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 read with great interest the recent article by Matsumura et al. [1]. Their perspective on the evaluation of sarcopenia prevalence and its prognostic significance in older adults with stage B heart failure provides valuable insight for geriatric practice. It represents an important contribution to the literature. However, we would like to highlight a few points that may further assist in interpreting their findings. The first table in the study shows that the proportion of patients with prior cardiac surgery was 41% among those with sarcopenia and 21% among those without. However, the indications for these prior surgeries (e.g., valvular procedures, coronary bypass, or other structural interventions) were not clearly specified. Whether surgical indications are related to structural abnormalities causing heart failure can offer valuable clinical context that affects both the classification of stage B heart failure and the interpretation of long-term prognosis. As shown by Grimaldi et al. [2] the type of surgery and access to surgical treatment in patients with structural heart disease are closely associated with mortality outcomes. Therefore, providing brief information on the primary indications for cardiac surgery and their relationship with heart failure would enhance the interpretability of the results. Another point is that although chronic oral diuretic therapy is listed as an exclusion criterion in the methods section, the study's first table lists “thiazides” under baseline antihypertensive treatment. Because thiazide-type agents are also classified as diuretics, it is not entirely clear whether the exclusion criterion referred only to loop diuretics used for congestion or to any oral diuretic, including thiazides. Sica et al. [3] have underscored that thiazide-type diuretics are recommended as first-line antihypertensive agents with proven benefits on cardiovascular morbidity and mortality, whereas loop diuretics are generally reserved for clinically significant fluid overload, such as heart failure or advanced chronic kidney disease. Clarifying whether patients receiving thiazides solely for blood pressure control were included, and specifying exactly which diuretic classes were excluded, would help readers better appraise patient selection and the potential for selection bias. Third, in the multivariable Cox regression analysis, several clinical parameters (age, hemoglobin, serum albumin, and high-sensitivity C-reactive protein) were entered into the model along with sarcopenia. Because some of these variables may reflect overlapping biological processes—such as nutritional status and inflammation—there may be a potential risk of multicollinearity. Clarifying whether multicollinearity was assessed (e.g., using the variance inflation factor [VIF] or a similar diagnostic measure) would enhance methodological transparency and help confirm the independent prognostic role of sarcopenia. The importance of evaluating multicollinearity in Cox regression models has also been emphasized in recent prognostic studies [4]. Dyslipidaemia was reported as a comorbidity in the baseline characteristics, and antihypertensive regimens were described in detail; however, information on statin or other lipid-lowering therapies was not provided. Statin therapy may influence the relationship between sarcopenia and cardiovascular prognosis, given its potential effects on muscle mass and physical performance. Indeed, a long-term population-based cohort study in community-dwelling middle-aged and older adults in Japan found no significant association between statin use and the risk of sarcopenia, low muscle strength, or low muscle mass [5]. Therefore, reporting the frequency of statin (or other lipid-lowering) therapy would enhance the clinical interpretation of the study's findings. The study presents comorbidities limited to hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, coronary artery disease, prior myocardial infarction, and cardiac surgery. However, in older adults, the overall burden of multiple comorbidities can substantially influence the relationship between sarcopenia and long-term prognosis [6]. Clarifying whether a cumulative comorbidity score, such as the Charlson Comorbidity Index, was evaluated—or whether other chronic conditions (e.g., chronic obstructive pulmonary disease, stages of chronic kidney disease, and neurological disorders) were recorded—would provide a clearer understanding of the independence of sarcopenia as a prognostic factor. Finally, the study did not specify whether patients diagnosed with sarcopenia received any exercise-based cardiac rehabilitation, nutritional counseling, or similar interventions, even as part of routine clinical care. Given that improvement in sarcopenia status through cardiac rehabilitation has been shown to significantly reduce all-cause mortality among patients with heart failure, [7] it would be valuable to know whether any such exercise- or nutrition-based interventions were implemented during the follow-up period. This information would enhance the generalizability of the findings to real-world clinical settings. We would like to congratulate Matsumura and colleagues on this valuable study that highlights the prognostic significance of sarcopenia in older adults with stage B heart failure. We believe that the points outlined above will provide additional clarity for readers and researchers working in this field. Z.I.T. and M.C.K. wrote the letter, and all co-authors have read and approved the final version of the manuscript. 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 article by Matsumura and Nakazawa. To view this article, visit https://doi.org/10.1111/jgs.70309.