Quantification of Oscillatory Shear Stress from Reciprocating CSF Motion on 4D Flow Imaging

BACKGROUND AND PURPOSE

Oscillatory shear stress could not be directly measured in consideration of direction, although cerebrospinal fluid has repetitive movements synchronized with heartbeat. Our aim was to evaluate the important of oscillatory shear stress in the cerebral aqueduct and foramen magnum in idiopathic normal pressure hydrocephalus by comparing it with wall shear stress and the oscillatory shear index in patients with idiopathic normal pressure hydrocephalus.

MATERIALS AND METHODS

By means of the 4D flow application, oscillatory shear stress, wall shear stress, and the oscillatory shear index were measured in 41 patients with idiopathic normal pressure hydrocephalus, 23 with co-occurrence of idiopathic normal pressure hydrocephalus and Alzheimer-type dementia, and 9 age-matched controls. These shear stress parameters at the cerebral aqueduct were compared with apertures and stroke volumes at the foramen of Magendie and cerebral aqueduct.

RESULTS

Two wall shear stress magnitude peaks during a heartbeat were changed to periodic oscillation by converting oscillatory shear stress. The mean oscillatory shear stress amplitude and time-averaged wall shear stress values at the dorsal and ventral regions of the cerebral aqueduct in the idiopathic normal pressure hydrocephalus groups were significantly higher than those in controls. Furthermore, those at the ventral region of the cerebral aqueduct in the idiopathic normal pressure hydrocephalus group were also significantly higher than those in the co-occurrence of idiopathic normal pressure hydrocephalus with Alzheimer-type dementia group. The oscillatory shear stress amplitude at the dorsal region of the cerebral aqueduct was significantly associated with foramen of Magendie diameters, whereas it was strongly associated with the stroke volume at the upper end of the cerebral aqueduct rather than that at the foramen of Magendie.

CONCLUSIONS

Oscillatory shear stress, which reflects wall shear stress vector changes better than the conventional wall shear stress magnitude and the oscillatory shear index, can be directly measured on 4D flow MR imaging. Oscillatory shear stress at the cerebral aqueduct was considerably higher in patients with idiopathic normal pressure hydrocephalus.

Weight loss early after discharge predicts the risk of rehospitalization in non-obese patients with heart failure preserved ejection fraction

Background

Weight loss (WL) has been considered as a prognostic factor in heart failure with reduced ejection fraction (HFrEF). However, the prognosis and associated factors of WL in heart failure with preserved ejection fraction (HFpEF) have remained unclear.

Purpose

This study aimed to examine the prevalence, prognosis, and clinical characteristics of worse prognosis based on the identified WL after discharge in HFpEF.

Methods

The study was conducted as a part of a multicenter cohort study (Flagship). The cohort study enrolled ambulatory HF who hospitalized due to acute HF or exacerbation of chronic HF. Patients with severe cognitive, psychological disorders or readmitted within 6-month after discharge were excluded in the study. WL was defined as ≥5% weight loss in 6-month after discharge and HFpEF was defined as left ventricular ejection fraction (LVEF) ≥50% at discharge. Age, gender, etiology, prior HF hospitalization, New York Heart Association (NYHA) class, brain natriuretic peptide (BNP) or N-terminal-proBNP (NT-proBNP), anemia (hemoglobin; male <13g/dL, female <12g/dL), serum albumin, Geriatric Depression Scale, hand grip strength and comorbidities were collected at discharge. Patients were stratified according to their body mass index (BMI) at discharge as non-obese (BMI <25) or obese (BMI ≥25). We analyzed the association between WL and HF rehospitalization from 6 month to 2 years after discharge using Kaplan-Meier curve analysis and Cox regression analysis adjusted for age and gender, and clinical characteristics associated to worse prognosis in WL using logistic regression analysis adjusted for potential confounders in HFpEF.

