Sarcopenia is characterized by a progressive and generalized loss of muscle mass and function, typically associated with ageing, and an increased risk of adverse events such as falls, fractures, cognitive impairment, disability, and mortality.1,2 In addition to affecting metabolism, sarcopenia negatively influences the body’s immunological and inflammatory responses.

In people with chronic disorders such as cardiovascular diseases (CVDs), it can exacerbate catabolic factors associated with these comorbidities, intensifying skeletal muscle dysfunction, thereby making the condition more severe.3,4 Factors such as malnutrition, inflammation, oxidative stress, sedentarism and insulin resistance are common to both sarcopenia and cardiac disorders and contribute to their development and progression.4

The prevalence of sarcopenia ranges from 10 to 16 % in older adults,2 35 % in older adults with CVDs,5 and 44 % in those hospitalized for cardiovascular disorders.6 It is initially diagnosed based on poor muscle strength (probable sarcopenia) and confirmed by concomitant low muscle mass. Sarcopenia is classified as severe when poor muscle strength, low muscle mass, and impaired physical performance are present.1 According to the European Working Group on Sarcopenia in Older People 2 (EWGSOP2), muscle strength can be assessed using the chair stand (CST) and handgrip strength (HGS) tests. Muscle mass can be evaluated using a variety of methods, the most widely recommended being dual energy X-ray absorptiometry (DEXA) and bioelectrical impedance analysis (BIA). Physical performance is measured by tests such as gait speed, the Short Physical Performance Battery (SPPB), timed up and go (TUG), and 400-meter walk test, the last used to determine sarcopenia severity.1

Despite the high prevalence of sarcopenia among older adults hospitalized for CVDs, functional assessment in this setting is challenging due to physical limitations such as swelling, chest pain, and breathing difficulties. Moreover, handgrip dynamometers are often unavailable in most hospital admission settings, further limiting the feasibility of muscle strength assessment. These barriers hinder the routine application of physical tests for sarcopenia diagnosis in hospitals.7,8 Screening for the risk of sarcopenia (particularly probable and confirmed sarcopenia) is clinically relevant because older adults with CVDs frequently present with reduced muscle strength, making them more susceptible to developing severe weakness and cardiac cachexia, which are associated with worse outcomes such as hospital readmission and mortality. Therefore, early identification and active intervention are vital to improve prognosis in this population.8

The self-report SARC-F and SARCCalF questionnaires stand out as alternative screening tools for sarcopenia risk to overcome the difficulties of assessing hospitalized older adults. The SARC-F contains five questions that assess older adults’ perceptions of their limitations in terms of strength, walking ability, rising from a chair, climbing stairs, and history of falls.1 The SARCCalF was developed to complement the SARC-F and includes calf circumference, an easily obtained and low-cost anthropometric measurement.9 Recent studies indicate moderate to high specificity for both questionnaires, with the SARCCalF exhibiting greater sensitivity than the SARC-F.10–19

However, the diagnostic accuracy of these questionnaires has yet to be compared in older adults hospitalized with cardiac diseases. There is a need to investigate the efficacy of these tools in this specific population, given the particularities of cardiovascular comorbidities, such as swelling of the lower limbs frequently observed in older adults with chronic heart failure (CHF).8 The present study aimed to identify the prevalence of sarcopenia and sarcopenia risk, and to assess the diagnostic accuracy of the SARC-F and SARCCalF questionnaires in screening for probable and confirmed sarcopenia in older adults hospitalized with cardiovascular diseases.

During the data collection period, 349 patients with cardiac conditions were admitted and assessed for eligibility. Of these, 189 were excluded for not meeting the inclusion criteria or refusing to take part. Thus, analyses were carried with 160 participants (Fig. 1). All participants completed the questionnaires and underwent HGS and CC assessments. Gait speed testing was conducted in 65 participants; the remaining participants were temporarily unable to perform the test due to a medical prescription of absolute rest at hospital admission. Most of the participants were men (62.5 %), with a median age of 70 years [IQR: 65 - 77] and median of 4 years of schooling [IQR: 2 - 8] (Table 1).

