Both High and Low Body Mass Indexes are Prognostic Risks in Japanese Patients With Chronic Heart Failure: Implications From the CHART Study

Heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) accounts for nearly half of all heart failure cases and has a prevalence that is expected to rise with the growing ageing population. HFpEF is associated with significant morbidity and mortality. Specific HFpEF risk factors include age, diabetes, hypertension, obesity and atrial fibrillation. Haemodynamic contributions to HFpEF include changes in left ventricular structure, diastolic and systolic dysfunction, left atrial myopathy, pulmonary hypertension, right ventricular dysfunction, chronotropic incompetence, and vascular dysfunction. Inflammation, fibrosis, impaired nitric oxide signalling, sarcomere dysfunction, and mitochondrial and metabolic defects contribute to the cellular and molecular changes observed in HFpEF. HFpEF impacts multiple organ systems beyond the heart, including the skeletal muscle, peripheral vasculature, lungs, kidneys and brain. The diagnosis of HFpEF can be made in individuals with signs and symptoms of heart failure with abnormality in natriuretic peptide levels or evidence of cardiopulmonary congestion, facilitated by the use of HFpEF risk scores and additional imaging and testing with the exclusion of HFpEF mimics. Management includes initiation of guideline-directed medical therapy and management of comorbidities. Given the significant impact of HFpEF on quality of life, future research efforts should include a particular focus on how patients can live better with this disease.

Sex Differences in Cardiac and Clinical Phenotypes and Their Relation to Outcomes in Patients with Heart Failure

Biological sex is one of the major factors characterizing the heart failure (HF) patient phenotype. Understanding sex-related differences in HF is crucial to implement personalized care for HF patients with various phenotypes. There are sex differences in left ventricular (LV) remodeling patterns in the HF setting, namely, more likely concentric remodeling and diastolic dysfunction in women and eccentric remodeling and systolic dysfunction in men. Recently supra-normal EF (snLVEF) has been recognized as a risk of worse outcome. This pathology might be more relevant in female patients. The possible mechanism may be through coronary microvascular dysfunction and sympathetic nerve overactivation from the findings of previous studies. Further, estrogen deficit might play a significant role in this pathophysiology. The sex difference in body composition may also be related to the difference in LV remodeling and outcome. Lower implementation in guideline-directed medical therapy (GDMT) in female HFrEF patients might also be one of the factors related to sex differences in relation to outcomes. In this review, we will discuss the sex differences in cardiac and clinical phenotypes and their relation to outcomes in HF patients and further discuss how to provide appropriate treatment strategies for female patients.

Nutritional management of heart failure

Nutrition in the cardiovascular field to date has focused on improving lifestyle-related diseases such as hypertension and diabetes from the viewpoint of secondary prevention. For these conditions, "nutrition for weight loss" is recommended, and nutritional guidance that restricts calories is provided. On the other hand, in symptomatic Stage C and D heart failure, it is known that underweight patients who manifest poor nutrition, sarcopenia, and cardiac cachexia have a poor prognosis. This is referred to as the "Obesity paradox". In order to "avoid weight loss" in patients with heart failure, a paradigm shift to nutritional management to prevent weight loss is needed. Rather than prescribing uniform recommendation for salt reduction of 6 g/day or less, awareness of the behavior change stage model is attracting attention. In this setting, the value of salt restriction will need to be determined to determine the priority level of intervention for undernutrition versus the need to prevent congestive signs and symptoms. In the Intensive Care Unit (ICU)/Cardiac Care Unit (CCU) for acute heart failure, nutritional intervention should be considered within 48 h of admission. Key points are selection of access route, timing of intervention, and monitoring of side effects. In nutritional management at home and in end-of-life care, food is a reflection of an individual's values, as well as a source of joy and encouragement. The importance of digestive tract should also be recognized in heart failure from oral flail to intestinal edema, constipation, and the intestinal bacteria called the heart-gut axis. Finally, we would like to propose a new term "heart nutrition" for nutritional management in patients with heart failure in this review. Compared to the evidence for exercise therapy in heart failure, studies assessing nutritional management remain scarce and there is a need for research in this area in the future.

Multimorbidity, guideline-directed medical therapies, and associated outcomes among hospitalized heart failure patients

Aims

Multimorbidity is common among heart failure (HF) patients and may attenuate guideline‐directed medical therapy (GDMT). Multimorbid patients are under‐represented in clinical trials; therefore, the effect of multimorbidity clustering on the prognosis of HF patients remains unknown. We evaluated the prevalence of multimorbidity clusters among consecutively registered hospitalized HF patients and assessed whether GDMT attenuated outcomes.

