Phase Angle as an Indicator of Sarcopenia, Malnutrition, and Cachexia in Inpatients with Cardiovascular Diseases

Evaluation of Change in Body Composition, including Phase Angle, in Post-Myocardial Infarction Patients Rehabilitated under the KOS-Zawał (MC-AMI) Programme

Background: Ischaemic heart disease, including myocardial infarction, is one of the main causes leading to heart failure as a consequence of ischaemic myocardial damage. In recent years, survival in the acute phase of myocardial infarction has improved significantly, but the high mortality rate within 12 months of hospital discharge (reaching up to 9.8% in Poland) remains a challenge. Therefore, the KOS-Zawał (MC-AMI) comprehensive 12-month post-MI care programme was introduced in Poland in 2017. Aim: This study aimed to assess body composition (including, but not limited to, the phase angle, visceral fat, total body fat, redistribution between intracellular and extracellular fluid in the body, and metabolic age) using a bioelectrical impedance analysis (BIA) in post-MI patients before and after early post-MI rehabilitation who were participating in the KOS-Zawał (MC-AMI) programme. Methods: This study involved an examination (before rehabilitation) of 94 post-myocardial infarction patients who were referred to a cardiology appointment within 7-10 days of hospital discharge, during which a clinical assessment, electrocardiogram, and biochemical blood tests (complete blood count, CRP, and serum creatinine) were performed. For various reasons (death, qualification for device implantation, non-completion of rehabilitation, failure to attend a follow-up BIA), data from 55 patients who were examined twice (before and after rehabilitation) were used for the final analysis. Measurements were taken using a high-grade Tanita MC-780 BIA body composition analyser, which measured the resistance of tissues to a low-intensity electrical impulse (not perceptible to the subject). Results: Participation in rehabilitation as part of the KOS-Zawał (MC-AMI) programme was associated with a decrease in metabolic age in patients, with a reduction in visceral fat levels and levels of adipose tissue in the lower and upper limbs. Moreover, a clinically beneficial reduction in the ratio of extracellular water to total body water was also observed. These changes were statistically significant (p < 0.005). In contrast, there were no statistically significant differences in the change in phase angle values in the subjects before and after the 5-week post-infarction rehabilitation. Conclusions: Participation in early post-myocardial infarction rehabilitation as part of the KOS-Zawał (MC-AMI) programme (25 training sessions) is associated with significant improvements in body composition parameters, such as visceral adipose tissue, limb fat, and water redistribution, and, consequently, a reduction in metabolic age, despite no significant increase in phase angle values. It was hypothesised that the good baseline condition of the subjects might explain the lack of significant change in the phase angle over the short observation period. For further analysis, it would be worthwhile to increase the number of patients with baseline reduced phase angle values and monitor changes in this parameter throughout rehabilitation and the entire MC-AMI programme, because changes in the phase angle may also be influenced by other programme components such as dietary or psychological education. It is worth considering implementing a regular BIA assessment in patients in the programme as a motivating stimulus for diligent exercise and extending rehabilitation to be followed by telerehabilitation or hybrid telerehabilitation.

Pathophysiological roles of the serum acylcarnitine level and acylcarnitine/free carnitine ratio in patients with cardiovascular diseases

Introduction

L-carnitine exerts protective effects, such as maintaining mitochondrial functions and decreasing reactive oxygen species, while acylcarnitine (AC) is linked to the development of heart failure and atherosclerosis.

Hypothesis

Serum carnitines play important pathophysiological roles in cardiovascular diseases.

Methods

Pre-operative biochemical data were obtained from 117 patients (71 men, average age 69.9 years) who underwent surgery for cardiovascular diseases. Measurements included pre-operative biochemical data including estimated glomerular filtration rate (eGFR), physical functions, skeletal muscle mass index (SMI) measured by bioelectrical impedance analysis, anterior thigh muscle thickness (MTh) measured by ultrasound, and routine echocardiography. Carnitine components were measured with the enzyme cycling method. Muscle wasting was diagnosed based on the Asian Working Group for Sarcopenia criteria.

Results

Plasma brain natriuretic peptide (BNP) level was correlated with serum free carnitine (FC) and AC level, and the acylcarnitine/free carnitine ratio (AC/FC). AC/FC was elevated with stage of chronic kidney disease. In multivariate analysis, log (eGFR) and log (BNP) were extracted as independent factors to define log (serum AC) (eGFR: β = 0.258, p = 0.008; BNP: β = 0.273, p = 0.011), even if corrected for age, sex and body mass index. AC/FC was negatively correlated with hand-grip strength (r = -0.387, p = 0.006), SMI (r = -0.314, p = 0.012), and anterior thigh MTh (r = -0.340, p = 0.014) in men.

Conclusions

A significant association between serum AC level and AC/FC, and chronic kidney disease and heart failure exists in patients with cardiovascular diseases who have undergone cardiovascular surgery. Skeletal muscle loss and muscle wasting are also linked to the elevation of serum AC level and AC/FC.

Conflicting Associations among Bioelectrical Impedance and Cardiometabolic Health Parameters in Young White and Black Adults

PURPOSE

The purpose of this cross-sectional evaluation was to determine the associations between raw bioelectrical impedance and cardiometabolic health parameters in a sample of young non-Hispanic White and African American adults.

METHODS

A total of 96 (female: 52, male: 44) non-Hispanic White ( n = 45) and African American adults ( n = 51) between the ages of 19 and 37 yr (22.7 ± 3.83 yr) completed several fasted assessments including resting systolic blood pressure (rSBP), blood glucose (FBG), blood lipids, and bioelectrical impedance spectroscopy. Bioelectrical impedance spectroscopy-derived measurements included phase angle, bioimpedance index (BI), impedance ratio (IR), reactance index (XCi), fat-free mass (FFM), FFM index (FFMi), and absolute (a) and relative (%) total body water (TBW) and extracellular (ECF) and intracellular fluid (ICF). All bioelectric variables were collected at 50 kHz other than IR (250 kHz/5 kHz). Multiple regressions were conducted and adjusted for sex, age, and body mass index.

RESULTS

rSBP was positively, and HDL was inversely, associated with all bioelectrical impedance and absolute hydration variables (all P ≤ 0.050) other than XCi for rSBP and XCi and FFMi for HDL. rSBP ( P < 0.001) was inversely, and HDL ( P = 0.034) was positively, associated with IR. FBG was positively associated with BI, XCi, FFM, TBWa, and ECFa (all P < 0.050). Metabolic syndrome severity was positively associated with BI, FFM, TBWa, and ECFa for women (all P ≤ 0.050) and with ICFa for African American women ( P = 0.016).

CONCLUSIONS

Given the rapid increase in the prevalence of cardiometabolic health risks among young adults and the broad use of bioelectrical impedance in practice, the conflicting associations we observed in this age group suggest that bioelectrical impedance parameters should be used with caution in the context of cardiometabolic health risks and age.

Prognostic value of bioelectrical impedance analysis in head and neck cancer patients undergoing radiotherapy: a VALOR® study

Introduction

Bioelectrical impedance analysis (BIA) serves as a method to estimate body composition. Parameters such as phase angle (PA), standardized phase angle (SPA), body mass cell (BCM), BCM index (BCMI), and fat-free mass (FFM) might significantly impact the prognosis of head and neck cancer (HNC) patients. The present study aimed to investigate whether bioelectrical parameters can be used to predict survival in the HNC population and establish the optimal cutoff points for predictive accuracy.

Methods

A multicenter observational study was performed across 12 tertiary hospitals in Andalusia (a region from the south of Spain). A total of 494 patients diagnosed with HNC between 2020 and 2022 at different stages were included in this study, with a minimum follow-up period of 12 months. The BIA assessment was carried out during the first 2 weeks of radical radiotherapy treatment with chemotherapy or other systemic treatments. A multivariate logistic regression analysis of overall survival, complications, hospital admission, and palliative care and its relationship with BIA nutritional assessment was performed.

Results

Significant prognostic factors identified in the multivariable analysis encompassed phase angle (PA), standardized phase angle (SPA), body cell mass (BCM), and BCM index (BCMI). Lower PA and BCM values were significantly associated with adverse clinical outcomes. A BCM threshold above 17 kg/m2 was the most significant predictor for predicting survival within the overall HNC population. The PA values of <5.1° in male and <4.8° in female patients showed the best predictive potential for mortality. Increased PA (as a continuous variable) demonstrated a significantly reduced risk for mortality (OR, 0.64; 95% CI, 0.43-0.94; p < 0.05) and a decreased likelihood of hospital admission (OR, 0.75; 95% CI, 0.52-1.07; p < 0.05). Higher BCM correlated with a lower risk of mortality (OR, 0.88; 95% CI, 0.80-0.96; p < 0.01) and a diminished probability of hospital admission (OR, 0.91; 95% CI, 0.83-0.99; p < 0.05).