Results

A total of 619 patients with HFpEF were included in the analysis. The prevalence of WL was 12.9% in 482 non-obese and 15.3% in 137 obese patients. During 2 years, 72 patients were readmitted for HF (non-obese: 48, obese: 24). WL in non-obese independently associated with poor prognosis (hazard ratio: 2.2: 95% confidence interval: 1.13–4.25) after adjustment for age and sex, while WL in obese patients did not. Logistic regression analysis chose age (odds ratio 1.02 per 1 year; 1.00–1.05), anemia (2.14; 1.32–3.48), and BNP ≥200pg/mL or NT-proBNP ≥900pg/mL (1.83; 1.18–2.86) as independent associated factors for worse prognosis of WL in non-obese patients.

Conclusion

In HFpEF, WL in early after discharge in non-obese elderly patients may be a prognostic indicator for HF rehospitalization. HF management including WL prevention along with controlling anemia is likely to improve prognosis in this population.

Kaplan Meier survival curves

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): A Grant-in-Aid for Scientific Research (A) from the Japan Society for the Promotion of Science

Predicters of physical activity at 3-month after discharge in patients underwent percutaneous coronary intervention -A multicenter prospective cohort study

Background

Long-term prognosis after percutaneous coronary intervention (PCI), particularly non-target region stenosis, has not been well improved. Therefore, lifestyle modification should be considered along with medication to prevent the progression of coronary atherosclerosis. Particularly, the promotion of physical activity (PA) is recommended as a core intervention for secondary prevention because of its direct effects on coronary risk factors. However, the factors related to PA after PCI have not been fully investigated.

Purpose

To explore predictors of PA after discharge in patients underwent PCI.

Methods

We conducted a multicenter prospective cohort study. Participants were patients aged <75 years who underwent PCI. The main outcome was PA {step counts (SC) and a time of moderate-to-vigorous physical activity (MVPA)} measured for 7 consecutive days using an accelerometer at 3-month post discharge. We collected demographic data, comorbidities, medical history, laboratory data, and medications from medical record. In addition, severity of chest pain at the onset, physician's explanation regarding long-term prognosis, exercise environments, social support, work, lifestyle except exercise, self-efficacy for walking, difficulty in daily activities and depression were evaluated using questionnaires at discharge and 1-month post-discharge. The study participants were divided into two groups based on the median SC and MVPA at 3-month, and clinical characteristics were compared between the groups using χ2test or Mann Whitney U test. Then, multiple logistic regression analysis adjusted for age, gender, and diagnosis {stable angina or acute coronary syndrome (ACS)} was conducted with 3-month PA as dependent variable. Independent variables were those with a p<0.2 in the univariate analysis. In addition, the area under the curve (AUC) was calculated by receiver operating characteristic analysis to assess predictive accuracy of the regression model.

Results

We enrolled 313 patients [median age: 63 {inter-quartile range (IQR):56–67} years, women: 13.1%, ACS: 16.4%]. The median of SC and MVPA at 3-month were 6902 steps (IQR:5078–9095) and 16.2 min (IQR: 8.6–28.9), respectively. Predictors of SC at 3-month ≥the median were SC at 1-month (odds ratio 1.78, per 1000 steps/day; 95% confidence interval 1.51–2.09), hemoglobin (1.43, per 1g/dl; 1.10–1.86), body mass index (BMI) (0.87, per 1kg/m2; 0.82–0.99), use of β-blocker (0.49, 0.25–0.95), and self-efficacy for walking (1.06, per 1 point; 1.00–1.11). Predictors of MVPA ≥the median were MVPA at 1-month (5.66, per 10 minutes/day; 3.63–8.84), hemoglobin (1.57, per 1g/dl; 1.19–2.06), and BMI (0.85, per 1kg/m2; 0.76–0.94). The AUC of the regression model for SC and MVPA were 0.87 and 0.89, respectively.

Conclusion

PA after PCI could be predicted by modifiable factors with good predictive accuracy. The findings of this study suggest the possibility to develop tailored PA promotion program.

Funding Acknowledgement

Type of funding source: None

Efficacy of neuromuscular electro stimulation on muscle strength in elderly patients with diabetes mellitus underwent cardiovascular surgery – a multicenter randomized controlled trial

Introduction

Cardiovascular surgery causes muscle weakness probably due to a postoperative increase in inflammatory cytokine production, and diabetes mellitus (DM) may promote the postoperative muscle weakness because of increased insulin resistance.

