Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020

The prevalence of sleep disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared in order to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Because sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.

Sleep Apnea Syndrome (SAS) Clinical Practice Guidelines 2020

The prevalence of sleep-disordered breathing (SDB) is reportedly very high. Among SDBs, the incidence of obstructive sleep apnea (OSA) is higher than previously believed, with patients having moderate-to-severe OSA accounting for approximately 20% of adult males and 10% of postmenopausal women not only in Western countries but also in Eastern countries, including Japan. Since 1998, when health insurance coverage became available, the number of patients using continuous positive airway pressure (CPAP) therapy for sleep apnea has increased sharply, with the number of patients about to exceed 500,000 in Japan. Although the "Guidelines for Diagnosis and Treatment of Sleep Apnea Syndrome (SAS) in Adults" was published in 2005, a new guideline was prepared to indicate the standard medical care based on the latest trends, as supervised by and in cooperation with the Japanese Respiratory Society and the "Survey and Research on Refractory Respiratory Diseases and Pulmonary Hypertension" Group, of Ministry of Health, Labor and Welfare and other related academic societies, including the Japanese Society of Sleep Research, in addition to referring to the previous guidelines. Since sleep apnea is an interdisciplinary field covering many areas, this guideline was prepared including 36 clinical questions (CQs). In the English version, therapies and managements for SAS, which were written from CQ16 to 36, were shown. The Japanese version was published in July 2020 and permitted as well as published as one of the Medical Information Network Distribution Service (Minds) clinical practice guidelines in Japan in July 2021.

Type and duration of emergency recovery work and its longitudinal effects on mental health symptoms among Fukushima Daiichi Nuclear Power Plant workers: The Fukushima NEWS project study

BACKGROUND

The Fukushima Nuclear Energy Workers' Support study showed the Fukushima nuclear disaster caused psychological distress in the workers, with higher rates of post-traumatic stress responses (PTSR). To understand how the type and duration of emergency recovery work performed immediately following this disaster impacted workers' psychological status, a longitudinal analysis was conducted with 4-year follow-up data since 2011.

METHOD

Fukushima Daiichi nuclear power plant workers were assessed annually with general psychological distress (GPD) and PTSR questionnaires between 2011 and 2014. Combined, 697 Fukushima Daiichi plant workers provided baseline GPD and PTSR in 2011 and their record of working days for approximately one month immediately following the disaster. The relationship between type of emergency recovery work, working days immediately following the disaster, and psychological distress over four years was analyzed using a mixed effects logistic regression model.

RESULTS

At baseline, GPD and PTSR scores were significantly higher in nuclear power plant workers who worked 3-5 days immediately following the disaster compared to those who worked only 0-2, particularly in the field engineer subgroup. The effect of working days on GPD remained for over a year, and the impact on PTSR remained significant throughout the four years of observation after the disaster.

CONCLUSIONS

The Fukushima Daiichi plant field engineers showed significantly higher psychological distress than other workers. The impact of emergency recovery work on psychological distress persisted for over one year, but PTSR in field engineer workers remained significantly elevated four years after the disaster.

Distinct association of VEGF-C and VEGF-D with prognosis in patients with chronic heart failure: the PREHOSP-CHF study

Background

The lymphatic system has been suggested to play an important role in cardiovascular (CV) diseases including heart failure (HF). Vascular endothelial growth factor C (VEGF-C) and VEGF-D are key regulators of lymphoangiogenesis.

Purpose

To investigate the association of VEGF-C and VEGF-D with prognosis in patients with chronic HF (CHF).

Methods

The PREHOSP-CHF study is a multicenter prospective cohort study to determine the predictive value of angiogenesis-related biomarkers in CHF. A total of 1,024 patients (mean age, 75.5±12.6 years; male, 58.7%) admitted to acute decompensated HF were included in the analyses. The primary outcome was MACE defined as a composite of CV death or HF hospitalization. The secondary outcomes were all-cause death, CV death, and HF hospitalizations. Serum levels of VEGF-C and VEGF-D, as well as N-terminal pro B-type natriuretic peptide (NT-proBNP), high sensitivity cardiac troponin-I (hs-cTnI), high sensitive C reactive protein (hs-CRP), VEGF, and soluble VEGF receptor-2 (sVEGFR-2) were measured at the time of discharge. Patients were followed-up over two years.