Conclusion

BIA is a crucial tool in the nutritional assessment of HNC patients. BCM and PA are the main bioelectrical parameters used to predict clinical outcomes in this population. Future studies are needed to validate BIA variables in a large cohort to ensure whether early intensification of nutritional treatment would improve survival.

The ability of phase angle and body composition to predict risk of death in maintenance hemodialysis patients

OBJECTIVE

The objective of this study was to investigate the ability of phase angle and body composition to identify risk factors for mortality among patients receiving maintenance hemodialysis (MHD) treatment.

METHODS

In this retrospective study, we examined the causes of death in 43 MHD patients who were treated at our hemodialysis center between January 2016 and December 2021 and compared the patients to 71 patients who survived during the same period. Body composition was measured using direct segmental multi-frequency bioelectrical impedance to obtain phase angle, fat-free mass (FFM), extracellular water/total body water (ECW/TBW), and waist circumference (WC). Laboratory data were also collected. Phase angle cut-off value-associated variables were identified using ROC analysis. The ability of body composition variables to identify risk factors for death in MHD patients was evaluated.

RESULTS

We found that cardiovascular disease was the most common cause of death among MHD patients. ROC curve analysis revealed that the optimal cut-off value for phase angle as a predictor of death risk in MHD patients was 4.50°. Additionally, lower phase angle, increased age, longer dialysis vintage, lower KT/V, and hypoproteinemia were identified as significant risk factors for death in MHD patients.

CONCLUSION

In conclusion, our findings suggest that cardiovascular disease is the leading cause of death among MHD patients and that lower phase angle, increased age, longer dialysis duration, and hypoproteinemia can be used to predict the risk of mortality in this patient population. The underlying mechanism by which lower phase angle can be used to predict the prognosis of MHD patients warrants further investigation.

Skeletal Muscle Quality Assessment in Patients With Cardiac Disease Associated With Type 2 Diabetes Mellitus: A Pilot Study

Background Type 2 diabetes mellitus (T2DM) is associated with changes in skeletal muscle quantity and quality, such as increased ectopic fat. Cardiac rehabilitation (CR) aims to improve the exercise capacity and muscle strength. This study aimed to determine the relationship between qualitative changes in the skeletal muscles and exercise function in patients with and without diabetes mellitus. Methods The study included patients with cardiovascular diseases who entered CR. Of 72 CR patients (68.1±9.0 years) who underwent a cardiopulmonary exercise test and skeletal muscle assessment at discharge, 15 patients with T2DM and 15 without DM were selected using propensity score matching by age and gender. Results No significant differences in the skeletal muscle echo intensity (EI) (T2DM: 58.4, Non-DM: 53.4, p=0.32), skeletal muscle index (T2DM: 7.5 kg/m2, Non-DM: 7.2 kg/m2, p=0.36), or the weight-bearing index (WBI)(T2DM: 0.44, Non-DM: 0.50, p=0.35) existed between the two groups. The phase angle (PhA) (T2DM: 3.67°, Non-DM: 4.49°, p<0.05) and peak oxygen uptake (T2DM: 12.3 mL/kg/min, Non-DM: 14.8 mL/kg/min, p<0.05) were significantly lower in the T2DM group. PhA values showed a significant correlation with the WBI, a parameter of lower limb muscle strength (r=0.50, p<0.05). Conclusion The coexistence of cardiovascular disease and T2DM resulted in a decrease in the PhA, indicating a qualitative decrease in skeletal muscle mass. The PhA is also associated with lower limb muscle strength.

Phase Angle as a Reliable Biomarker of Frailty to Predict Postoperative Outcomes in Patients Undergoing Off-Pump Coronary Artery Grafting: A Prospective Observational Study

OBJECTIVE

To elucidate the association between phase angle (PA) and a composite adverse outcome in patients requiring off-pump coronary artery bypass grafting (OPCAB).

DESIGN

A prospective observational study.

SETTING

High-volume single center.

PARTICIPANTS

A total of 229 adult patients who underwent OPCAB from May 2019 to October 2020.

INTERVENTIONS

Each patient underwent bioelectrical impedance analysis, including PA assessment before surgery (PApre), immediately postoperatively (PApost), and 1 day postoperatively (PAPOD1), using an Inbody S10. Frailty index and nutritional assessments also were obtained before surgery.

MEASUREMENTS AND MAIN RESULTS

Patient outcomes were assessed using a composite adverse outcome comprising death, myocardial infarction, revascularization, new-onset atrial fibrillation, acute kidney injury, stroke, postoperative pulmonary complications, wound complications, sepsis, reoperation, and/or delirium occurring during hospitalization and over the following year. Patients for whom composite adverse outcomes were reported had lower PApre than those without complications (5.4 ± 0.9 v 6.0 ± 0.9, p < 0.001). The PA was significantly associated with in-hospital and 1-year composite postoperative outcomes. The odds ratios (OR, [95% confidence interval]) for PApre by time were in-hospital complications (0.435 [0.314, 0.604], p < 0.001; 1-year complications: 0.459 [0.330, 0.638], p < 0.001) and PAPOD1 (OR, in-hospital complications: 0.400 [0.277, 0.576], 1-year complications: 0.429 [0.298, 0.619], p < 0.001). The PApre was significantly associated with days alive and out of hospital until 1 year. The cut-off value of PApre for optimal prediction of in-hospital complications was 6.0 (area under the curve: 0.691 [0.623-0.758], p < 0.001).

CONCLUSION

Low PA as an indicator of frailty is associated with adverse postoperative outcomes after OPCAB. Low PA may be employed as a noninvasive and practical tool for the prediction of prognosis in patients with coronary artery disease.

Is Phase Angle Useful in Screening for Sarcopenia in Patients with Hematologic Malignancies?

The purposes of this study were to investigate the relationship between sarcopenia and phase angle (PhA), and to examine whether PhA cutoff values can be used to identify sarcopenia in patients with hematologic malignancies. The study population comprised 108 patients with hematologic malignancies who were admitted for chemotherapy, and were undergoing rehabilitation for exercise therapy. The diagnostic criteria for sarcopenia were determined according to the Asian Working Group for Sarcopenia 2019. Muscle strength, endurance, and body composition (including PhA), were assessed. Logistic regression and receiver operating characteristic (ROC) curve analyses were performed to investigate associations between sarcopenia and PhA, and to determine cutoff values. Sarcopenia was found in 17.6% of the participants. PhA was significantly associated with sarcopenia (p < 0.01). The areas under the curve were 0.84 for the males and 0.87 for the females, and the cutoff values were 4.75° for the males (sensitivity 69%, specificity 83%) and 3.95° for the females (sensitivity 78%, specificity 85%). Our results suggest that PhA, which can be measured noninvasively, objectively, and rapidly, can be used as a screening tool for sarcopenia in patients with hematologic malignancies.

Skeletal muscle quality, measured via phase angle, and cardiorespiratory fitness in patients with obesity and heart failure with preserved ejection fraction

OBJECTIVES

Cardiorespiratory fitness (CRF) is influenced by body composition quantity and quality in heart failure with preserved ejection fraction (HFpEF) and obesity. Bioelectrical impedance analysis (BIA) provides a noninvasive quantitative and qualitative body composition assessment. The aim of this study was to determine the role of phase angle (PhA), a BIA-measure of skeletal muscle quality and body cell mass, on CRF in patients with obesity and HFpEF.

METHODS

Fifty-nine consecutive outpatients with HFpEF underwent cardiopulmonary exercise testing to measure CRF. Single-frequency segmental BIA was used to measure PhA and body composition quantity. Resting Doppler echocardiography and biomarkers were measured to assess cardiac function and systemic inflammation.

RESULTS

Compared with patients with lower PhA, patients with higher PhA (above mean 5.8°) presented a greater absolute peak oxygen consumption (VO2; 1.83 [1.3-2.1] versus 1.39 [1.1-1.6] L/min, P = 0.003), VO2 peak adjusted for body weight (17.5 [12.3-18.1] versus 13.3 [12.7-15.2] mL/kg/min, P = 0.040), and a lower edema index (48.7 [2.9] versus 51.4% [2.7], P < 0.001) and N-terminal pro-B-type natriuretic peptide (NT-proBNP; 64 [50-121] versus 183 [68-343.5] pg/dL, P < 0.001). In the overall sample, PhA was correlated with absolute VO2 peak (r = 0.468, P < 0.001), VO2 peak adjusted for body weight (r = 0.368, P = 0.004), VO2 peak adjusted for fat-free mass (r = 0.315, P = 0.015), edema index (r = -0.508, P < 0.001), and NT-proBNP (r = -0.579, P < 0.001). PhA remained a significant predictor for CRF even after adjustment for potential confounders and HFpEF severity.