Methods and results

We examined 1924 hospitalized HF patients with reduced left ventricular ejection fraction (<50%) in a multicentre registry (West Tokyo HF Registry: WET‐HF). Ten comorbid conditions in the WET‐HF were abstracted: coronary artery disease, atrial fibrillation, stroke, anaemia, chronic obstructive pulmonary disease, renal dysfunction, obesity, hypertension, dyslipidaemia, and diabetes. Patients were divided into three groups (0–2: n = 451; 3–4: n = 787; and ≥5: n = 686) based on the number of comorbid conditions. The primary composite endpoint was all‐cause mortality and HF rehospitalization. The most prevalent comorbidities were renal dysfunction (67.9%), hypertension (66.0%), and anaemia (53.8%). Increased comorbidity was associated with increased adverse outcomes [3–4: hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.13–1.77, P = 0.003; ≥5: HR 2.12, 95%CI 1.69–2.65, P < 0.001; and reference: 0–2] and lower GDMT prescription rate (0–2: 69.2%; 3–4: 57.7%; and ≥5: 57.6%). GDMT was associated with decreased adverse outcomes; this association was maintained even as the comorbidity burden increased but tended to weaken (0–2: HR 0.53, 95%CI 0.35–0.78; P = 0.001; 3–4: HR 0.82, 95%CI 0.65–1.04, P = 0.095; and ≥5: HR 0.81, 95%CI 0.65–1.00, P = 0.053; P for interaction = 0.156).

Conclusions

Comorbidity clusters were prevalent and associated with poorer outcomes. GDMT remained beneficial regardless of the comorbidity burden but tended to weaken with increasing comorbidity burden. Further research is required to optimize medical care in these patients.

Obesity, inflammation, and heart failure: links and misconceptions

Obesity has been linked with heart failure (HF) with preserved left ventricular (LV) ejection fraction (HFpEF). This link has been attributed to obesity-induced metabolic and inflammatory disturbances leading to HFpEF. However, HF is a syndrome in which disease evolvement is associated with a dynamic unraveling of functional and structural changes leading to unique disease trajectories, creating a spectrum of phenotypes with overlapping distinct characteristics extending beyond the LV ejection fraction (LVEF). In this regard, despite quantitative differences between the two extremes (HFpEF and HF with reduced LVEF, HFrEF), there is important overlap between the phenotypes along the entire spectrum. In this paper, we describe the systemic pro-inflammatory state that is present throughout the HF spectrum and emphasize that obesity intertwines with HF beyond the LVEF construct.

Prognostic impacts of serum uric acid levels in patients with chronic heart failure: insights from the CHART-2 study

AIMS

Prognostic impacts of serum uric acid (UA) levels in patients with chronic heart failure (CHF) remain inconclusive, especially for the whole range of serum UA levels.

METHODS AND RESULTS

In the Chronic Heart Failure Registry and Analysis in the Tohoku District-2 (CHART-2) study, we enrolled 4652 consecutive patients with CHF and classified them into four groups based on baseline serum UA levels by the Classification and Regression Tree: G1 (<3.8 mg/dL, N = 313), G2 (3.8-7.1 mg/dL, N = 3070), G3 (7.2-9.2 mg/dL, N = 1018), and G4 (>9.2 mg/dL, N = 251). Mean age was 71 ± 12, 69 ± 12, 68 ± 13, and 69 ± 15 years in G1, G2, G3, and G4, respectively (P < 0.001). During the median follow-up of 6.3 years, in G1, G2, G3, and G4, 111 (35%), 905 (29%), 370 (36%), and 139 (55%) patients died and 79 (25%), 729 (24%), 300 (29%), and 115 (46%) experienced heart failure hospitalization, respectively (both P < 0.001). G1 was characterized by a significantly high prevalence of women as compared with G2, G3, and G4 (59%, 32%, 24%, and 23%, respectively). Serum creatinine levels (0.8 ± 0.4, 0.9 ± 0.4, 1.2 ± 0.6, and 1.4 ± 0.8 mg/dL, respectively), prevalence of atrial fibrillation (34%, 39%, 45%, and 50%, respectively), and diuretics use (36%, 45%, 67%, and 89%, respectively) increased from G1, G2, G3 to G4 (all P < 0.001), while left ventricular ejection fraction decreased from G1, G2, G3 to G4 (59 ± 15, 58 ± 15, 54 ± 15, and 52 ± 17%, respectively, P < 0.001). Multivariable Cox proportional hazards models showed that, as compared with G2, both G1 and G4 had increased incidence of all-cause death [adjusted hazard ratio (aHR) 1.34, 95% confidence interval (CI) 1.08-1.67, P = 0.009; aHR 1.28, 95% CI 1.02-1.61, P = 0.037, respectively] and heart failure admission (aHR 1.39, 95% CI 1.09-1.78, P = 0.008 and aHR 1.35, 95% CI, 1.06-1.71, P = 0.014, respectively). This U-shaped relationship was evident in the elderly patients. Furthermore, abnormal transitions to either higher or lower levels of serum UA from G2 were associated with increased mortality (aHR 1.29, 95% CI 1.06-1.57, P = 0.012; aHR 1.57, 95% CI 1.12-2.20, P = 0.009).

CONCLUSIONS

These results demonstrate that serum UA levels have the U-shaped prognostic effects and abnormal transitions to either higher or lower levels are associated with poor prognosis in the elderly patients with CHF.

Obesity paradox in Korean male and female patients with heart failure: A report from the Korean Heart Failure Registry

BACKGROUND

Although the survival benefit of obesity has been suggested in patients with heart failure (HF), the impact of sex on obesity paradox is less clear. This study was performed to investigate whether there is a sex difference in the association between body mass index (BMI) and long-term clinical outcomes in patients hospitalized for HF.

