The nationwide registry of hospitalized heart failure patients in Japan: Japanese Registry Of Acute Decompensated Heart Failure (JROADHF)

Background and aim

Heart failure (HF) is a growing healthcare problem worldwide. This study aimed to describe clinical characteristics and long-term outcomes of HF patients in Japan.

Methods and results

JROADHF (the Japanese Registry Of Acute Decompensated Heart Failure) is a retrospective, multicentre, nationwide observational database of 13,238 patients hospitalized due to HF in 128 hospitals randomly selected from Japanese Circulation Society (JCS)-certified teaching hospitals during 2013. At inclusion, demographic and clinical data were collected from medical records with linkage to a nationwide claim-based database, the Japanese Diagnosis Procedure Combination (DPC). Patients were followed up to 5 years after discharge at each participating site. Patients were old as the median age of 81 years and women were older (74.8±12.8 vs 81.6±11.1 y.o). Mean left ventricular ejection fraction (LVEF) was 47%, and 45% were HF with preserved ejection fraction of >50% (HFpEF). Causes of HF included ischemic in 27%, valvular in 19%, arrhythmia in 17%, and hypertensive in 16%. Median length of hospital stay was 18 days and in-hospital mortality was 7.7%. All-cause mortality during 1 and 4 years were 22.3% and 48.4%, respectively. Hospitalization rates due to HF within 1 and 4 years were as high as 30.5 and 48.4%, respectively.

Conclusions

Contemporary nationwide registry revealed that hospitalized HF patients were elder and had more HFpEF, and their prognosis was still poor compared to the data shown in prior registries.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development (AMED) Practical Research Project for Life-Style related Diseases including Cardiovascular Diseases and Diabetes Mellitus

A novel three-dimensional visualization system revealed an essential adaptive angiogenic response during the early phase of pulmonary hypertension

Background

Pulmonary hypertension (PH) is characterized by increased pulmonary vascular resistance and right heart failure with progressive narrowing or occlusion of the pulmonary artery. However, the assessment of vascular remodeling is mostly limited to averaged increases in wall thickening, and even the role of vascular endothelial growth factor (VEGF), remains incompletely understood; Although abundantly expressed VEGF is expected to elicit angio-obliteration and the knockout of hypoxia inducible factor (HIF) prevents PH in mice, VEGF inhibitor Sugen exacerbates hypoxia (Hx)-induced PH model, which is referred to as VEGF paradox.

Purpose

To analyze three-dimensional (3D) spatiotemporal changes of pulmonary microstructure and function, which reflect the disease activity and lead to resolve the paradox.

Methods and results

We developed a novel 3D visualization system of microstructural networks in whole mouse organ with single-cell resolution, using combined tissue clearing technique called CUBIC and multiphoton excitation microscope. The system enabled the simultaneous 3D evaluation of microvascular structure, invaded macrophages and fibrosis with effective penetration of several mm (whole organ). Three-dimensional observations of PH mice models including Hx, Sugen/Hx, and human-like Alk1+/− hereditary PH models, revealed that not only inward (negative) microvessel remodeling with stenosis, but also marked elongation of microvascular ECs, was evident except Sugen/Hx model at the early phase, which had not been detected by 2D histological sections. Comparable transcriptome analysis revealed that PGC1α, which regulates HIF-independent VEGF expression and angiogenesis, plays an important role in the characteristic response for mitochondrial and microvascular maintenance. PGC1α was up-regulated in the early phage in Hx and Alk1+/− PH models with microvascular angiogenetic change, whereas Sugen/Hx-model did not increase PGC1α expression and did not show microvascular remodeling. Furthermore pulmonary ECs-specific PGC1α-deficient mice exacerbated Hx-PH model with decreased VEGF expression and microvessel density, and administration of Baicalin, a flavonoid enhancing PGC1α expression, ameliorated Hx-PH model with increased VEGF expression.

Conclusions

The 3D visualization system disclosed an unexpected change of angiogenic microvascular structure in the early phage of PH, which is regulated by EC PGC1α. Microvascular angiogenesis which is induced by up-regulation in PGC1α -VEGF pathway is a crucial factor for compensation of PH in the early phase, which provides a potential novel therapeutic target for PH.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): JSJP

Identification of predictors of response to initial oral combination therapy in WHO-functional class II or III PAH patients: a post-hoc analysis of the AMBITION study

Background

AMBITION Study (NCT01178073) provided the first long-term clinical evidence for initial combination therapy with ambrisentan and tadalafil (COMB) compared with monotherapy of either agent (MONO), and the results contributed to the ESC/ERS guidelines recommending initial combination therapy in PAH patients with low and intermediate risk. However, predictors of response to initial oral combination therapy to identify PAH patients who benefit most from it have not been assessed.