CONCLUSION

In patients with obesity and HFpEF, a greater PhA is an independent predictor for favorable CRF.

Prognostic impact of pretreatment skeletal muscle index and CONUT score in diffuse large B-cell Lymphoma

BACKGROUND

Although the prognostic value of the Controlling Nutritional Status (CONUT) score in diffuse large B-cell lymphoma (DLBCL) has been reported in several previous studies, its clinical relevance for the presence of sarcopenia has not been assessed.

METHODS

In this study, 305 DLBCL patients were reviewed. They were categorized into normal/mild (n = 219) and moderate/severe (n = 86) CONUT groups. Sarcopenia was assessed using the L3-skeletal muscle index measured by baseline computed tomography imaging. Based on CONUT score and sarcopenia, patients were grouped: A (normal/mild CONUT and no sarcopenia), B (either moderate/severe CONUT or sarcopenia, but not both), and C (both moderate/severe CONUT and sarcopenia).

RESULTS

The moderate/severe CONUT group showed higher rates of ≥ grade 3 febrile neutropenia, thrombocytopenia, non-hematologic toxicities, and early treatment discontinuation not related to disease progression, compared to the normal/mild CONUT group. The moderate/severe CONUT group had a lower complete response rate (58.1% vs. 80.8%) and shorter median overall survival (18.5 vs. 162.6 months) than the normal/mild group. Group C had the poorest prognosis with a median survival of 8.6 months, while groups A and B showed better outcomes (not reached and 60.1 months, respectively). Combining CONUT score and sarcopenia improved the predictive accuracy of the Cox regression model (C-index: 0.763), compared to the performance of using either CONUT score (C-index: 0.754) or sarcopenia alone (C-index: 0.755).

CONCLUSIONS

In conclusion, the moderate/severe CONUT group exhibited treatment intolerance, lower response, and poor prognosis. Additionally, combining CONUT score and sarcopenia enhanced predictive accuracy for survival outcomes compared to individual variables.

A Novel Frailty Score Based on Laboratory Parameters (FIMS Score) for the Management of Older Patients with Severe Aortic Stenosis

This study aimed to develop a novel score based on common laboratory parameters able to identify frail and sarcopenic patients as well as predict mortality in elderly patients with severe aortic stenosis (AS) for tailored clinical decision-making. A total of 109 patients (83 ± 5 years; females, 68%) with AS underwent a multidisciplinary pre-operative assessment and finalized a "frailty-based management" for the AS interventional treatment. Laboratory parameters of statistically significant differences between sarcopenic and non-sarcopenic individuals were tested in the structural equation model (SEM) to build a Frailty Inflammation Malnutrition and Sarcopenia score (FIMS score). Mortality at 20 months of follow-up was considered an outcome. FIMS score, in particular, the cut-off value ≥ 1.28 was able to identify "frail" and "early frail" patients and predict mortality with a sensitivity of 83.3% and 82.6%, respectively (p = 0.001) and was an independent determinant associated with a higher risk of mortality (HR 5.382; p-value = 0.002). The FIMS score, easily achievable and usable in clinical practice, was able to identify frail and sarcopenic patients as well as predict their adverse clinical outcomes. This score could provide appropriate guidance during decision-making regarding elderly patients with severe AS.

Clinical usefulness of phase angle as an indicator of muscle wasting and malnutrition in inpatients with cardiovascular diseases

Background and Objectives: Extracellular water is increased in patients with edema, such as those with chronic heart failure, and it is difficult to assess skeletal muscle mass with the skeletal muscle mass index when extracellular water is high. We investigated the relationship between phase angle and physical function, nutritional indices, and sarcopenia in patients with cardiovascular diseases, including chronic heart failure. Methods and Study Design: In 590 patients with cardiovascular diseases (372 men), handgrip strength, gait speed, and anterior mid-thigh muscle thickness by ultrasound were measured, and the skeletal muscle mass index, phase angle, and the extracellular water: total body water ratio were measured with a bioelectrical impedance analyzer, and presence of sarcopenia was evaluated. Results: Phase angle, but not the skeletal muscle mass index, was correlated with serum albumin (r = 0.377, p < 0.001) and hemoglobin values in women. Multivariate regression analysis showed that at the extracellular water: total body water ratio below 0.4, both phase angle and skeletal muscle mass index were independent determinants of handgrip strength and log mid-thigh muscle thickness in men, after adjustment for age and presence of chronic heart failure. In contrast, for the ratio of 0.4 or greater, after adjustment for age and presence of chronic heart failure, phase angle was a stronger independent determinant of handgrip strength and log mid-thigh muscle thickness than the skeletal muscle mass index in men. Conclusions: Phase angle is a good marker of muscle wasting and malnutrition in patients with cardiovascular disease, including chronic heart failure.

Phase angle is related to physical function and quality of life in preoperative patients with lumbar spinal stenosis

Lumbar spinal stenosis (LSS) can interfere with daily life and quality of life (QOL). Evaluating physical function and QOL and helping patients to improve is the focus of rehabilitation. Phase angle (PhA) assessment is widely used to measure body composition and is considered an indicator of physical function and QOL. This study investigated the relationship between PhA and physical function, physical activity, and QOL in patients with LSS. PhA, handgrip strength, walking speed, Timed Up and Go test (TUG), Life Space Assessment (LSA), Prognostic Nutritional Index (PNI), Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), and EQ-5D were assessed and statistically analyzed. The study included 133 patients with LSS. Multiple regression analysis of PhA adjusted for age, sex, and body mass index (Model 1) and for Model 1 + PNI (Model 2) showed significant correlations (P < 0.05) with handgrip strength, walking speed, TUG, and LSA. Regarding QOL, PhA was significantly correlated (P < 0.05) with lumbar function in JOABPEQ. PhA was associated with physical function and QOL in patients with LSS and might be a new clinical indicator in this population.

Reduced body cell mass and functions in lower extremities are associated with mild cognitive impairment and Alzheimer's dementia

This study examined the alterations of segmental body composition in individuals with Alzheimer's pathology (AD), including mild cognitive impairment (MCI) and dementia. A multifrequency bioimpedance analysis (BIA) was used to provide segmental water and impedance variables from 365 cognitively normal (CN), 123 MCI due to AD, and 30 AD dementia participants. We compared the BIA variables between the three groups, examined their correlations with neuropsychological screening test scores, and illustrate their 95% confidence RXc graphs. AD dementia participants were older, more depressive, and had worse cognitive abilities than MCI due to AD and CN participants. Although the BIA variables showed weak partial correlations with the cognitive test scores, we found patterns of an increasing water content in lean mass, increasing extra to intracellular water ratio, and decreasing reactance and phase angle in the lower extremities with effect sizes ranging from 0.26 to 0.51 in the groups of MCI and dementia due to AD compared with CN individuals. The RXc graphs upheld the findings with a significant displacement downward and toward the right, dominantly in the lower extremities. Individuals with AD pathology exhibit a reduced body cell mass or cell strength, an abnormal cellular water distribution, and an overhydration status in lean mass, especially in the lower extremities.

Phase angle of bioimpedance as a marker of inflammation in cardiovascular diseases: A systematic review

OBJECTIVE

The aim of this systematic review was to investigate whether phase angle (PhA) of bioelectrical impedance is associated with inflammatory markers in cardiovascular diseases (CVDs).

METHODS

A search was performed in the following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Latin American Caribbean Health Sciences Literature (LILACS), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus; and in the gray literature up to January 2022. Studies with individuals with CVDs were included, to evaluate the association between PhA and the inflammatory markers interleukin (IL)-6, IL-10, IL-18, IL-1β, IL-33, tumor necrosis factor (TNF)-α, C-reactive protein (CRP), toll-like receptor (TLR) 2, TLR 4, nuclear factor κB, pathogen-associated molecular pattern molecules, lipopolysaccharides, interferon-γ-inducing factor, and JAK STAT.

RESULTS

We identified 755 articles and, after an eligibility analysis, 5 studies were included. The inflammatory markers investigated in the studies were CRP, TNF-α, and IL-33. In patients with CVDs, PhA was negatively associated with CRP and TNF-α in 80% and 100% of the studies, respectively.

CONCLUSIONS

The present results suggested that PhA is inversely associated with inflammatory markers in individuals with CVDs, and its clinical use is encouraged for better therapeutic planning.

Not only muscle mass but also muscle quality is associated with knee extension muscle strength in patients with hip fractures

Our results revealed that the decrease in isometric knee extension muscle strength on the operated and nonoperated sides in patients with hip fractures was associated with not only a decrease in skeletal muscle mass but also a decrease in muscle quality, characterized by a decreased PhA.

