## 4 Discussion  
Cardiac cachexia represents a critical and often overlooked complication inACHD and HF. This study underscores its profound clinical implications and highlights the need for early recognition and intervention.  
To the best of our knowledge, this is the first large-scale study to address the presence of underweight and cachexia in a large cohort of ACHD and HF. In this increasingly rising population, this complication carries profound clinical implications.  
In patients with acquired cardiac diseases, cachexia and underweight are not merely symptoms of end-stage HF but a distinct clinical syndrome. Underweight and cachexia, and not only obesity and metabolic syndrome, may aggravate cardiac dysfunction and accelerate the progression of HF [12, 13]. Its development is driven by a combination of systemic inflammation, neurohormonal dysregulation, altered metabolism, and nutritional deficiencies, all of which interact to create a vicious cycle of muscle wasting, frailty, and cardiac deterioration.  
It is well documented that cachexia significantly worsens the prognosis in the affected patients, increasing mortality risk and severely reducing quality of life. This is largely due to the loss of skeletal muscle mass, which affects pulmonary ventilation and oxygenation by impairing respiratory muscle function, physical strength, and mobility, leading to increased frailty and susceptibility to infections. There may be some parallels here to the sarcopenia  
\begin{table}
\begin{tabular}{c c c c c c c c} \hline \hline \multirow{2}{*}{ID} & **Age** & \multirow{2}{*}{**Sex**} & \multirow{2}{*}{**BMI**} & \multirow{2}{*}{**Met. BW**} & \multirow{2}{*}{**Type of CHD**} & \multicolumn{2}{c}{**Native/ Post OP/**} & \multirow{2}{*}{**Cardiac Medication**} \\  & & & & & & **CHD** & **Intersection** & \\ \hline \multirow{2}{*}{001-1543} & \multirow{2}{*}{45–54} & \multirow{2}{*}{male} & \multirow{2}{*}{17.3} & \multirow{2}{*}{21.56} & \multirow{2}{*}{VSD} & \multirow{2}{*}{Post-OP} & \multicolumn{2}{c}{ACE-1} \\  & & & & & & & & & \\  & & & & & & & & \\  & & & & & & & & \\  & & & & & & & & \\  & & & & & & & & \\ \hline \multirow{2}{*}{001-1548} & \multirow{2}{*}{55–64} & \multirow{2}{*}{male} & \multirow{2}{*}{17.4} & \multirow{2}{*}{22.73} & \multirow{2}{*}{Maran} & \multirow{2}{*}{Post-OP} & \multicolumn{2}{c}{Beta blockers} \\  & & & & & & & & & \\  & & & &  
seen in older patients. These issues are especially relevant in ACHD, who often have both cardiac and pulmonary abnormalities that can be exacerbated by cachexia [14].  
The prevalence of underweight and cachexia in the current study cohort of ACHD, particularly in individuals with complex congenital heart anomalies or syndromic conditions such as Marfan syndrome, may also reflect the intricate interplay between systemic inflammation, metabolic dysregulation, and the unique pathophysiological challenges inherent to ACHD.  
In addition, patients with cachexia appear to be prone to mental health comorbidities such as depression, anxiety, and social isolation due to physical deterioration and altered body image. These psychological stressors are particularly pronounced in ACHD, who often face lifelong medical challenges and social difficulties related to their congenital heart conditions [15]. Addressing these psychosocial dimensions through comprehensive, multidisciplinary care may be essential for improving overall outcomes for ACHD as well.