Purpose

A multicenter randomized controlled trial was conducted to examine the effects of postoperative neuromuscular electrical stimulation (NMES) on muscle strength for elderly patients with DM after cardiovascular surgery (UMIN000029940).

Methods

Patients underwent cardiovascular surgery were consecutive screened for eligibility (With DM and age ≥65 years) as study subjects. If eligible, patients were randomly assigned either to the NMES or the sham group. Both of group underwent NMES or sham stimulation (60 minutes / 5 times) and usual postoperative early mobilization program until postoperative day (POD) 7. The primary outcome was the percent change in knee extensor isometric muscle strength (%ΔKEIS) between preoperative to POD 7. Secondary outcomes were the percent change in usual (%ΔUsual walking speed) and maximum walking speed (%ΔMaximum walking speed) and grip strength (%ΔGS). Assessors for physical function were blinded to the outcomes. The statistician who was blinded to the allocation analyzed the data using preoperative value adjusted ANCOVA.

Results

Of 1151 consecutive patients screened for eligibility from February 2018 to January 2020, 158 participants (NMES group, n=79; sham group, n=79) were enrolled. NMES group demonstrated significantly lower %ΔKEIS compared with those in the sham group (Table). Among secondary outcomes, NMES group showed significantly lower %ΔMaximum walking speed and tendency of lower %ΔUsual walking speed and %ΔGS (Table).

Conclusion

NMES prevented postoperative muscle weakness in the elderly patients with DM, indicating that NMES along with early mobilization could be implicated as specific intervention to those populations.

Funding Acknowledgement

Type of funding source: None

Changes in nutritional status by recovery phase interventions would be a powerful determinant of cardiovascular prognosis in heart failure patients

Background

Adequate nutrition has been proposed for better cardiovascular prognosis as well as fitness, although the impact of the “changes” in nutrition and fitness at recovery phase on the future prognosis has been unclear.

Purpose

We aimed to examine whether the change in nutritional level as a result of dietary intervention combined with exercise would determine patients' cardiovascular prognosis.

Methods

This study involved 398 consecutive patients who participated in phase II comprehensive cardiac rehabilitation (CCR) for at least three months. All patients underwent cardiopulmonary exercise test (CPX) at the initial and completion periods of CCR. Individual dietary guidance was periodically performed with exercise. Peak oxygen uptake (PVO2) was measured through CPX to evaluate the fitness level, whereas nutritional status was evaluated using the geriatric nutritional risk index (GNRI). Patients were divided in two groups according to the baseline GNRI and the change in GNRI (ΔGNRI) by the median, respectively, to compare their prognosis between groups. Then they were classified into four categories according to the median values of the changes in GNRI (ΔGNRI) and PVO2 (ΔPVO2) during CCR: “Both improved”, “Only GNRI improved”, “Only PVO2 improved” and “Both NOT improved”, to compare MACCE-free rate between categories.

Results

The rate of MACCE showed significant difference between categories (14%, 18%, 19% and 36%, p<0.001), which was approximately 2 times higher in “Both NOT improved” than the others. Kaplan-Meier analysis showed that according to the level of ΔGNRI, “higher ΔGNRI group” showed significantly higher in MACCE-free survival rate than “lower ΔGNRI group” (log rank p=0.010), whereas there was no significant difference according to the baseline GNRI (see figure). According to the categories divided by ΔGNRI and ΔPVO2, MACCE-free rate was significantly lower in “Both NOT improved” (log rank p<0.001) compared to the other categories. Cox proportional hazard regression analysis revealed that “both NOT improved” was an independent predictor of MACCE (hazard ratio, 2.1, 95% confident interval, 1.344–3.175, p<0.001).

Conclusion

Changes in nutritional level would determine patients' cardiovascular prognosis rather than the baseline nutritional level. Non-responders who showed no improvement in nutritional or fitness by interventions may result in a poor cardiovascular outcome.