Results

Median [interquartile range] of VEGF-C and VEGF-D levels were 4821 [3633–6131] pg/ml and 404 [296–559] pg/ml, respectively. In multivariate stepwise regression analysis, independent determinants of VEGF-C levels were younger age, female gender, absence of prior HF hospitalization, chronic kidney disease, and anemia, lower ejection fraction, lower NT-proBNP levels, higher VEGF levels, and higher sVEGFR-2 levels, while those of VEGF-D levels were lower body mass index, presence of diabetes and atrial fibrillation, and higher NT-proBNP levels. During the follow-up, a total of 209 (20.4%) all-cause deaths, 112 (10.9%) CV deaths, and 309 (30.2%) HF hospitalizations occurred. After adjusting for established risk factors and CV biomarkers, VEGF-C levels were significantly and inversely associated with the incidence of MACE and non-CV death (Fig.1, model 4). On the other hand, VEGF-D levels were significantly and positively associated with the incidence of HF hospitalization (Fig. 1, model 4). When we divided the patients into 4 groups based on the median of VEGF-C and VEGF-D levels, patients with low VEGF-C and high VEGF-D showed significantly higher incidence of MACE, all-cause death, CV death, and HF hospitalization compared to those with high VEGF-C and low VEGF-D (Fig. 2).

Conclusions

Among patients with CHF, VEGF-C and VEGF-D had different characteristic and association with the incidence of adverse events. VEGF-C levels were inversely associated with the incidence of MACE and non-CV death, and VEGF-D levels were positively associated with the incidence of HF hospitalization. These results suggests different effects of VEGF-C and VEGF-D in CHF. Combination of VEGF-C and VEGF-D enables us to make good risk stratification in patients with CHF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Clinical Research from the National Hospital Organization Figure 1Figure 2

Comparison of clinical effect of living alone between urban area and rural area in patient with acute coronary syndrome

Background and objective

Living alone is reported as an independent risk factor for worse clinical outcomes after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Manifestations of psychological stress such as depression and anxiety in patients living alone is thought to be associated with subsequent cardiovascular events. The impact of living alone on the psychological factors of patients may be differ depending on their living environment. However, comparison of the effects of living alone in different living environment on the prognosis of patients with ACS has not been reported.

Purpose

The aim of the present study was to compare the clinical effect of living alone on clinical outcomes in patients with ACS between urban area and rural area.

Methods

Data from a multi-center, observational study of consecutive patients who underwent emergency PCI for ACS between January 2012 and December 2016 were analyzed. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE). MACCE was defined as composite of cardiovascular death, ACS, and stroke.

Results

In this study, 1349 patients were enrolled and divided into two population according to their living environment: urban area population (n=417), and rural area population (n=932). In urban area population, 87 patients (20.9%) were living alone, and 330 (79.1%) were living together. In rural area population, 169 (18.1%) were living alone, and 763 (81.9%) were living together. There are no significant differences in baseline characteristics between the living alone group and the living together group in both urban area population and rural area population. During a median follow-up period of 2.1 years, Kaplan-Meier curves showed the living alone group had higher risk of MACCE than the living together group in urban area population (log-rank, p=0.01). On the other hands, there are no significant differences in the incidences of MACCE between two groups in rural area population (p=0.86). After adjustment for other covariates, the living alone was significantly associated with MACCE (hazard ratio [HR], 2.83; 95% confidential interval [CI], 1.16–6.91; p=0.02) compared with the living together group in urban area population. However, in rural area population, the living alone group was not significantly associated with MACCE (HR, 1.02; 95% CI, 0.66–1.57; p=0.92) compared with the living together group.

Conclusion

Living alone was significantly associated with worse clinical outcomes after emergency PCI of ACS in urban area but not in rural area.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Association of low total cholesterol level with clinical outcomes in patients with atrial fibrillation: the Fushimi AF registry

Background

Hyperlipidemia is a well-established risk factor for cardiovascular disease. However, low cholesterol is also reported to be associated with poor outcome in patients with chronic disease, which is called “cholesterol paradox”, and the association of cholesterol level with the incidence of clinical outcomes in patients with atrial fibrillation (AF) remains unclear.

Methods

In the Fushimi AF Registry, a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto, Japan, follow-up data and baseline total cholesterol levels were available in 3,054 patients. We excluded 767 patients who were taking statins, and 2,267 patients were included in the analyses. We defined low cholesterol as total cholesterol <150 mg/dl, and examined the incidence of all-cause death, stroke/systemic embolism (SE), heart failure (HF) hospitalization, and major bleeding.

