Zhang L, Bartz TM, Santanasto A, et al. - Findings demonstrate a positive association of total lean mass with incident heart failure (HF), while total fat mass and thigh muscle density were inversely linked with incident HF. These observations emphasize the limitations of dual‐energy X‐ray absorptiometry (DEXA) for evaluation of HF risk in elders and lend support to the preeminence of computed tomography–measured skeletal muscle quality over mass as a determinant of HF incidence.

• This study included 2 older cohorts, including 3621 persons who underwent DEXA and 2332 who had computed tomography, to evaluate the contribution of body composition to incident HF in elders.

• HF occurred in 927 participants, and DEXA principal components demonstrated no association with HF.

• Post-adjustment for height, weight, and cardiovascular risk factors, total lean mass was found to be near significantly related to higher HF (hazard ratio [HR], 1.25 per SD [1.00–1.56]), whereas total fat mass and thigh muscle density were revealed to be significantly associated with lower HF (HRs, 0.82 and 0.87, respectively).

• Across HF subtypes, similar patterns were seen.

• Attenuation in the links with HF for total lean and fat mass occurred post-adjusting for intercurrent atrial fibrillation or excluding high natriuretic peptide levels.