Heart failure (HF), a clinical syndrome characterized by impaired cardiac pumping, is strongly associated with aging and manifests as a progressive decline in cardiac structure and function (1, 2). Sarcopenia, a prevalent geriatric syndrome, involves the age-related loss of skeletal muscle mass, strength, and physical function (3). These two conditions are intricately interrelated and influenced by shared risk factors, including advanced age, obesity, chronic inflammation, malnutrition, and physical inactivity (4, 5). Following the onset of HF, adaptive changes in the musculoskeletal system play a pivotal role in the manifestation of many symptoms associated with the syndrome (6).

In recent years, growing interest has emerged regarding the prognostic implications of sarcopenia in HF patients. However, findings across studies remain highly inconsistent. For example, Sato et al. (7) reported that sarcopenia—defined using the Asian Working Group for Sarcopenia (AWGS) criteria—had no significant impact on major adverse cardiovascular events (MACE) among 546 older adult HF patients aged 65 and above. In contrast, Katano et al. (8), in a study involving 534 older adult Japanese HF patients, found that AWGS-defined sarcopenia was significantly associated with all-cause mortality and served as an independent risk factor [hazard ratio (HR) = 1.65; 95% confidence interval (CI): 1.05–2.59]. Similarly, in a cohort of 272 hospitalized patients with acute HF, severe sarcopenia (AWGS-defined) independently predicted cardiac death or readmission within 1 year (HR = 2.58; 95% CI: 1.40–4.74) (9). Two studies from China examining the relationship between sarcopenia and clinical outcomes in older adult HF patients reported higher rates of readmission and MACE in sarcopenic patients compared to controls. However, no significant differences were found in endpoints such as all-cause mortality or malignant arrhythmias (10, 11). To address these conflicting findings, several meta-analyses have sought to synthesize the existing evidence. Liu et al. (12) analyzed data from 12 studies encompassing 3,696 HF patients and found that sarcopenia was significantly associated with increased risks of all-cause mortality and MACE. However, substantial heterogeneity existed due to differences in geographical populations and diagnostic definitions (12). Among the 12 studies, eight distinct sarcopenia definitions were used, with some relying solely on muscle mass. In another meta-analysis, Prokopidis et al. (13) examined 18 longitudinal studies to assess the prognostic value of sarcopenia and its components (e.g., muscle mass and grip strength) in HF. While sarcopenia defined by European Working Group on Sarcopenia in Older People (EWGSOP1) or AWGS criteria showed no significant predictive value for all-cause mortality within 1–2 years (HR = 1.35; 95% CI: 0.76–2.38), specific components—such as low psoas muscle mass at the L3–L4 level and slow gait speed—were significantly associated with increased mortality risk (13).

In recent years, growing insights into sarcopenia have led to a surge in studies investigating its impact on patients with HF. These studies increasingly adopt comprehensive and standardized diagnostic criteria, such as the AWGS (14), the revised EWGSOP2 (15), and the Ishii score-based criteria (16). In this context, we conducted a meta-analysis to examine the relationship between sarcopenia—defined using multidimensional criteria—and clinical outcomes in HF patients. This study aims to clarify the association between sarcopenia and adverse prognoses in HF and to offer clinicians evidence-based guidance for identifying high-risk patients and optimizing management strategies.

This analysis aimed to provide evidence-based guidance for clinical risk stratification and management in this population. Our meta-analysis included 15 cohort studies with a total of 5,713 participants. The results demonstrated that sarcopenia, when defined using multidimensional diagnostic criteria, is an independent risk factor for poor prognosis in HF patients (HR = 1.62; 95% CI: 1.35–1.89), corroborating findings from prior studies. For instance, among 534 older adult HF patients, AWGS-defined sarcopenia was significantly associated with all-cause mortality (HR = 1.65) (8). Similarly, Liu et al.’s (12) meta-analysis of 12 studies with 3,696 patients found increased risks of all-cause death and MACE in sarcopenic individuals. Our findings suggest that multidimensionally defined sarcopenia is closely associated with adverse clinical outcomes in HF, highlighting the complex interplay between the two conditions. They share multiple risk factors—such as aging, obesity, chronic inflammation, malnutrition, and sedentary behavior—and the musculoskeletal adaptations that follow HF onset significantly contribute to symptom burden (4, 6, 30). Subgroup analyses further revealed that sarcopenia defined using AWGS or the Ishii score was significantly associated with adverse outcomes in HF patients. In contrast, sarcopenia defined by EWGSOP2 criteria did not show a statistically significant association. However, this result should be interpreted cautiously. Only two studies in our analysis used the EWGSOP2 criteria, with a combined sample size of just 366. The limited data and small sample size may have reduced the statistical power and reliability of this finding. Future research with larger, well-designed cohorts is warranted to clarify the prognostic relevance of EWGSOP2-defined sarcopenia in HF.

