Cardiac cachexia

Specialty: Cardiovascular.

• wasting due to heart failure
• cardiac weight loss
• myocardial wasting

Why it occurs

• End-end congestive heart failure (AHA/ACC Stage D, NYHA Functional Class IV)
• Severe pulmonary arterial hypertension with advanced right ventricular dysfunction
• Idiopathic dilated cardiomyopathy with intestinal malabsorption due to splanchnic congestion
• Complex decompensated valve disease with chronic systemic inflammatory state

Initial workup

Full laboratory workup with total serum albumin, prealbumin, total cholesterol and triglycerides (typically low from malabsorption and protein-calorie malnutrition), natriuretic peptides (BNP/NT-proBNP), proinflammatory cytokines such as TNF-alpha and IL-6 (useful in research), and thyroid and renal function tests; transthoracic Doppler echocardiography to quantify ventricular function and pulmonary pressures; bioimpedance analysis to assess loss of lean body mass.

Standard management

• Spironolactone — mineralocorticoid receptor antagonist to block aldosterone and reduce the systemic pro-inflammatory and fibrotic state; 12.5 to 25 mg once daily orally, with close monitoring of potassium and creatinine
• Enalapril — ACEI indicated for the control of systemic neurohormonal activation and reduction of afterload; 2.5 mg twice daily orally, titrated according to blood pressure tolerance
• Carvedilol — beta blocker indicated to counteract the increased sympathetic tone that favors protein catabolism; start with very low doses of 3,125 mg every 12 hours orally, monitoring clinical stability
• Furosemide (to maintain euvolemia and reduce edema and congestion of the intestinal wall, promoting nutrient absorption; 40 to 80 mg per day orally).