Characteristics, management, and outcomes for patients during hospitalization due to worsening heart failure-A report from the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD)

Sex Differences in Cardiovascular Disease-Related Hospitalization and Mortality in Japan - Analysis of Health Records From a Nationwide Claim-Based Database, the Japanese Registry of All Cardiac and Vascular Disease (JROAD)

BACKGROUND

The prevalence of cardiovascular disease (CVD) is rising in Japan with its aging population, but there is a lack of epidemiological data on sex differences in CVD, including acute coronary syndrome (ACS), acute heart failure (AHF), and acute aortic disease.Methods and Results: This retrospective study analyzed data from 1,349,017 patients (January 2012-December 2020) using the Japanese Registry Of All Cardiac and Vascular Diseases database. ACS patients were youngest on average (70.5±12.9 years) and had the lowest female proportion (28.9%). AHF patients had the oldest mean age (79.7±12.0 years) and the highest proportion of females (48.0%). Acute aortic disease had the highest in-hospital mortality (26.1%), followed by AHF (11.5%) and ACS (8.9%). Sex-based mortality differences were notable in acute aortic disease, with higher male mortality in Stanford Type A acute aortic dissection (AAD) with surgery (males: 14.2% vs. females: 10.4%, P<0.001) and similar rates in Type B AAD (males: 6.2% vs. females: 7.9%, P=0.52). Aging was a universal risk factor for in-hospital mortality. Female sex was a risk factor for ACS and acute aortic disease but not for AHF or Types A and B AAD.

CONCLUSIONS

Sex-based disparities in the CVD-related hospitalization and mortality within the Japanese national population have been highlighted for the first time, indicating the importance of sex-specific strategies in the management and understanding of these conditions.

Changes in walking speed 6 months after discharge may be more sensitive to subsequent prognosis than handgrip strength in patients hospitalized for heart failure

BACKGROUND

Despite the prognostic importance of walking speed (WS) and handgrip strength (HGS) in patients with heart failure (HF), no study has reported the prognostic impact of changes in these parameters. This study aimed to examine the association between changes after discharge and the subsequent prognosis.

METHODS

This study included 881 elderly patients hospitalized for HF. WS and HGS were measured at discharge and 6 months after discharge. Based on the presence of slowness (WS <0.98 m/s) or weakness (HGS <30.0 kg for men and < 17.5 kg for women) at both points, patients were divided into four groups (WS: A = -/-, B = -/+, C = +/-, D = +/+; HGS: E = -/-, F = -/+, G = +/-, H = +/+). The study endpoint was a composite of all-cause mortality and HF rehospitalization during the 18 months after 6 months of discharge. The Cox proportional hazards model was used to assess the association between the groups and study outcomes.

RESULTS

Stratified by the WS change patterns, groups B and D showed higher risk of the study outcomes than group A [B: hazard ratio 2.34, 95% confidence interval (CI) 1.29-4.28; D: 2.38, 1.67-3.39], whereas group C was not. When stratified by the HGS change in patterns, only group H was associated with a worse prognosis (HR; 1.85, 95%CI; 1.31-2.60).

CONCLUSION

Changes in WS were related to HF prognosis, suggesting that changes in WS may be more sensitive to further risk stratification than changes in HGS.

Interaction of heart failure and stroke: A clinical consensus statement of the ESC Council on Stroke, the Heart Failure Association (HFA) and the ESC Working Group on Thrombosis

Heart failure (HF) is a major disease in our society that often presents with multiple comorbidities with mutual interaction and aggravation. The comorbidity of HF and stroke is a high risk condition that requires particular attention to ensure early detection of complications, efficient diagnostic workup, close monitoring, and consequent treatment of the patient. The bi-directional interaction between the heart and the brain is inherent in the pathophysiology of HF where HF may be causal for acute cerebral injury, and - in turn - acute cerebral injury may induce or aggravate HF via imbalanced neural and neurovegetative control of cardiovascular regulation. The present document represents the consensus view of the ESC Council on Stroke, the Heart Failure Association and the ESC Working Group on Thrombosis to summarize current insights on pathophysiological interactions of the heart and the brain in the comorbidity of HF and stroke. Principal aspects of diagnostic workup, pathophysiological mechanisms, complications, clinical management in acute conditions and in long-term care of patients with the comorbidity are presented and state-of-the-art clinical management and current evidence from clinical trials is discussed. Beside the physicians perspective, also the patients values and preferences are taken into account. Interdisciplinary cooperation of cardiologists, stroke specialists, other specialists and primary care physicians is pivotal to ensure optimal treatment in acute events and in continued long-term treatment of these patients. Key consensus statements are presented in a concise overview on mechanistic insights, diagnostic workup, prevention and treatment to inform clinical acute and continued care of patients with the comorbidity of HF and stroke.

The impact of geriatric nutritional risk index on one-year outcomes in hospitalized elderly patients with heart failure

Background

Strategies that accurately predict outcomes in elderly heart failure (HF) patients have not been sufficiently established. In previous reports, nutritional status, ability to perform activities of daily living (ADL), and lower limb muscle strength are known prognostic factors associated with cardiac rehabilitation (CR). In the present study, we investigated which CR factors can accurately predict one-year outcomes in elderly patients with HF among the above factors.

Methods

Hospitalized patients with HF over 65 years of age from January 2016 to January 2022 were retrospectively enrolled in the Yamaguchi Prefectural Grand Medical (YPGM) Center. They were consequently recruited to this single-center retrospective cohort study. Nutritional status, ADL, and lower limb muscle strength were assessed by geriatric nutritional risk index (GNRI), Barthel index (BI), and short physical performance battery (SPPB) at discharge, respectively. One year after discharge, the primary and secondary outcomes were evaluated by all-cause death or HF readmission and major adverse cardiac and cerebrovascular events (MACCE), respectively.

Results

Overall, 1,078 HF patients were admitted to YPGM Center. Of those, 839 (median age 84.0, 52% female) met the study criteria. During the follow-up of 228.0 days, 72 patients reached all-cause death (8%), 215 experienced HF readmission (23%), and 267 reached MACCE (30%: 25 HF death, six cardiac death, and 13 strokes). A multivariate Cox proportional hazard regression analysis revealed that the GNRI predicted the primary outcome (Hazard ratio [HR]: 0.957; 95% confidence interval [CI]: 0.934-0.980; p < 0.001) and the secondary outcome (HR: 0.963; 95%CI: 0.940-0.986; p = 0.002). Furthermore, a multiple logistic regression model using the GNRI most accurately predicted the primary and secondary outcomes compared to those with the SPPB or BI models.

Conclusion

A nutrition status model using GNRI provided a better predictive value than ADL ability or lower limb muscle strength. It should be recognized that HF patients with a low GNRI at discharge may have a poor prognosis at one year.

In-Hospital Outcomes of Heart Failure Patients with Valvular Heart Disease: Insights from Real-World Claims Data

Purpose

Heart failure (HF) is a serious public health burden that is rapidly increasing in the aging population. Valvular heart disease (VHD) is a known etiology of heart failure (HF); however, the impact of VHD on outcomes of patients with HF has not been well-studied in Japan. This study aimed to determine the rates of VHD in Japanese patients admitted for HF and explore associations of VHD with in-hospital outcomes through a claim-based analysis.

Patients and methods

We analyzed claims data from 86,763 HF hospitalizations (January 2017 through December 2019) from the Medical Data Vision database. Common etiologies of HF were examined, then hospitalizations were categorized into those with VHD and those without. Covariate-adjusted models were used to explore the association of VHD with in-hospital mortality, length of stay, and medical cost.

Results

Of 86,763 hospitalizations for HF, 13,183 had VHD and 73,580 did not. VHD was the second most frequent etiology of HF (15.2%). The most frequent type of VHD was mitral regurgitation (36.4% of all hospitalizations with VHD), followed by aortic stenosis (33.7%) and aortic regurgitation (16.4%). There was no significant difference in in-hospital mortality between hospitalizations with VHD vs those without (9.0% vs 8.9%; odds ratio [95% CI]: 1.01 [0.95-1.08]; p=0.723). Hospitalizations with VHD were associated with significantly longer length of stay (26.1 vs 24.8 days; incident rate ratio [95% CI]: 1.05 [1.03-1.07]; p<0.001) and higher medical costs (1536 vs 1195 thousand yen; rate ratio [95% CI]: 1.29 [1.25-1.32]; p<0.001).