METHOD

A total of 2616 patients hospitalized for HF (Mean age 66 years and 52% males) from the nation-wide registry database were analyzed. Patients were categorized using baseline BMI as normal (18.5 to 22.9 kg/m²), overweight (23 to 27.4 kg/m²) and obese (≥ 27.5 kg/m²). Their all-cause mortality and long-term composite events, including all-cause mortality and HF readmission, were assessed according to the BMI groups.

RESULTS

During the median follow-up period of 1499 days, there were 662 patients (25.3%) with all-cause mortality and 1071 patients (40.9%) with composite events. Compared to the normal weight group, the overweight (hazard ratio [HR], 0.71; 95% confidence interval [CI], 0.51-0.99; P = 0.045) and obese (HR, 0.53; 95% CI, 0.29-0.95; P = 0.032) group showed lower all-cause mortality rates even after adjusting for confounding factors in the male patients. Otherwise, BMI was not associated with composite events in males; it was not associated with all-cause mortality or composite events in females in the multivariable analyses (P > 0.05 for each).

CONCLUSIONS

Among patients with HF, a greater BMI was associated with low all-cause mortality in males, but not in females. Obesity paradox should be considered in the management of HF patients.

Does Low Body Mass Index Predict Mortality in Asian Hospitalized Patients?

BACKGROUND

Studies on malnutrition suggest low body mass index (BMI) may be associated with poor clinical outcomes. We investigated published data to identify whether low BMI could predict short-term and long-term clinical outcomes in Asian hospitalized patients.

METHODS

A search was conducted in the PubMed database including terms "body mass index" or "BMI" or "malnutrition" or "undernutrition" AND "Asia" or "Asian" AND "outcome" or "complication" or "mortality" or "survival" or "ICU" for publications in English in the past 10 years. Papers with data and clinical outcomes from Asian hospitalized patients with BMI <18.5 kg/m² and sample size >50 were included. Forest plots were constructed to determine the odds of hospital complications, hospital mortality, intensive care unit (ICU) mortality, and 5-year mortality in patients with BMI <18.5 kg/m² vs BMI ≥18.5 kg/m² .

RESULTS

Twenty-three studies were included, 16 of which were analyzed for the association between low BMI and clinical outcomes. The prevalence of BMI <18.5 kg/m² varied from 3% to 48% in different disease settings and Asian areas. Patients with BMI <18.5 kg/m² had significantly higher ICU mortality (odds ratio [OR], 1.92; 95% CI, 1.84-2.01), higher hospital mortality (OR, 2.48; 95% CI, 2.42-2.55), and higher 5-year mortality (OR, 2.74; 95% CI, 2.08-3.63). Complications during hospital stay were significantly higher in patients with BMI <18.5 kg/m² (OR, 1.99; 95% CI, 1.65-2.40).

CONCLUSIONS

Low BMI defined as <18.5 kg/m² may predict worse short-term and longer-term outcomes in Asian hospitalized patients.

Complex interaction of obesity, intentional weight loss and heart failure: a systematic review and meta-analysis

OBJECTIVE

The aim of the meta-analysis was to determine the association of obesity and heart failure (HF) and the cardiac impact of intentional weight loss following bariatric surgery on cardiac structure and myocardial function in obese subjects.

METHODS

MEDLINE, Embase and Web of Science were searched up to 3 April 2018. Studies reporting association and prognostic impact of obesity in HF and the impact of intentional weight loss following bariatric surgery on cardiac structure and myocardial function in obesity were included in the meta-analysis.

RESULTS

4959 citations were reviewed. After exclusions, 29 studies were analysed. A 'J curve' relationship was observed between body mass index (BMI) and risk of HF with maximum risk in the morbidly obese (1.73 (95% CI 1.30 to 2.31), p<0.001, n=11). Although 'obesity paradox' was observed for all-cause mortality, the overweight group was associated with lower cardiovascular (CV) mortality (OR=0.86 (95% CI 0.79 to 0.94), n=11) with no significant differences across other BMI groups. Intentional weight loss induced by bariatric surgery in obese patients (n=9) without established HF, atrial fibrillation or known coronary artery disease, was associated with a reduction in left ventricular mass index (p<0.0001), improvement in left ventricular diastolic function (p≤0.0001) and a reduction in left atrial size (p=0.02).

CONCLUSIONS

Despite the increased risk of HF with obesity, an 'obesity paradox' is observed for all-cause mortality. However, the nadir for CV mortality is observed in the overweight group. Importantly, intentional weight loss was associated with improvement in indices of cardiac structure and myocardial function in obese patients.

TRIAL REGISTRATION NUMBER

APP 74412.

Prognostic significance of serum cholinesterase in patients with acute decompensated heart failure: a prospective comparative study with other nutritional indices

BACKGROUND

Nutritional status is associated with poor outcomes in patients with heart failure. Serum cholinesterase (CHE) concentration, a marker of malnutrition, was reported to be a prognostic factor in patients with chronic heart failure. The geriatric nutritional risk index (GNRI), the controlling nutritional status (CONUT) score, and the prognostic nutritional index (PNI) are established objective nutritional indices.