In our meta-analysis, 80% of the included studies (12/15) did not stratify HF subtypes, with a notable absence of investigations specifically targeting HF with reduced ejection fraction (HFrEF). Only three studies addressed distinct HF phenotypes: (1) Xiaolin et al. (11) identified sarcopenia as an independent risk factor for adverse cardiovascular events in 300 patients with HF with mildly reduced ejection fraction (HFmrEF); (2) Kılıç et al. (28) demonstrated that sarcopenia was associated with increased hospitalization and mortality in 722 HFmrEF patients; and (3) Zhengguang et al. (10) reported an independent association between sarcopenia and adverse outcomes (HR = 1.439) in 240 patients with HF with preserved ejection fraction (HFpEF). Exploratory analysis of HFmrEF cohorts revealed a significant association between sarcopenia and prognosis (OR = 1.70, 95% CI: 1.08–2.33; Supplementary Figure 1); however, the substantial heterogeneity (I² = 81.7%) warrants cautious interpretation. Given the distinct pathophysiological mechanisms underlying HF subtypes—where neurohormonal activation predominates in HFrEF and metabolic dysregulation is more characteristic of HFpEF—the complete lack of HFrEF-specific data represents a critical gap. Future research should prioritize the evaluation of sarcopenia’s prognostic relevance across all HF phenotypes, particularly in HFrEF populations.

Our study employed a multidimensional diagnostic framework for sarcopenia, integrating assessments of muscle mass, strength, and physical performance. This approach reflects the dual structural and functional pathology of sarcopenia, characterized by loss of muscle mass and reduced muscle function. Sole reliance on muscle mass indicators—such as SMI measured via computed tomography (CT)—risks overlooking the broader metabolic impairments affecting muscle tissue. Conversely, isolated functional metrics like grip strength cannot fully capture variations in nutritional status or physical reserves across individuals (15). The dual-aspect assessment adopted in our study aligns with the multidimensional diagnostic criteria endorsed by both the EWGSOP and the AWGS (14, 15). Traditional single-parameter definitions are limited in their ability to reflect the complex pathophysiological profile of sarcopenia (31). In contrast, a combined diagnostic model enhances precision by identifying individuals who truly meet the criteria for sarcopenia, thereby reducing the risk of misclassification (32). In this study, sarcopenia defined using both the AWGS and Ishii score criteria was significantly associated with adverse HF outcomes, suggesting that a multidimensional approach more effectively captures prognosis-related determinants. While each diagnostic framework has unique strengths, AWGS and EWGSOP2—though more operationally complex—are well-suited for comprehensive inpatient screening due to their thorough inclusion of functional and structural indicators. In contrast, the Ishii score offers a practical, rapid screening method more appropriate for outpatient settings (16, 20). By leveraging these complementary tools according to the clinical context, diagnostic accuracy can be optimized.

The Ishii score is a simple, cost-effective screening tool for sarcopenia, integrating three readily obtainable parameters: age, grip strength, and calf circumference. It facilitates efficient risk stratification in primary care and low-resource settings by circumventing the need for advanced imaging modalities such as CT, MRI, or DXA (16). Prior studies have confirmed its high sensitivity and specificity in identifying sarcopenia among community-dwelling older adults. The original cut-off values (≥105 for men, ≥120 for women) demonstrated robust predictive performance in the initial validation cohort (20). However, in specific populations such as HF patients, tailored cut-off values may yield greater diagnostic precision. For instance, a study of 1,244 older adult HF patients found that adjusted thresholds (≥141 for men, ≥165 for women) provided superior prognostic and diagnostic accuracy (25). Despite underlying heterogeneity, our subgroup analysis indicated that sarcopenia defined by the Ishii score was significantly associated with poor HF prognosis (HR = 1.78), underscoring its utility in risk prediction. In summary, the Ishii score is a practical and economical option for initial sarcopenia screening, particularly in outpatient and resource-limited settings. However, to enhance its clinical utility, diagnostic thresholds should be calibrated to specific patient populations. Future multicenter studies are warranted to establish HF-specific Ishii scoring systems and define dynamic intervention thresholds.

This study has several multidimensional limitations. First, there is substantial geographic bias: 80% of the 15 included studies were conducted in Asian populations (Japan: 8; China: 4), while only 3 involved European cohorts, and none represented African or Latin American populations. This geographic imbalance limits the generalizability of the findings. Second, follow-up durations were skewed, with 93.3% (14/15) of studies reporting follow-up periods of ≤4 years (including two studies with <1 year), and only one study exceeding 5 years, thereby limiting insights into the ultra-long-term (≥5 years) prognostic impact of sarcopenia. Third, HF subtype stratification was insufficient, as most studies failed to differentiate between HFrEF and HFpEF, introducing uncontrolled heterogeneity into subgroup analyses and leaving a critical evidence gap for HFrEF. Fourth, the risk of residual confounding is high: key lifestyle factors—such as protein intake and moderate-to-vigorous physical activity—were not consistently adjusted for, despite their bidirectional relationships with sarcopenia, complicating causal inference. Fifth, methodological heterogeneity was evident. Several single-center studies had small sample sizes (<300 patients), and inconsistent diagnostic criteria for sarcopenia (e.g., varying DXA/BIA cutoffs) contributed to result variability. Finally, publication bias cannot be ruled out, as the potential underreporting of negative results may have led to an overestimation of sarcopenia’s effect magnitude.

Sarcopenia, when assessed using multidimensional criteria, is significantly associated with adverse clinical outcomes in patients with HF. Such a comprehensive approach offers improved prognostic precision and opportunities for timely intervention. Clinically, adopting a multidimensional evaluation strategy for sarcopenia and implementing early targeted interventions may enhance patient outcomes.