Conclusion

VHD was a frequent etiology of HF that was associated with significant medical resource use. Future studies are needed to investigate whether timely VHD treatment could reduce HF progression and its associated healthcare resource utilization.

Minimal clinically important difference of the short physical performance battery and comfortable walking speed in old-old adults with acute cardiovascular disease: a multicenter, prospective, observational study

PURPOSE

The physical function of older adults age ≥ 75 years hospitalized for cardiovascular disease (CVD) often decrease. The Minimal Clinically Important Difference (MCID) is the smallest clinically meaningful difference due to therapy. The Short Physical Performance Battery (SPPB) and Comfortable Walking Speed (CWS) are physical function evaluations commonly used in people with CVD. This study aims to clarify the MCIDs of the SPPB and CWS in old-old adult with CVD.

MATERIALS AND METHODS

This was a multicenter, prospective study of 58 old-old adults with acute CVD and rehabilitation. The MCID was estimated using the participants' and physical therapists' (PT) Global Rating of Change (GRC) scales as anchors for changes in the SPPB and CWS. The area under the curve (AUC) was used to measure the discrimination accuracy.

RESULTS

The MCID of SPPB was 3 points when the GRC from PT was used as an anchor (AUC = 0.70). The MCID of CWS was 0.10 m/s when the GRC from participants and PT were used as anchors (AUC = 0.70 and 0.73, respectively).

CONCLUSIONS

The MCID of 3 SPPB points and 0.10 m/s CWS in old-old adults with acute CVD may help determine the effectiveness of therapy and improve prognosis.Implications for rehabilitationFor people with cardiovascular disease (CVD), the Short Physical Performance Battery (SPPB) and comfortable walking speed (CWS) are often used to measure physical function.The MCID of SPPB and CWS was estimated to be 3 points and 0.10 m/s, respectively, in older adults with CVD aged ≥75 years.This finding is useful for clinicians to evaluate the efficacy of cardiac rehabilitation.

Association between the Length of Hospital Stay and 30-Day Outcomes in Patients Admitted with Acute Decompensated Heart Failure

Method

This study is performed in the context of the Persian Registry of Cardiovascular Disease/Heart Failure (PROVE/HF). We included all patients admitted with ADHF regardless of the etiology of heart failure (HF). LOS was classified in tertiles (<4 days, >4 and <6 days, and >6 days). Our outcomes were 30-day all-cause mortality and rehospitalization. Baseline characteristics and outcomes are reported according to the tertiles of LOS. A binary logistic regression and cox regression analysis were performed to evaluate the association between LOS and rehospitalization and death, respectively.

Results

Between April 2019 and March 2020, 385 patients with ADHF were registered in our study. The mean length of hospitalization was 6.35 ± 5.46 days, varying from a minimum of 0 days to a maximum of 47 days. One hundred patients had a hospital stay lower than 4 days; 151 individuals had an intermediate LOS (4-6 days); and 134 were hospitalized for more than 6 days. Our analysis indicated no association between LOS and 30-day rehospitalization and death in multivariable or univariable models.

Conclusion

This study found no association between LOS and rehospitalization or death in patients admitted with ADHF; however, further investigations are warranted.

Outcomes and predictors of one-year mortality in patients hospitalized with Acute Heart Failure

BACKGROUND

Registries of patients hospitalized with acute heart failure (AHF) provided useful description of characteristics and outcomes. However, a contemporary registry which provides sufficient evidence on outcomes after discharge is needed.

OBJECTIVE

The study aims to identify 1-year clinical outcomes and prognostic predictors of patients hospitalized with AHF.

METHOD

This is a retrospective registry which enrolled patients who were hospitalized due to a principal diagnosis of AHF in a tertiary care center in Thailand between July 2017 and June 2019. Baseline characteristics and hospital courses between the deceased patients and the survivors at 1 year were compared. Prognostic predictors for 1-year mortality were analyzed using Cox regression model.

RESULTS

A total of 759 patients were enrolled (mean age of 68.9 ± 15 years, 49.8% men, mean ejection fraction of 47.1 ± 19.2%, 55.7% heart failure reduced ejection fraction (HFrEF)). Among these, 40.7% had no history of heart failure. The in-hospital and 1-year mortality was 5.8% and 21.5%, respectively. Patients with HFrEF had lower 1-year mortality compared to those without (HR = 0.57, p = 0.04). Age ≥ 70 years, the history of heart failure, prior heart failure hospitalization, cerebrovascular accident (CVA), reactive airway disease, cancer, length of stay > 10 days and NT-proBNP ≥ 10,000 pg/mL were associated with higher 1-year mortality (p < 0.05). The multivariate analysis showed age, CVA and NT-proBNP were independent predictors.

CONCLUSION

Patients with AHF had high mortality after discharge. Patients with poor prognostic predictors, such as elderly, may benefit from continuous care. The study is the most recent registry of patients with AHF in Thailand.

Risk of Mortality Prediction Involving Time-Varying Covariates for Patients with Heart Failure Using Deep Learning

Heart failure (HF) is challenging public medical and healthcare systems. This study aimed to develop and validate a novel deep learning-based prognostic model to predict the risk of all-cause mortality for patients with HF. We also compared the performance of the proposed model with those of classical deep learning- and traditional statistical-based models. The present study enrolled 730 patients with HF hospitalized at Toho University Ohashi Medical Center between April 2016 and March 2020. A recurrent neural network-based model (RNNSurv) involving time-varying covariates was developed and validated. The proposed RNNSurv showed better prediction performance than those of a deep feed-forward neural network-based model (referred as "DeepSurv") and a multivariate Cox proportional hazard model in view of discrimination (C-index: 0.839 vs. 0.755 vs. 0.762, respectively), calibration (better fit with a 45-degree line), and ability of risk stratification, especially identifying patients with high risk of mortality. The proposed RNNSurv demonstrated an improved prediction performance in consideration of temporal information from time-varying covariates that could assist clinical decision-making. Additionally, this study found that significant risk and protective factors of mortality were specific to risk levels, highlighting the demand for an individual-specific clinical strategy instead of a uniform one for all patients.

Burden of Repeated Hospitalizations on Patients with Heart Failure: An Analysis of Administrative and Claims Data in Japan

Background

Repeated hospitalization is a predictor of outcomes in heart failure, indicating the presence of symptoms, a deteriorated condition at pre-admission, and worsened prognosis.

Objectives

The current database study aimed to understand the clinical and economic burden of repeated hospitalizations among patients with heart failure in Japan. The effect of repeated hospitalizations on the subsequent in-hospital mortality was the primary objective; economic burden of heart failure after discharge was investigated as a secondary outcome.

Methods

Between 2013 and 2018, administrative claims and discharge summary data of patients aged ≥ 20 years and diagnosed with heart failure were obtained from a Diagnosis Procedure Combination database maintained by Medical Data Vision. Hospitalization, mortality, and economic burden data were analyzed.

Results

This study included 49,094 patients. The mean length of the first hospital stay was 22.9 days. The in-hospital mortality rate was approximately 10%, with one to five repeated hospitalizations. The time interval between repeated hospitalizations for heart failure decreased with an increasing number of hospitalizations. In-hospital mortality did not increase even with an increasing number of hospitalizations. The mean heart failure-related healthcare cost per patient was ¥564,281 ± 990,447 (US$5178 ± 9,088), 67.3% of which was hospitalization costs. Among hospitalization costs, other costs were high, mainly for basic hospitalization fees (71.7%; ¥233,146/person-year).

Conclusions

Repeated hospitalization did not increase in-hospital mortality; however, it may shorten the intervals between heart failure-related hospitalizations, potentially caused by deterioration of the patient’s condition, and increase the clinical and economic burden on patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40801-022-00315-5.