Funding Acknowledgement

Type of funding source: None

Pancreatic Neuroendocrine Neoplasm Invading the Entire Main Pancreatic Duct Diagnosed by a Preoperative Endoscopic Biopsy

A 78-year-old man was referred to our hospital for a detailed examination of a pancreatic tumor that filled the main pancreatic duct (MPD). The histological diagnosis of the endoscopic biopsy specimen was neuroendocrine tumor (NET) G3. The patient subsequently underwent total pancreatectomy. The histological diagnosis of the surgical specimen was also NET G3. This is the first report of a NET that occupied the MPD and was diagnosed by a preoperative endoscopic biopsy through the papilla of Vater. This case is a good example of a histopathological diagnostic method for pancreatic tumors invading the entire MPD.

Very late relapse of high-grade osteosarcoma: A case report and review of the literature

RATIONALE

Osteosarcoma is the most common primary malignant bone tumor in children. The prognosis of osteosarcoma has improved with the use of aggressive systemic chemotherapy in addition to surgery. The relapse of osteosarcomas is usually as lung metastasis observed within 2 to 3 years after the initial treatment. A relapse is rarely observed at >10 years.

PATIENT CONCERNS

We report the case of a 51-year-old Japanese man who was treated for high-grade osteosarcoma of the femur at 13 years old. He was referred to our hospital with a suspicion of primary lung cancer based on back pain, respiratory distress, and an abnormal mass on chest radiograph.

DIAGNOSES

Computed tomography-guided biopsy confirmed the lung lesion as a metastatic recurrence of high-grade osteosarcoma without local recurrence.

INTERVENTIONS

Chemotherapy was planned, but the patient's general condition rapidly deteriorated and thus palliative therapy was provided.

OUTCOMES

The patient died 2 months after the initial consultation.

LESSONS

The survival durations of osteosarcoma patients have been prolonged by recent progress in multimodality therapy, and thus clinicians as well as osteosarcoma patients should always keep in mind the possibility of very late relapse.

Phase I/II study of adding intraperitoneal paclitaxel in patients with pancreatic cancer and peritoneal metastasis

BACKGROUND

Intraperitoneal chemotherapy using paclitaxel is considered an experimental approach for treating peritoneal carcinomatosis. This study aimed to determine the recommended dose, and to evaluate the clinical efficacy and safety, of the combination of intravenous gemcitabine, intravenous nab-paclitaxel and intraperitoneal paclitaxel in patients with pancreatic cancer and peritoneal metastasis.

METHODS

The frequencies of dose-limiting toxicities were evaluated, and the recommended dose was determined in phase I. The primary endpoint of the phase II analysis was overall survival rate at 1 year. Secondary endpoints were antitumour effects, symptom-relieving effects, safety and overall survival.

RESULTS

The recommended doses of intravenous gemcitabine, intravenous nab-paclitaxel and intraperitoneal paclitaxel were 800, 75 and 20 mg/m² respectively. Among 46 patients enrolled in phase II, the median time to treatment failure was 6·0 (range 0-22·6) months. The response and disease control rates were 21 of 43 and 41 of 43 respectively. Ascites disappeared in 12 of 30 patients, and cytology became negative in 18 of 46. The median survival time was 14·5 months, and the 1-year overall survival rate was 61 per cent. Conversion surgery was performed in eight of 46 patients, and those who underwent resection survived significantly longer than those who were not treated surgically (median survival not reached versus 12·4 months). Grade 3-4 haematological toxicities developed in 35 of 46 patients, whereas non-haematological adverse events occurred in seven patients.

CONCLUSION

Adding intraperitoneal paclitaxel had clinical efficacy with acceptable tolerability.

1215 Improving Sleep Disorders And Chronic Neck Pain By Adjusting Height Of The Pillow Through Cervical Posture Management

Introduction

Recent studies have suggested that chronic musculoskeletal system pain, including chronic neck pain, accounts for approximately 70% of all sleeping disorders. Simultaneously, sleeping disorders increase pain sensitivity and create a vicious cycle of chronic neck pain. Patients with chronic pain experience a variety of somatic symptoms (e.g., Stomach or bowel problems, Back pain, Pain in your joints, headaches, chest pain, shortness of breath, dizziness, fatigue, and Trouble sleeping) that are difficult to treat. However, treatment of both neck chronic pain and sleeping disorders through cervical posture management by adjusting height of the pillow used while sleeping has yet to be considered.

