ABC | Volume 110, Nº1, January 2018

Letter to the Editor Cardiac Cachexia – A Window to the Wasting Disorders Andrew J Stewart Coats IRCCS, San Raffaele-Pisana, Roma, Italy Mailing Address: Andrew • Monash University, 3068, Melbourne, Australia Manuscript received August 13, 2017, revised manuscript September 28, 2017, accepted September 28, 2017 Keywords Cachexia; Wasting Syndrome; Exercise; Nutritional Physiological Phenomena. 1. Okoshi MP, Capalbo RV, Romeiro FG, Okoshi K. Cardiac cachexia: perspectives for prevention and treatment. Arq Bras Cardiol. 2017;108(1):74-80. doi: 10.5935/abc.20160142. 2. Stewart Coats AJ, Ho GF, Prabhash K, von Haehling S, Tilson J, Brown R, Beadle J, Anker SD; for and on behalf of the ACT-ONE study group. Espindolol for the treatment and prevention of cachexia in patients with stage III/IV non-small cell lung cancer or colorectal cancer: a randomized, double-blind, placebo-controlled, international multicentre phase II study (the ACT-ONE trial). J Cachexia SarcopeniaMuscle. 2016;7(3):355-65. doi: 10.1002/jcsm.12126. 3. Lainscak M, Laviano A. ACT-ONE - ACTION at last on cancer cachexia by adapting a novel action beta-blocker. J Cachexia Sarcopenia Muscle. 2016;7(4):400-2. doi: 10.1002/jcsm.12136. 4. Ferraro E, Pin F, Gorini S, Pontecorvo L, Ferri A, Mollace V, et al. Improvement of skeletal muscle performance in ageing by the metabolic modulator Trimetazidine. J Cachexia Sarcopenia Muscle. 2016;7(4):449-57. doi:10.1002/jcsm.12097. 5. Loncar G, Springer J, Anker M, Doehner W, Lainscak M. Cardiac cachexia: hic et nunc. J Cachexia Sarcopenia Muscle. 2016;7(3):246-60. doi: 10.1002/jcsm.12118. References DOI: 10.5935/abc.20180009 To The Editor I read with interest the recent review by Okoshi and colleagues in the journal. 1 This was a thoroughly enjoyable read that reviewed the main areas of focus. I would like, however, to reinforce some of the arguments. In the section on neurohormonal blockade there has also been a successful phase 2 trial of the fourth generation beta-blocker espindolol in cancer cachexia. 2,3 Clearly beta-blockers can be helpful also in cardiac cachexia given their crucial role in heart failure in general. Other cardiovascular drugs are also being explored for their beneficial or protective effects on skeletal muscle. These include, as the authors point out, the ACE inhibitor Imidapril. Others including trimetazidine are also being studied. 4 One issue of difficulty is that we are starting from the point of no effective therapies and testing therapies one by one. The true multi-system complexity of cachexia and yet its similarity across different organ failure syndromes implies it will be a multi-barrelled approach that may be needed to solve it. We may need to combine neurohormonal blockade, immune modulation, nutritional and exercise support with pro-anabolic agents to get real clinical benefits. Perhaps as the authors point out Cardiac Cachexia where several of these agents are already on board may be a good place to start. The time for a much greater focus on all cachexias, including of course cardiac cachexia, is truly here and now. 5 102