Importance of healthy lifestyle factors and ideal cardiovascular health metrics for risk of heart failure in Chinese adults

BACKGROUND

The relative importance of healthy lifestyle factors and cardiovascular health metrics for the risk of heart failure is uncertain in Chinese populations. We aimed to compare the strength of associations between healthy lifestyle factors and ideal cardiovascular health metrics in the risk of heart failure in middle-aged Chinese adults.

METHODS

A healthy lifestyle score (HLS) was constructed using smoking, drinking, physical activity, diet, body mass index and waist circumference, and compared with a more comprehensive set of metrics that included cardiovascular-disease risk biomarkers (blood pressure, blood glucose and blood lipids) in addition to the HLS. This broader set of factors [called 'ideal cardiovascular health metrics' (ICVHMs)] was evaluated in 487 197 participants in the China Kadoorie Biobank.

RESULTS

A total of 4208 incident cases of heart failure were recorded during a median follow-up of 10 years. Both HLS [hazard ratio (HR), 0.88; 95% confidence interval (CI), 0.85, 0.91] and ICVHMs (0.87: 0.84, 0.89) were inversely associated with risk of heart failure (P < 0.001 for linear trend). Compared with participants with 0-1 HLS, the multivariable-adjusted HR of those with 4-5 HLS was 0.68 (0.59, 0.77). Compared with participants with 0-2 ICVHMs, the adjusted HR (95% CIs) of those who had 7-8 ICVHMs was 0.47 (0.36, 0.60). ICVHMs were more strongly predictive of risk of heart failure (area under curve, 0.61 vs 0.58, P < 0.001) than healthy lifestyle factors alone.

CONCLUSIONS

Higher levels of healthy lifestyle factors and ICVHMs were each inversely associated with heart failure, and lifestyle factors combined with cardiometabolic factors improved the prediction of heart failure compared with healthy lifestyle factors alone.

Management, survival, and predictors of mortality among hospitalized heart failure patients at Debre Markos comprehensive specialized hospital, Northwest Ethiopia: Prospective cohort study

Introduction:

Heart failure is a major public health problem worldwide. Since heart failure with reduced ejection fraction and preserved ejection fraction are different clinical entities, in-hospital mortality may occur at different rates. This study aimed to assess the management, survival, and predictors of mortality among hospitalized heart failure patients at Debre Markos comprehensive specialized medical ward.

Methods:

A prospective cohort study was conducted on 228 heart failure patients at Debre Markos Comprehensive Specialized Hospital medical wards. A structured data collection tool was used to collect data. Data were analyzed using SPSS version 21.0. The Kaplan–Meier survival curve was used to investigate if there was a difference in the in-hospital survival between heart failure with a reduced ejection fraction and heart failure with a preserved ejection fraction. Those variables having p-value < 0.05 were considered statistically significant.

Results:

From the 228 participants, 126 (55.3%) were females with a mean age of 53.32 ± 15.68 years. One hundred thirty-three (58.3%) patients were presented with preserved (⩾50%) level of ejection fraction. The all-cause in-hospital death rate was 12.7%, and the risk of in-hospital mortality was higher in heart failure patients with reduced ejection fraction (7.4% vs 5.3%; p = 0.005). Current occupation (p = 0.041), elevated serum creatinine (p = 0.010), reduced ejection fraction (p = 0.017), and asthma/chronic obstructive pulmonary disease comorbidity (p = 0.002) were the independent predictors of high hospital mortality.

Conclusion:

The rate of in-hospital mortality among heart failure patients was high. Healthcare providers should provide effective education activities and define disease management strategies for patients with reduced ejection fractions.

Clinical Characteristics and In-Hospital Outcome of Acute Heart Failure Patients Admitted to the Medical Ward of University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

Background

Despite the growing burden of heart failure in developing countries, data describing the clinical characteristics and in-hospital outcomes of acute heart failures are limited. Therefore, this study aimed at describing the clinical characteristics and in-hospital outcomes of acute heart failure patients admitted to the medical ward of University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia.

Methods

A prospective observational hospital-based cross-sectional study was conducted on 226 patients with acute heart failure at the University of Gondar Comprehensive Specialized Hospital from November 2019 to October 2020. Data were collected by using a pretested data abstraction format and analyzed with Statistical Package for Social Sciences version 21. Bivariable and multivariable binary logistic regression model were fitted to identify factors associated with in-hospital outcome and reported with 95% confidence interval (CI). P-value <0.05 was considered as statistically significant.

Results

The mean (± standard deviation) age of the study participant was 51.17±19.03 years and 59.3% were females. Majority, 60.6% of patients were admitted with new onset heart failure. Dyspnea (88.05%) and peripheral edema (80.5%) were the most frequent clinical findings. The in-hospital mortality was 10.6% (95% CI: 7.1–14.7). Atrial fibrillation (AOR=9.46; 95% CI: 1.49–60.29), concurrent ischemic heart disease (AOR=8.23; 95% CI: 1.15–58.89), being admitted with reduced left ventricular ejection fraction (AOR=5.36; 95% CI: 2.81–35.52), presence of orthopnea (AOR=6.63; 95% CI: 2.94–46.76), and using intranasal oxygen therapy (AOR=9.41; 95% CI: 1.35–65.82) were significantly associated with in-hospital mortality in patients with acute heart failure.

Conclusion

The in-hospital mortality of acute heart failure patients was relatively higher in the study area. Therefore, specific preventative and therapeutic strategies focusing on heart failure patients with reduced left ventricular ejection fraction, atrial fibrillation, ischemic heart disease, orthopnea, and intranasal oxygen therapy are required to reduce the mortality rate.

Mode of death in elderly and super-elderly patients with acute heart failure: Insights from Japanese heart failure registry

Background

In Japan, both the prevalence of the elderly and super‐elderly and those of acute heart failure (AHF) have been increasing rapidly.

Methods

This registry was a prospective multicenter cohort, which enrolled a total of 1253 patients with AHF. In this study, 1117 patients' follow‐up data were available and were categorized into three groups according to age: <75 years old (nonelderly), 75–84 years old (elderly), and ≥ 85 years old (super‐elderly). The endpoint was defined as all‐cause death and each mode of death after discharge during the 3‐years follow‐up period.

Results

Based on the Kaplan–Meier analysis, a gradually increased risk of all‐cause death according to age was found. Among the three groups, the proportion of HF death was of similar trend; however, the proportion of infection death was higher in elderly and super‐elderly patients. After adjusting for potentially confounding effects using the Cox and Fine–Gray model, the hazard ratio (HR) of all‐cause death increased significantly in elderly and super‐elderly patients (HR, 2.60; 95% confidence interval [CI], 1.93–3.54 and HR, 5.04; 95% CI, 3.72–6.92, respectively), when compared with nonelderly patients. The highest sub‐distribution HR in detailed mode of death was infection death in elderly and super‐elderly patients (HR, 4.25; 95% CI, 1.75–10.33 and HR, 10.10; 95% CI, 3.78–27.03, respectively).

Conclusions

In this population, the risk of all‐cause death was found to increase in elderly and super‐elderly. Elderly patients and especially super‐elderly patients with AHF were at a higher risk for noncardiovascular death, especially infection death.

Clinical Characteristics and Outcomes of Hospitalized Patients With Heart Failure From the Large-Scale Japanese Registry Of Acute Decompensated Heart Failure (JROADHF)

BACKGROUND

With aging population, the prevalence and incidence of heart failure (HF) have been increasing worldwide. However, the characteristics and outcomes of patients with HF in an era of aging are not well established in Japan.Methods and Results:The Japanese Registry Of Acute Decompensated Heart Failure (JROADHF), a retrospective, multicenter, nationwide registry, was designed to study the clinical characteristics and outcomes of patients hospitalized with HF throughout Japan in 2013. One hundred and twenty-eight hospitals were selected by cluster random sampling and 13,238 hospitalized patients with HF were identified by medical record review. Demographics, medical history, severity, treatment, and in-hospital and long-term outcome data were collected from the Diagnostic Procedure Combination and medical charts. Data were analyzed using univariate and multivariate logistic regression or Cox regression analysis. The mean age of registered patients was 78.0±12.5 years and 52.8% were male. Elderly patients (age >75 years) accounted for 68.9%, and HF with preserved ejection fraction (HFpEF) accounted for 45.1%. Median length of hospital stay was 18 days and in-hospital mortality was 7.7%. The median follow-up period was 4.3 years, and the incidence rates for cardiovascular death and rehospitalization for HF were 7.1 and 21.1 per 100 person-years, respectively.