PURPOSE

This study aimed to assess the relationship between isometric knee extension muscle strength on the operated or nonoperated sides and PhA in patients with hip fractures at approximately 6 months postoperatively.

METHODS

This study was a cross-sectional study. Skeletal muscle index (SMI), PhA, knee extension muscle strength on the operated and nonoperated sides, and other physical function variables were assessed at approximately 6 months postoperatively. To identify predictors of knee extension muscle strength on the operated and nonoperated sides, hierarchical multiple regression analysis was performed.

RESULTS

A total of 90 patients with hip fractures were included (mean age, 80.1 ± 6.9 years). SMI (0.45) and PhA on the operated side (0.27) were the significant associated factors extracted for isometric knee extension muscle strength on the operated side (standardized partial regression coefficients), independent of age, sex, and body mass index (BMI). Movement control during one-leg standing on the nonoperated side (0.26), SMI (0.32), and PhA on the nonoperated side (0.40) were the significant associated factors extracted for isometric knee extension muscle strength on the nonoperated side, independent of age, sex and BMI.

CONCLUSIONS

Our results revealed that the decrease in isometric knee extension muscle strength on the operated and nonoperated sides in patients with hip fractures at approximately 6 months postoperatively was associated with not only a decrease in skeletal muscle mass but also a decrease in muscle quality, characterized by a decreased PhA.

A Current Review of the Uses of Bioelectrical Impedance Analysis and Bioelectrical Impedance Vector Analysis in Acute and Chronic Heart Failure Patients: An Under-valued Resource?

BACKGROUND

There is a need to detect and prevent fluid overload and malnutrition in heart failure. Bioelectrical impedance analysis and bioelectrical impedance vector analysis are medical instruments that can advance heart failure management by generating values of body composition and body water, assisting clinicians to detect fluid and nutritional status. However, there is a lack of evidence to summarise how they have been used among heart failure patients.

METHOD

A systematic search was conducted.

RESULT

Two hundred and four papers were screened. Forty-eight papers were reviewed, and 46 papers were included in this review. The literature shows that bioelectrical impedance analysis and bioelectrical impedance vector analysis were mostly used to assess fluid and nutritional status, together with diagnostic and prognostic values. Contraindication of using BIA and implications for practice are also demonstrated.

CONCLUSION

The findings suggest that bioelectrical impedance vector analysis is superior to bioelectrical impedance analysis when assessing hydration/nutritional status in heart failure. Assessing a patient using bioelectrical impedance analysis /bioelectrical impedance vector analysis, together with natriuretic peptide -heart failure biomarkers, increases the diagnostic accuracy of heart failure. Further studies are required to examine the cost effectiveness of using these instruments in clinical practice.

Association of phase angle values and sarcopenia in older patients with heart failure

BACKGROUND

Sarcopenia presents an accelerated and accentuated muscle loss in patients with heart failure (HF), leading to a worse prognosis for these patients. This study sought to assess the association of phase angle (PA) values with sarcopenia and its components, as well as to establish a PA cutoff point to predict outcomes such as hospitalization and mortality in older adult patients with HF.

METHODS

Sarcopenia diagnosis followed the European Working Group on Sarcopenia in Older People criteria. Anthropometric, bioelectrical impedance (PA and body composition), functional capacity and inflammatory markers were assessed.

RESULTS

Included patients were predominantly male (67%) and White, with a mean age of 69 ± 7 years, and a predominance of New York Heart Association I and II functional classes (82.1%) and reduced left ventricular ejection fraction (70.8%). Of the total sample, 23.6% were identified as sarcopenic. Mean PA values were lower in patients with sarcopenia (4.9 ± 0.9 and 6.0 ± 0.8°; P < 0.001). The cutoff point detected for sarcopenia in the receiver operating characteristic curve was 5.45°, which is an independent predictor for sarcopenia. PA values below this cutoff point were also associated with each of the sarcopenic components evaluated. PA proved to be an independent predictor for hospitalization (P = 0.042) in the entire sample studied.

CONCLUSION

PA is associated with diagnostic components of sarcopenia and the cutoff point 5.45° proved to be an independent predictor of sarcopenia and hospitalization >3 years in older adult patients with HF.

Effects of muscle mass and muscle quality estimated by phase angle on functional outcomes in older patients undergoing rehabilitation: A prospective cohort study

BACKGROUND

Both skeletal muscle mass and muscle quality are important predictors of poor prognosis in older patients. However, the effects of muscle mass and muscle quality estimated by the phase angle (PhA) on functional outcomes in older patients undergoing rehabilitation have yet to be reported. This study aimed to investigate whether appendicular skeletal muscle index (SMI) and muscle quality estimated by PhA were independently associated with activities of daily living (ADL) and physical function in older patients undergoing rehabilitation.

METHODS

This prospective cohort study included older patients in a subacute rehabilitation hospital (n = 443). Baseline SMI and PhA were measured using bioelectrical impedance analysis, and low SMI or low PhA were determined using each cutoff value. The primary outcomes were ADL abilities measured using the functional independence measure for motor function (FIM-M) score and physical function measured using the short physical performance battery (SPPB) score at hospital discharge. Association between low SMI and low PhA and FIM-M or SPPB scores at discharge were determined using multiple regression analysis adjusted for confounding factors.

RESULTS

There were significant differences between the normal- and low-PhA groups in the FIM-M and SPPB scores at discharge (P < 0.001). In multiple regression analysis, low PhA was independently associated with FIM-M (β = -0.109, P = 0.013) and SPPB scores (β = 0.535, P < 0.001) at discharge; however, low SMI was not independently associated with these functional outcomes.

CONCLUSION

Decreased muscle quality estimated by the PhA was independently associated with poor ADL abilities and poor physical function in older patients undergoing rehabilitation.

Screening efficacy of PhA and MNA-SF in different stages of sarcopenia in the older adults in community

OBJECTIVE

To compare the screening ability of the phase Angle (PhA) and the Short-Form Mini Nutritional Assessment (MNA-SF) alone and combined detection in the different stages of sarcopenia among the older adults in the community.

METHODS

The older adults aged 65 and above were enlisted during community outpatient service and their nutritional status was evaluated by MNA-SF scale. PhA was measured by bioelectrical impedance analysis (BIA). AWGS2019 and EWGSOP2010 were used to define the different stages of sarcopenia. We measured skeletal mass index (SMI) and grip strength with BIA and electronic grip apparatus and measured body function with 6-m pace, SPPB test, and standing test.

RESULTS

The AUC of PhA in the screening of possible sarcopenia was 0.640, the sensitivity was 58.49%, the specificity was 66.67%, and the cut-off value was 4.5. The AUC of the combined PhA and MNA-SF for possible sarcopenia was 0.642, the sensitivity was 57.55%, and the specificity was 70.00%. The AUC of MNA-SF for the screening of pre-sarcopenia was 0.805, the sensitivity was 66.67%, the specificity was 85.83%, and the cut-off value was 12. The AUC of the combined PhA and MNA-SF was 0.826, the sensitivity was 75.00%, and the specificity was 85.00%. The AUC of PhA in the screening of sarcopenia (common type) was 0.808, the sensitivity was 82.35%, the specificity was 73.33%, the cut-off value was 4.4. The AUC of the combined PhA and MNA-SF for sarcopenia (common type) was 0.835, the sensitivity was 76.47% and the specificity was 81.67%. The AUC of PhA and for the screening of severe sarcopenia was 0.935, the sensitivity was 93.33%, the specificity was 92.50%, and the cut-off value was 4.1. The AUC of the combined PhA and MNA-SF was 0.943, the sensitivity was 86.67%, and the specificity was 93.33%.

CONCLUSION

The screening ability of PhA alone or in combination was higher than that of MNA-SF in the screening of possible sarcopenia. The screening ability of the combined detection was higher than that of PhA alone in the screening of pre-sarcopenia. The combination of PhA and MNA-SF or PhA alone all performed better value in the screening of sarcopenia (common type). Compared to MNA-SF, the PhA performed better in the screening of severe sarcopenia, which provided references for identifying patients with different stages of sarcopenia in the community.

