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Many of the mechanisms leading to skeletal muscle wasting in COPD and heart failure are common to both conditions. These encompass neurohormonal activation and systemic inflammation. The mechanisms leading to muscle dysfunction are both qualitative and quantitative. Qualitative changes comprise the transition from aerobic metabolism and prevalent slow fibers composition toward anaerobic metabolism and fast fibers synthesis. Quantitative changes are mainly linked to muscle loss. These changes occur not only in the major muscles bulks of the body but also in respiratory muscles. The mechanisms leading to muscle wastage include cytokine-triggered skeletal muscle apoptosis and ubiquitin-proteasomeand non-ubiquitin-dependent pathways. The regulation of fiber type involves the growth hormone/insulin-like growth factor 1/calcineurin/transcriptional coactivator PGC1 cascade. The imbalance between protein synthesis and degradation plays an important role. Protein degradation can occur through ubiquitin-dependent and non-ubiquitin-dependent pathways. Very recently, two systems controlling ubiquitin-proteasome activation have been described: FOXO-ubiquitin ligase and NFkB ubiquitin ligase. These are triggered by TNFα and growth hormone/insulin-like growth factor 1. Moreover, apoptosis, which is triggered by tumor necrosis factor α, plays an important role. Another mechanism acting on muscle wastage is malnutrition, with an imbalance between catabolic and anabolic factors toward the catabolic component. Catabolism is also worsened by the activation of the adrenergic system and alteration of the cortisol/DEHA ratio toward cortisol production. Sarcomeric protein oxidation and its consequent contractile impairment can be another cause of skeletal muscle dysfunction in CHF.
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