OBJECTIVE

The aim of this study was to clarify the prognostic significance of CHE concentration and to compare it with other well-established objective nutritional indices in patients with acute decompensated heart failure (ADHF).

METHODS

We prospectively enrolled 371 consecutive patients admitted for ADHF with survival discharge. Laboratory data including CHE and the objective nutritional indices were obtained at discharge. The primary endpoint of this study was all-cause mortality.

RESULTS

During a mean ± SD follow-up period of 2.5 ± 1.4 y, 112 patients died. CHE concentration was significantly associated with all-cause mortality independently of GNRI, CONUT score, or PNI, after adjustment for major confounders including other nutritional indices, such as age, sex, systolic blood pressure, BMI, left ventricular ejection fraction, history of hypertension, diabetes mellitus, dyslipidemia, prior heart failure hospitalization, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, β-blocker use, statin use, hemoglobin, sodium, blood urea nitrogen, albumin, C-reactive protein, and brain natriuretic peptide concentrations via multivariable Cox analysis. Kaplan-Meier analysis revealed that the risk of all-cause mortality significantly increased in accordance with CHE stratum [lowest tertile: 53%, adjusted HR: 6.92; 95% CI: 3.87, 12.36, compared with middle tertile: 28%, adjusted HR: 2.72; 95% CI: 1.45, 5.11, compared with highest tertile: 11%, adjusted HR: 1.0 (reference), P < 0.0001]. CHE showed the best area under the curve value (0.745) for the prediction of all-cause mortality compared with the other objective nutritional indices. Net reclassification improvement afforded by adding CHE to the fully adjusted multivariable model was statistically significant for all-cause mortality (0.330; 95% CI: 0.112, 0.549, P = 0.0030).

CONCLUSION

CHE is a simple, strong prognostic marker for the prediction of all-cause mortality in patients with ADHF.

Pre- and post-diagnosis body mass index and heart failure mortality: a dose-response meta-analysis of observational studies reveals greater risk of being underweight than being overweight

OBJECTIVE

To investigate the dose-response association between pre- and post-diagnosis body mass index (BMI) and heart failure (HF) mortality.

METHODS

Eligible observational studies were searched in databases, up to November 2017. We used random-effects generalized least squares spline models for trend estimation to derive pooled BMI unit-HF mortality relationship.

RESULTS

Sixteen cohort studies (six pre-diagnosis and 10 post-diagnosis BMI) were included, comprising a total of 258,379 subjects with 13,201 deaths due to HF. A nonlinear U-shaped association was found between pre-diagnosis BMI and the risk of HF mortality, with a greater risk from being at the lowest extreme, rather than being at the top category. The combined hazard ratio of HF mortality among the highest compared to the lowest category of pre-diagnosis BMI was 1.24 (0.65-2.37, I²  = 90.7%). No significant nonlinear association was found between post-diagnosis BMI and HF mortality as well as when comparing the highest to the lowest category of BMI.

CONCLUSIONS

This meta-analysis showed those with both high and low pre-diagnosis BMI had higher risk for HF mortality, with a greater risk from being too underweight, rather than being obese. No significant association was found between post-diagnosis BMI and the risk of HF mortality. Further detailed investigations are needed to accurately examine the potential mechanistic links between BMI and health outcomes.

Geriatric Nutritional Risk Index Predicts Cardiovascular Events in Patients at Risk for Heart Failure

BACKGROUND

The geriatric nutritional risk index (GNRI) is a simple and objective nutritional assessment tool for elderly patients. Lower GNRI values are associated with a worse prognosis in patients with heart failure (HF). However, few data are available regarding the prognostic effect of the GNRI value for risk stratification in patients at risk for HF.Methods and Results:We retrospectively investigated 1,823 consecutive patients at risk for HF (Stage A/B) enrolled in the IMPACT-ABI Study. GNRI on admission was calculated as follows: 14.89×serum albumin (g/dL)+41.7×body mass index/22. Patients were divided into 2 groups according to the median GNRI value (107.1). The study endpoint was a composite of cardiovascular (CV) events, including CV death and hospitalization for worsening HF. Over a 4.7-year median follow-up, CV events occurred in 130 patients. In the Kaplan-Meier analysis, patients with low GNRI (<107.1, n=904) showed worse prognoses than those with high GNRI (≥107.1, n=919) (20.2% vs. 12.4%, P<0.001). In the multivariable Cox proportional hazards analysis, low GNRI was significantly associated with the incidence of CV events (hazard ratio: 1.48, 95% confidence interval: 1.02-2.14; P=0.040).

CONCLUSIONS

The simple and practical assessment of GNRI may be useful for predicting CV events in patients with Stage A/B HF.

