Reply to: Comment on “Prevalence and Prognostic Implication of Sarcopenia Among Patients With Stage B Heart Failure: The <scp>PAPRIKA</scp> ‐ <scp>HF</scp> Cohort Study”

We sincerely thank Turgut ZI and colleagues for their thoughtful and constructive comments on our recent article [1]. We also appreciate their kind recognition of the clinical importance of evaluating sarcopenia in older adults with asymptomatic (stage B) heart failure (HF). Regarding the history of prior cardiac surgery, this included coronary artery bypass grafting (CABG) and valvular surgery. CABG was more frequent in patients with sarcopenia than in those without (14% [8/56] vs. 6% [15/261], p = 0.03), as was valvular surgery (29% [16/56] vs. 17% [44/261], p = 0.04); five patients had undergone both procedures. To examine their prognostic impact, we additionally performed multivariable Cox regression analyses, which showed that neither CABG nor valvular surgery was independently associated with the composite outcome (Table 1). With respect to diuretic therapy, the exclusion criterion referred to chronic oral loop diuretic use for congestion. Thiazide-type diuretics were permitted when prescribed solely for blood pressure control. In our cohort, despite a high prevalence of hypertension (> 80%), thiazide use was infrequent (4%), which is consistent with prescription patterns reported in Japanese nationwide data [2]. Thus, inclusion of patients receiving thiazides is unlikely to have materially affected patient classification or introduced selection bias. In response to concerns regarding multicollinearity, we assessed variance inflation factors (VIFs) for all covariates included in the multivariable model. All VIF values were < 5.0, indicating no clinically relevant multicollinearity (Table 1). Evidence regarding an association between statin therapy and sarcopenia remains limited and heterogeneous [3]. In our study, statin use was less frequent in patients with sarcopenia than in those without (45% vs. 62%, p = 0.02), whereas ezetimibe use did not differ significantly between groups (Sarcopenia group 18% vs. Non-sarcopenia group 16%, p = 0.75). Given the observational nature of the study, we cannot infer a causal relationship between statin use and sarcopenia. In addition to sarcopenia, physical frailty based on the Fried criteria and physical performance assessed by the short physical performance battery (SPPB) were evaluated. Physical frailty was more prevalent in patients with sarcopenia (38% vs. 16%, p < 0.001), and SPPB scores were significantly lower in this group (9.1 ± 0.3 vs. 11.1 ± 0.1, p < 0.0001). Data on other chronic conditions such as chronic obstructive pulmonary disease or cognitive impairment were not systematically collected, which we acknowledge as a limitation. Information on exercise-based cardiac rehabilitation or nutritional interventions during follow-up was not systematically available. However, such interventions were rarely implemented in this cohort, reflecting current real-world practice in Japan, where outpatient cardiac rehabilitation uptake remains limited. This underscores the importance of early identification of sarcopenia and the need for preventive, multidisciplinary strategies in older patients with stage B HF. We again thank the authors for their insightful comments, which have helped clarify the interpretation of our findings and highlight important directions for future research. All authors met the criteria for authorship. Preparation of manuscript: K. Matsumura and G. Nakazawa. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. This publication is linked to a related comment by Turgut et al. To view this article, visit https://doi.org/10.1111/jgs.70306.