Results

Patients with low cholesterol (N=464 (20.4%)) were older, more often male, and had higher prevalence of low body weight (<50 kg), permanent/persistent AF, prior stroke/SE, HF, chronic kidney disease, and anemia (hemoglobin <11 g/dl). CHA2DS2-VASc score was higher in patients with low cholesterol (low cholesterol vs others; 3.6±1.6 vs 3.2±1.7: P<0.001). Prescription of oral anti-coagulants was comparable between the groups (50.0% vs 54.5%: P=0.09). During the median follow-up of 1,805 days, the incidence of all-cause death, stroke/SE, HF hospitalization, and major bleeding was significantly higher in patients with low cholesterol (all-cause death, 10.9 vs 3.8 /100 person-years; stroke/SE, 3.4 vs 1.9 /100 person-years; HF hospitalization, 4.7 vs 2.5 /100 person-years; major bleeding, 2.7 vs 1.4 /100 person-years) (Figure 1). After adjustment for the components of CHA2DS2-VASc score, low body weight, permanent/persistent AF, chronic kidney disease, anemia, and prescription of oral anti-coagulants, low cholesterol was significantly associated with the incidence of all-cause death and stroke/SE, but not with that of HF hospitalization or major bleeding (Figure 2, model 3). Total cholesterol levels were still significantly and inversely associated with the incidence of all-cause death (hazard ratio, 0.94; 95% confidence interval, 0.92–0.96 for 10 mg/dl increase) and stroke/SE (hazard ratio, 0.96; 95% confidence interval, 0.92–0.999 for 10 mg/dl increase), when analyzed as continuous variables. Subgroup analysis revealed that the risk of low cholesterol for all-cause death was more pronounced in female (interaction P, 0.049), patient without prior stroke/SE (interaction P, 0.01), those without HF (interaction P, 0.01), and those without vascular disease (interaction P, 0.001). The risk for stroke/SE was more pronounced in patients without vascular disease (interaction P, 0.01).

Conclusion

Low total cholesterol level was significantly associated with the incidence of all-cause and stroke/SE in AF patients not taking statins, suggesting the existence of cholesterol paradox in AF.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi-Sankyo, Novartis Pharma, MSD, Sanofi-Avent

The relationship between diastolic blood pressure and the risk of cardiovascular events in patients with atrial fibrillation whose systolic blood pressure was treated to less than 130 mmHg

Background

Hypertension is one of the major risk factors of cardiovascular events in patients with atrial fibrillation (AF). Low diastolic blood pressure (DBP) has been reported to be associated with the incidence of cardiovascular events, but current guidelines recommend an intensive blood pressure target of less than 130/80 mmHg for AF patients taking oral anticoagulants without mentioning the lower limits of DBP.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in a city of Japan. Follow-up data were available in 4,472 patients, and hypertensive patients who received prescription of any antihypertensive agents and whose systolic blood pressure was treated to less than 130 mmHg were available were examined (n=1,319). We divided the patients into four groups according to their DBP at baseline; G1 (DBP<60 mmHg, n=349), G2 (60≤DBP<70, n=434), G3 (70≤DBP<80, n=386) and G4 (80≤DBP, n=150), and compared the clinical background and outcomes among groups.

Results

The proportion of female was grater in G1 group, and the patients in G1 group were older. During the median follow-up of 2,458 days, in Kaplan-Meier analysis, the incidence rates of cardiovascular events (composite of cardiac death, ischemic stroke, systemic embolism, non-fatal myocardial infarction and heart failure hospitalization during follow up) were the highest in G1 group and the lowest in G3 group (G1: 7.2% per person-year vs. G2: 4.9% vs. G3: 2.2% vs. G4: 4.4%; p<0.01). Multivariate Cox proportional hazards regression analysis revealed that DBP was an independent determinant of cardiovascular events (G1 vs. G3; hazard ratio (HR): 1.96, 95% confidence intervals (CI): 1.39–2.76, G2 vs. G3; HR: 1.79, 95% CI: 1.28–2.50, G4 vs. G3; HR: 1.56, 95% CI: 0.99–2.45) (Figure 1). When we examined the association of DBP according to 10 mmHg increment, patients with excessively low DBP (<50 mmHg) had significantly higher incidence of cardiovascular events than patients with DBP of 70–79 mmHg (HR: 2.80, 95% CI: 1.81–4.33), and DBP exhibited J curve association with higher incidence of cardiovascular events (Figure 2).

Conclusion

In Japanese AF patients whose systolic blood pressure was treated to less than 130 mmHg, patients with excessively low DBP had significantly higher incidence of cardiovascular events, and DBP exhibited J curve association with higher incidence of cardiovascular events.

Funding Acknowledgement

Type of funding sources: None.