Predictive Value of Underweight Status for Patients With Peripheral Artery Disease With Claudication

We evaluated whether underweight status is associated with poor prognosis in patients with peripheral artery disease (PAD) with claudication, excluding critical limb ischemia. We identified 441 claudicants hospitalized for cardiovascular disease between 2005 and 2012. Patients were divided into 4 groups according to body mass index (BMI): an underweight group (BMI < 18.5 kg/m2; n = 48), a normal group (BMI = 18.5-25.0 kg/m2; n = 286), an overweight group (BMI = 25.0-30.0 kg/m2; n = 92), and an obese group (BMI ≥ 30.0 kg/m2; n = 15). The mean follow-up period was 3.5 ± 1.9 years. The underweight group had significantly lower levels of hemoglobin, albumin, estimated glomerular filtration rate, triglycerides, and hemoglobin A1c; higher levels of C-reactive protein and B-type natriuretic peptide; and a higher prevalence of hemodialysis. The incidence of all-cause death and cardiovascular death was significantly higher in the underweight group (underweight vs normal, 77.1% vs 33.0%; P < .001 and 43.3% vs 14.4%; P < .001, respectively). In a multivariate Cox analysis, underweight status was an independent predictor of all-cause death (hazard ratio, 2.53; 95% confidence interval, 1.58-4.18; P < .001). Therefore, promoting weight gain, as well as managing cardiovascular disease, may be important for underweight patients with PAD.

The presence of obesity paradox in Greek patients with chronic heart failure

Purpose

To investigate the effect of body mass index (BMI) values on 1- and 2-year mortality rates in patients with chronic heart failure (HF).

Patients and methods

We conducted a retrospective cohort study of 112 patients with confirmed HF who visited the HF outpatient unit of a tertiary hospital of Athens, Greece, during a 5-month period (December 2012 – April 2013). These patients were assigned to four groups based on their BMI category. Data collection was carried out through a review of the medical patient records and the filling in of a structured questionnaire, including information on the demographic and clinical patient variables. Additionally, 1- and 2-year patient mortality was recorded. The statistical significance was two-tailed, and p-values of less than 0.05 were considered significant. The statistical analysis was performed with Mann–Whitney U test, χ² test, and Student’s t-test using the SPSS software (IBM SPSS 21.0 for Windows).

Results

Obese patients had significantly lower 1-year (13% vs 34.6%, p=0.039) and 2-year (4% vs 21.4%, p=0.022) mortality rates compared with those with normal BMI values. Additionally, we found clinically and not statistically significant lower mortality in overweight and obese patients, when compared with normal BMI and overweight patients, respectively.

Conclusion

Obesity paradox seems to be present in our study, translating to significantly lower long-term mortality rates of obese patients compared to those with normal BMI. The significantly higher left ventricular ejection fraction and hematocrit levels among obese HF patients could justify our study findings. Further research is needed due to the inherent weaknesses of BMI and the other study limitations.

A U-shaped association of body mass index and all-cause mortality in heart failure patients: A dose-response meta-analysis of prospective cohort studies

BACKGROUND AND AIMS

The role of body mass index (BMI) for the prognosis of heart failure (HF) patients remains to be a great interest for a long time. However, the precise effect of dose-response for BMI and mortality risk in patients with HF is still unclear. We conducted a dose-response meta-analysis to quantitatively assess the effect of BMI on all-cause mortality in subjects with HF.

METHODS

Fourteen prospective cohort studies included 13 508 death cases identified among 46 794 patients with HF.

RESULTS

The summary HR per 5 units increase in BMI was 0.95 (95% CI=0.92-0.97) with evidence of high heterogeneity (I² =90.10%, P_{heterogeneity} <.00001), and an U-shaped nonlinear relationship of BMI and risk of mortality from all-causes was revealed (P_nonlinearity =.0025). When stratified analyses were conducted, the heterogeneity in patients with HF aged more than 60 years decreased.

CONCLUSION

Heart failure patients with higher BMI (>28 kg/m² ) have a better survival, whereas underweight and those with severe obesity (eg, BMI>37 kg/m² ) have a higher mortality.

BMI is inversely correlated to the risk of mortality in patients with type 2 diabetes hospitalized for acute heart failure: Findings from the Gulf aCute heArt failuRE (Gulf-CARE) registry

BACKGROUND

A U-shaped relationship has been reported between BMI and cardiovascular events among patients with acute heart failure (AHF). We hypothesized that an obesity paradox also governs the relationship between BMI and mortality in patients with type 2 diabetes (T2D) and AHF.

METHODS

We studied 3-month and 12-month mortality in patients with T2D hospitalized for AHF according to 5 BMI categories: Underweight (<20kg/m²), normal weight (referent group, 20-24.9kg/m²), overweight, (25-29.9kg/m²), obese (30-34.9kg/m²) and severely obese (≥35kg/m²), in the Gulf aCute heArt failuRe rEgistry (GULF-CARE).

RESULTS

Among the 5005 participants in this cohort, 2492 (49.8%) had T2D. Underweight patients had a higher 3-month and 12-month mortality risk (OR 2.04, 95% CI [1.02-4.08]; OR 2.44, 95% CI [1.35-4.3]; respectively), compared to normal weight. Severe obesity was associated with a lower 3-month and 12-month mortality risk (OR 0.53, 95% CI [0.34-0.83]; OR 0.58, 95% CI [0.42-0.81]; respectively). After adjustment for several risk variables in 2 different models, the primary outcome was still significantly increased in underweight patients, and decreased in severely obese patients, at 3months and 12months. Further, the odds of mortality decreases with increasing BMI by 0.38 at 3months and at 0.45 at 12months in a near-linear shape (p=0.007; p=0.037; respectively).