Fig. 1.

Flowchart of the sample.

On admission to the hospital, the prevalence of sarcopenia risk was 32.5 and 42.5 % according to the SARC-F and SARCCalF, respectively. In relation to the specific sarcopenia parameters, 40 % of participants exhibited low muscle strength (probable sarcopenia), 53.8 % low muscle mass, and 61.5 % poor physical performance. Based on these criteria, 21.3 % were classified as confirmed sarcopenic (confirmed or severe sarcopenia) (Table 1).

In relation to the SARC-F components (Fig. 2), most participants experienced no difficulty with the activities evaluated. Among the risks identified, the most prevalent was difficulty and/or inability to climb stairs (58.1 %), followed by smaller calf circumference (53.7 %), difficulty lifting and carrying a weight of 5 kg (48.8 %), history of falls (36.9 %), rising from a bed or chair (36.3 %), and walking across a room (32.5 %).

Fig. 2.

Characterization of participants’ degree of difficulty in SARC-F and SARCCalF components.

A comparison of SARC-F and SARCCalF scores between the subgroups is presented in Fig. 3. There were no significant differences in SARC-F scores between older adults with normal and low muscle strength (probable sarcopenia), nor between those with and without confirmed sarcopenia. However, SARCCalF scores were significantly higher (indicating greater risk of sarcopenia) among older adults with low muscle strength (probable sarcopenia) compared to those with normal strength, and also among those with confirmed sarcopenia compared to older adults without confirmed sarcopenia.

Fig. 3.

Comparison of SARC-F and SARCCalF scores between subgroups of older adults classified according to probable and confirmed sarcopenia (U Mann Whitney test).

In analyses of the ROC curves (Fig. 4), AUCs of SARC-F scores were not significant in identifying low muscle strength (probable sarcopenia) and confirmed sarcopenia (p > 0.05). By contrast, AUCs of SARCCalF scores were significant in detecting low muscle strength (AUC = 0.71 [95 %CI: 0.62, 0.79; p < 0.001 and confirmed sarcopenia (AUC = 0.854 [95 %CI: 0.79, 0.91; p < 0.001].

Fig. 4.

ROC curves showing the diagnostic accuracy of the SARC-F and SARCCalF questionnaires for identifying confirmed sarcopenia and probable sarcopenia in older adults hospitalized with cardiovascular diseases.

Identifying sarcopenia in hospital settings is an important step in guiding rehabilitation and counter-referral interventions. This study aimed to identify the prevalence and risk of sarcopenia in older adults hospitalized with CVDs, and to assess the accuracy of the SARC-F and SARCCalF questionnaires in detecting probable and confirmed sarcopenia. The results indicated that these older adults already exhibit impaired muscle strength and physical function on admission, with 58.1 % experiencing difficulty climbing stairs, 53.7 % low muscle mass, 48.8 % unable to lift a weight of 5 kg, 36.9 % a history of falls, 36.3 % difficulty rising from a bed or chair, 32.5 % problems walking across a room unaided, and 21.3 % diagnosed with sarcopenia. The SARCCalF questionnaire was better able to identify older adults at risk of sarcopenia with greater prevalence and accuracy than the SARC-F and proved to be better suited to screening these older adults.

The prevalence of sarcopenia risk was 42.5 % on the SARCCalF and 32.5 % according to the SARC-F, corroborating previous studies in which SARCCalF consistently identified a higher proportion of older adults at risk compared to the SARC-F.10–12,14–19,28 Regarding the prevalence of confirmed sarcopenia, the 21.3 % found in our study was lower than expected. Although this value is higher than the prevalence reported for the general older population (10 %−16 %),2 it remains below estimates found in older adults with CVDs (35 %)5 and those hospitalized with cardiovascular conditions (44 %).6 However, the systematic review6 reporting this 44 % prevalence described a wide range of values (11.9 % to 68 %), reflecting heterogeneity in study populations, the types and severity of CVDs, and differences in diagnostic methods6 and criteria used across studies. Notably, our assessments were conducted upon hospital admission in an emergency department setting, whereas some studies perform assessments at discharge, a time when patients may already exhibit muscle loss related to hospitalization. These methodological and clinical differences may explain the lower prevalence observed in our sample and should be considered when comparing findings across studies.