Purpose

To identify potential predictors of response to initial combination therapy with ambrisentan and tadalafil (COMB) in PAH patients with WHO-FC II or III in the AMBITION study.

Methods

We examined 302 COMB patients from the modified intention to treat (mITT) population enrolled in the AMBITION study (n=605). The mITT population includes PAH patients with risk factors related to heart failure with preserved ejection fraction (Ex-PAS) who were excluded from the primary analysis set (PAS). A responder (i.e. event-free subject) was defined as not having a clinical failure event. Univariate and multivariate analyses were performed to identify the factors associated with responders. Multivariate logistic regression analysis was used to determine independent risk for each factor that showed a significant difference between cohorts by interactive backward selection. Odds ratio (OR), 95% confidence intervals (CIs) and p-values are presented.

Results

Univariate analysis showed that responders tended to be lower age, female, typical PAH (i.e. PAS), absence of coronary artery disease, non-use of oxygen therapy, and have better baseline parameters (i.e., lower NT-proBNP, longer 6-minute walk distance, low Borg index, high SaO2, WHO-FC II). A multivariate logistic regression analysis showed that female gender (OR=2.669, 95% CI: 1.291–5.518, P=0.0081), use of aldosterone antagonist diuretics (OR=2.535, 95% CI: 1.027–6.257, P=0.0436), lower log NT-proBNP (OR=0.704, 95% CI: 0.524–0.944, P=0.0190), and longer 6-minute walk distance (OR=1.006, 95% CI: 1.002–1.010, P=0.0039) were independent predictors of response to initial combination therapy.

Conclusion

These findings suggest that initial combination therapy with ambrisentan and tadalafil is beneficial, especially in less severe typical PAH patients. It also demonstrates that there is a potential contributing factor (i.e. use of aldosterone antagonist diuretics) which is not listed in the risk assessment table of the ESC/ERS guidelines.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): AMBITION study was funded by GlaxoSmithKline (GSK; study number 112565; trial registration number: NCT01178073) and Gilead Sciences, Inc. This analysis was funded by both companies.

Novel procedural method for balloon pulmonary angioplasty to treat chronic thromboembolic pulmonary hypertension

Background

The current strategy of balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH) is to dilate branches as many as possible without lung injury to normalize mean pulmonary artery pressure and oxygenation. The shape of guiding catheter is one of the important factors to achieve this strategy. However, conventional guiding catheters which are typically used for BPA are difficult to introduce into particular branches. The Ikari-curve left (IL) guiding catheter may be suitable for this purpose by adjusting its curves (Figure 1); however, its utility and effectiveness for lung injury are unclear.

Purpose

The aim of this study is to clarify utility and safety of IL guiding catheter for BPA.

Methods

We retrospectively analyzed 202 consecutive BPA sessions of 40 patients with CTEPH from November 2016 to October 2019 and divided them into two groups; IL group, in which we used IL guiding catheter; and non-IL group in which we used others. IL guiding catheter was used for branches of left lung which are difficult to introduce by conventional catheter prior Nov. 2018. After Nov.2018, we also used it for the same type branches of right lung. The occurrence of lung injury was determined by the presence of bloody sputum during the perioperative period. We compared success rate of introduction into target vessels and of occurrence of lung injury.

Results

The average age of enrolled patients was 60.3±14.4 year-old and female was 65%. There were 99 sessions in IL group. The median treated branches significantly differed between groups (IL group: 15 vs. non-IL group: 10, p<0.05). The lung injury rate tended to low in the IL group (4.0% vs. 11.7%, p=0.07). The IL group had more successful insertions into branches than did the non-IL group (right lung: middle lobe*, 84.4% vs. 57.5%; medial basal branch*, 46.9% vs. 7.5%; left lung: anterior ascending and descending branches, 82.9% vs. 70.8%; lingular branches*, 90.0% vs. 62.5%; anterior basal branch, 75.7% vs. 62.5%, * p<0.05).