CONCLUSIONS

A contemporary nationwide registry demonstrated that hospitalized HF patients were very elderly, HFpEF was common, and their prognosis was still poor in Japan.

Clinical Characteristics and Contemporary Management of Patients With Cardiomyopathies in Japan - Report From a National Registry of Clinical Personal Records

Background: The clinical features of patients with cardiomyopathy, including dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), or restrictive cardiomyopathy (RCM), have not been recently elucidated in Japan.

Methods and Results: We collected individual patient data regarding demographics, echocardiogram, and treatment in DCM from 2003 to 2014 and in HCM and RCM from 2009 to 2014 from the national registry of clinical personal records organized by the Japanese Ministry of Health, Labour and Welfare. In all, 44,136 patients were included in this registry: 40,537 with DCM, 3,553 with HCM, and 46 with RCM. The median age at diagnosis was older for DCM and HCM than RCM (54 and 55 vs. 42 years, respectively). Male patients accounted for 74.6%, 58.7%, and 60.9% of the DCM, HCM, and RCM groups, respectively. NYHA functional Class III–IV was found in 26.9%, 11.3%, and 58.1% of patients in the DCM, HCM, and RCM groups, respectively. In the DCM group, the rates of β-blocker and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker prescription were 69% and 76%, respectively. In regional subgroup analysis, the median age at diagnosis of DCM and HCM was younger in the Kanto region. A family history of HCM was less frequent in the Hokkaido/Tohoku region.

Conclusions: The national registry of clinical personal records of cardiomyopathy could provide important information regarding the demographics, clinical characteristics, and management of cardiomyopathy throughout Japan.

The clinical characteristics and outcomes of heart failure patient with chronic obstructive pulmonary disease from the Japanese community-based registry

Both heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common diseases, but few studies have assessed the relationship between COPD and outcomes in patients with acute HF, especially in relation to age or ejection fraction (EF). The Kitakawachi Clinical Background and Outcome of Heart Failure Registry was a prospective, multicenter, community-based cohort and enrolled a total of 1,102 patients with acute HF between 2015 and 2017 in this study. The primary endpoint was defined as a composite endpoint that included all-cause mortality and hospitalization for HF. We stratified patients into two groups: those aged ≥ 80 years (elderly) and < 80 years (nonelderly). HF with preserved EF (HFpEF) was defined as EF ≥ 50%, whereas HF with reduced ejection fraction (HFrEF) was defined as EF < 50%. A total of 159 patients (14.4%) with COPD and 943 patients (83.6%) without COPD were included. COPD was found to be independently associated with a higher risk of the composite endpoint (adjusted hazard ratio: 1.42, 95% confidence interval: 1.14-1.77; p = 0.003). During a subgroup analysis, COPD was exposed as an independent risk factor of the composite endpoint in nonelderly patients; however, there was not such a finding observed among elderly patients. Separately, there was a significant association with COPD and the composite endpoint in patients with HFpEF. COPD showed a significantly higher risk of the composite endpoint after discharge in acute HF. However, this heightened risk was observable only in the subgroup of nonelderly patients and those of HFpEF.

Clinical Characteristics and Outcomes of Heart Failure Patients With Long-Term Care Insurance - Insights From the Kitakawachi Clinical Background and Outcome of Heart Failure Registry

BACKGROUND

In Japan, the long-term care insurance (LTCI) system has an important role in helping elderly people, but there have been no clinical studies that have examined the relationship between the LTCI and prognosis for patients with acute heart failure (HF).Methods and Results:This registry was a prospective multicenter cohort, 1,253 patients were enrolled and 965 patients with acute HF aged ≥65 years were comprised the study group. The composite endpoint included all-cause death and hospitalization for HF after discharge. We divided the patients into 4 groups: (i) patients without LTCI, (ii) patients requiring support level 1 or 2, (iii) patients with care level 1 or 2, and (iv) patients with care levels 3-5. The Kaplan-Meier analysis identified a lower rate of the composite endpoint in group (i) than in the other groups. After adjusting for potentially confounding effects using a Cox proportional regression model, the hazard ratio (HR) of the composite endpoint increased significantly in groups (iii) and (iv) (adjusted HR, 1.62; 95% confidence interval [CI], 1.22-1.98 and adjusted HR, 1.62; 95% CI, 1.23-2.14, respectively) when compared with group (i). However, there was no significant difference between groups (i) and (ii).

CONCLUSIONS

The level of LTCI was associated with a higher risk of the composite endpoint after discharge in acute HF patients.

Dysphagia worsens short-term outcomes in patients with acute exacerbation of heart failure

Dysphagia, defined as a dysfunction in any stage or process of eating, is common in patients with acute exacerbation of heart failure (HF). In some diseases, dysphagia worsens in-hospital mortality, length of hospital stay, and discharge disposition. However, it remains unclear whether dysphagia is associated with poor short-term outcomes in HF patients. The objective of the present study was to determine whether dysphagia affects short-term outcomes in patients with acute exacerbation of HF. A total of 327 patients hospitalized with acute exacerbation of HF were eligible for the study. Patients were divided into a dysphagia group (DG) or a non-dysphagia group (NDG) based on results of the functional oral intake scale (FOIS), which evaluates a patient's ability of eating and swallowing. FOIS is a 7-point scale, with a level of ≤ 5 indicating dysphagia. Following the withdrawal of 16 patients, short-term outcomes such as in-hospital mortality, length of hospital stay, and discharge disposition, of 311 patients were analyzed. All indexes of short-term outcomes were significantly worse in the DG than in the NDG. After propensity score matching, which was performed to adjust for baseline characteristics such as age, sex, height, weight, body mass index, medical history, complications, HF severity, ejection fraction, and biochemical data excluding nutritional status, all short-term outcomes remained significantly worse in the DG than in the NDG. Multivariate analysis showed that FOIS was an independent predictor of in-hospital survival, length of hospital stay, and discharge to home. The present study suggested that dysphagia affected short-term outcomes in patients with acute exacerbation of HF. Therefore, early detection and intervention of dysphagia in HF patients are important.

Clinical Impact and Associated Factors of Delayed Ambulation in Patients With Acute Heart Failure

Background: In heart failure (HF) management, early ambulation is recommended to prevent physical deconditioning. The effects of delayed ambulation on later clinical outcomes and the factors linked to delayed ambulation in hospitalized HF patients, however, remain unestablished.

Methods and Results: We retrospectively investigated 101 patients (mean age, 66±17 years) who were hospitalized for acute decompensated HF. During the mean follow-up of 244±15 days after hospital discharge, 34 patients had cardiovascular events leading to death or unplanned readmission. Patients with cardiovascular events had longer median days to acquire ambulation than those without cardiovascular events (11 days, IQR, 8–20 days vs. 7 days, IQR, 5–15 days, P<0.001). The optimal cut-off period until initiation of ambulation to discriminate cardiovascular events was 8 days, indicating that longer days (≥8 days) to acquire ambulation was associated with higher rates of cardiovascular events, even after adjustment of multiple confounders. On multivariate analysis, age >65 years (odds ratio [OR], 2.49; 95% confidence interval [CI]: 1.04–6.09) and increase in blood urea nitrogen (BUN; OR, 1.04; 95% CI: 1.01–1.08) were independent predictors of delayed ambulation.

Conclusions: Delayed ambulation is associated with older age and increased BUN in patients with acute HF. Time to ambulation in the recovery phase of acute HF is important, and delayed ambulation may increase the rate of cardiovascular events after hospital discharge.

