been used to refer to a state in which there is loss of body fat to less than 27% for men and 29% for women, together with a body weight of less than 80 – 90% of ideal weight [5  ,6  ,7]. Recently it was suggested that clinical cardiac cachexia be defined in CHF patients without signs of other primary cachectic states (e.g. cancer, thyr- oid disease, or severe liver disease) as weight loss of more than 6% of the previous normal weight over 6 months associated with CHF [5  ,6  ]. Heart failure itself may be defined as a condition in which an abnormality of cardiac structure or function is responsible for the inability of the heart to fill with or eject blood at a rate commensurate with the requirements of the metabolizing tissues [8 – 10]. In most instances of chronic CHF, the progressive decline of cardiac performance is usually secondary to myocardial infarction, ischemic cardiomyopathy or long- standing hypertension [9–11]. Other risk factors predis- posing to heart failure include diabetes mellitus and/or valvular heart disease [1–4,8–11,12  ]. In addition to having significant myocardial impairment, CHF itself impacts multiple body systems, with abnormalities observed in the vascular, musculoskeletal, neuroendo- crine, renal, gastrointestinal and immune systems 18