CONCLUSIONS

In this cohort of patients with AHF, BMI was inversely correlated to the risk of mortality in patients with T2D. Moreover, severe obesity was associated with less mortality risk.

Cachexia research in Japan: facts and numbers on prevalence, incidence and clinical impact

Even though most clinical data on cachexia have been reported from Western countries, cachexia may be a growing problem in Asia as well, as the population in this area of the world is considerably larger. Considering the current definitions of obesity and sarcopenia in Japan, which are different from the ones in Western countries, the lack of a distinct cachexia definition in Japan is strinking. Only one epidemiological study has reported the prevalence of cachexia using weight loss as part of the definition in patients with stage III or IV non-small cell lung cancer. Although the reported prevalence of 45.6% is within the range of that in Western countries (28-57% in advanced cancer), we cannot compare the prevalence of cachexia in other types of cancer, heart failure, chronic obstructive pulmonary disease (COPD), and kidney disease (CKD) between Japan and Western countries. In patients with heart failure, one third of Japanese patients has a body mass index <20.3 kg/m² whereas the prevalence of underweight is 13.6% in reports from Western countries. These results may suggest that there are more cachectic heart failure patients in Japan, or that using the same definition like Western countries leads to gross overestimation of the prevalence of cachexia in Japan. The rate of underweight patients in COPD has been reported as 31-41% in COPD and seems to be high in comparison to the prevalence of cachexia in Western countries (27-35%). The reported lowest quartile value of BMI (19.6 kg/m²) in CKD may match with the prevalence of cachexia in Western countries (30-60%). The number of clinical trials targeting cachexia is very limited in Japan so far.

The Obesity-Mortality Paradox in Patients With Heart Failure in Taiwan and a Collaborative Meta-Analysis for East Asian Patients

A global heart failure (HF) registry suggested that the inverse association between body mass index (BMI) and all-cause mortality differed by race, particularly stronger in Japanese patients at 1-year follow-up. Whether this finding was consistent across all East Asian populations was unknown. In a multicenter prospective study in Taiwan, we enrolled 1,301 patients hospitalized for systolic HF from 2013 to 2014 and followed up the mortality after their discharge for a median of 1-year period. Cox proportional hazard regression analyses were used to assess the association of BMI with all-cause mortality. The results showed that BMI was inversely associated with all-cause mortality (hazard ratio and 95% CI per 5-kg/m(2) increase: 0.75 [0.62 to 0.91]) after adjusting for demographics, traditional risk factors, HF severity, and medications at discharge. Subsequently, we sought previous studies regarding the BMI association with mortality for East Asian patients with HF from Medline, and a random-effect meta-analysis was performed by the inverse variance method. The meta-analysis including 7 previous eligible studies (3 for the Chinese and 4 for the Japanese cohorts) and the present one showed similar results that BMI was inversely associated with all-cause mortality (hazard ratio 0.65 [0.58 to 0.73], I(2) = 37%). In conclusion, our study in Taiwan and a collaborative meta-analysis confirmed a strong inverse BMI-mortality association consistently among East Asian patients with HF.

Adaptive servoventilation versus oxygen therapy for sleep disordered breathing in patients with heart failure: a randomised trial

BACKGROUND

Both adaptive servoventilation (ASV) and nocturnal oxygen therapy improve sleep disordered breathing (SDB), but their effects on cardiac parameters have not been compared systematically.

METHODS AND RESULTS

43 patients with chronic heart failure (CHF; left ventricular ejection fraction (LVEF) ≤50%) with SDB were randomly assigned to undergo ASV (n=19, apnoea hypopnoea index (AHI)=34.2±12.1/h) or oxygen therapy (n=24, 36.9±9.9/h) for 3 months. More than 70% of SDB events in both groups were central apnoeas or hypopnoeas. Although nightly adherence was less for the ASV group than for the oxygen group (4.4±2.0 vs 6.2±1.8 h/day, p<0.01), the improvement in AHI was larger in the ASV group than in the oxygen group (-27.0±11.5 vs -16.5±10.2/h, p<0.01). The N-terminal pro-brain natriuretic peptide (NT-proBNP) level in the ASV group improved significantly after titration (1535±2224 to 1251±2003 pg/mL, p=0.01), but increased slightly at follow-up and this improvement was not sustained (1311±1592 pg/mL, p=0.08). Meanwhile, the level of plasma NT-proBNP in the oxygen group did not show a significant change throughout the study (baseline 1071±1887, titration 980±1913, follow-up 1101±1888 pg/mL, p=0.19). The significant difference in the changes in the NT-proBNP level throughout the study between the 2 groups was not found (p=0.30). Neither group showed significant changes in echocardiographic parameters.

