Exocrine Pancreatic Insufficiency in Heart Failure: Clinical Features and Association With Cardiac Cachexia

Background

Cardiac cachexia is a complex syndrome, and the underlying mechanisms are not completely understood. Exocrine pancreatic insufficiency (EPI) causes malabsorption, malnutrition and sarcopenia; and might contribute to cardiac cachexia. The prevalence of EPI and its clinical profile in patients with heart failure (HF) remain unknown. The objective of this study is to prospectively examine the prevalence and clinical characteristics of EPI in a wide spectrum of patients with HF and to relate these findings to malnutrition and cardiac cachexia.

Methods

Exocrine pancreatic function was examined in patients with HF using faecal elastase 1 (FE-1) measurements. A FE-1 level of ≤206 μg/g (<200 ± 3%) supported the diagnosis of EPI. All patients were well characterized (including echocardiography and biomarkers); in 36 patients, invasive hemodynamics were measured. Cardiac cachexia was defined as non-edematous weight loss >5% in at least six months. Malnutrition was assessed by the Simplified Nutritional Appetite Questionnaire (SNAQ). Comparisons were made between patients with and without EPI.

Results

We enrolled 60 consecutive patients; mean age was 60 ± 10 years, 25 (42%) were women, mean left ventricular ejection fraction (LVEF) was 29 ± 14% and median N-terminal pro-B-type natriuretic peptide (NT-proBNP) was 3926 [2126–6645] pg/mL. Six patients (10%) had EPI. They had a lower body weight (61.7 versus 83.0 kg; p = 0.003) and lower BMI (22.3 ± 3.3 versus 26.9 ± 4.5 kg/m², p = 0.02), but functional class, LVEF and NT-proBNP were similar (p = 0.53, p = 0.78 and p = 0.97, respectively). Patients with EPI had a higher SNAQ-score, indicating (more symptoms of) malnutrition (1 [0–3] versus 3 [2–4], p = 0.045). Cardiac cachexia was present in three (50%) of the patients with EPI (versus 26% in patients without EPI, p = 0.35). Patients with EPI exhibited lower serum lipase than patients without EPI (23 [14–25] U/L versus 39 [26–71] U/L, p = 0.003). The aetiology of HF was different between groups (p = 0.016); patients with congenital heart disease appeared to be more often affected by EPI (p = 0.07).

Conclusions

EPI is present in a significant proportion of patients with HF but is not associated with conventional HF parameters. Patients with HF and EPI are characterized by lower body weight and BMI, malnutrition and lower plasma lipase. Since EPI is treatable, these findings may have clinical and therapeutic consequences in patients with HF.