Association of Phase Angle with Overall Survival in Patients with Cancer: A Prospective Multicenter Cohort Study

Low phase angle (PhA) is related with poor clinical status of cancer patients. The objective of this study was to establish sex- and age-specific cutoff points and examine the association between PhA and overall survival (OS) in Chinese cancer patients. This cohort study included data on 1,814 patients with cancer from December 2013 to October 2020. The association between low PhA and overall survival was analyzed using the Kaplan-Meier method and Cox regression model. Among 1,814 participants, there were 993 (54.70%) male and 821 (45.30%) female patients. The optimal cutoff points of low PhA were 4.8°, 4.2°, 4.4°, and 3.8° for the young male, elderly male, young female, and elderly female, respectively. Low PhA was independently associated with poorer OS in young female, elderly female and male (HR: 1.59, 95% CI: 1.08-2.34; HR: 1.65, 95% CI: 1.03-2.67; HR: 2.00, 95% CI: 1.45-2.75). In addition, low PhA was demonstrated to be an adverse prognostic factor in patients with lung cancer, colorectal cancer, and esophagus cancer (HR: 1.85, 95% CI: 1.39-2.47; HR: 2.05, 95% CI: 1.13-3.70; HR: 2.92, 95% CI: 1.49-5.71). Based on cutoff points, low PhA was associated with worse prognosis in patients with cancer.

Evaluation of raw segmental bioelectrical impedance variables throughout anterior cruciate ligament reconstruction rehabilitation

Background.Raw bioelectrical impedance analysis (BIA) variables are related to physical function in healthy and diseased populations. Therefore, BIA may be an insightful, noninvasive method of assessment to track following anterior cruciate ligament reconstruction (ACLR).Objectives.Evaluate phase angle, reactance and impedance at 50 kHz (PhA₅₀, Xc₅₀, andZ₅₀, respectively) in the operative (OP) and non-operative (NOP) limbs during ACLR rehabilitation.Approach.Seventeen patient (12 M, 5 F; 18.8 ± 4.8 years) clinic reports were evaluated prior to ACLR (PRE), two- (2 W), six- (6 W), and twelve-weeks (12 W) post-ACLR and at return to sport testing (RTS).Setting.All observations occurred during the participant's physical therapy visits.Measurements.A multi-frequency BIA device measured segmental PhA, Xc, andZ. Linear mixed effects models were used to assess any leg and time interaction and changes over leg and time, independently. Any interactions or main effects were considered significant atp< 0.05.Main results.Significant legxtime interactions were observed for each variable. PhA₅₀and Xc₅₀of NOP were higher (p< 0.001) than OP at each time point by an average of by 0.9° and 4.9 Ω, respectively. In OP, PhA₅₀and Xc₅₀decreased from PRE to 2 W and increased from 6 to 12 W and 12 W to RTS (p< 0.01, for all). At RTS, PhA₅₀and Xc₅₀were similar to PRE in OP (p> 0.05). ForZ₅₀, the OP leg did not change over time (p> 0.05).Z₅₀was greater in NOP at 2 and 6 W (p< 0.01, for both). There were differences in PhA₅₀in NOP between PRE and 6 W and from 6 W to RTS (p< 0.05 for both). Xc₅₀did not change (p> 0.05), andZ₅₀PRE was lower than at 2 W (p< 0.05).Significance.A multi-frequency BIA device can detect changes in segmental BIA variables following ACLR.

Phase angle derived from bioelectrical impedance analysis as a marker for predicting sarcopenia

Sarcopenia is commonly defined as the age-related loss of muscle mass and function and may be caused by several factors, such as genetics, environmental conditions, lifestyle, drug use, and, in particular, comorbidities. People with pre-existing conditions are more likely to develop sarcopenia and subsequently have a less favorable prognosis. Recently, phase angle (PhA), which is derived from bioelectrical impedance analysis (BIA), has received a great deal of attention, and numerous studies have been carried out to examine the relationship between PhA and sarcopenia in different conditions. Based on these studies, we expect that PhA could be used as a potential marker for sarcopenia in the future.

Phase angle and cellular health: inflammation and oxidative damage

Phase angle is a composite measure that combines two raw bioelectrical impedance analysis measures: resistance and reactance. Phase angle has been considered an indicator of cellular health, integrity, and hydration. As inflammation and oxidative stress can damage cellular structures, phase angle has potential utility in early detecting inflammatory and oxidative status. Herein, we aimed to critically review the current understanding on the determinants of phase angle and its relationship with markers of inflammation and oxidative stress. We also discussed the potential role of phase angle in detecting chronic inflammation and related adverse outcomes. Several factors have been identified as predictors of phase angle, including age, sex, extracellular to intracellular water ratio, and fat-free mass. In addition to these factors, body mass index (BMI) also seems to influence phase angle. Available data also show that lower phase angle values are correlated (negligible to high correlation coefficients) with higher c-reactive protein, tumour necrosis factor-α, interleukin-6, and interleukin-10 in studies involving the general and aging populations, as well as patients with chronic conditions. Although fewer studies have evaluated the relationship between phase angle and markers of oxidative stress, available data also suggest that phase angle has potential to be used as an indicator (for screening) of oxidative damage. Future studies including diverse populations and bioelectrical impedance devices are required to confirm the validity and accuracy of phase angle as a marker of inflammation and oxidative stress for clinical use.

Study of pulsed electrostatic field (PESF) in the perfusion of peripheral tissues: Microangiopathy, nutrition and quality of perceiver life

Microangiopathy compromises the structural and functional integrity of organs and tissues in patients with type II diabetes mellitus (T2DM) negatively affecting the perceived quality of life. Nitric oxide (NO) is a multifunctional signalling molecule, acting as a vasodilator, neurotransmitter, and modulator of inflammatory processes. Patients with type II diabetes mellitus and chronic kidney disease, controlled from glycaemic status, were treated or not with pulsed electrostatic field (PESF) cycles to evaluate effect on the perfusion of peripheral tissues. Everyone was monitored for the metabolic profile, and we tested circulating NO with a commercial enzyme immunoassay kit. In addition, we tested the perceived quality of life of patients before/after a PESF cycle using a questionnaire. Patients treated with PESF were improved circulating NO levels, significant changes in systolic and diastolic blood pressure, heart rate and were more homogeneous for their metabolic profile. The questionnaire showed also a marked improvement in the perceived quality of life. The use of pulsed electrostatic fields has allowed us to observe an improvement in the metabolic, psychological, and clinical profile in patients with T2DM and chronic kidney disease whose pathological profile is strongly compromised.

Combined resistance training with aerobic training improves physical performance in patients with coronary artery disease: A secondary analysis of a randomized controlled clinical trial

Background

The efficacy of combined resistance training (RT) and aerobic training (AT) compared with AT alone is well established in cardiac rehabilitation (CR); however, it remains to be elucidated whether RT load (high load [HL] vs. low load [LL]) modifies the outcomes. The aim of our study was to investigate the effects of HL-RT and LL-RT combined with AT in comparison to AT alone on body composition and physical performance in patients with coronary artery disease (CAD) enrolled in phase II CR.

Methods

We randomized 79 patients with a stable CAD to 12 weeks of lower limb LL-RT + AT (35-40% of one repetition maximum [1-RM]; n = 28), HL-RT + AT (70-80% of 1-RM; n = 26), or AT (n = 25). Fifty-nine patients (75% men) with mean (standard deviation) age 61 (8) years and left ventricular ejection fraction 53 (9)% completed LL-RT (n = 19), HL-RT (n = 21) and AT (n = 19). Body composition and physical performance (upper and lower submaximal muscle strength, flexibility, balance, and mobility) were measured at baseline and post-training.

Results

Training intervention had no significant impact on time × group interaction in the body composition measures. There was a significant time × group interaction for the gait speed test, chair sit-and-reach test, arm curl test, Stork balance test, up and go test, STS-5, and 6-min walk distance (p-values ≤ 0.001-0.04) following the training intervention. After the training intervention, HL-RT improved gait speed (+12%, p = 0.044), arm curl (+13%, p = 0.037), and time of Up and Go test (+9%, p < 0.001) to a greater extent compared with AT group, while there was a greater improvement in time of Up and Go test (+18%, p < 0.001) and time of five sit-to-stand tests (+14%, p = 0.016) following LL-RT when compared with AT. There were no differences between HL-RT and LL-RT in post-training improvement in any of the physical performance measures.

Conclusion

The combination of AT with HL-RT or LL-RT promoted similar improvements in physical performance, which were superior to AT. Therefore, both types of combined AT and RT can be applied to patients with CAD.

Clinical trial registration

[https://clinicaltrials.gov/ct2/show/NCT04638764] Identifier [NCT04638764].

Bioimpedance phase angle and sarcopenia in older patients with prostate cancer

AIM

The purpose of this study was to evaluate the factors associated with the bioimpedance phase angle (PhA) in older patients with prostate cancer, and to determine the optimal cutoff for the PhA in patients with sarcopenia and prostate cancer.

METHODS

This retrospective cross-sectional analysis enrolled patients with prostate cancer aged ≥60 years. Appendicular skeletal muscle mass and PhA estimated by bioimpedance analysis, grip strength, the five-time chair stand test, gait speed, the Short Physical Performance Battery, the 2-min walk test and the International Physical Activity Questionnaire Short Form were obtained at enrollment. The diagnosis of sarcopenia was based on the 2019 consensus of the Asian Working Group for Sarcopenia.