CONCLUSIONS

Although ASV produced better resolution of SDB in patients with CHF as compared with oxygen therapy, neither treatment produced a significant improvement in cardiac function in the short term. Although we could not draw a definite conclusion because of the small number of participants, our data do not seem to support the routine use of ASV or oxygen therapy to improve cardiac function in patients with CHF with SDB.

TRIAL REGISTRATION NUMBER

NCT01187823 (http://www.clinicaltrials.gov).

Weight Loss in Obese Patients With Heart Failure

BACKGROUND

In heart failure (HF), weight loss (WL) has been associated with an adverse prognosis whereas obesity has been linked to lower mortality (the obesity paradox). The impact of WL in obese patients with HF is incompletely understood. Our objective was to explore the prevalence of WL and its impact on long-term mortality, with an emphasis on obese patients, in a cohort of patients with chronic HF.

METHODS AND RESULTS

Weight at first visit and the 1-year follow-up and vital status after 3 years were assessed in 1000 consecutive ambulatory, chronic HF patients (72.7% men; mean age 65.8±12.1 years). Significant WL was defined as a loss of ≥5% weight between baseline and 1 year. Obesity was defined as body mass index ≥30 kg/m(2) (N=272). Of the 1000 patients included, 170 experienced significant WL during the first year of follow-up. Mortality was significantly higher in patients with significant WL (27.6% versus 15.3%, P<0.001). In univariable Cox regression analysis, patients with significant WL had 2-fold higher mortality (hazard ratio 1.95 [95% CI 1.39-2.72], P<0.001). In multivariable analysis, adjusting for age, sex, body mass index, New York Heart Association functional class, left ventricular ejection fraction, HF duration, ischemic etiology, diabetes, and treatment, significant WL remained independently associated with higher mortality (hazard ratio 1.89 [95% CI 1.32-2.68], P<0.001). Among obese patients with HF, significant WL was associated with an even more ominous prognosis (adjusted hazard ratio for death of 2.38 [95% CI 1.31-4.32], P=0.004) than that observed in nonobese patients (adjusted hazard ratio 1.83 [95% CI 1.16-2.89], P=0.01).

CONCLUSIONS

Weight loss ≥5% in patients with chronic HF was associated with high long-term mortality, particularly among obese patients with HF.

Heart failure as a general pandemic in Asia

Heart failure (HF) is an epidemic in healthcare worldwide, including Asia. It appears that HF will become more serious in the near future, with the epidemiological transition and ageing of the population. However, in contrast to Western countries, information on HF epidemiology is still limited in Asia, particularly in South Asia. In this review, we will briefly summarize available information regarding the current and future burden of HF in Asia, which indicates the importance of both primary prevention of underlying diseases of HF and secondary prevention, including management of ischaemic HF, HF with preserved EF, and HF in the elderly.

Meta-analysis of the relation of body mass index to all-cause and cardiovascular mortality and hospitalization in patients with chronic heart failure

Clinical studies have indicated the existence of an "obesity paradox" in patients with chronic heart failure (HF), that is, reduced mortality in patients who have elevated body mass index (BMI) scores compared with normal-weight reference groups. The aim of this study was to investigate the relation of BMI with all-cause and cardiovascular (CV) mortality and hospitalization in patients with chronic HF though a systematic review and meta-analysis of published research. PubMed, the Cumulative Index to Nursing and Allied Health Literature, Cochrane Central, Scopus, web of science and Embase were searched for studies reporting rates of total mortality, cardiac mortality, and risk for hospitalization in patients with HF in various BMI categories (<20 kg/m(2) [low], 20 to 24.9 kg/m(2) [normal reference], 25 to 29.9 kg/m(2) [overweight], 30 to 34.9 [obese], and ≥35 kg/m(2) [severely obese]). Event rates were compared using a forest plot of relative risk (RR) using a random-effects model assuming interstudy heterogeneity. Two study investigators independently reviewed the 124 reports retrieved and identified 6 for final analyses (n = 22,807). After a mean follow-up period of 2.85 years, the risk for adverse events was highest in patients with low BMIs: total mortality RR 1.27 (95% confidence interval [CI] 1.17 to 1.37), CV mortality RR 1.20 (95% CI 1.01 to 1.43), and hospitalization RR 1.19 (95% CI 1.09 to 1.30). Risk for CV mortality and hospitalization was lowest in overweight patients (RR 0.79, 95% CI 0.70 to 0.90, and RR 0.92, 95% CI 0.86 to 0.97, respectively). Increasing degree of obesity failed to achieve a statistically significant effect on CV mortality (RR 0.82, 95% CI 0.64 to 1.05, and RR 0.71, 95% CI 0.50 to 1.01, for obese and severely obese, respectively) and on hospitalization (RR 0.99, 95% CI 0.92 to 1.07, and RR 1.28, 95% CI 0.88 to 1.87, for obese and severely obese, respectively). In conclusion, risk for total mortality and CV mortality and hospitalization was highest in patients with chronic HF who were underweight as defined by low BMI, whereas risk for CV mortality and hospitalization was lowest in overweight subjects.

