Can Heart Failure Lead to Weight Loss? And Is It Dangerous?

As heart failure progresses and gets worse, a very worrying symptom may develop: unintentional weight loss. It occurs due to a type of malnutrition called cardiac cachexia. “Cardiac cachexia is most likely to develop with severe or end-stage heart failure,” says cardiologist Rachel-Maria Brown Talaska, M.D., director of inpatient cardiac services at Northwell Lenox Hill in New York City, NY.

Here, top cardiologists explain what cardiac cachexia is, the reasons behind this type of weight loss, what it means for your heart failure prognosis, and how it can be addressed.

Defined as the unintentional loss of at least 5% of your body weight in one year, cardiac cachexia results from many different factors that occur due to changes in the body brought on by heart failure, according to the Cleveland Clinic.

“It’s a complex disorder that has to do with the way your body absorbs and uses the nutrients and calories you eat,” explains Michelle Bloom, M.D., a heart failure cardiologist and the director of the cardiology-oncology program at NYU Langone Health in New York City. “I would worry that it’s a sign that the heart failure has progressed significantly, and that the person is either at an end stage of disease or at a very advanced stage of disease.”

A driving factor of cardiac cachexia is the impact of heart failure on your gut, which limits your ability to absorb carbohydrates and fats, says Ajay Vallakati, M.D., a cardiologist who specializes in advanced heart failure at The Ohio State University Wexner Medical Center in Columbus, OH. “This is due to decreased blood flow to the gut, edema [swelling] of the inner lining of the gut wall, and changes to gut bacteria,” he explains.

And, he adds, hormonal changes and inflammation can also play a part. Together, they cause the breakdown of proteins, a loss of fat tissue, and muscle-wasting, all of which contribute to weight loss.

On top of that, people who are experiencing advanced heart failure often lose their desire to eat—which can have exponential consequences. “Loss of appetite can also lead to diminished intake of protein,” says Deepak Vivek, M.D., an interventional cardiologist for Orlando Health Heart and Vascular Institute in Orlando, FL.

As you eat less and absorb fewer nutrients, your ability to exercise and engage in other types of physical activity drops. This inactivity speeds muscle loss, or sarcopenia, already underway due to your cachexia—which may lead to additional weight loss, a vicious circle.

Estimates vary regarding how many people with heart failure develop cardiac cachexia, ranging from 10% to nearly 40%, per the Cleveland Clinic. One thing that experts do agree upon: It’s a dangerous development.

“Cardiac cachexia is associated with poor prognosis” that is associated with higher mortality rates, says Dr. Vallakati. “Only one in two patients with cardiac cachexia live longer than 18 months.”

In addition to unintentional weight loss, the following symptoms often occur due to cardiac cachexia:

• Low energy that interferes with your day-to-day activities due to inadequate nutrition

• Loss of appetite

• Reduced strength from muscle loss

What’s more, cardiac cachexia can worsen your existing heart failure symptoms, leading to increased fatigue and shortness of breath, as well as an unhealthy boost in your heart rate, called tachycardia, Dr. Brown Talaska notes.

Weight loss due to cachexia can be hard for patients to recognize if they are only looking at the numbers on their scale. That’s because people with heart failure often retain fluid, which leads to weight gain.

“Their scale does not reflect that fat mass and muscle mass is being lost because it’s being replaced by water weight,” says cardiologist Amanda Vest, M.D., the section head of heart failure and transplantation cardiology at the Cleveland Clinic in Cleveland, OH.

The risk of cardiac cachexia should be on your doctor’s mind, especially as your heart failure progresses to more advanced stages. You’ll discuss any new symptoms associated with your weight loss, such as muscle weakness and fatigue. You will undergo a physical exam during which your doctor will look for signs of fat and muscle loss as well as weight changes that could indicate you’re not getting enough to eat. Your doctor also may test your handgrip strength. A weak handgrip can be a sign of poor nutrition, according to the Cleveland Clinic.

Blood tests, meanwhile, can reveal signs of inflammation, anemia, and lower than normal levels of the protein albumin, called hypoalbuminemia. These conditions are common in cardiac cachexia. Another blood test measures a protein called N-terminal pro b-type natriuretic peptide (NT-proBNP), which helps your doctor better understand how advanced your heart failure has become, says Dr. Vest.

You also may undergo a cardiopulmonary exercise test, in which you walk on a treadmill or ride a stationary bike. This shows your doctor how well your heart works under the stress of exercise, providing more information about the progression of your heart failure.

Other tests may be used to define your body composition—your body’s percentages of fat, bone, and muscle—and muscle strength, which will show how cachexia has affected your body. Such tests include dual X-ray absorptiometry (DXA), which uses very low level X-rays to measure bone density. However, such advanced testing is frequently unnecessary.

“Most commonly, cardiac cachexia is recognized when a patient has unintentionally lost weight over the past six to 12 months and particularly when the muscles of the arms, hands, legs, or around the face are seen to have decreased in size,” Dr. Vest explains.