Methods

Patients who visited our hospital with chief complaints of chronic neck pain were rated according to the Numerical Rating Scale (NRS) and were asked to answer the Somatic Symptom Scale-8 (SSS-8), to ascertain the degree of somatic symptoms. Out of all the patients, only 84 scored at least 8 out of 32 in the SSS-8. Based on the individual results of the 84 respondents, they were given customized pillows to be used for 3 months. The pillows were adjusted using the SSS method developed at our clinic. We adjusted the height of the pillow by 5mm increments to check the cervical inclination angle at approximately 15 degrees in supine position, lateral position with the center line from face to neck at left-right symmetry and finally confirming smooth turning over. The respondents performed NRS and SSS-8 after 2 weeks and 3 months of using the pillow.

Results

The results of this study showed that at 0 weeks / 2 weeks / 3 months. NRS score was 6.8 / 5.1 / 4.1 (p <0.01), and the overall SSS-8 score was 13.2 / 9.9 / 8.2 (p <0.01), showed a marked improvement. By symptom, all symptoms except Stomach or bowel problems showed significant improvement. Trouble sleeping showed the highest improvement at 2.6 / 1.7 / 1.3 (p <0.01).

Conclusion

Chronic neck pain and sleeping disorders improved in the patients. These results suggested that cervical posture management by adjusting height of the pillow is an effective treatment method.

Support

None

Search for an Invisibly Decaying Z^{'} Boson at Belle II in e^{+}e^{-}→μ^{+}μ^{-}(e^{±}μ^{∓}) Plus Missing Energy Final States

Theories beyond the standard model often predict the existence of an additional neutral boson, the Z^{'}. Using data collected by the Belle II experiment during 2018 at the SuperKEKB collider, we perform the first searches for the invisible decay of a Z^{'} in the process e^{+}e^{-}→μ^{+}μ^{-}Z^{'} and of a lepton-flavor-violating Z^{'} in e^{+}e^{-}→e^{±}μ^{∓}Z^{'}. We do not find any excess of events and set 90% credibility level upper limits on the cross sections of these processes. We translate the former, in the framework of an L_{μ}-L_{τ} theory, into upper limits on the Z^{'} coupling constant at the level of 5×10^{-2}-1 for M_{Z^{'}}≤6  GeV/c^{2}.

The Performance of Belle II High Level Trigger in the First Physics Run

The Belle II experiment is a new generation B-factory experiment at KEK in Japan aiming at the search for New Physics in a huge sample of B-meson decays. The commissioning of the accelerator and the detector for the first physics run has started from March this year. The Belle II High Level Trigger (HLT) is fully working in the beam run. The HLT is now operated with 1600 cores clusterized in 5 units, which is 1/4 of the full configuration. The software trigger is performed using the same offline reconstruction code, and events are classified into a set of physics categories. Only the events in the categories of interest are finally sent out to the storage. Live data quality monitoring is also performed on HLT. For the selected events, the reconstructed tracks are extrapolated to the surface of the pixel detector (PXD) and quickly fed back to the readout electronics for the real time data reduction by sending only the associated hits. The maximum trigger rate in the first physics run was 3.5kHz, and the Belle II data acquisition system was stably operated. There were several problems in the HLT operation, but they have successfully been fixed during the data taking period. The HLT reduction factor is measured to be 8 which is still higher than the design because of the high background environment.

Metabolic Syndrome and Cognitive Function: Cross-Sectional Study on Community-Dwelling Non-Demented Older Adults in Japan

AIM

This is a cross-sectional study of relation between metabolic syndrome and cognitive function in community-dwelling non-demented older adults in Japan. We examine the effect of metabolic syndrome and its components on global cognitive function. We also aim to clarify differences of specific cognitive domains between the subjects with and without metabolic syndrome.

METHODS

We studied 2150 subjects aged between 60 and 90 years whose scores on mini mental state examination (MMSE) were over 23 points. We analyzed difference in MMSE scores between the subjects with and without metabolic syndrome. Logistic regression analysis was performed with MMSE score as the dependent variable and metabolic syndrome components as the independent variable adjusted with age. We also examined differences in attention, logical memory, and verbal and category fluency between the subjects with and without metabolic syndrome.