Previous pacemaker therapy was not associated with the risk of clinical events in patients with atrial fibrillation: the Fushimi AF Registry

Background

Patients with atrial fibrillation (AF) occasionally require pacemaker implantation. Meanwhile, patients with implanted pacemaker are occasionally found to have subclinical AF and develop clinical AF. However, little is known about the clinical outcomes of AF patients with implanted pacemaker.

Purpose

We aimed to investigate the clinical outcomes in AF patients undergoing previous pacemaker therapy.

Methods

The Fushimi AF Registry is a community-based prospective survey of the AF patients in a city of Japan. Follow-up data including prescription status were available for 4,447 patients. After exclusion of patients with implantable cardioverter defibrillator and cardiac resynchronization therapy, we investigated 293 AF patients with pacemaker implantation at baseline. We performed propensity score-matching analysis to assess the impact of pacemaker therapy in AF patients.

Results

Of a total cohort, patients with pacemaker were more often female (51.2% vs. 39.7%; p<0.01) and older (78.0 vs. 73.3 years of age; p<0.01). Patients with pacemaker were more likely to have pre-existing heart failure (33.1% vs. 26.6%; p<0.01), valvular heart disease (22.9% vs. 16.8%; p<0.01), chronic kidney disease (48.8% vs. 34.7%; p<0.01), and history of performing direct current cardioversion (7.2% vs. 3.1%; p<0.01), compared with patients without pacemaker. Mean CHA2DS2-VASc score was higher in patients with pacemaker (3.80 vs. 3.34; p<0.01). Patients with pacemaker were more often prescribed oral anticoagulants (62.1% vs. 55.2%; p=0.02), verapamil (13.3% vs. 9.4%; p=0.03), and loop diuretics (30.7% vs. 21.8%; p<0.01). Using propensity score-matching, 291 patients with pacemaker and 291 without pacemaker were matched and baseline characteristics were comparable. The median follow-up period was 1,819 days. All-cause death occurred in 91 patients with pacemaker (6.0 /100 person-years) and 79 patients without pacemaker (5.9 /100 person-years), with a hazard ratio (HR) for patients with pacemaker of 1.01 (95% confidence interval [CI], 0.75 to 1.37; p=0.93). Furthermore, HR of cardiac death for patients with pacemaker was 1.00 (95% CI, 0.23 to 4.32; p=0.99), that of stroke or systemic embolism was 0.69 (95% CI, 0.44 to 1.07; p=0.10) and that of hospitalization for heart failure was 0.94 (95% CI, 0.65 to 1.37; p=0.76).

Conclusion

We identified that patients undergoing previous pacemaker therapy were not associated with the incidence of various adverse clinical events in Japanese AF patients.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim, Bayer Healthcare, Pfizer, Bristol-Myers Squibb, Astellas Pharma, AstraZeneca, Daiichi Sankyo, Novartis Pharma, MSD, Sanofi-Aventis, Takeda Pharmaceutical, and the Practical Research Project for Life-Style related Diseases including Cardiovascular Diseases and Diabetes Mellitus from Japan Agency for Medical Research and Development.

Association of the degree of thrombocytopenia with cause of death in patients with atrial fibrillation: the Fushimi AF Registry

Background

Thrombocytopenia is sometimes found in routine blood tests and is associated with an increased risk of mortality in general population. We have previously reported that atrial fibrillation (AF) patients with thrombocytopenia have a higher mortality than those without thrombocytopenia. However, association of the degree of thrombocytopenia with cause of death in AF patients is unknown.

Purpose

We aimed to investigate the association of baseline platelet count with cause of death including cardiac death, intracranial death, malignancy, infection, extracranial bleeding death, renal failure death, respiratory failure death and undetermined death.

Methods

The Fushimi AF Registry was designed to enroll all of the AF patients in Fushimi-ku, Kyoto. Fushimi-ku is densely populated with a total population of 283,000 and is assumed to represent a typical urban community in Japan. We started to enroll patients from March 2011, and follow-up data with baseline platelet counts less than 150,000/μL were available in 853 patients by the end of September 2020. We divided them into 3 groups according to baseline platelet level: Mild thrombocytopenia (100,000–149,999/μL, n=703), Moderate thrombocytopenia (50,000–99,999/μL, n=120), and Severe thrombocytopenia (<50,000/μL, n=30).

