QUALITY-OF-LIFE DIMENSIONS IN PATIENTS WITH HEART FAILURE AND SARCOPENIA: A SCOPING REVIEWABSTRACT
Objective: to map the existing evidence on the quality-of-life dimensions in patients with heart failure and sarcopenia.
Method: this scoping review followed the JBI Evidence Synthesis Manual. Studies published between 2011 and 2023 in 15 databases were selected, initially totaling 7,703 articles. After applying the eligibility criteria, seven studies were included. The search was conducted in September 2023, with an update in December 2024.
Results: the studies identified key dimensions of quality of life affected by sarcopenia in patients with heart failure, including functional capacity, exercise capacity, mobility, pain/discomfort, and emotional and social aspects. Quality of life was assessed using instruments such as the Short Form-36, the EuroQol 5-Dimensions, and the Kansas City Cardiomyopathy Questionnaire. Functional and exercise capacities were the most frequently reported as impaired.
Conclusion: quality of life in patients with heart failure and sarcopenia is primarily impacted by functional capacity and exercise capacity, requiring targeted interventions to improve these dimensions.
DESCRIPTORS:
Quality of life; Scoping review; Surveys and questionnaires; Heart failure; Sarcopenia
RESUMO
Objetivo: mapear as evidências existentes sobre as dimensões da qualidade de vida em pacientes com insuficiência cardíaca e sarcopenia.
Método: esta revisão de escopo seguiu o Manual do JBI para Síntese de Evidências. Foram selecionados estudos publicados entre 2011 e 2023 em 15 bases de dados, totalizando inicialmente 7.703 artigos. Após a aplicação dos critérios de elegibilidade, sete estudos foram incluídos. A busca foi realizada em setembro de 2023, com atualização em dezembro de 2024.
Resultados: os estudos identificaram dimensões-chave da qualidade de vida afetadas pela sarcopenia em pacientes com insuficiência cardíaca, incluindo capacidade funcional, capacidade de exercício, mobilidade, dor/desconforto e aspectos emocionais e sociais. A qualidade de vida foi avaliada por meio de instrumentos como o Short Form-36, o EuroQol 5-Dimensions e o Kansas City Cardiomyopathy Questionnaire. As capacidades funcional e de exercício foram as mais frequentemente relatadas como prejudicadas.
Conclusão: a qualidade de vida em pacientes com insuficiência cardíaca e sarcopenia é primariamente impactada pela capacidade funcional e pela capacidade de exercício, sendo necessárias intervenções direcionadas para melhorar essas dimensões.
DESCRITORES:
Qualidade de vida; Revisão de escopo; Inquéritos e questionários; Insuficiência cardíaca; Sarcopenia
RESUMEN
Objetivo: mapear la evidencia existente sobre las dimensiones de la calidad de vida en pacientes con insuficiencia cardíaca y sarcopenia.
Método: esta revisión exploratoria siguió el Manual de Síntesis de Evidencia de JBI. Se seleccionaron estudios publicados entre 2011 y 2023 en 15 bases de datos, con un total inicial de 7703 artículos. Tras aplicar los criterios de elegibilidad, se incluyeron siete estudios. La búsqueda se realizó en septiembre de 2023, con una actualización en diciembre de 2024.
Resultados: los estudios identificaron dimensiones clave de la calidad de vida afectadas por la sarcopenia en pacientes con insuficiencia cardíaca, incluyendo la capacidad funcional, la capacidad de ejercicio, la movilidad, el dolor/malestar y los aspectos emocionales y sociales. La calidad de vida se evaluó mediante instrumentos como el Short Form-36, el EuroQol 5-Dimensions y el Kansas City Cardiomyopathy Questionnaire. La capacidad funcional y la capacidad de ejercicio fueron las que se reportaron con mayor frecuencia como afectadas.
Conclusión: la calidad de vida en pacientes con insuficiencia cardíaca y sarcopenia se ve afectada principalmente por la capacidad funcional y la capacidad de ejercicio, lo que requiere intervenciones específicas para mejorar estas dimensiones.
DESCRIPTORES:
Calidad de vida; Revisión exploratoria; Encuestas y cuestionarios; Insuficiencia cardíaca; Sarcopenia
INTRODUCTION
Heart failure (HF) is a complex clinical syndrome in which the heart has difficulty pumping enough blood to meet the body’s metabolic demands or can only do so under high filling pressures. It is a chronic condition which can lead to multiple complications, including sarcopenia1,2. Sarcopenia is characterized by the progressive loss of muscle mass and strength, and can be induced by factors common in patients with HF, such as reduced muscle perfusion, chronic inflammation, and hormonal imbalances. The presence of sarcopenia in individuals with HF is associated with an increased risk of adverse events, such as falls, fractures, physical limitations, deterioration of cardiac function, worsening prognosis, and a higher risk of hospitalizations and mortality, representing a growing public health challenge. It is estimated that approximately 30% to 50% of patients with HF have sarcopenia, with the prevalence being even higher among older adults, and may vary according to the diagnostic criteria used and the population studied2.