Clinical characteristics of hospitalized heart failure patients with preserved, mid-range, and reduced ejection fractions in Japan

Aims

There are regional differences in the patient characteristics, management, and outcomes of hospitalized patients with heart failure (HF). The aim of this study was to evaluate the clinical characteristics and outcomes of Japanese patients who are hospitalized with HF on the basis of the left ventricular ejection fraction (LVEF) stratum.

Methods and results

We retrospectively conducted a multicentre cohort study of 1245 hospitalized patients with decompensated HF between 2013 and 2014. Of these patients, 36% had an LVEF < 40% [HF with reduced ejection fraction (HFrEF), median age 72 years, 71% male], 21% had an LVEF 40–49% [HF with mid‐range EF (HFmrEF), 77 years, 56% male], and 43% had an LVEF ≥ 50% [HF with preserved EF (HFpEF), 81 years, 44% male]. The primary outcome was death from any cause, and the secondary outcomes were cardiac death and re‐hospitalization due to worsened HF after hospital discharge. There were high proportions of non‐ischaemic cardiomyopathy (32%) in HFrEF patients, coronary artery disease (44%) in HFmrEF patients, and valvular disease (39%) in HFpEF patients. The frequencies of intravenous diuretic and natriuretic peptide administration during hospitalization were 66% and 30%, respectively. The median hospital stay for the overall population was 19 days, and the length of stay was >7 days for >90% of patients. In‐hospital mortality was 7%, but was not different among the LVEF groups (HFrEF 7%, HFmrEF 6%, and HFpEF 8%). After a median follow‐up of 19 months (range, 3–26 months), 192 (17%) of the 1156 patients who were discharged alive died, and 534 (46%) were re‐hospitalized after hospital discharge. There were no significant differences in mortality after hospital discharge among the three LVEF groups (HFrEF 18%, HFmrEF 16%, and HFpEF 16%). There were no differences in cardiac death or re‐hospitalization due to worsened HF after hospital discharge among the LVEF groups (cardiac death: HFrEF 8%, HFmrEF 7%, and HFpEF 7%; re‐hospitalization due to worsened HF: HFrEF 19%, HFmrEF 16%, and HFpEF 17%). Multivariable‐adjusted analyses showed that the HFmrEF and HFrEF groups, compared with the HFpEF group, were not associated with an increased risk for in‐hospital death or death after hospital discharge. Non‐cardiac causes of death and re‐hospitalization after hospital discharge accounted for 35% and 38%, respectively.

Conclusions

Our results revealed different clinical characteristics but similar mortality rates in the HFrEF, HFmrEF, and HFpEF groups. The most common cause of death and re‐hospitalization after hospital discharge was HF, but non‐cardiac causes also contributed to their prognosis. Integrated management approaches will be required for HF patients.

Complex assessment of patients with decompensated heart failure: The clinical value of impedance cardiography and N-terminal pro-brain natriuretic peptide

BACKGROUND

Acute decompensated heart failure (ADHF) is a serious clinical problem and a condition requiring immediate diagnostics, supporting the therapeutic decision adequate to the specific ADHF mechanism. N-terminal pro-brain natriuretic peptide (NT-proBNP) is an established biochemical marker of heart failure, strongly related to hemodynamic status. Impedance cardiography (ICG) provides non-invasive hemodynamic assessment that can be performed immediately at the bedside and revealed to be useful diagnostic tool in some clinical settings in cardiology.

OBJECTIVES

The aim of this study was to evaluate the usefulness of ICG in the admission diagnostics and monitoring the effects of treatment in patients hospitalized due to ADHF, with special emphasis on its relation to NT-proBNP.

METHODS

This study enrolled 102 patients, aged over 18 years, hospitalized due to ADHF. The subjects underwent detailed clinical assessment, including ICG and NT-proBNP at admission and at discharge day.

RESULTS

Among all analyzed ICG parameters thoracic fluid content (TFC), a marker of chest overload, was the most significantly correlated with NT-proBNP level (R = 0.46; p = 0.000001). In comparison with patients with low thoracic fluid content (TFC ≤ 35/kΩ), those with higher TFC values (>35/kΩ) exhibited a greater severity of symptoms (NYHA functional class); higher NT-proBNP levels; lower left ventricular ejection fraction (LVEF), stroke index (SI), and cardiac index (CI); as well as significantly higher systemic vascular resistance index (SVRI). These TFC-based subgroups showed no significant differences in terms of heart rate (HR), systolic blood pressure (SBP), or diastolic blood pressure (DBP).

CONCLUSIONS

The evaluation of hemodynamic parameters, especially TFC, seems to be a worthwhile addition to standard diagnostics, both at the stage of hospital admission and while monitoring the effects of treatment. Impedance cardiography is a useful method in evaluating individual hemodynamic profiles in patients with ADHF.

Clinical Characteristics and Outcomes in the Very Elderly Patients Hospitalized for Acute Heart Failure: Importance of Pharmacologic Guideline Adherence

The prognostic factors and pharmacological effects of the very elderly patients (aged ≥80 years) with acute heart failure (AHF) remain unclear. The study, therefore, investigated the prognostic impacts of the guideline-recommended pharmacological therapy in these patients. A cohort of 1297 very elderly patients [85.1 ± 4.0 years, 69.7% male, 32.6% heart failure with reduced left ventricular ejection fraction (LVEF), HFrEF], hospitalized for AHF, was studied. The percentage of the recommended prescription for HFrEF at discharge, including renin-angiotensin system inhibitors, β-blockers, and mineralocorticoid receptor antagonists, was calculated as guideline adherence indicator (GAI). Among the 1233 survivors at discharge, 495 subjects (40.1%) died during a mean follow-up of 27.1 ± 23.9 months. Mean GAIs in HFrEF and HFpEF were 70.6 ± 34.9% and 64.1 ± 35.9%, respectively. A higher GAI was associated with less overall mortality [hazard ratio and 95% confidence interval per-1SD: 0.781, 0.655–0.930] and cardiovascular death (0.718, 0.558–0.925), independent of age, gender, diabetes, hypertension, mean blood pressure, LVEF, eGFR, sodium, and NT-proBNP. A GAI of 100% was associated with a better survival in both HFrEF and HFpEF. A prescription of the three recommended medications for HFrEF to the very elderly AHF patients was associated with a better survival after discharge.

Mortality after admission for heart failure in the UK compared with Japan

Objective

Mortality amongst patients hospitalised for heart failure (HHF) in Western and Asian countries may differ, but this has not been investigated using individual patient-level data (IPLD). We sought to remedy this through rigorous statistical analysis of HHF registries and variable selection from a systematic literature review.

Methods and results

IPLD from registries of HHF in Japan (n=3781) and the UK (n=894) were obtained. A systematic literature review identified 23 models for predicting outcome of HHF. Five variables appearing in 10 or more reports were strongly related to prognosis (systolic blood pressure, serum sodium concentration, age, blood urea nitrogen and creatinine). To compare mortality in the UK and Japan, variables were imputed in a propensity model using inverse probability of treatment weighting (IPTW) and IPTW with logistic regression (doubly robust IPTW). Overall, patients in the UK were sicker and in-patient and post-discharge mortalities were greater, suggesting that the threshold for hospital admission was higher. Covariate-adjusted in-hospital mortality was similar in the UK and Japan (IPTW OR: 1.14, 95% CI 0.70 to 1.86), but 180-day postdischarge mortality was substantially higher in the UK (doubly robust IPTW OR: 2.33, 95% CI 1.58 to 3.43).

Conclusions

Despite robust methods to adjust for differences in patient characteristics and disease severity, HHF patients in the UK have roughly twice the mortality at 180 days compared with those in Japan. Similar analyses should be done using other data sets and in other countries to determine the consistency of these findings and identify factors that might inform healthcare policy and improve outcomes.

