ABC | Volume 112, Nº6, June 2019

Original Article Sympatho-Vagal Imbalance is Associated with Sarcopenia in Male Patients with Heart Failure Guilherme Wesley Peixoto da Fonseca, 1 Marcelo Rodrigues dos Santos, 1 F rancis Ribeiro de Souza, 1 Marcel Jose A. da Costa, 1 Stephan von Haehling, 2 Liliam Takayama, 3 R osa Maria R. Pereira, 3 C arlos Eduardo Negrão, 1 Stefan D. Anker, 2 Maria Janieire de Nazaré Nunes Alves 1 Instituto do Coração (InCor), 1 São Paulo, SP – Brazil Department of Cardiology and Pneumology - University of Göttingen Medical Centre, 2 Göttingen – Germany Divisão de Reumatologia - Laboratório de Metabolismo Ósseo da Faculdade de Medicina da Universidade de São Paulo, 3 São Paulo, SP – Brazil Mailing Address: Maria Janieire de Nazaré Nunes Alves • Avenida Doutor Enéas de Carvalho Aguiar, 44. Postal Code 05403-900, Jardim Paulista, São Paulo, SP – Brazil E-mail: janieire.ja@gmail.com, guilhermefonseca@usp.br Manuscript received June 11, 2018, revised manuscript September 14, 2018, accepted October 02, 2018 DOI: 10.5935/abc.20190061 Abstract Background: Resting sympathetic hyperactivity and impaired parasympathetic reactivation after exercise have been described in patients with heart failure (HF). However, the association of these autonomic changes in patients with HF and sarcopenia is unknown. Objective: The aim of this study was to evaluate the impact of autonomic modulation on sarcopenia in male patients with HF. Methods: We enrolled 116 male patients with HF and left ventricular ejection fraction < 40%. All patients underwent a maximal cardiopulmonary exercise testing. Maximal heart rate was recorded and delta heart rate recovery (∆HRR) was assessed at 1 st and 2 nd minutes after exercise. Muscle sympathetic nerve activity (MSNA) was recorded by microneurography. Dual‑energy X-ray absorptiometry was used to measure body composition and sarcopenia was defined by the sum of appendicular lean muscle mass (ALM) divided by height in meters squared and handgrip strength. Results: Sarcopenia was identified in 33 patients (28%). Patients with sarcopenia had higher MSNA than those without (47 [41-52] vs. 40 [34‑48] bursts/min, p = 0.028). Sarcopenic patients showed lower ∆HRR at 1 st (15 [10-21] vs. 22 [16‑30] beats/min, p < 0.001) and 2 nd min (25 [19-39] vs. 35 [24-48] beats/min, p = 0.017) than non-sarcopenic. There was a positive correlation between ALM and ∆HRR at 1 st (r = 0.26, p = 0.008) and 2 nd min (r = 0.25, p = 0.012). We observed a negative correlation between ALM and MSNA (r = -0.29, p = 0.003). Conclusion: Sympatho-vagal imbalance seems to be associated with sarcopenia in male patients with HF. These results highlight the importance of a therapeutic approach in patients with muscle wasting and increased peripheral sympathetic outflow. (Arq Bras Cardiol. 2019; 112(6):739-746) Keywords: Heart Failure; Sarcopenia; Sympathetic Hyperactivity; Blunted Vagal Reactivation. Introduction Changes in body composition play an important role in the pathogenesis and progression of chronic heart failure (HF). 1 Sarcopenia, which is characterized by a decrease in skeletal muscle mass and strength, affects 19.5% of ambulatory patients with HF, 2 and is associated with several alterations such as impaired endothelial function, reduced 6-minute walking distance, and attenuated peak VO 2 . 2, 3 Although sarcopenia has been frequently described in elderly patients as a consequence of the ageing process, it can also be present in younger patients with HF. 4 Resting sympathoexcitation is a hallmark in chronic HF. 5 In addition, accumulated evidence shows that this autonomic dysregulation is highly associated with increased morbidity and mortality. 5 In normal conditions, sympathetic nervous system exerts anabolic action via β 2 -adrenoceptors on skeletal muscle, 6 but in experimental model of HF, the exacerbated sympathetic nervous activity contributes todownregulationof β 2 ‑adrenoceptors favoring skeletal muscle atrophy and weight loss. 7 Reduced parasympathetic activity has also been reported in patients with HF. 8,9 Binkley and colleagues 10 showed impaired parasympathetic activity in patients with HF evaluated by heart rate variability. Moreover, heart rate recovery (HRR), an important cardiac deceleration mechanism after maximum effort, can also be used to assess parasympathetic activity immediately after maximal exercise testing. 11 Furthermore, HRR is an easy, low-cost, and clinical assessment of vagal reactivation, and provides additional prognostic information. 12-14 Muscle sympathetic nerve activity (MSNA) and HRR, as measures of sympathetic and parasympathetic activity, respectively, have not been studied in sarcopenic patients with HF. Therefore, the aim of this study was to evaluate the impact of autonomic modulation assessed by MSNA (by microneurography technique) and HRR immediately after maximal exercise testing in patients with HF and sarcopenia. 739