RESULTS

In total, 119 male participants (mean age = 70.7 ± 6.1 years) were available for analysis. A multivariable linear regression model revealed that age, body mass index and the maximal grip strength value were associated with the PhA. The area under the receiver operating characteristic curve value of the PhA for sarcopenia diagnosis was 0.77 (95% confidence interval 0.64-0.90, P < 0.001), with a PhA cutoff value of 4.87°.

CONCLUSIONS

PhA estimated by bioimpedance analysis may be utilized as useful clinical biomarker for reflecting muscle strength and sarcopenia in older patients with prostate cancer. Geriatr Gerontol Int 2022; ••: ••-••.

Preoperative Phase Angle as a Risk Indicator in Cardiac Surgery-A Prospective Observational Study

Background: The phase angle (PhA) can be used for prognostic assessments in critically ill patients. This study describes the perioperative course of PhA and associated risk indicators in a cohort of elective cardiac surgical patients. Methods: The PhA was measured in 168 patients once daily until postoperative day (POD) seven. Patients were split into two groups depending on their median preoperative PhA and analyzed for several clinical outcomes; logistic regression models were used. Results: The PhA decreased from preoperative (6.1° ± 1.9°) to a nadir on POD 2 (3.5° ± 2.5°, mean difference −2.6° (95% CI, −3.0°; −2.1°; p < 0.0001)). Patients with lower preoperative PhA were older (71.0 ± 9.1 vs. 60.9 ± 12.0 years; p < 0.0001) and frailer (3.1 ± 1.3 vs. 2.3 ± 1.1; p < 0.0001), needed more fluids (8388 ± 3168 vs. 7417 ± 2459 mL, p = 0.0287), and stayed longer in the ICU (3.7 ± 4.5 vs. 2.6 ± 3.8 days, p = 0.0182). Preoperative PhA was independently influenced by frailty (OR 0.77; 95% CI 0.61; 0.98; p = 0.0344) and cardiac function (OR 1.85; 95%CI 1.07; 3.19; p = 0.028), whereas the postoperative PhA decline was independently influenced by higher fluid balances (OR 0.86; 95% CI 0.75; 0.99; p = 0.0371) and longer cardiopulmonary bypass times (OR 0.99; 95% CI 0.98; 0.99; p = 0.0344). Conclusion: Perioperative PhA measurement is an easy-to-use bedside method that may critically influence risk evaluation for the outcome of cardiac surgery patients.

Phase Angle as a Comprehensive Tool for Nutritional Monitoring and Management in Patients with Crohn's Disease

Background and Aims: Crohn’s disease (CD) is usually accompanied by malnutrition. CD-related malnutrition can increase morbidity, disability, mortality, and hospitalization costs. The purpose of this study was to find a reliable indicator for evaluating CD patients’ nutritional status. Methods: All data were retrospectively collected from Xiangya Hospital, Central South University between May 2021 and February 2022. All patients were evaluated for nutritional status using the Global Leadership Initiative on Malnutrition (GLIM) criteria. Body composition, resistance, and reactance were recorded by a body analyser, and the phase angle (PhA) was calculated simultaneously. The Mann−Whitney U test, chi-square test, Fisher’s exact test, and univariate and multivariate logistic regression analyses were used. A receiver operating characteristic (ROC) curve was built to evaluate the predictive value of differential variables for diagnosing malnutrition based on the GLIM criteria. Results: A total of 169 CD patients were enrolled, of which 74 (58.3%) males and 32 (76.2%) females were diagnosed with malnutrition; 34 (45.9%) males and 22 (68.8%) females were severely malnourished. Univariate analysis identified that as nutritional status deteriorated, body mass index, PhA, and levels of haemoglobin and albumin decreased, while platelet count, erythrocyte sedimentation rate, and levels of C-reactive protein and fibrinogen increased (p < 0.05). Logistic regression analysis revealed that the PhA was significantly independently associated with malnutrition (p < 0.05). The ROC curve analysis indicated that the optimal PhA cut-off levels of 6.11° and 5.55° could be used to predict malnutrition according to the GLIM criteria in males and females, respectively, with a PhA < 5.53° and < 5.12° indicating severe malnutrition in males and females, respectively. Conclusion: The PhA is a sensitive, noninvasive, portable, inexpensive tool that can be used to monitor and manage the nutritional status of CD patients.

Cancer, Phase Angle and Sarcopenia: The Role of Diet in Connection with Lung Cancer Prognosis

Lung cancer is the most common cause of cancer death and is associated with malnutrition and sarcopenia. The detection of sarcopenia and conduction of simple body composition measurements, such as the phase angle (PhA) deriving from bioelectrical impedance analysis (BIA), can help to early identify, monitor, prevent and treat malnutrition. The present review aims to clarify the relationship between PhA and sarcopenia with the pathophysiology, clinical outcomes, and therapeutic aspects of lung cancer. PhA and sarcopenia are connected to lung cancer prognosis through various mechanisms including inflammation and oxidative stress, although more research is needed to identify the critical thresholds for increased mortality risk. Moreover, emphasis is given on the role of dietary interventions (oral nutritional supplementation, and dietary counseling) to manage sarcopenia and related variables in patients with lung cancer. Oral nutritional supplements and/or those containing n - 3 polyunsaturated fatty acids may have a positive effect on physical strength measures and muscle mass if administered at the beginning of chemotherapy. Data on sole dietary counseling or multimodal interventions are less promising so far. In the future, sophisticated body composition phenotypes deriving from the described methods along with artificial intelligence techniques could be used to design personalized nutrition interventions and timely treat these patients.

Prevalence of Sarcopenia in Women with Breast Cancer

Sarcopenia is a common finding in patients with cancer and potentially influences the patient’s outcome. The aim of this study was to evaluate the prevalence of sarcopenia, according to the European Working Group on Sarcopenia in Older People, in a sample of women with breast cancer (BC) and a BMI lower than 30 kg/m2. This cross-sectional study was conducted in patients with BC, stage 0-III, and receiving therapy for BC; the women were recruited at the Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy. A control group with similar age and BMI was selected from the internal database. Anthropometry, bioimpedance analysis (BIA) and hand grip strength (HGS) were measured to detect sarcopenia. A total of 122 patients (mean age 49.3 ± 11.0 years, BMI 24.6 ± 3.0 kg/m2) and 80 healthy controls were analyzed. Sarcopenia was found in 13.9% patients with BC, while none of the subjects in the control group was sarcopenic. By comparing BC patients with and without sarcopenia and the control group, the fat-free mass of sarcopenic BC patients were significantly lower than those of both non-sarcopenic BC patients and the control (p < 0.05). The phase angle was also significantly lower in sarcopenic patients (−0.5 degrees, p = 0.048) than in the control group. Considering the prevalence of sarcopenia in patients with BC, our findings suggest the usefulness of body composition and HGS evaluation for early screening of sarcopenia to reduce the risk of associated complications.

Phase angle of bioimpedance at 50 kHz is associated with cardiovascular diseases: systematic review and meta-analysis

The phase angle of bioimpedance is an important prognostic tool in clinical practice. The aim of this study was to investigate the association between phase angle and cardiovascular diseases. Electronic searches were carried out on MEDLINE, EMBASE, Cochrane, SCIELO, LILACS, CINAHL, Scopus, and the Web of Science. The PECO was "P" adults over 18 years of age, "E" the presence of cardiovascular disease, "C" absence of cardiovascular disease, and "O" phase angle values. The phase-angle means difference (MD) was analyzed separately by sex. Subgroup metanalysis with age, body mass index, and heart failure disease and meta-regressions were analyzed with random-effects models. Sensitivity analysis was performed considering only studies with high quality. The heterogeneity among studies was assessed using the Q-Cochran test and I² statistics. Four-hundred-thirty-nine articles were identified, and 22 studies were included in this systematic review, totaling 10.010 participants. Eight studies met the criteria for the meta-analysis, involving 2164 participants. The phase angle (PA) was measured at 50 kHz frequency in all studies. Individuals with cardiovascular disease had a smaller PA compared to the control group, for both males (MD -0.70; 95% CI -1.01 to -0.39) and females (MD -0.76; 95% CI -1.39 to -0.13). In the sensitivity analysis, in men, the quality of studies (P < 0.01), and in women, heart failure (P < 0.01) was significantly different between groups.The values of the phase angle were lower in individuals with cardiovascular disease than in control subjects. This result reinforces the importance of this tool in clinical practice, highlighting its potential to assess health status. Registration: The systematic review protocol was registered in the PROSPERO database as CRD42020164178.