Patients with heart failure (HF) and sarcopenia have poorer quality of life and lower functional capacity compared to those without sarcopenia. These individuals frequently exhibit significant reductions in muscle strength, lower peak oxygen consumption (VO₂ peak) values, shorter distances covered in the six-minute walk test, and greater difficulty performing activities of daily living3,4.
Muscle loss exacerbates physical weakness and reduces mobility, which in turn worsens HF symptoms and compromises quality of life (QoL)5. In addition, limitations in performing physical activities and daily tasks resulting from symptoms such as dyspnea and fatigue contribute to greater muscle mass loss. This scenario, coupled with the prolonged progression and complexity of the disease, intensifies functional disability and not only affects biological aspects, but also social, psychological, and spiritual dimensions, resulting in a comprehensive negative impact on quality of life3,6,7.
Although there are different definitions of quality of life in the context of health, health-related quality of life (HRQoL) refers to the assessment of a patient’s perception of the effects of their illness and treatment on different aspects of their life, considering the physical, emotional, and social dimensions. Assessment instruments can measure this construct in a general or specific way, and are validated for both the general population and specific groups, such as patients with heart failure, allowing for standardized analyses8,9.
While the relationship between sarcopenia and cardiovascular disease is well documented, recent systematic reviews have predominantly focused on the prevalence, pathophysiological mechanisms, and clinical outcomes associated with sarcopenia in patients with cardiovascular disease, including HF. However, these reviews do not specifically and integrally explore the quality-of-life dimensions in this population9-12. This gap highlights the need for syntheses which articulate the different domains of quality of life in the context of the coexistence between HF and sarcopenia, justifying the present scoping review.
The scarcity of reviews on this topic makes it difficult to identify concepts and methods for assessing quality of life in patients with HF and sarcopenia, limiting application of effective clinical strategies for the integrated management of this population. The present study seeks to fill this gap by adopting a scoping review approach, providing an overview of how sarcopenia affects the quality of life of these patients. Evidence mapping can therefore support clinical practice, assisting in early identification of sarcopenia and in formulating targeted interventions with a view to improving prognosis, quality of life and reducing the social and economic impact of this condition10-12.
Despite the advancement of scientific production on sarcopenia in the context of heart failure, there is still a lack of syntheses which structurally integrate its relationship with quality of life, especially considering the heterogeneity of outcomes, assessment instruments and methodological approaches. In this context, developing a scoping review which enables mapping, organizing and critically analyzing the available evidence becomes relevant.
Thus, the objective of this scoping review is to map the existing evidence on the quality-of-life dimensions in patients with heart failure and sarcopenia.
METHOD
This is a scoping review study conducted in accordance with the JBI methodology13 and the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)14,15.
Protocol and registration
The protocol for this scoping review was developed and registered with the Open Science Framework (OSF) to ensure the transparency and reproducibility of the research process. It can be accessed via the following link: https://archive.org/details/osf-registrations-jn387-v1. The protocol record includes the identifier 10.17605/OSF.IO/JN387. The protocol has been published and is available in open access.
Eligibility criteria
This scoping review included primary studies with different methodological approaches, such as randomized and non-randomized clinical trials, cohort studies, case-control studies, cross-sectional studies, descriptive studies, and qualitative studies. Non-primary documents, such as guidelines, theses, dissertations, and systematic reviews, were exclusively considered for the analysis of reference lists.
Abstracts, conference proceedings, editorials, and articles published in languages other than Portuguese, English, or Spanish were excluded. The study selection sought to ensure a comprehensive analysis of the quality-of-life dimensions in patients with HF and sarcopenia, without restriction as to the publication year.
The key elements of this review were defined based on the Population-Concept-Context (PCC) strategy: (1) Population: adult patients diagnosed with HF and sarcopenia; (2) Concept: sarcopenia in the different quality-of-life dimensions; and (3) Context: studies conducted in any healthcare setting, without geographical restriction, in which patients with HF and sarcopenia were assessed for quality of life.