Conclusion

IL guiding catheter can be introduced into branches that cannot be accessed via conventional guiding catheters and has potential to reduce the occurrence of lung injury. 2228 characters including space

Figure1

Funding Acknowledgement

Type of funding source: None

Trend survey on adverse event profiles of antipsychotic long-acting injections and oral agents using the Japanese adverse drug event report database

This study aims to assess the differences in adverse event profiles of long-acting injectable antipsychotics (LAIs) and oral antipsychotics (OAPs) using real-world data in the Japanese Adverse Drug Event Report database. Reporting odds ratios were determined using disproportionality analysis to estimate the risk of adverse events for LAIs and OAPs. Differences in adverse event profiles between formulations were determined after propensity score matching. Time-to-onset of adverse events was compared between LAIs and OAPs using the Weibull shape parameter. Signals were detected for approximately 50% of the adverse events (12 of 22) with LAIs and for the majority of adverse events (19 of 22) with OAPs. LAIs was associated with significantly lower reporting rate than OAPs for extrapyramidal symptom, neuroleptic malignant syndrome, and dystonia. For QT prolongation, convulsions, and hyperglycemia associated with LAIs, the 95% Confidence Interval of β included 1 in time-to-onset analysis. Real-world data suggest that LAIs tend to reduce the occurrence of extrapyramidal symptom and neuroleptic malignant syndrome, but a number of other adverse events have potential risks as well as OAPs. In addition, onset of adverse events with LAIs have been shown to be slightly delayed, requiring more careful long-term monitoring.

Acceptance of the Deltoid Muscle Injection of Aripiprazole Long-acting Injectable in the Patients with Schizophrenia

Objective

To improve poor medication adherence in schizophrenic patients, long-acting injectable (LAI) antipsychotics are used. However, it has not yet become common in Japan. Recently, aripiprazole LAI was approved for alternative injection into the deltoid muscle in addition to the gluteal muscle. The acceptance for the proposal to switch from gluteal to deltoid injections of aripiprazole LAI was investigated.

Methods

The subjects were 32 outpatients with schizophrenia who had continuously received aripiprazole LAI administration into the gluteal muscle for ≥ 6 months. In the patients who had continued deltoid injection for 3 months after switching, the changes in the pain and shame in comparison with gluteal injections were evaluated.

Results

Switching to the deltoid injection was chosen by 17 out of 32 patients. Three months later, 9 patients were still receiving deltoid injections with highly rated satisfaction. The main reasons for switching to deltoid injections included the pain and shame associated with gluteal injections. The main reason for returning to the gluteal injection was the pain experienced from the injection in the deltoid.

Conclusion

The option to select the injected area was based on the amount of pain in the deltoid and gluteal sites, leading to the widespread use of aripiprazole LAI.

Effectiveness in Switching from Antipsychotic Polypharmacy to Monotherapy in Patients with Schizophrenia: A Case Series

In Japan, drug therapy for schizophrenia is characterized by high-dose antipsychotic polypharmacy, which is an uncommon approach internationally. In this study, we reduced the number of antipsychotic agents in 5 patients using the Safety Correction of High-dose Antipsychotic Polypharmacy (SCAP) method and conducted a survey regarding treatment satisfaction. The switch from polypharmacy to monotherapy was achieved in all patients. There was no deterioration in psychiatric symptoms, and adverse reactions were reduced. Three of the subjects were satisfied with the decrease in the number of antipsychotic agents and dose-reduction. These results suggest that the SCAP method is a safe and useful method that can be applied in a clinical setting.

Efficacy and safety of lithium and lamotrigine for the maintenance treatment of clinically stable patients with bipolar disorder: A systematic review and meta-analysis of double-blind, randomized, placebo-controlled trials with an enrichment design

Aim

Whether patients with adult bipolar disorder (BD) who have been clinically stabilized with lithium or lamotrigine should continue this medication is not established fully. This systematic review and meta‐analysis evaluated the efficacy and safety of lithium and lamotrigine for maintenance treatment in clinically stable patients with adult BD.