Neuromuscular Impairment of Knee Stabilizer Muscles in a COVID-19 Cluster of Female Volleyball Players: Which Role for Rehabilitation in the Post-COVID-19 Return-to-Play?

COVID-19 athletes reported persistent and residual symptoms many weeks after initial infection, including cough, fatigue, and neuromuscular disorders. Poor neuromuscular control may cause inefficient movement strategies increasing anterior cruciate ligament load. This is particularly relevant in female athletes, who show a 3-time higher risk than male counterparts. Aim is to evaluate the impairment in thigh muscles activation, body composition, and physical performance after COVID-19 in volleyball athletes. We recruited a cohort of female professional players from the same team. We assessed the pre-activation time of Rectus Femoris (RF), Vastus Medialis (VM), Medial Hamstring (MH), and Lateral Hamstring (LH) before (T0) and after (T1) COVID-19 infection, bioelectrical impedance analysis (BIA), and jump tests. We included 12 athletes with COVID-19 infection diagnosis in January 2021. At T1 we found a significant (p < 0.05) delay (ms) of the activation time of RF (426 ± 188 vs. 152 ± 106); VM (363 ± 192 vs. 140 ± 96); BF (229 ± 60 vs. 150 ± 63); MH (231 ± 88 vs. 203 ± 89), and a significant reduction of body composition at BIA. The neuromotor imbalance of the knee stabilizer muscle in female athletes after COVID-19 infection determines a deficit of knee stabilization. Physicians should consider neuromuscular and metabolic sequelae to identify athletes at higher risk of injury and set up specific neuromuscular rehabilitation protocols.

Worth the Wait? Time Course of Supine Shifts in Body Water Compartments on Variables of Bioelectrical Impedance Analysis

Bioelectrical impedance analysis (BIA) reference values are based on supine assessments. Little is known regarding the effects of time course shifts in body water compartments after assuming a supine position. The aim of this study was to characterize these effects and provide recommendations regarding the optimal waiting time to perform BIA. Thirty-eight healthy adults underwent BIA via the RJL Quantum Legacy analyzer immediately upon lying down and every 5 minutes for 15 minutes. Differences in resistance (R), reactance (Xc), intracellular (ICW), extracellular (ECW), total body water (TBW), body fat percentage (%BF), and phase angle (PhA) were assessed. There were small but significant increases in R, Xc, and %BF (all p<0.001), as well as small but significant decreases in ICW, ECW, and TBW (all p<0.001) over 15 minutes. No difference was observed for PhA (p=0.065). Average values changed over 15 minutes by +7.14Ω, +1.36Ω, -0.2L, -0.2L, -0.4L, +0.05° and +0.1% for R, Xc, ICW, ECW, TBW, PhA and %BF, respectively. BIA measurements are affected by shifts in body water compartments after assuming a supine position, but these differences lack clinical significance in healthy adults. Technicians working with healthy adults can perform BIA within 15 minutes after participants assume a supine position.

Phase Angle as an Indicator of Baseline Nutritional Status and Sarcopenia in Acute Stroke

OBJECTIVES

This study aimed to investigate whether phase angle is an indicator of malnutrition and sarcopenia in acute-phase stroke patients.

MATERIALS AND METHODS

We conducted a retrospective observational study of stroke patients in a single acute-care hospital. The phase angle was measured within 5 days after admission, and the correlation between nutritional status and sarcopenia index was investigated. The cut-off point that distinguishes malnutrition and sarcopenia was evaluated using the receiver operating characteristic curve. The effects of the geriatric nutritional risk index (GNRI) and sarcopenia on the phase angle were examined using multivariate linear regression analysis.

RESULTS

A total of 211 stroke patients (140 men) with a median age of 74 (65-83) were included in the analysis. Malnutrition was present in 38 (18.0%) patients, and 65 (30.8%) had sarcopenia. The phase angle significantly correlated with GNRI, grip strength, skeletal muscle musss index, and calf circumference in both men and women. The cut-off points for discriminating malnutrition were 5.05 for men and 3.96 for women, while the cut-off points for discriminating sarcopenia were 5.28 for men and 4.62 for women. Multivariate linear regression analysis showed that the GNRI and sarcopenia were independently related to the phase angle.

CONCLUSIONS

Phase angle is a useful indicator for distinguishing malnutrition and sarcopenia in patients with acute stroke.

Predictive value of phase angle in sarcopenia in patients on maintenance hemodialysis

OBJECTIVES

The aim of this study was to analyze the factors influencing sarcopenia in patients on maintenance hemodialysis (MHD) in mainland China and to explore the role of phase angle (PhA) in sarcopenia.

METHODS

We enrolled 346 patients on MHD with regular dialysis and collected relevant data. According to the diagnostic criteria of the Asian Sarcopenia Working Group, the patients were placed into one of two groups: sarcopenia and non-sarcopenia. The differences between groups were compared and the statistically significant factors were included in binary logistic regression analysis to screen for independent factors influencing sarcopenia. Receiver operating characteristic curve and area under the curve were used to evaluate the predictive value of PhA in sarcopenia.

RESULTS

The prevalence of sarcopenia was 32.66% in patients on MHD. Logistic regression analysis showed that sarcopenia was significantly associated with age (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.08-1.15; P < 0.001), body mass index (OR, 0.66; 95% CI, 0.58-0.76; P < 0.001), and PhA (OR, 0.24; 95% CI, 0.15-0.40; P < 0.001). The best cutoff value of PhA on sarcopenia was 4.67° for both sexes, 4.67° and 4.60° for men and women, respectively (P < 0.001).

CONCLUSION

The present study showed that PhA was an important influencing factor of sarcopenia adjusted by age and body mass index in Asian patients on MHD. PhA may have an optimistic predictive value to identify sarcopenia in these population, and it is convenient and accessible in clinical practice than the diagnostic criteria of sarcopenia.

Safety, Feasibility, and Effects of Short-Term Calorie Reduction during Induction Chemotherapy in Patients with Diffuse Large B-Cell Lymphoma: A Pilot Study

Short-term calorie reduction (SCR) requires individuals to reduce their calorie intake to less than 50% of normal requirements and has shown good tolerance and potential benefits in prior studies addressing gynecological cancer patients. More studies are needed to further confirm its safety, feasibility, and effects in patients with different cancers, including hematological malignancies. This pilot cohort study with a matched-pair comparison group was registered at ClinicalTrails.gov [201810112RIND]. Adult patients diagnosed with advanced-stage diffuse large-B cell lymphoma were recruited (SCR group) and matched with one comparison patient (comparison group), each in a manner blinded to their outcomes. The SCR group undertook at least two cycles of 48 h water fast along with their chemotherapy R-CHOP. Descriptive analysis and generalized estimating equations were used to analyze the data. Six participants completed multiple cycles of SCR and were compared to their six counterparts in the comparison group. The results showed that SCR is safe and feasible in terms of a high compliance rate and stable nutritional status. The SCR was associated with benefits in post-chemotherapy hematological parameters (i.e., erythrocyte [p < 0.001] and lymphocyte counts [p < 0.001]). More randomized controlled trials are needed to validate the effects of SCR on different types of cancer populations.

Association of phase angle with hospital-acquired functional decline in older patients undergoing cardiovascular surgery

OBJECTIVE

The aim of this study was to examine whether preoperative phase angle (PhA) measured by bioelectrical impedance analysis was associated with a hospital-acquired functional decline in older patients undergoing cardiovascular surgery.

METHODS

This was an observational study of prospectively collected data of 114 patients (>65 y of age) with cardiovascular disease who underwent elective cardiovascular surgery between September 2019 and August 2020. Patients were classified into tertiles based on PhA levels. Factors associated with the occurrence of hospital-acquired functional decline (postoperative recovery to preoperative physical function was not possible) were analyzed using univariate and multivariate analyses.

RESULTS

Patients in the low PhA group were significantly older than those in the middle and high PhA groups; were predominantly women; had higher New York Heart Association cardiovascular and EuroSCORE severity scores; and had significantly lower levels of body mass index, Geriatric Nutritional Risk Index, hemoglobin, and albumin. There was a significant correlation between PhA and nutrition and physical function. The incidence of hospital-acquired functional decline occurred in 26.3% of all patients, with a significantly higher incidence in patients in the low PhA group. Multivariate analysis showed that PhA was extracted as a factor for the hospital-acquired functional decline in all the models.

CONCLUSIONS

PhA was associated with hospital-acquired functional decline in older patients undergoing cardiovascular surgery. PhA is likely to be a comprehensive indicator of physical health that indicates nutritional status, physical function, and geriatric syndrome (frailty/sarcopenia), and is an important predictor of hospital-acquired functional decline in this group of older patients.