Results

In the entire cohort, the mean age was 76 years, 34% were women, the mean body weight and body mass index was 59.3 kg and 22.9 kg/m2, and the median platelet count were 121,000/μL (interquartile range 109,000 to 141,000/μL). Compared to Mild thrombocytopenia, patients with Moderate or Severe thrombocytopenia were more likely to have chronic kidney disease (42.2% vs 54.2% vs 73.3%, p=0.0003), have higher HAS-BLED score (1.90 vs 2.14 vs 2.00, p=0.047) and lower hemoglobin (12.8g/dL vs 11.7g/dL vs 11.2g/dL, p<0.0001) and were less often prescribed anti platelet drugs. Age, sex, body weight, systolic blood pressure, previous stroke, previous major bleeding, hypertension, diabetes mellitus, CHADS2 score and CHA2DS2-VASc score were comparable between three groups. During the median follow-up period, the incidence rate (per 100 person-years) of all-cause death was 6.82 vs 15.27 vs 9.64. (p<0.001) On univariate analysis, the incidence of all-cause death was higher in Moderate group than Mild group. (HR: 2.15; 95% CI 1.61–2.87, p<0.0001), but there was no significant difference between Mild and Severe groups. (HR: 1.44; 95% CI 0.78–2.64, p=0.243). The incidence of cardiac death was comparable between three groups. (Mild vs Moderate: HR 0.65; 95% CI 0.15–2.75, p=0.56, Mild vs Severe: HR 1.11; 95% CI 0.15–8.23, p=0.92) Regarding other causes of death such as intracranial bleeding, extracranial bleeding, malignancy, infection, renal failure, respiratory failure and undetermined cause, there was no significant difference.

Conclusion

Mortality was higher according to the degree of thrombocytopenia in AF patients, but the cause of death was not different among three groups.

Funding Acknowledgement

Type of funding sources: None.

Predictors and risk model for heart failure hospitalization in atrial fibrillation patients without pre-existing heart failure: the Fushimi AF Registry

Background

Atrial fibrillation (AF) increases the risk of hospitalization for heart failure (HF), as well as that of thromboembolism. The strategy for prediction of thromboembolism has been well-established; however, little focus has been placed on the risk stratification for and prevention of HF hospitalization in AF patients.

Purpose

The aim of this study is to investigate the predictors and risk model of HF hospitalization in non-valvular AF patients without pre-existing HF.

Methods

The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Kyoto, Japan. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,472 patients by the end of October 2020. From the registry, we excluded patients without a pre-existing HF (defined as having one of the following; prior hospitalization for HF, New York Heart Association class ≥2, or left ventricular ejection fraction [LVEF] <40%), and those with valvular AF (mitral stenosis or prosthetic heart valve). Among 3,188 non-valvular AF patients without pre-existing HF, we explored the risk factors for the HF hospitalization during follow-up period. The risk model for predicting HF hospitalization was determined by the cumulative numbers of risk factors which were significant on multivariate analysis.

Results

The mean age was 72.4±10.8 years, 1197 were female and 1787 were paroxysmal AF. The mean CHADS2 and CHA2DS2-VASc scores were 1.7±1.2 and 2.9±1.6, respectively. During the median follow-up period of 5.1 years, HF hospitalization occurred in 285 (8.9%), corresponding to an annual incidence of 1.8 events per 100 person-years. In multivariable Cox regression analysis, advanced age (≥75 years), valvular heart disease, coronary artery disease, reduced LVEF (<60%), chronic obstructive pulmonary disease (COPD) and anemia were independently associated with the higher incidence of HF hospitalization (all P<0.001) (Picture 1). A risk model based on these 6 variables could stratify the incidence of HF hospitalization during follow-up period (log-rank; P<0.001) (Picture 2). Patients with ≥3 risk factors had an 11-fold higher incidence of HF hospitalization compared with those not having any of these risk factors (hazard ratio: 11.3, 95% confidence interval: 7.0–18.4; P<0.001).

Conclusions

Advanced age, coronary artery disease, valvular heart disease, reduced LVEF, COPD and anemia were independently associated with the risk of HF hospitalization in AF patients without pre-existing HF. There was good prediction for endpoint of HF hospitalization using these 6 variables, providing the opportunities for the implementation of strategies to reduce the incidence of HF among AF patients.

Funding Acknowledgement

Type of funding sources: None.

Impact of atrial fibrillation on soluble fms-like tyrosine kinase-1 and cardiovascular events in patients with suspected or known coronary artery disease: the EXCEED-J study

Background

Soluble fms-like tyrosine kinase-1 (sFlt-1), a vascular endothelial growth factor (VEGF) antagonist, has been suggested as a marker of endothelial dysfunction. Circulating sFlt-1 levels are associated with adverse outcomes in patients with preeclampsia, chronic kidney disease, and heart failure. Atrial fibrillation (AF) and coronary artery disease (CAD) are both associated with endothelial dysfunction. However, whether sFlt-1 can predict cardiovascular (CV) events and whether AF modifies the relationship between sFlt-1 and CV events in patients with suspected or known CAD are unknown.