This type of unintentional weight loss has numerous potential consequences. Dr. Vivek cites the loss of muscle mass and the weakness that results from it, which can make you unsteady on your feet, as points of concern.

“This predisposes an individual to falls,” he says.

Falls are dangerous enough on their own, but cardiac cachexia adds to the harm they can cause. When cardiac cachexia prevents your body from getting enough nutrition, Dr. Vivek explains, it can lead to osteoporosis, a dangerous weakening of your bones. That boosts your chances of a fracture, should you fall.

Dr. Vallakati says that malnutrition from cardiac cachexia can also increase your risk of complications after surgery and interfere with healing. And it can make treating your heart failure more difficult.

“Heart failure patients with cardiac cachexia may not tolerate routine heart failure medications, due to side effects such as low blood pressure,” says Dr. Vallakati.

And, says Dr. Brown Talaska, cardiac cachexia weakens your immune system—which raises your risk of infections.

In addition to taking standard heart failure medications, if you can tolerate them, your doctor may recommend a cardiac rehabilitation program. Such programs help you to meet your nutrition and exercise needs to help improve your heart health and your overall fitness, allowing you to return to daily activities. Guided by a cardiologist, such programs involve nutritionists, physical therapists, and other health professionals.

“A supervised cardiac rehab program can lead to improved functional capacity, quality of life, and improved survival,” says Dr. Vivek.

If you have been hospitalized for heart failure, your cardiac rehab program may begin before you are discharged and then continue on an outpatient basis. These programs generally last for about three months.

Dr. Vallakati says exercise—or at least regular physical activity—is crucial to recovery. It reduces muscle loss and promotes protein production, he points out. That protein, in turn, contributes to muscle growth. Your doctor or your cardiac rehab program team will work with you to tailor a workout regimen appropriate for you.

The other key to better health? Nutrition. Specifically, that means a high-calorie eating plan, comprised of high-protein foods and protein supplements.

“A high-calorie diet can increase body weight and reduce inflammation seen in patients with cardiac cachexia,” says Dr. Vallakati.

Your doctor also may recommend vitamin C and E, as well as omega-3 fatty acid, supplements. And, if your cachexia has led to an iron deficiency, you may undergo intravenous (IV) iron supplementation, says Dr. Vallakati.

But Dr. Vest points out that nutritional interventions like protein-heavy diets are under-studied for cardiac cachexia.

“We don’t actually know whether the recommendation to increase protein intake truly helps to regain muscle mass,” she says. Currently, she’s leading a National Institutes of Health-funded study to answer this question.

If you notice any of the symptoms of cardiac cachexia, including unexplained weight loss, worsening fatigue, weakness, call your doctor right away. Dr. Vest says it’s critical to keep an eye on your muscles for signs of deterioration.

“I want patients and their families to be vigilant about this,” she says. “If you notice loss of, particularly, muscle mass in the arms and legs, with unintentional weight loss over time, this is a concerning feature and may mean your heart failure is not being adequately treated. It probably also means that the patient would benefit from a dietitian consultation to review nutritional intake and determine if there are strategies to rebuild lost weight.”

Dr. Bloom agrees that you should not ignore any signs of cachexia.

“It could be a sign that [your] heart failure has progressed to a point where it’s beyond just using general [heart failure] medications and should be addressed by an advanced heart failure team,” says Dr. Bloom.

If that proves to be the case, she continues, your doctor may decide that you require either:

• A left ventricular assist device (LVAD), an implantable device that helps your heart’s main pumping chamber (your left ventricle) pump blood out to the rest of your body.

• A heart transplant, which will replace your failing heart with a healthy donor heart.

It’s important to note that weight loss in people with heart failure is not always unhealthy. Sometimes, losing a few pounds is a sign that your body is responding to your medications. Yet, weight gain can be a big red flag never to ignore. That’s because weight loss from cachexia occurs gradually, but weight gain can be sudden. According to the American Heart Association, gaining more than two to three pounds in one day or more than five pounds in a week indicates worsening heart failure, potentially requiring hospitalization. If you notice any significant shifts in your weight, see your cardiologist.

“There is a good kind of weight loss in heart failure,” explains Dr. Bloom. Fluid buildups caused by heart failure can lead to weight gain, causing swelling in your legs and stomach. When fluid collects in your lungs, it causes shortness of breath. Heart failure medications help remove excess fluid, as well as prevent it from building up in the first place.

“When [your heart failure meds] are working properly and [you’re] taking them properly, that will result in weight loss,” Dr. Bloom notes. “That’s what we look for—that’s actually a good response to medical therapy. But with heart failure, weight gain is usually problematic, and that’s sometimes how we know that a patient is having a heart failure flare or heart failure exacerbation.”

Bottom line? If you have heart failure, your weight can offer important clues to how well you are managing your condition.

Unexplained weight loss in heart failure usually indicates that your disease has entered an advanced stage. Treatment for cardiac cachexia can help you regain lost muscle and weight. However, it may mean it’s time to consider a heart transplant or an implantable device to help your heart work better, says Dr. Bloom, to keep your ticker functioning to its full capacity.