The present study demonstrated that the SARCCalF exhibited good diagnostic accuracy for screening sarcopenia in older adults hospitalized with CVDs. Comparative analyses indicated that older adults with low muscle strength and those with confirmed sarcopenia obtained significantly higher SARCCalF scores than those without sarcopenia. The SARCCalF correctly identified 71 % of cases with low muscle strength (probable sarcopenia) and 85 % with confirmed sarcopenia, while the SARC-F was unable to satisfactorily differentiate sarcopenia. These results are in line with previous investigations that demonstrate the superiority of the SARCCalF in different populations, including a study to validate the questionnaire,9 research with community-dwelling older adults10,15 and people with diabetes.19

These findings are particularly relevant for older adults hospitalized with CVDs, because confirmed sarcopenia is associated with severe complications, such as higher mortality and prolonged hospital stays, which may exacerbate the clinical picture of CVDs and result in worse health outcomes.2,6 A strong point of the present study is the fact that it was conducted in an emergency room, where older adults admitted for CVD exacerbation have difficulty performing physical tests. This complex clinical scenario reinforces the relevance of the findings, because older adults in critical condition are challenged to undergo sarcopenia assessment. Moreover, to the best of our knowledge, this is the first study to compare the diagnostic accuracy of the SARC-F and SARCCalF questionnaires in older adults hospitalized with CVDs. Early screening for muscle weakness and sarcopenia at hospital admission enables more targeted interventions during hospitalization and improve the clinical prognosis.6 Additionally, in-hospital sarcopenia screening facilitates counter-referral to primary care, ensuring the continuity and comprehensiveness of care.29

Despite the relevant findings, this study also has some limitations. The main limitation concerns the methodological overlap between the sarcopenia diagnostic reference and the SARCCalF questionnaire, as both rely on calf circumference to estimate muscle mass. This overlap may have introduced measurement bias, potentially overestimating the diagnostic performance of the tool. Nevertheless, in our study, the SARCCalf demonstrated good discriminatory ability not only for confirmed sarcopenia (which includes calf circumference in its definition), but also for probable sarcopenia, which is based solely on muscle strength. Additionally, calf circumference may have limited accuracy in certain clinical conditions. In obese older adults, excess adipose tissue can lead to overestimation of muscle mass, hindering the identification of sarcopenic obesity.9 Similarly, in older adults with edema, such as those with heart failure, fluid retention may reduce the reliability of this measure.8 Although the overall sample size was relatively large, it was not sufficient to allow for adequately powered stratified analyses by specific cardiovascular diagnoses. Nevertheless, in hospital emergency settings, particularly in low-resource environments, calf circumference remains a widely accepted and often the only feasible proxy for estimating muscle mass in older populations.9

The prevalence of sarcopenia was 21.3 %, with 42.5 % of older adults classified as at risk by the SARCCalf and 32.5 % by the SARC-F. The SARCCalf exhibited better diagnostic performance than the SARC-F, proving accurate in identifying probable and confirmed sarcopenia. Our findings complement existing research on using the SARCCalf and SARC-F questionnaires to screen for sarcopenia, providing new information specifically on their application in hospital settings for older adults with cardiovascular diseases.

Luciana de Lima Sousa: Conceptualization, Methodology, Investigation, Data curation, Writing – review & editing, Supervision, Project administration. Paloma Boni de Lima: Conceptualization, Methodology, Writing – original draft, Writing – review & editing, Visualization, Project administration. Thais Ribas Konrad Ribeiro: Writing – original draft, Writing – review & editing. Mariana de Grande dos Santos: Investigation. Patrícia Azevedo Garcia: Conceptualization, Methodology, Formal analysis, Resources, Data curation, Writing – original draft, Writing – review & editing, Visualization, Supervision, Project administration, Funding acquisition.