Methods

We performed a nationwide, multicenter, prospective cohort study to determine the prognostic value of sFlt-1 and other biomarkers in patients with suspected or known CAD undergoing elective angiography. Heparin-free fasting serum was collected from the peripheral vein to determine levels of sFlt-1, VEGF, placental growth factor, cystatin C, neutrophil gelatinase-associated lipocalin, N-terminal pro-brain natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin-I (hs-cTnI), and high-sensitivity C-reactive protein (hs-CRP). The primary outcome was 3-point major adverse CV events (3P-MACE) defined as a composite of CV death, nonfatal myocardial infarction, and nonfatal stroke. The secondary outcomes were all-cause death, CV death, and 5P-MACE defined as a composite of 3P-MACE, heart failure hospitalization, and coronary/peripheral artery revascularization.

Results

3311 patients were consecutively enrolled between Nov 2013 and May 2017. After excluding 56 ineligible patients, 3255 patients (324 AF and 2931 non-AF) were followed up over 3 years (follow-up rate, 99%). During the follow-up, 156 patients developed 3P-MACE, 215 died from any cause, 82 died from cardiovascular disease, and 1361 developed 5P-MACE. The sFlt-1 level was significantly higher in AF compared to non-AF patients (p<0.001). Stepwise regression analysis revealed that the sFlt-1 level was independently associated with AF. After adjusting for potential clinical confounders, serum levels of sFlt-1, NT-proBNP, hs-cTnI and cystatin C, but not other biomarkers, were significantly associated with 3P-MACE in the entire cohort. These associations were still significant in non-AF patients, whereas only the sFlt-1 level was significantly associated with 3P-MACE in AF patients. Serum levels of sFlt-1, but not other biomarkers, were also significantly associated with CV death in AF patients. Among the biomarkers, only the hs-CRP level was significantly associated with all-cause death, and no biomarker was significantly associated with 5P-MACE in AF patients. Furthermore, sFlt-1 provided an incremental prognostic information for 3P-MACE to the model with potential clinical confounders in AF, but not in non-AF patients.

Conclusions

Serum levels of sFlt-1 were significantly associated with 3P-MACE in patients with suspected or known CAD. This association was pronounced in AF patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The EXCEED-J study is supported by Health Labour Sciences Research Grant (2013-2014), AMED (2015-2017, Grant Number JP17ek0210008) and Grant-in-Aid for Clinical Research from the National Hospital Organization (2018-2020).

Long-term effect of continuous positive airway pressure therapy on blood pressure in patients with obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common cause of hypertension. Previous studies have demonstrated beneficial short-term effects of continuous positive airway pressure (CPAP) therapy on blood pressure. However, long-term antihypertensive effects of CPAP have not been properly verified. This study examined the longitudinal effect of CPAP therapy adherence on blood pressure among OSA patients. All patients diagnosed with OSA and undergoing subsequent CPAP therapy at a Kanagawa-area sleep clinic were clinically followed for 24 months to examine CPAP adherence, as well as longitudinal changes in blood pressure and body weight because it may become a confound factor for changes in blood pressure. The hours of CPAP usage were collected over the course of 30 nights prior to each follow-up visit (1st, 3rd, 6th, 12th, and 24th month). The relationship between CPAP adherence and blood pressure was analyzed using mixed-effect logistic regression models. A total of 918 OSA patients were enrolled in the study. We found a significant reduction in diastolic blood pressure among patients with good CPAP adherence during the 24-month follow-up period (β = − 0.13, p = 0.03), when compared to the group with poor CPAP adherence. No significant association was found between CPAP adherence and weight loss (β = − 0.02, p = 0.59). Long-term, good CPAP therapy adherence was associated with lower diastolic blood pressure without significant weight loss.

Association between marital status and insomnia-related symptoms: findings from a population-based survey in Japan

BACKGROUND

Marital status is one of the socio-economic factors associated with health. Several studies have indicated a significant association between marital status and insomnia. The increases in the percentages of unmarried people in Japan are expected to produce a significant impact on insomnia. The purpose of this study was to examine the association between marital status and insomnia.

METHODS

The participants were 35 288 people aged 30-59 years selected from the 2010 comprehensive survey of living conditions. We categorized marital status into five groups: single, married couples living with other family members, married couples living without other family members, widowed and divorced. Insomnia-related symptoms (IRS) were based on the participants who chose the answer, 'I couldn't sleep'. Sex-specific multivariable odds ratios (ORs) and 95% confidence intervals (CI) of IRS according to marital status were calculated using the logistic regression model, which was adjusted for potential confounding factors.