Clinical impacts of additive use of olmesartan in hypertensive patients with chronic heart failure: the supplemental benefit of an angiotensin receptor blocker in hypertensive patients with stable heart failure using olmesartan (SUPPORT) trial

We examined whether an additive treatment with an angiotensin receptor blocker, olmesartan, reduces the mortality and morbidity in hypertensive patients with chronic heart failure (CHF) treated with angiotensin-converting enzyme (ACE) inhibitors, β-blockers, or both. In this prospective, randomized, open-label, blinded endpoint study, a total of 1147 hypertensive patients with symptomatic CHF (mean age 66 years, 75% male) were randomized to the addition of olmesartan (n = 578) to baseline therapy vs. control (n = 569). The primary endpoint was a composite of all-cause death, non-fatal acute myocardial infarction, non-fatal stroke, and hospitalization for worsening heart failure. During a median follow-up of 4.4 years, the primary endpoint occurred in 192 patients (33.2%) in the olmesartan group and in 166 patients (29.2%) in the control group [hazard ratio (HR) 1.18; 95% confidence interval (CI), 0.96–1.46, P = 0.112], while renal dysfunction developed more frequently in the olmesartan group (16.8 vs. 10.7%, HR 1.64; 95% CI 1.19–2.26, P = 0.003). Subgroup analysis revealed that addition of olmesartan to combination of ACE inhibitors and β-blockers was associated with increased incidence of the primary endpoint (38.1 vs. 28.2%, HR 1.47; 95% CI 1.11–1.95, P = 0.006), all-cause death (19.4 vs. 13.5%, HR 1.50; 95% CI 1.01–2.23, P = 0.046), and renal dysfunction (21.1 vs. 12.5%, HR 1.85; 95% CI 1.24–2.76, P = 0.003). Additive use of olmesartan did not improve clinical outcomes but worsened renal function in hypertensive CHF patients treated with evidence-based medications. Particularly, the triple combination therapy with olmesartan, ACE inhibitors and β-blockers was associated with increased adverse cardiac events. This study is registered at clinicaltrials.gov-NCT00417222.

Supplemental benefit of an angiotensin receptor blocker in hypertensive patients with stable heart failure using olmesartan (SUPPORT) trial--rationale and design

BACKGROUND

Although angiotensin receptor blockers (ARBs) are now one of the first-line drug classes for the management of hypertension, recommendations for the management of chronic heart failure (CHF) are limited. The supplemental benefit of angiotensin receptor blocker in hypertensive patients with stable heart failure using olmesartan (SUPPORT) trial investigates whether an additive treatment with an ARB, olmesartan, reduces the mortality and morbidity in hypertensive patients with stable chronic heart failure.

METHODS AND RESULTS

The SUPPORT trial is a prospective randomized open-label blinded endpoint study. Between October 2006 and March 2010, 1147 stable CHF patients treated with evidence-based medications were successfully randomized to either olmesartan or control group. In the olmesartan group, the ARB was initiated at the dose of 5.0-10mg, and was then increased up to 40mg/day, when possible. No ARBs were allowed in the control group. Primary outcome measure in the SUPPORT trial is the composite of all-cause death, non-fatal acute myocardial infarction, non-fatal stroke and hospital admission due to worsening heart failure. The participants will be followed for at least 3 years until March 2013.

CONCLUSIONS

The SUPPORT trial will elucidate the supplemental benefits of an ARB, olmesartan, in hypertensive patients with CHF.

The diversity of heart failure in a hospitalized population: the role of age

BACKGROUND

The prevalence of heart failure (HF) among hospitalized elderly patients is high and steadily growing. However, because most studies have focused mostly on young patients, little is known about the clinical characteristics, echocardiographic measures, prognostic factors, and outcome of hospitalized elderly HF patients.

METHODS AND RESULTS

We identified all HF patients aged ≥50 years who had undergone ≥1 echocardiography study and had been hospitalized during January 2000 to December 2009. A comparative analysis was performed between 3,897 "young" patients (aged 50-75 years) and 5,438 "elderly" patients (aged >75 years), followed for a mean 2.8 ± 2.6 years. Elderly HF patients were more often female (50% vs 35%; P < .0001) and had a higher prevalence of HF with preserved ejection fraction (64.8% vs 53%; P < .0001), more significant valvular disease (35.7% vs 32.5%; P < .0001), and lower rates of ischemic heart disease (65.5% vs 70.9%; P < .0001) and diabetes (34.4% vs 53.9%; P < .0001). Thirty-day and 1-year mortality rates were significantly higher among the elderly population (12.2% vs 6.9% [P < .0001] and 34.3% vs 21.2% [P < .0001], respectively). Prognostic markers differed significantly between age groups. Young-specific predictors were chronic renal failure, diastolic dysfunction, malignancy, and tricuspid regurgitation, whereas elderly-specific predictors were HF with reduced ejection fraction, chronic obstructive pulmonary disease, pulmonary hypertension, and mitral regurgitation.

CONCLUSIONS

Hospitalized elderly, compared with young, HF patients differed in prevalence of cardiac and noncardiac comorbid conditions, echocardiographic parameters, and predictors of short- and intermediate-term mortality. Identifying unique features in the elderly population may render age-tailored therapeutics.