Methods

This meta‐analysis included only double‐blind, randomized, placebo‐controlled trials with an enrichment design that selected patients who responded acutely to lithium or lamotrigine. Reports prior to November 15, 2018, were retrieved from the PubMed/Cochrane Library/Embase. The primary outcome was the relapse rate due to any mood episode at the study endpoint. Other outcomes were relapse rates due to a manic/hypomanic/mixed episode or depression at the study endpoint, discontinuation rate, death, and death by suicide. Risk ratios (RRs) (95% confidence intervals) were calculated. When the random‐effects model showed significant differences between groups, the number‐needed‐to‐treat (NNT) was estimated.

Results

The search retrieved two studies regarding lithium (N = 218) and four evaluating lamotrigine (N = 706). Both drugs were superior to placebo for reducing the relapse rate due to any mood episode [lithium: RR = 0.52 (0.41‐0.66), P < 0.00001, I² = 0%, NNT = 2.3 (1.6‐4.2); lamotrigine: RR = 0.81 (0.70‐0.93), P = 0.004, I² = 0%, NNT = 8.3 (5.0‐25.0)] and all‐cause discontinuation. There were no significant differences in other outcomes between lithium or lamotrigine and the placebo groups.

Conclusion

Both drugs showed benefit for preventing relapse in clinically stable patients with adult BD. However, the number of studies and patients in this analysis was small.

Study, patient, and treatment characteristics of the included double‐blinded, randomized placebo‐controlled trials of patients with bipolar disorder

The effects of different periods of co-administration of oral and long-acting injectable aripiprazole: A propensity score analysis

OBJECTIVE

Long-acting injectable (LAI) aripiprazole is recommended to be combined with oral aripiprazole for 2 weeks after its introduction. However, we often experience patients who require more than 2 weeks of combined use. Therefore, differences in combination periods need to be examined.

METHODS

This was a case-control study. We surveyed prescription profiles for oral aripiprazole administration in conjunction with LAI aripiprazole introduction and assessed the clinical course during a 12-week follow-up period.

RESULTS

Among 121 patients, 58 (47.9%) were administered both oral and LAI aripiprazole for more than 2 weeks. Although there was no significant difference in treatment failure (defined as psychiatric hospitalization or discontinuation of LAI aripiprazole from any cause) between the two groups, the group that was administered oral aripiprazole for more than 2 weeks received less additional benzodiazepines compared with that of the 2 weeks group (adjusted odds ratio, 0.055; 95% confidence interval [0.0060, 0.50]; p < 0.01).

CONCLUSIONS

Our data support a flexible co-administration period for oral and LAI aripiprazole in consideration of the pharmacokinetics, but further studies are needed.

Extending coherence time of macro-scale diamond magnetometer by dynamical decoupling with coplanar waveguide resonator

Ultimate sensitivity for quantum magnetometry using nitrogen-vacancy (NV) centers in a diamond is limited by a number of NV centers and coherence time. Microwave irradiation with a high and homogeneous power density for a large detection volume is necessary to achieve a highly sensitive magnetometer. Here, we demonstrate a microwave resonator to enhance the power density of the microwave field and an optical system with a detection volume of 1.4 × 10^-3 mm³. The strong microwave field enables us to achieve 48 ns Rabi oscillation which is sufficiently faster than the phase relaxation time of NV centers. This system combined with a decoupling pulse sequence, XY16, extends the spin coherence time (T ₂) up to 27 times longer than that with a spin echo method. Consequently, we obtained an AC magnetic field sensitivity of 10.8 pt/ Hz using the dynamical decoupling pulse sequence.

Improving the electron spin properties of nitrogen-vacancy centres in nanodiamonds by near-field etching

The nitrogen-vacancy (NV) centre in diamond is a promising candidate for quantum computing applications and magnetic sensing applications, because it is an atomic-scale defect with stable coherence time (T2) and reliable accessibility at room temperature. We demonstrated a method for improving the NV spin properties (the full width half maximum (FWHM) value of the magnetic resonance spectrum and T2) through a near-field (NF) etching method under ambient conditions. The NF etching method, based on a He-Cd ultraviolet laser (325 nm), which is longer than the absorption edge of the oxygen molecule, enabled selective removal of defects on the nanodiamond surface. We observed a decrease in the FWHM value close to 15% and an increase in T2 close to 25%. Since our technique can be easily reproduced, a wide range of NV centre applications could be improved, especially magnetic sensing applications. Our results are especially attractive, because they have been obtained under ambient conditions and only require a light source with wavelength slightly above the O2 absorption edge.