RESULTS

The proportions of people with IRS were 2.5% in men and 2.8% in women. The multivariable ORs (95% CI) were 1.15 (0.89-1.49) for single, 1.69 (1.11-2.58) for divorced and 1.01 (0.73-1.39) for married couples living without other family members in men, and 1.56 (1.20-2.03) for single, 2.43 (1.83-3.22) for divorced and 1.31 (1.01-1.71) for married couples living without other family members in women.

CONCLUSIONS

We found divorced men and single, divorced and married women living without other family members had higher IRS than those who were married couples living with other family members in Japanese. This association was more evident in unemployed men.

Association of sleep-disordered breathing and alcohol consumption with hypertension among Japanese male bus drivers

There is limited evidence regarding the combined effects of sleep-disordered breathing (SDB) and alcohol consumption on hypertension. The aim of this study was to examine the combined effects of SDB and alcohol consumption on hypertension in Japanese male bus drivers. This cross-sectional study included 2525 Japanese male bus drivers aged 20-65 years. SDB was assessed using a single-channel airflow monitor, which measured the respiratory disturbance index (RDI) during overnight sleep at home. Alcohol consumption (g/day) was assessed by a self-administered questionnaire and calculated per unit of body weight. Hypertension was defined as systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg and/or use of antihypertensive medications. Multiple logistic regression analyses were performed to examine the association of the combined categories of RDI and alcohol consumption with hypertension. The multivariable-adjusted odds ratio (OR) and 95% confidence interval (95% CI) of hypertension for the alcohol consumption ≥1.0 g/day/kg and RDI ≥ 20 events/h group were 2.41 (1.45-4.00) compared with the alcohol consumption <1.0 g/day/kg and RDI < 10 events/h group. Our results suggest that Japanese male bus drivers with both SDB and excessive alcohol consumption are at higher risk of hypertension than those without SDB and excessive alcohol consumption, highlighting the importance of simultaneous management of SDB and excessive alcohol consumption to prevent the development of hypertension among bus drivers.

Work-family conflict and insomnia symptoms among women working in aged care services in Japan

OBJECTIVE

The association between work-family conflict and insomnia has not been thoroughly studied. Therefore, we sought to examine the relationship between work-family conflict and insomnia symptoms among Japanese working women.

METHODS

In a cross-sectional study, 608 women aged 18-60 years old who worked in aged care services between 2015 and 2016 were selected, and 445 of these women were ultimately included. Insomnia symptoms were measured using the Athens Insomnia Scale. Work-to-family conflict (WFC) and family-to-work conflict (FWC) were assessed through a self-administered questionnaire and were divided into four categories: low work-family conflict (low WFC and FWC), high FWC, high WFC, and high work-family conflict (high WFC and FWC). The prevalence ratio (PR) and 95% confidence interval (CI) of insomnia symptoms were calculated using a Poisson regression model after multivariable adjustment.

RESULTS

The multivariable-adjusted PR (95% CI) of insomnia symptoms was 1.99 (1.34-2.93) in the high work-family conflict group compared to the low work-family conflict group.

CONCLUSIONS

The results from the present study suggest that insomnia symptoms are highly prevalent among working women in aged care services with high work-family conflict.

Association of diagnostic delay with medical cost for patients with Crohn's disease: A Japanese claims-based cohort study

Background and Aim

Longer diagnostic delay (DD) in Crohn's disease (CD) is associated with complications and related surgeries. However, the impact of DD on medical cost after CD diagnosis remains uncertain.

Methods

This was a claims‐based cohort study. Our analysis used data from 2005 to 2018 from the Japanese Claims Database. We enrolled a total of 528 newly diagnosed CD patients (76.9% male) aged 31.5 ± 13.6 years. High medical cost was defined as the highest quartile of the average monthly medical cost. DD was defined as the interval between the first visit to a gastroenterologist and diagnosis with CD. In the multivariable logistic regression analysis, patients were stratified by the use of anti‐tumor necrosis factor alpha (anti‐TNFα) agents to exclude their influence on the observed effects. This study was approved by the ethics review board of the Juntendo University Faculty of Medicine (No. 2019178).

Results

The multivariable‐adjusted odds ratios and 95% confidence intervals of high medical cost were 1.41 (0.81–2.43) and 0.91 (0.57–1.46), respectively, for a DD of >12 months and 1 to ≤12 months compared to <1 month. In patients receiving anti‐TNFα agents, the multivariable‐adjusted odds ratios for high medical cost were 2.63 (1.34–5.16) and 1.35 (0.79–2.28) for a DD of >12 months and 1 to ≤12 months, respectively, compared to <1 month. In patients without anti‐TNFα, multivariable logistic regression analyses were not presented because of a small number of patients categorized into the high medical cost group.