Clinical Significance of Get With the Guidelines-Heart Failure Risk Score in Patients With Chronic Heart Failure After Hospitalization

Background The Get With the Guidelines-Heart Failure ( GWTG - HF ) risk score was developed using American Heart Association GWTG - HF program data and predicts in-hospital mortality in patients with acute heart failure (HF). We aimed to clarify the prognostic impacts of the GWTG - HF risk score in patients with HF after discharge. Methods and Results We examined the GWTG - HF score in 1452 patients with HF, who were admitted to our hospital and discharged after treatment, by calculating 7 predetermined variables. We divided all subjects into 3 groups according to the GWTG - HF risk score (low, moderate, and high score groups). The plasma B-type natriuretic peptide level significantly increased with increasing GWTG - HF risk score severity (median values of B-type natriuretic peptide: 167.0 in low, 260.7 in moderate, and 418.2 pg/mL in high score groups). We followed up all subjects after discharge, and there were 347 (23.9%) all-cause deaths and 407 (28.0%) cardiac events in follow-up periods. A Kaplan-Meier survival curve demonstrated that event rates of all-cause death and cardiovascular events, including worsening HF and cardiac death, significantly increased with increasing GWTG - HF risk score severity in all subjects, and also in 749 patients with HF with preserved ejection fraction (ejection fraction ≥50%) and 703 patients with HF with reduced ejection fraction (ejection fraction <50%) patients. The multivariable Cox proportional hazard regression analysis demonstrated that the GWTG - HF risk score was one of the significant predictors of all-cause mortality and cardiac events (all-cause mortality: hazard ratio, 1.537, 95% confidence interval, 1.172-2.023; cardiac events: hazard ratio, 1.584, 95% confidence interval, 1.344-1.860, per 10-point increase of GWTG - HF score). Conclusions The GWTG - HF risk score is a useful multivariable score model for several years after hospitalization in patients with HF in a Japanese population.

Self-management of congestive heart failure among elderly men in Japan

The purpose of this study was to explore the process of self-management in elderly male patients with congestive heart failure among those who have had not needed re-hospitalization for more than 2 years. Semi-structured interviews were conducted with 10 male congestive heart failure patients. Interviews were audio-recorded and transcribed verbatim. Data were analysed using the modified grounded theory approach. As a result of the analysis, the core concept identified was a process of living life such that symptoms do not worsen, while balancing good choices and preferences. By trial and error, the men tried to find the limits of physical capacity and dietary choices that would lead to the worsening of symptoms, while also trying to maintain quality of life to the extent possible.

Prognostic factors for in-hospital mortality of patients hospitalized for acutely decompensated heart failure

Objectives Despite improved treatment during last 20 years, prognosis for patients hospitalized for acutely decompensated heart failure (ADHF) is poor and mortality rates reported for these patients are high. Laboratory results can assist clinicians in evaluation and triaging of patients on hospital admission, and are important for the medical decision-making and prognosis assessments. Recently, new guidelines for the diagnosis and treatment of acute and chronic HF patients were published introducing a new group of patients with mid-range left ventricular ejection fraction (LVEF). Methods In order to explore the prognostic value for the in-hospital mortality of ADHF patients we analyzed laboratory test results for 165 emergency hospitalized patients regarding the survival and LVEF. Results In-hospital mortality was 16%. Patients who died were older than survivals (p = 0.003). There were no differences in LVEF between survivals and non-survivals. Patients who survived had significantly lower N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T (hs-cTnT), uric acid, urea, creatinine, and red blood cell distribution width (RDW) than patients who died (p < 0.001). All these tests had a good discrimination power between survivals and non-survivals (p < 0.001), but their incremental addition to NT-proBNP didn't improve its overall prognostic value. There was only a very weak correlation between NT-proBNP concentrations and LVEF. Groups with different LVEF status showed significant difference in number of erythrocytes, RDW and hemoglobin concentrations. Conclusions NT-proBNP had the best discriminatory power between survivals and non-survivals. Some routine laboratory test results, like RDW, uric acid, urea, and creatinine, have potentially significant value.

Validation of U.S. mortality prediction models for hospitalized heart failure in the United Kingdom and Japan

AIMS

Prognostic models for hospitalized heart failure (HHF) were developed predominantly for patients of European origin in the United States of America; it is unclear whether they perform similarly in other health care systems or for different ethnicities. We sought to validate published prediction models for HHF in the United Kingdom (UK) and Japan.

METHODS AND RESULTS

Patients in the UK (n =894) and Japan (n =3158) were prospectively enrolled and were similar in terms of sex (∼60% men) and median age (∼77 years). Models predicted that British patients would have a higher mortality than Japanese, which was indeed true both for in-hospital (4.8% vs. 2.5%) and 180-day (20.7% vs. 9.5%) mortality. The model c-statistics for the published/derivation (range 0.70-0.76) and Japanese (range 0.75-0.77) cohorts were similar and higher than for the UK (0.62-0.75) but models consistently overestimated mortality in Japan. For in-hospital mortality, the OPTIMIZE-HF model performed best, providing similar discrimination in published/derivation, UK and Japanese cohorts [c-indices: 0.75 (0.74-0.77); 0.75 (0.68-0.81); and 0.77 (0.70-0.83), respectively], and least overestimated mortality in Japan. For 180-day mortality, the c-statistics for the ASCEND-HF model were similar in published/derivation (0.70) and UK [0.69 (0.64-0.74)] cohorts but higher in Japan [0.75 (0.71-0.79)]; calibration was good in the UK but again overestimated mortality in Japan.

CONCLUSION

Calibration of published prediction models appears moderately accurate and unbiased when applied to British patients but consistently overestimates mortality in Japan. Identifying the reason why patients in Japan have a better than predicted prognosis is of great interest.

Newer hormonal pharmacotherapies for heart failure

INTRODUCTION

Heart failure (HF) is characterized by maladaptive neurohormonal activation of the cardiovascular and renal systems resulting in circulatory inadequacy and frequent acute exacerbations. The increasing burden of HF prompted investigation of underlying pathophysiological mechanisms and the design of pharmacotherapeutics that would target these pathways.

AREAS COVERED

A MEDLINE search for relevant original investigations and review articles of newer hormonal drugs for HF since the year 2005 till October 2017 provided us with necessary literature. Major trials and relevant clinical investigations were discussed.

EXPERT COMMENTARY

A multitude of hormonal pathways central to HF were identified, including the natriuretic peptide system and neurohormones such as relaxin, arginine vasopressin, and endothelin. However, drugs targeting these novel pathways (aliskiren, tolvaptan, ularitide, serelaxin, bosentan, macitentan) failed to show mortality benefit. This emphasizes a tremendous unmet need in the pharmacotherapy for HF, especially for the subtypes of acute HF and HF with preserved ejection fraction. Sacubitril/valsartan demonstrated substantial mortality benefit in chronic systolic HF population and is endorsed by international HF guidelines. If proven to be efficacious in larger outcome trials, finerenone can be a valuable addition baseline HF therapy. More basic, translational, and phenotype specific clinical research is warranted to improve HF pharmacotherapy.

The evolution of natriuretic peptide augmentation in management of heart failure and the role of sacubitril/valsartan

Heart failure (HF) is one of the leading causes of morbidity, mortality, and health care expenditures in the US and worldwide. For three decades, the pillars of treatment of HF with reduced ejection fraction (HFrEF) were medications that targeted the sympathetic nervous system (SNS) and the renin-angiotensin-aldosterone system (RAAS). Prior attempts to augment the natriuretic peptide system (NPS) for the management of HF failed either due to lack of significant clinical benefit or due to the unacceptable side effect profile. This review article will discuss the NPS, the failure of early drugs which targeted the NPS as therapies for HF, and the sequence of events which led to the development of sacubitril plus valsartan (Entresto; LCZ696; Novartis). LCZ696 has been shown to be superior to the standard of care available for treatment of HFrEF in several substantial hard endpoints including heart failure hospitalizations, cardiovascular mortality, and all-cause mortality.

Kyoto Congestive Heart Failure (KCHF) study: rationale and design

AIMS

Over the last decade, major developments in medicine have led to significant changes in the clinical management of heart failure patients. This study was designed to evaluate the recent trends in clinical characteristics, management, and short-term and long-term prognosis of patients with acute decompensated heart failure (ADHF) in Japan.