Evidence sources
The search for evidence was conducted in September 2023 with the support of a librarian. A preliminary search was initially conducted in the MEDLINE/PubMed and BVS/Bireme (Virtual Health Library) databases with the aim of identifying relevant articles on the topic. The keywords present in the titles and abstracts of the selected studies, as well as the indexing terms used, were employed in the development of a comprehensive search strategy for the other databases.
The following databases were included: SCOPUS, EMBASE/Elsevier, LILACS, IBECS, BDENF (Nursing Database via BVS), SciELO, Web of Science Core Collection (Clarivate Analytics), CINAHL, Academic Search Premier (EBSCO), PsycINFO (APA), Cochrane Library, Epistemonikos, in addition to the academic search engines Google Scholar and Bielefeld Academic Search Engine (BASE). The Cost-Effectiveness Analysis (CEA) Registry, which compiles relevant cost-effectiveness analyses, was also included.
It was not necessary to contact the authors of the studies, as all pertinent information was available in the included articles. The search was conducted in two stages: the initial search took place in September 2023, followed by an update in December 2024, with the aim of identifying studies published after the initial stage and ensuring inclusion of the most recent evidence available until the completion of the review.
Search
The search strategy used in the MEDLINE/PubMed database is presented in Chart 1.
Selection of evidence sources
After identifying the studies in the databases, all citations were grouped and exported to EndNote software, used for reference management. Duplicates were removed in this software, and the records were subsequently imported into Rayyan to manage the process of selecting evidence sources.
Two independent reviewers initially screened the citations by reading titles and abstracts, based on previously established eligibility criteria. Articles considered potentially relevant were selected for the subsequent full-text reading stage. Disagreements between reviewers were resolved by consensus and by consulting a third reviewer when necessary, ensuring impartiality and consistency in the selection process.
After this initial stage, the full texts of potentially eligible studies were evaluated by two independent reviewers regarding compliance with the inclusion and exclusion criteria. Any disagreements were resolved by consensus or with the participation of a third reviewer if/when necessary.
All decisions regarding the inclusion and exclusion of studies were recorded in an Excel spreadsheet generated using Rayyan to ensure process control, allowing for detailed tracking of each step. The reference lists of the included studies were additionally examined to identify potentially relevant additional publications.
Data extraction process
Data extraction was performed using a form developed by the authors based on variables relevant to the analysis of quality-of-life dimensions in patients with HF and sarcopenia11. The instrument was previously tested through a pilot study, allowing for the necessary adjustments to ensure its suitability.
Data extraction was independently conducted by two reviewers who performed a detailed reading of the studies and extracted the information separately. Disagreements were discussed between the reviewers until consensus was reached. A third reviewer was consulted if disagreement persisted to resolve the issue, ensuring consistency of the extracted data. The data were organized in spreadsheets, facilitating analysis and comparison between the included studies.
Variables of interest
The data were extracted based on variables aligned with the study objectives, including:
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Study identification: authors, year of publication, and country of origin.
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Study objective: focus on heart failure, sarcopenia, and quality of life.
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Study design: type of study (experimental, observational, or qualitative), allowing for methodological analysis.
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Population: characteristics of participants, including age range (≥18 years) and clinical condition.
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Quality-of-life dimensions: main dimensions affected by sarcopenia in patients with heart failure.
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Quality-of-life assessment: instruments used in the studies.
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Level of evidence: classification according to the Oxford Centre for Evidence-Based Medicine (OCEBM)16 and the GRADE system (Grading of Recommendations Assessment, Development and Evaluation)17.
Critical appraisal of evidence sources
A critical appraisal of the evidence sources was conducted to ensure reliability of the conclusions. For this purpose, two widely recognized systems were used: the OCEBM evidence level tables and the GRADE system.
The OCEBM classifies evidence into five levels, ranging from Level 1 (highest level of evidence) to Level 5 (expert opinion), based on the methodological design of the studies. Level 1 includes systematic reviews of randomized controlled trials (RCTs) and high-quality individual RCTs, while Level 5 corresponds to the lowest level of evidence16.
The GRADE system classifies the quality of evidence into four categories: high, moderate, low, and very low, offering a systematic approach to assessing confidence in the results and the likelihood that new evidence will modify the conclusions17.
Synthesis
The study selection process was presented using a PRISMA flowchart, facilitating visualization of the inclusion and exclusion steps14,15. Data synthesis was performed through tabular and narrative analysis. The information was initially organized into a figure that grouped data on population, quality-of-life dimensions, study designs, and instruments used.