Conclusion

A delayed diagnosis of CD may incur high medical cost in patients who develop aggressive disease that requires treatment with anti‐TNFα agents.

Phenyl-bonded monolithic silica capillary column liquid chromatographic separation and detection of fluorogenic derivatized intact proteins

Prior to the identification of proteins for proteomics analysis in human cells, separation of fluorogenic derivatized proteins with a fluorogenic reagent, 7-chloro-N-[2-(dimethylamino)ethyl]-2,1,3-benzoxadiazole-4-sulfonamide, has typically been performed by using a conventional reversed-phase HPLC column. However, the number of proteins in human cells (HepaRG) that are separated by this conventional approach is limited to approximately 500. In this study, a nanoflow liquid chromatography system with an evaluated phenyl-bonded monolithic silica capillary column (0.1 mm i.d., 700 mm length) was used to increase the number of separated fluorogenic derivatized proteins. This system was used to separate derivatized human cell proteins (K562) and yeast (Saccharomyces cerevisiae) proteins as model cell proteomes. More than 1,300 protein peaks were separated/detected from both cell proteomes. We present a straightforward comparison of multiple separation profiles using a novel chromatogram display approach, termed the "spiderweb" chromatogram. In addition, to validate that the detected peaks are derived from proteins, a mass spectrometer was connected to the capillary column and deconvolution of the obtained mass spectra was performed. Furthermore, different molecular weight distribution profiles of the expressed proteins were observed between the two cell proteomes.

Derivation and validation of a novel score to detect heart failure with preserved ejection fraction in patients with atrial fibrillation: the Fushimi AF registry

Background

Heart failure with preserved ejection fraction (HFpEF) is an important comorbidity of atrial fibrillation (AF). However, it is sometimes difficult to detect HFpEF among AF patients with preserved EF, since AF and HF share similar symptoms.

Purpose

The aim of this study was to identify factors associated with having HFpEF in AF patients with preserved EF, and derive a new score for HFpEF in AF patients.

Methods

The Fushimi AF Registry is a community-based prospective survey of the AF patients in Fushimi-ku, Kyoto, Japan. Follow-up data were available for 4,466 patients, and 3,083 patients had preserved EF (≥50%). Of the 3,083 patients, 444 had prior HF hospitalization at baseline and we defined these patients as HFpEF. We examined the factors associated with having HFpEF, and derived a new score for detecting HFpEF in AF patients. Thereafter, we validated this score in patients without prior HF hospitalization.

Result

The mean age of the patients with EF ≥50% was 73.6 years, and 41.3% were female. Compared with the patients without prior HF hospitalization, HFpEF patients were older, more often female, less in body weight, had more heart disease (valvular heart disease, cardiomyopathy, old myocardial infarction, and coronary artery disease), chronic kidney diseases (CKD), anemia (Hb &lt;11 g/dL), sustained AF (persistent or permanent), left atrial enlargement (&gt;45 mm), and dilation of cardio-thoracic ratio (CTR) (&gt;54%) at baseline. In multivariate analysis, heart diseases, CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia were significantly associated with HFpEF (Table 1). We derived a new score to diagnose HFpEF in AF patients (2 points for heart diseases, 1 point for CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia; range 0 to 7 points). In a receiver-operating characteristic curve, optimal cut-off point for detecting HFpEF was 3 (Figure 1). We validated this score in patients without prior hospitalization for HF (n=2,639). Of these, 298 patients had HF symptoms of NYHA 2–4 (Symptomatic-HF), and 2,341 patients had neither prior HF hospitalization nor HF symptoms (No-HF). Notably, 207 patients (69.5%) in symptomatic-HF group and 748 patients (32.0%) in No-HF group were classified into HFpEF based on this new score. Furthermore, patients diagnosed as HFpEF by this score had higher incidence of new hospitalization for HF during the follow-up in both symptomatic-HF group and No-HF group. (Figure 2).

Conclusion

We derived a new score to diagnose HFpEF in AF patients based on the presence of prior HF hospitalization (2 points for heart diseases, 1 point for CKD, sustained AF, dilatation of CTR, left atrial enlargement, and anemia). In patients without prior HF hospitalization, sizable number of patients had high HFpEF score (≥3), and those patients showed higher incidence of new HF hospitalization.

Funding Acknowledgement

Type of funding source: None