METHODS AND RESULTS

The Kyoto Congestive Heart Failure study is a prospective, observational, multicentre cohort study, enrolling consecutive ADHF patients from 19 participating hospitals in Japan from November 2014 to March 2016. A total of 4000 patients will be enrolled into the study and patients' anthropometric, socio-economic, and clinical data from hospital admission to discharge will be collected. In addition, in a pre-determined subgroup of patients (n=1500), a longitudinal follow-up for 2 years is scheduled.

CONCLUSIONS

The Kyoto Congestive Heart Failure study will provide valuable information regarding patients with ADHF in the real-world clinical practice of Japan and will be indispensable for future clinical and policy decision-making with respect to heart failure.

An NPPB Promoter Polymorphism Associated With Elevated N-Terminal pro-B-Type Natriuretic Peptide and Lower Blood Pressure, Hypertension, and Mortality

Background

Elevated B‐type natriuretic peptide (BNP) levels are associated with heart failure and increased mortality in the general population. We investigated rs198389, a functional variant in the promoter region of the BNP gene (NPPB), in patients from the Atherosclerosis Risk in Communities Study to investigate associations with N‐terminal pro‐BNP (NT‐proBNP) levels and outcomes.

Methods and Results

A total of 11 361 black and white patients with rs198389 genotyping attended visit 1 (aged 45–64 years; 1987–1989), with follow‐up visits occurring every 3 years (visit 2–visit 4, 1990–1999), followed by visit 5 (2011–2013). NT‐proBNP levels were measured at visits 2, 4, and 5. At visit 2, the GG genotype (frequency 18%) was associated with a 41% higher mean plasma level of NT‐proBNP compared with the AA genotype (frequency 34%), with intermediate values observed in AGs (P=4.2×10⁻⁵²). The GG genotype was associated with reduced systolic blood pressure (−1.6 mm Hg, P=0.006), diastolic blood pressure (−1 mm Hg, P=0.003), antihypertension medication use (odds ratio, 0.85; 95% CI, 0.74–0.97 [P=0.02]), and hypertension (odds ratio, 0.81; 95% CI, 0.72–0.92 [P=0.002]) compared with the AA genotype with intermediate values in AGs. These relationships persisted throughout subsequent visits. After a median follow‐up of 23 years, there were 4031 deaths. With and without covariate adjustment, the GG genotype was associated with modestly lower mortality (hazard ratio, 0.86; 95% CI, 0.78–0.95), primarily reflective of cardiovascular death (hazard ratio, 0.75; 95% CI, 0.61–0.92), and increased residual lifespan of 8 months from 50 years of age (P=0.02) versus AAs.

Conclusions

The rs198389 G allele in the NPPB promoter is associated with elevated levels of NT‐proBNP throughout adult life, reduced blood pressure, hypertension and cardiovascular mortality, and increased lifespan.

Advances in chemical pharmacotherapy for managing acute decompensated heart failure

INTRODUCTION

Acute decompensated heart failure (ADHF) contributes largely to the burden of heart failure and is associated with a poorer prognosis. Although numerous clinical trials evaluated the benefit of newer medications for ADHF, most of them were not successful. Areas covered: This review focusses on the updates on recent developments in chemical pharmacotherapy for the management of ADHF. A MEDLINE search for relevant review articles and original investigations on newer drugs for ADHF provided us with necessary literature. Expert opinion: Currently, popular therapies like diuretics, vasodilators, and inotropes offer symptomatic relief but do not provide survival benefit. Although multiple medications targeting novel pathways in ADHF were studied extensively, they failed to show either symptomatic or mortality benefit in available randomized trials. Improving our understanding of the complex pathophysiology of ADHF along with designing studies which include patients who are more representative of the real-world heart failure population, standardizing methods for endpoint assessment, and evaluating the role on novel biomarkers of organ dysfunction is important to improve ADHF research. Enhancing preventive strategies like improving baseline therapy in chronic heart failure patients and developing strategies for early identification of ADHF are important as our quest for innovative ADHF pharmacotherapy continues.

Relationship between worsening renal function and long-term cardiovascular mortality in heart failure patients

BACKGROUND

Recently several studies showed that worsening renal function (WRF) during hospitalization might be a strong independent predictor of poor prognosis in decompensated heart failure (HF) patients. However, these studies had a relatively short follow-up duration and their data were limited to in-hospital outcomes. Our purpose was to assess the relationship between WRF and long-term cardiovascular mortality in HF patients.

METHODS

We enrolled decompensated HF patients who were admitted to our hospital between April 2010 and March 2015. WRF was defined as a relative increase in serum creatinine of at least 25% or an absolute increase in serum creatinine ≥0.3mg/dL from the baseline. We assessed the cardiovascular mortality and all-cause mortality in HF patients with WRF (WRF group) and without WRF (no WRF group).

RESULTS

Among 301 patients enrolled, WRF developed in 118 patients (39.2%). During a median follow-up period of 537days [interquartile range, 304.3 to 1025.8days], cardiovascular mortality and all-cause mortality were significantly higher in the WRF group than in the no WRF group (23.2% vs. 6.1%, P<0.001; 30.3% vs. 14.7%, P<0.001, respectively). In the multivariate Cox proportional hazards model, age and serum B-type natriuretic peptide (BNP) level were associated with both cardiovascular death and all-cause death. However, WRF was not the independent predictor of cardiovascular death (P=0.19) nor all-cause death (P=0.57).

CONCLUSIONS

WRF was associated with cardiovascular death in patients with HF. Although not an independent predictor, WRF might be one of useful markers to identify patients who should be followed carefully after discharge.

Heart failure epidemiology and novel treatments in Japan: facts and numbers

Japan has the highest proportion of older people in the world, 25.9% of the population were aged 65 or above in 2014. Although there have been no population‐based studies that precisely examined the prevalence of heart failure in Japan, one report estimated the number of Japanese outpatients with left ventricular dysfunction was 979, 000 (0.8% of total population), which was projected to increase gradually as the population ages, reaching 1.3 million by 2030. Ischemic etiology was less frequently observed in Japan (31–47%) than in western population (54–57%). The prevalence of HF with preserved ejection fraction was similar between Japan (34–68%) and western countries (34–51%). Non‐cardiac co‐morbidities such as chronic obstructive pulmonary diseases and anemia were observed in 6–9% in Japan and 19–31% in western countries, and 35–58% in Japan and 37–56% in western countries, respectively. The definition of chronic kidney disease widely differed among studies. A relatively good survival prognosis in Japanese patients has been discussed. One‐year mortality after discharge from initial hospitalization was 9–12%, which seems to be better than the western cohort. Although length of stay was remarkably longer in Japan (15–21 days) than western countries (4–9 days), it will have to be shortened, as Japan is now being faced with an upcoming HF pandemic. Some treatments in Japan are not approved outside Japan. Such treatments include carperitide infusion (used in 58% of hospitalized HF), nicorandil infusion (9.6%), and oral pimobendan (5%). More recently, landiolol and tolvaptan have been approved. Although these drugs might have a potential to be an effective therapeutic option, lack of corroborating evidence in many of such treatments would emphasize the need for larger clinical trials.

Neprilysin inhibition to treat heart failure: a tale of science, serendipity, and second chances

This review describes the role of neprilysin (also known as neutral endopeptidase or enkephalinase) in the degradation of natriuretic and other vasoactive peptides, including bradykinin and adrenomedullin. The initial development of neprilysin inhibitors, then angiotensin converting enzyme-neprilysin inhibitors and, most recently, the angiotensin receptor neprilysin inhibitor (ARNI) LCZ696 (sacubitril valsartan) as an extension of the nurohumoral basis for the treatment of heart failure is also summarised. Finally, the implications of the compelling benefits of LCZ696 compared with enalapril in the Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure trial (PARADIGM-HF) is discussed.