In addition, a narrative analysis was conducted to interpret the results, highlighting the main trends and clinical implications. The quality of evidence was classified based on the OCEBM and GRADE systems, allowing contextualization of the robustness of the findings. Patterns were identified in the quality-of-life dimensions affected in patients with HF and sarcopenia, as well as methodological and population differences among the included studies.
Statement on the use of artificial intelligence
Artificial intelligence tools were used during the preparation of this manuscript, specifically ChatGPT (OpenAI), model GPT-5.3 (March 2026), exclusively to support textual organization and preliminary linguistic review. No AI tools were employed in generating scientific content, data analysis, or interpretation of results. All content was critically reviewed by the authors, who assume full responsibility for the integrity and accuracy of the manuscript, in accordance with international ethical recommendations.
RESULTS
The initial search identified 7,703 articles, of which 3,591 were excluded due to duplication, leaving 4,112 records. In the next step, two independent reviewers screened the titles and abstracts based on eligibility criteria, resulting in the exclusion of 4,037 records that did not meet the established requirements. Additionally, one article could not be retrieved, leaving 74 studies available for full-text reading. Of these, 67 were excluded for the following reasons: three did not involve the target population, 35 were outside the conceptual scope, and 29 were reviews. In the end, seven articles were included in the review. The PRISMA-ScR flowchart illustrates the complete search and study selection process (Figure 1)14,15.
Characteristics of the studies
The seven studies included in the synthesis were published between 2011 and 2023. They were conducted in the United States, Brazil, Pakistan, and Germany, all published in international journals in English. The characteristics of the studies, including title, authors, country of origin, year of publication, objective, design, population, quality-of-life dimensions, assessment instruments, and level of evidence according to Oxford, are presented in Chart 2.
The investigated population exclusively consisted of outpatients. Heterogeneity was observed in the approaches of the studies regarding the relationship between heart failure and sarcopenia, encompassing different perspectives, such as resistance training and physical disability; sarcopenia in heart failure with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF); comparison between sarcopenia and cachexia; genetic factors; and sarcopenic obesity. Most studies were prospective observational, with only one retrospective study.
The review identified the main quality-of-life dimensions affected by sarcopenia in patients with heart failure as: functional capacity, exercise capacity, mobility, pain/discomfort, and emotional and social aspects. Among these, functional capacity was reported in all studies, while exercise capacity was highlighted in six of the seven articles, demonstrating its relevance in assessing quality of life.
The instruments used to assess quality of life included the Kansas City Cardiomyopathy Questionnaire (KCCQ), the EuroQol 5-Dimensions (EQ-5D), the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), and the Minnesota Living with Heart Failure Questionnaire (MLHFQ).
Exercise capacity was assessed using the International Physical Activity Questionnaire - Short Form (IPAQ-SF) and functional tests, such as the six-minute walk test (6MWT), the four-meter walking speed (4MW), and the cardiopulmonary exercise test (CPET). Body composition was measured by dual-energy X-ray absorptiometry (DEXA) and bioelectrical impedance analysis (BIA). Muscle strength was assessed using handgrip strength (HGS), quadriceps strength, and the chair stand test (CST).
Most studies had a prospective observational design, with a level of evidence 2B, according to the Oxford Centre for Evidence-Based Medicine classification (OCEBM)16.
GRADE assessment
The quality of evidence was asssessed using the GRADE system, and revealed important methodological limitations. The risk of bias was mainly associated with the use of non-randomized samples. Inconsistency resulted from the heterogeneity and small sample sizes, while imprecision was related to the low number of events analyzed in equally heterogeneous populations. These limitations, added to the variability of the methods used in the evaluation of outcomes, resulted in classifyingf the evidence quality as low (Chart 3)17.
Grading of Recommendations Assessment, Development and Evaluation. Niterói, RJ, Brazil, 2025.
DISCUSSION
This scoping review mapped the quality-of-life dimensions impacted by sarcopenia in patients with HF, highlighting a set of interrelated outcomes ranging from loss of physical functionality to changes in emotional well-being and social participation. The convergence of findings indicates that sarcopenia (characterized by a decline in strength, muscle mass, and physical performance) plays a significant role in the experience of living with HF, directly compromising domains such as autonomy, mobility, and exercise capacity2,3,6,10,18.
The occurrence of sarcopenia in patients with HF is associated with a clinical phenotype of greater frailty, lower physiological reserve, and worse prognosis, reflecting a higher risk of hospitalization, functional dependence, and mortality1,10. The findings of this review reinforce this scenario by identifying functional capacity as the most affected dimension of quality of life, present in all included studies, confirming its centrality in determining clinical and psychosocial outcomes2,3,6,18.