RESULTS

MMSE scores were not significantly different between subjects with and without metabolic syndrome. In logistic regression analysis, the score of MMSE was significantly negatively associated with triglycerides in males and significantly negatively associated with abdominal circumference in females. Subjects with metabolic syndrome showed significantly lower performance of attention tasks compared to subjects without metabolic syndrome.

CONCLUSIONS

Our results suggest that in community-dwelling non-demented Japanese older adults, attention but not global cognitive function may be impaired by metabolic syndrome. Inverted association between some components of metabolic syndrome and global cognitive function indicate necessity of further studies on the relation between undernutrition and cognitive function.

Cytohistology of morule in cribriform-morular variant of papillary thyroid carcinoma

INTRODUCTION

Cribriform-morular variant (CMV) is a rare variant of papillary thyroid carcinoma. It frequently occurs in association with familial adenomatous polyposis (FAP), although some cases are sporadic. Herein, we report a case of CMV and analyse morule cytohistology.

CASE REPORT

The patient was a 47-year-old woman with no familial history of FAP. A 3.0-cm unifocal mass was identified in the left thyroidal lobe. Fine-needle aspiration cytology revealed papillary clusters of atypical cells with nuclear grooves, which was suspected to be conventional papillary thyroid carcinoma. Histologically, the tumour comprised a papillary and cribriform growth of atypical cells with cytoplasmic accumulation and nuclear translocation of b-catenin. In addition, frequent morule formation was identified.

DISCUSSION

In this case, we performed morule analysis through correlative light and electron microscopy (CLEM), and revealed its ultrastructure. Although CMV is a rare form of thyroid carcinoma, it should be considered along with its distinct clinicopathological characteristics.

P3467Tricuspid annular isovolumic acceleration is more useful for the assessment of right ventricular systolic function in patients after repair of tetralogy of Fallot with pulmonary regurgitation

Introduction

The detrimental impact of pulmonary regurgitation (PR) on right ventricular (RV) function of patients after repair of tetralogy of Fallot (TOF) is recognized. Although tricuspid annular isovolumic acceleration (IVA) is useful for the evaluation of RV function, it requires complicated measurement. Tricuspid annular plane systolic excursion (TAPSE) is measured easily and has also been validated as a marker of RV systolic function.

Hypothesis

We assessed the hypothesis that IVA has advantage to the stratification of the detrimental impact of PR on RV systolic function after TOF repair compared with TAPSE.

Methods

We prospectively examined patients after TOF repair. Patients <1 year after the repair, those with the history of sustained arrhythmia and those who required concomitant tricuspid and/or pulmonary valve surgery were excluded from the study. IVA was measured by dividing the myocardial velocity during isovolumic contraction by the time interval from the onset of the myocardial velocity during the isovolumic contraction to the time at the peak velocity of this wave. TAPSE was measured using M-mode echocardiography with the M-line passing through the lateral annulus of tricuspid valve in the apical 4-chamber plane. PR jets were evaluated in the parasternal short-axis plane. PR degree was assessed by the number of correspondence to the following conditions; 1) diastolic flow reversal in the main pulmonary artery, 2) diastolic flow reversal in the branch pulmonary arteries, 3) pressure half-time of PR signal <100 msec and 4) the ratio of the duration of the PR signal to the total duration of diastole <0.77. PR degree was graded from 0 to 4.

Results

Twenty-two patients were enrolled to the study. Age, female, period after the TOF repair and body height of the patients were 11±6 years, 55%, 9±5 years and 137±28 cm, respectively. In all the patients, IVA and TAPSE were 160±27 cm/sec2 and 12±2 mm, respectively. PR degrees were graded as 2, 3 and 4 in 4, 14 and 4 patients, respectively. By the Kruskal-Wallis test, only IVA showed a significant difference among the 3 PR degrees.

Conclusion

In conclusion, IVA can be a useful index for the stratification of RV function in patients after TOF repair with various degrees of PR.