Assessment of Switching to Suvorexant versus the Use of Add-on Suvorexant in Combination with Benzodiazepine Receptor Agonists in Insomnia Patients: A Retrospective Study

Objective

Suvorexant is a novel hypnotic drug that does not interact with the conventional γ-aminobutyric acid (GABA)-A receptor. We investigated the method by which suvorexant was introduced in insomnia patients who were taking benzodiazepine receptor agonists (BzRA).

Methods

This was a retrospective study. We extracted clinical data for patients who were prescribed suvorexant and were already using BzRA. The patients were assigned to two groups, the switching and add-on groups. We assessed the suvorexant discontinuation rate at one month after the prescription of the drug.

Results

One hundred and nineteen patients were assigned to the switching group, and 109 were assigned to the add-on group. The add-on group exhibited a significantly higher all-cause discontinuation rate than the switching group (odds ratio, 2.7; 95% confidence interval, 1.5 to 5.0; adjusted p<0.001). Intolerability was a significantly stronger risk factor for suvorexant discontinuation in the add-on group (22.0% vs. 7.6%, p<0.002), and the most common adverse effect was oversedation.

Conclusion

Our results show that the add-on of suvorexant increases the frequency of oversedation compared with switching in insomnia patients that are taking BzRA. However, this was only a preliminary retrospective study, and further studies will be required to confirm our findings.

Assessment of the Latent Adverse Events of Antipsychotic Treatment Using a Subjective Questionnaire in Japanese Patients with Schizophrenia

Objective

The adverse effects of antipsychotic agents can have a marked influence on medication adherence. In this study, we investigated the adverse events of antipsychotics that are less likely to be reported by patients and the reasons why such symptoms remain latent.

Methods

Data were collected by interviewing patients using a subjective questionnaire, and the associations between unreported symptoms and background factors were investigated.

Results

A total of 306 patients with schizophrenia or schizoaffective disorder were examined. Their major symptoms were daytime sleepiness (50.0%), weight gain (42.2%), and sexual dysfunction (38.9%). Sexual dysfunction was nominal significantly more common among the patients that had been treated with antipsychotic agent polypharmacy (odds ratio [OR], 2.14; 95% confidence interval [CI], 1.07 to 4.30), and was nominal significantly more common among outpatients (OR, 1.78; 95% CI, 1.02 to 3.13). Only approximately 30% of the patients had reported their symptoms to their physicians.

Conclusion

Patients receiving antipsychotic treatment tolerate some symptoms and do not feel able to report them to their physicians. The most common reason for this is an insufficient patient-physician relationship. Sexual dysfunction is especially hard to identify because it is a delicate problem, and our findings demonstrate that subjective questionnaires are helpful for detecting such symptoms.

Association of the Number of HLA-DR Mismatches With Early Post-transplant Acute Cellular Rejection Among Heart Transplantation Recipients: A Cohort Study in Japanese Population

BACKGROUND

Although many risk factors are reported about graft rejection after heart transplantation (HTx), the effect of HLA mismatch (MM) still remains unknown, especially in the Japanese population. The aim of the present study was to investigate the influence of HLA MM on graft rejection among HTx recipients in Japan.

METHODS

We retrospectively investigated the association of the number of HLA MM including class I (A, B) and class II (DR) (for each locus MM: 0 to 2, total MM: 0 to 6) and the incidence of moderate to severe acute cellular rejection (ACR) confirmed by endomyocardial biopsy (International Society for Heart and Lung Transplantation grade ≥ 3A/2R) within 1 year after HTx.

RESULTS

Between 2007 and 2014, we had 49 HTx cases in our institute. After excluding those with insufficient data and positive donor-specific antigen, finally 35 patients were enrolled. Moderate to severe ACR was observed in 16 (45.7%) patients. The number of HLA-DR MM was significantly associated with the development of ACR (ACR+: 1.50 ± 0.63, ACR-: 1.11 ± 0.46, P = .029). From univariate analysis, DR MM = 2 was the only independent risk factor for ACR episodes (P = .017). The frequency of ACR within 1 year was significantly higher in those with DR MM = 2 (DR MM = 0 to 1: 0.3 ± 0.47, DR MM = 2: 1.17 ± 1.34 times, P = .007).

CONCLUSIONS

The number of HLA-DR MMs was associated with the development and recurrence of ACR episodes among HTx recipients within 1 year after transplantation in Japanese population.