The limitation of exercise capacity, reported in most studies, not only manifests itself through the objective reduction in performance on tests such as the six-minute walk test, but also through the subjective perception of effort and discouragement in performing daily activities2,3,19-22. This condition favors establishing a vicious cycle characterized by inactivity, progressive muscle loss, and deterioration of cardiorespiratory capacity, with negative repercussions on mental health, self-esteem, and overall quality of life4,10. These findings are consistent with recent evidence demonstrating the association between sarcopenia and worse clinical outcomes in patients with HF, including a higher occurrence of adverse events, greater use of health services, and impaired quality of life. In addition, contemporary reviews highlight the complexity of the mechanisms involved and the need for integrated approaches to assess and clinically manage this population, emphasizing the role of structured and patient-centered interventions in improving outcomes5,6,9,19.
Emotional well-being, including symptoms of anxiety and depression, was also identified as an impacted dimension, demonstrating that psychological suffering is a significant consequence of the physical limitations imposed by sarcopenia in HF18,21. This overlap of factors reinforces the need for multidimensional therapeutic approaches that integrate psychosocial interventions and strategies aimed at improving functionality22.
This review additionally identified contextual and biological factors associated with the quality-of-life dimensions2,20,21. Sarcopenic obesity stands out as an additional risk condition, associated with lower cardiorespiratory fitness, greater functional limitation, and lower response to rehabilitation interventions20,23. Genetic factors also emerge as relevant determinants of susceptibility to sarcopenia, indicating the need to incorporate biological markers and early screening strategies in patients with HF2,24,25.
From a methodological point of view, the heterogeneity of the instruments used to assess quality of life (EQ-5D, SF-36, MLHFQ, and KCCQ) reflects the diversity of approaches and constructs evaluated in the different contexts of the included studies2-3,18-20. Although all are validated instruments, their structural specificities may influence the measurement and interpretation of results, limiting comparability between studies. Therefore, the importance of using validated instruments for the population with heart failure and sensitive to changes resulting from sarcopenia stands out12,26-30.
Another relevant aspect is the predominance of prospective observational studies classified as level 2B by the Oxford Centre for Evidence-Based Medicine system16 and with evidence quality considered low by the GRADE system17. The main methodological limitations include the use of non-randomized samples, small sample sizes, population heterogeneity, insufficient control of confounding factors, and lack of standardization in the diagnostic criteria for sarcopenia. These limitations compromise the robustness of the inferences and reinforce the need for future studies with more rigorous designs and standardized diagnostic criteria17,22.
Furthermore, a temporal gap was observed in scientific production between 2011 and 2016, possibly related to the more recent development of the clinical concept of sarcopenia, formalized after the first consensus of the European Working Group on Sarcopenia in Older People (EWGSOP)31 and subsequently revised (EWGSOP2)22. The scarcity of systematic reviews which specifically address the quality-of-life dimensions in this population reinforces the relevance of this scoping review as an original contribution to the field.
CONCLUSION
This scoping review identified that functional capacity and exercise capacity are the most affected quality-of-life dimensions in patients with heart failure and sarcopenia, followed by mobility, pain/discomfort, and emotional and social aspects, highlighting a complex and vulnerable clinical profile. Evidence suggests that sarcopenia plays a significant role in the progression of heart failure and loss of autonomy, not merely constituting a comorbidity. Systematic assessment of quality of life using validated and specific instruments should be incorporated into clinical practice to support decision-making, risk stratification, and therapeutic planning.
This review highlights the need for integrated and multidimensional interventions which combine physical rehabilitation, nutritional support, and psychosocial support, with the aim of preserving functionality and increasing patient resilience. Such person-centered and evidence-based approaches should prioritize the most compromised quality-of-life domains.
The findings should be interpreted with caution given the methodological limitations of the included studies. The low evidence quality according to the GRADE system, and the predominance of observational studies with design and sampling weaknesses restrict generalizing the results. Furthermore, the exclusion of grey literature and the limitation to Portuguese, English, and Spanish may have reduced the scope of the analysis.
Therefore, future studies should prioritize greater methodological rigor, representative samples, standardized diagnostic criteria for sarcopenia, and the systematic use of validated and specific quality of life assessment instruments for heart failure. Randomized clinical trials and multicenter studies are essential to consolidate evidence on effective management strategies and support developing guidelines aimed at improving the quality of life of these patients.
This study offers relevant conceptual and practical support for researchers, clinicians, and managers by highlighting the multidimensional impact of sarcopenia on heart failure. The integration between functionality, physical condition, and emotional suffering is fundamental to providing more effective, humanized, and evidence-based care.
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