P6322Trajectories of functional limitations during 14 months after discharge among patients with heart failure: a multicenter cohort study

Background

Severity of functional limitations (FLs) has been considered as a prognostic factor in patients with heart failure (HF). However, trajectory patterns of FLs after discharge and their associated factors have remained unclear.

Purpose

This study aimed to explore trajectories of FLs after discharge and to examine clinical characteristics based on the identified trajectories.

Methods

This study was performed as a part of a multicenter cohort study. The cohort study enrolled hospitalized patients due to acute HF or exacerbation of chronic HF and who were able to walk at discharge. Patients with severe cognitive or psychological disorders or less than 6-month life expectancy were excluded. FLs were assessed using Performance Measure for Activities of Daily Living-8 (PMADL-8; higher scores indicate worse FLs) at discharge and 1-, 6-, 10- and 14-month after discharge. To identify FLs trajectories getting worse after discharge, we excluded patients already having severe FLs at discharge (PMADL-8 ≥21, a cut off value for predicting poor prognosis). Group-based trajectory modeling (GBTM) was conducted to identify distinct PMADL-8 trajectories. Then, associated factors of trajectory group that showed increasing FLs after discharge were examined using logistic regression analysis adjusted for potential confounders.

Results

A total of 953 patients were included in the analysis (age: 70.6±11.8 years, men: 70.9%, left ventricular ejection fraction <40%: 41.3%). GBTM identified four PMADL-8 trajectories: two separate trajectories where PMADL-8 remained low (T1: 14.1%, T2: 31.3%), mildly increasing PMADL-8 trajectory (T3: 41.0%) and rapidly increasing PMADL-8 trajectory (T4: 13.6%) (Figure). Logistic regression analysis showed that age (odds ratio 1.05, per 1 year; 95% confidence interval 1.02–1.07), women (2.12; 1.31–3.45), brain natriuretic peptide ≥200 pg/mL (1.88; 1.10–3.21), estimated glomerular filtration rate <30 mL/min/1.73m2 (2.50; 1.41–4.41), depression (2.34; 1.44–3.80), and re-hospitalization due to HF during 1-year follow-up (2.85; 1.56–5.21) were independent associated factors of T4 group.

Figure 1. Trajectories of PMADL-8

Conclusions

The high-risk population for increasing FLs after discharge was identified by GBTM. The findings of this study suggest the importance of long-term HF management for preventing FLs after discharge especially among those with older age, female gender and depression.

Acknowledgement/Funding

This work was supported by a Grant-in-Aid for Scientific Research (A) from the Japan Society for the Promotion of Science [16H01862].

P2528Responsiveness to nutritional intervention would impact on future cardiovascular prognosis in poor fitness patients

Purpose

Nutritional improvement has been proposed for long-term cardiovascular prognosis as well as fitness recovery. We aimed to examine whether “responsiveness” to nutritional and exercise interventions would impact patients' cardiovascular prognosis even patients in low baseline fitness level.

Methods

We included 254 consecutive patients who participated in the phase II comprehensive cardiovascular rehabilitation (CCR) for at least three months. All patients underwent cardiopulmonary exercise test (CPX) at the initial and completion phases of CCR. Nutritional guidance was periodically performed individually during CCR. Peak oxygen uptake (PVO2) was measured through CPX to evaluate the fitness level, whereas nutritional status was evaluated using the geriatric nutritional risk index (GNRI). Patients were divided into “low fitness” and “normal fitness” groups based on the median of baseline PVO2. Each group was further classified into four categories according to the changes in VO2 and GNRI during CCR: “Both NOT improved”, “Only GNRI improved”, “Only PVO2 improved”, and “Both improved”.

Results

Cox proportional regression analysis showed that the category of “both NOT improved” was an independent predictor for cardiovascular risk among the baseline low fitness group (Hazard ratio: 4.5, p=0.007); whereas no significant difference among the normal fitness group. Kaplan-Meier analysis revealed that the event-free survival rate was significantly lower in the “both NOT improved” category (log rank p=0.002) among the baseline low fitness group (figure); whereas no significant difference among the normal fitness group.

GNRI/PVO2 improvement vs. prognosis

Conclusion

Responsiveness to nutritional and exercise intervention could be a predictive factor of cardiovascular prognosis even in low fitness patients.