Preoperative Serum GDF-15, Endothelin-1 Levels, and Intraoperative Factors as Short-Term Operative Risks for Patients Undergoing Cardiovascular Surgery

Objectives: The Society of Thoracic Surgeons (STS) risk score is widely used for the risk assessment of cardiac surgery. Serum biomarkers such as growth differentiation factor-15 (GDF-15) and endothelin-1 (ET-1) are also used to evaluate risk. We investigated the relationships between preoperative serum GDF-15, ET-1 levels, and intraoperative factors and short-term operative risks including acute kidney injury (AKI) for patients undergoing cardiovascular surgery. Methods: In total, 145 patients were included in this study (92 males and 53 females, age 68.4 ± 13.2 years). The preoperative STS score was determined, and the serum GDF-15 and ET-1 levels were measured by ELISA. These were related to postoperative risks, including AKI, defined according to the Acute Kidney Injury Network (AKIN) classification criteria. Results: AKI developed in 23% of patients. The GDF-15 and ET-1 levels correlated with the STS score. The STS score and GDF-15 and ET-1 levels all correlated with preoperative eGFR, Alb, Hb, and BNP levels; perioperative data (urine output); ICU stay period; and postoperative admission days. Patients with AKI had longer circulatory pulmonary bypass (CPB) time, and male patients with AKI had higher ET-1 levels than those without AKI. In multivariable logistic regression analysis, the preoperative ET-1 level and CPB time were the independent determinants of AKI, even adjusted by age, sex, and BMI. The preoperative GDF-15 level, CPB time, and RCC transfusion were independent determinants of 30-day mortality plus morbidity. Conclusion: Preoperative GDF-15 and ET-1 levels as well as intraoperative factors such as CPB time may be helpful to identify short-term operative risks for patients undergoing cardiovascular surgery.

Segmental Phase Angle and Body Composition Fluctuation of Elite Ski Jumpers between Summer and Winter FIS Competitions

(1) Background: The purpose of this study was to observe segmental phase angle (PhA) and body composition fluctuation of elite ski jumpers. (2) Methods: In the study, 12 professional ski jumpers took part. Body composition was estimated with segmental multi-frequency bioelectrical impedance analysis. Repeated ANOVA was used to check the parameters' variability in time. The symmetry between the right and left side of the body was verified with the t-test for dependent samples. Pearson's linear correlation coefficient was calculated. (3) Results: The most stable parameter was body weight. An increase in the visceral fat area was noted, the fat-free mass dropped, and significant changes were noted in the internal and external cell water parameters. Parameters connected with water between the right and left side of the body were symmetrical. Significant correlation between PhA values and body parameters with regard to fat tissue and PhA values of the legs was noticed when PhA was measured at 50 kHz. (4) Conclusions: PhA could be considered as a ski jumper body symmetry monitoring tool. The described relationship may be useful for the assessment of body fat change, which, in the case of jumpers, is crucial. Moreover, our data suggest that segmental PhA evaluation could be a good solution for ski jumpers as a confirmation if lowered body mass and low BMI are still healthy and increase the chance for longer jumps and good performance.

Phase Angle as an Easy Diagnostic Tool of Meta-Inflammation for the Nutritionist

Phase angle (PhA), a noninvasive bioimpedance marker, is a useful tool for nutritional screening in several diseases. C-reactive protein (CRP), a strong risk factor for metabolic and cardiovascular diseases, is a commonly used biomarker of meta-inflammation. As both PhA and CRP are influenced by age, BMI, and nutritional status, and exhibit a clear sex dimorphism, we examined the association between PhA and CRP levels in 1855 subjects (680 males and 1175 females), aged 18-59 years, with BMIs ranging from 19.5 to 69.4 kg/m², stratified according to sex. PhA values and CRP levels were significantly lower in females than males (p < 0.001), while the adherence to the Mediterranean diet (MD) was lower in males compared to females (p < 0.001). After adjusting for age, physical activity, BMI, waist circumference, and adherence to the MD, PhA remained negatively associated with CRP levels in both genders (p < 0.001). In the ROC analysis, PhA ≤ 5.5° in males and ≤5.4° in females were the threshold values predicting increased hs-CRP levels. These results suggested that PhA might represent a valid predictor of CRP levels in both sexes regardless of body weight and adherence to the MD, which avoids the collection of blood sampling and expensive biochemical assays.

Phase angle measured by bioelectrical impedance analysis and the risk of cardiovascular disease among adult Danes

OBJECTIVE

This study aimed to examine associations between phase angle (PhA) and incident cardiovascular disease (CVD) morbidity and mortality in a healthy Danish subpopulation free of major chronic diseases.

METHODS

A random subset (n = 2601) of adult men and women born in 1922, 1932, 1942, and 1952 and examined in 1987 and 1988 were included, and followed over 24 y during which 643 men and 570 women developed CVD. Measures at baseline included age, weight, height, whole-body bioimpedance, from which PhA was calculated, and information on lifestyle, obtained by a self-administered questionnaire. The association between PhA and incident CVD was assessed by Cox proportional hazard model with age as the underlying time scale and with additional adjustment for covariates. To explore nonlinear associations, all results were presented using restricted cubic splines, with the median value of PhA as the reference.

RESULTS

PhA was lower among women who later developed CVD than among women who did not (6.3 vs. 6.0; P < 0.001). The highest risk of CVD was observed at the 5th percentile (hazard ratio: 1.33; 95% confidence interval, 1.11-1.60). Among men, PhA was not significantly associated with risk of CVD (7.1 vs. 7.0; P = 0.246).

CONCLUSIONS

Among apparently healthy Danish men and women, a lower PhA value was associated with a higher incidence of CVD over 24 y, also after adjusting for potential confounders, and particularly among women. These findings may encourage the future use of PhA as an additional index in predicting CVD. However, more studies are needed to confirm our results.

The relevance of whole or segmental body bioelectrical impedance phase angle and physical performance in adolescent athletes

Objective. The physical condition of athletes can be assessed easily and quantitatively using objective indicators. Bioelectrical impedance measures the phase angle (PA), representing hydration and cell function, and is a potential clinical indicator of physical condition. This study aimed to investigate the association between PA and physical performance in adolescent athletes.Approach. Overall, 170 adolescent athletes underwent a sports medical check-up, including body composition measurements and physical performance tests. Whole-body and segmental PAs (arm and leg) were determined based on body composition values. Isometric grip power and knee isokinetic muscle strength were measured as parameters of muscle strength. Counter movement jump height and squat jump height were measured as jump parameters. Associations between PA and each muscle strength or jump parameters were analysed using Pearson product-moment correlation coefficient or Spearman's rank correlation coefficient.Main results. Whole-body and upper limb PAs were highly correlated with grip power (r= 0.70-0.80). Whole-body and lower limb PAs were correlated with knee isokinetic muscle strength (r= 0.43-0.59). Whole and all segmental PAs were correlated with counter movement jump height (r= 0.46-0.57) and squat jump height (r= 0.42-0.52).Significance. PA can be used to monitor physical condition and sports performance in adolescent athletes. Segmental PAs can help assess the condition of the corresponding body part.

Low-Intensity Resistance Training with Moderate Blood Flow Restriction Appears Safe and Increases Skeletal Muscle Strength and Size in Cardiovascular Surgery Patients: A Pilot Study

We examined the safety and the effects of low-intensity resistance training (RT) with moderate blood flow restriction (KAATSU RT) on muscle strength and size in patients early after cardiac surgery. Cardiac patients (age 69.6 ± 12.6 years, n = 21, M = 18) were randomly assigned to the control (n = 10) and the KAATSU RT group (n = 11). All patients had received a standard aerobic cardiac rehabilitation program. The KAATSU RT group additionally executed low-intensity leg extension and leg press exercises with moderate blood flow restriction twice a week for 3 months. RT-intensity and volume were increased gradually. We evaluated the anterior mid-thigh thickness (MTH), skeletal muscle mass index (SMI), handgrip strength, knee extensor strength, and walking speed at baseline, 5-7 days after cardiac surgery, and after 3 months. A physician monitored the electrocardiogram, rate of perceived exertion, and the color of the lower limbs during KAATSU RT. Creatine phosphokinase (CPK) and D-dimer were measured at baseline and after 3 months. There were no side effects during KAATSU RT. CPK and D-dimer were normal after 3 months. MTH, SMI, walking speed, and knee extensor strength increased after 3 months with KAATSU RT compared with baseline. Relatively low vs. high physical functioning patients tended to increase physical function more after 3 months with KAATSU RT. Low-intensity KAATSU RT as an adjuvant to standard cardiac rehabilitation can safely increase skeletal muscle strength and size in cardiovascular surgery patients.