Incidence and predictors of ischemic stroke during hospitalization for congestive heart failure

Heart failure (HF) increases the risk of ischemic stroke. Data regarding the incidence and predictors of ischemic stroke during hospitalization for HF are limited. The study population of this retrospective cohort study consisted of patients with congestive HF, consecutively admitted to our center from October 2010 to April 2014. We excluded patients complicated with acute myocardial infarction, infective endocarditis, and takotsubo cardiomyopathy. We also excluded those with dialysis or mechanical circulatory support. We investigated the incidence of ischemic stroke during hospitalization for HF. Thereafter, we divided the patients without oral anticoagulants at admission into two groups: patients with ischemic stroke and those without it, and explored the predictors of ischemic stroke. A total of 558 patients (287 without atrial fibrillation (AF), 271 with AF) were enrolled. The mean age was 76.8 ± 12.3 years, and 244 patients (44 %) were female. The mean left-ventricular ejection fraction was 47.4 %. Oral anticoagulants were prescribed in 147 patients (8 without AF, 139 with AF). During hospitalization (median length 18 days), symptomatic ischemic stroke (excluding catheter-related) occurred in 15 patients (2.7 % of the total, 8 without AF, 7 with AF). Predictors significantly associated with increased risk of ischemic stroke in patients without oral anticoagulants were as follows; short-term increases in blood urea nitrogen after admission (at day 3; odds ratio (per 1 md/dl): 1.06, 95 % confidence interval (CI) 1.01-1.11, p = 0.02, and at day 7; odds ratio: 1.03, 95 % CI 1.00-1.07, p = 0.03, respectively), and previous stroke (odds ratio; 3.33, 95 % CI 1.01-11.00, p = 0.04). The incidence of ischemic stroke during hospitalization for HF was high, even in patients without AF. Previous stroke and short-term increases in blood urea nitrogen was significantly associated with the incidence of ischemic stroke.

Congestive Heart Failure With Apparently Preserved Left Ventricular Systolic Function: A 10-Year Observational Study

We analyzed the clinical presentation and outcomes (from 2003 to 2013) of heart failure (HF) with apparently normal systolic function (HFPEF). Based on the echocardiographic left ventricular ejection fraction (LVEF), patients were divided into 2 groups, group 1 (<50%) and group 2 (≥50%). Of 2212 patients with HF, 20% were in group 2. Patients in group 2 were more likely to be older, females, Arabs, hypertensive, and obese (P = .001). Patients in group 1 were mostly Asians and had more troponin-T positivity (P = .001). Inhospital cardiac arrest, shock, and deaths were significantly greater in group 1. On multivariate analysis, age, ST-segment elevation myocardial infarction, lack of on-admission β-blockers, and angiotensin-converting enzyme inhibitors use were independent predictors of mortality. HFPEF is associated with less mortality compared to those who presented with reduced LVEF. On admission, use of evidence-based medications could in part predict this difference in the hospital outcome.

Characteristics, management modalities and outcome in chronic systolic heart failure patients treated in tertiary care centers: results from the EVIdence based TreAtment in Heart Failure (EVITA-HF) registry

BACKGROUND

Limited data exist regarding baseline characteristics and management of heart failure with reduced ejection fraction (EF) in tertiary care facilities.

METHODS

EVITA-HF comprises web-based case report data on demography, comorbidities, diagnostic and therapy measures, quality of life, adverse events and 1-year follow-up of patients hospitalized for chronic heart failure and an ejection fraction of less than 40%.

RESULTS

Between February 2009 and June 2011, a total of 1,853 consecutive, hospitalized patients (pts) were included in 16 centers in Germany. Mean age was 70 years, 76% were male. Median EF was 30%, and 63% were in NYHA III/IV. Ischemic cardiomyopathy was present in 56%, history of hypertension in 76%, diabetes in 39%, impaired renal function in 33%, thyroid dysfunction in 12%, and malignoma in 7%. Sixty-eight percent of pts had a non-elective admission. Rhythm was sinus/atrial fibrillation or flutter/pacemaker in 64, 28 and 11%, respectively. Median heart rate amounted to 80 bpm, median blood pressure to 122/74 mmHg. LBBB was present in 26% of non-pacemaker pts. Eighteen percent had an ICD or CRT-D. Medication (admission vs. discharge) consisted of ACEI or ARB in 73 vs. 88%, β-blocker in 71 vs. 89%, mineral corticosteroid receptor antagonist (MRA) in 32 vs. 57%, diuretics in 68 vs. 83% (p < 0.001 for each). Forty-two percent of pts received a specific treatment procedure beyond pharmacotherapy, of these 48% revascularization, 39% device therapy, 14% electrical cardioversion, 5% ablation procedures, 9 % valvular procedures, 6% iv inotropes, 1.8% IABP or LVAD implantation. At discharge, 33% of survivors had ICD- or CRT-D implants. One-year mortality amounted to 16.8%, and death or rehospitalization to 56%. NYHA class III/IV was found in 30% (p < 0.001 vs. index admission), general health status was improved in 45% and unchanged in 36% of patients. Eighty-five percent of pts took ACEI or ARB, 86% β-blockers, 47% MRA, and 78% diuretics (p < 0.001 vs. index discharge for all).

CONCLUSION

Patients with chronic heart failure and low ejection fraction represent an elderly and multimorbid population. While hospitalized, they experience a significant optimization of prognosis-relevant medication, revascularization and device therapy. After 1 year, mortality is moderate; drug adherence is high and NYHA status favourable. The EVITA-HF registry is able to reflect coherently the real-world management, efforts and follow-up in heart failure pts managed in tertiary care facilities.

Novel diuretic strategies for the treatment of heart failure in Japan

Fluid management is of paramount importance in the treatment strategy of heart failure (HF), but the therapeutic efficacy of loop diuretic-based treatment for HF patients is limited by insufficient response and adverse effects. Clinical data establishing the efficacy and safety of tolvaptan, a selective oral vasopressin V2 receptor antagonist that induces aquaresis, have recently been accumulated over 3 years of daily clinical experience in Japan. Intravenous infusion of carperitide, a synthetic α-human atrial natriuretic peptide, has also been widely used as acute-phase therapy for acute decompensated HF in Japan. Combination therapy using loop diuretics, tolvaptan, and carperitide with differing and complementary mechanisms of action may maximize therapeutic activity, to minimize the dosage of loop diuretics and thereby reduce the adverse effects not only for volume removal but also for the stability of cardiorenal hemodynamics.

Hyponatremia is an independent predictor of adverse clinical outcomes in hospitalized patients due to worsening heart failure

BACKGROUND AND PURPOSE

Hyponatremia is common and is associated with poor in-hospital outcomes in patients hospitalized with heart failure (HF). However, it is unknown whether hyponatremia is associated with long-term adverse outcomes. The purpose of this study was to clarify the characteristics, clinical status on admission, and management during hospitalization according to the serum sodium concentration on admission, and determine whether hyponatremia was associated with in-hospital as well as long-term outcomes in 1677 patients hospitalized with worsening HF on index hospitalization registered in the database of the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD).

METHODS AND SUBJECTS

We studied the characteristics and in-hospital treatment in 1659 patients hospitalized with worsening HF by using the JCARE-CARD database. Patients were divided into 2 groups according to serum sodium concentration on admission <135mEq/mL (n=176; 10.6%) or ≥135mEq/mL (n=1483; 89.4%).

RESULTS

The mean age was 70.7 years and 59.2% were male. Etiology was ischemic in 33.9% and mean left ventricular ejection fraction was 42.4%. After adjustment for covariates, hyponatremia was independently associated with in-hospital death [adjusted odds ratio (OR) 2.453, 95% confidence interval (CI) 1.265-4.755, p=0.008]. It was significantly associated also with adverse long-term (mean 2.1±0.8 years) outcomes including all-cause death (OR 1.952, 95% CI 1.433-2.657), cardiac death (OR 2.053, 95% CI 1.413-2.983), and rehospitalization due to worsening HF (OR 1.488, 95% CI 1.134-1.953).

CONCLUSIONS

Hyponatremia was independently associated with not only in-hospital but also long-term adverse outcomes in patients hospitalized with worsening HF.