A community based epidemiological and clinical study of hospitalization of patients with congestive heart failure in Northern Iwate, Japan

Seasonal variation in the detection rate and all-cause in-hospital mortality of AKI in China: A nationwide cohort study

Background

Acute kidney injury (AKI) is a severe clinical syndrome that places a massive burden on medical systems worldwide, yet the seasonality of AKI remains unexplored in China. The aim of this study was to describe the seasonal variation in the detection rate and all-cause in-hospital mortality of AKI in China based on a nationwide cohort study.

Methods

This was a retrospective cohort recruiting a national sample of 7,291 adult patients treated in hospitals in 22 provinces of mainland China during January or July 2013. AKI was defined according to the 2012 Kidney Disease Improving Global Outcomes AKI creatinine criteria or expanded criteria of increase or decrease in serum creatinine level of 50% during the hospital stay. The seasonal group was determined according to the corresponding admission date for each patient. The detection rate of AKI refers to the ratio of identified AKI cases to the total number of adult admissions from the same regional or seasonal group.

Results

Both the detection rate (2.31 vs. 2.08%, p = 0.001) and in-hospital mortality rate (13.3 vs. 10.7%, p = 0.001) of AKI were higher in winter than in summer. The patients with AKI detected in winter had higher proportions of prehistory diseases, cardiac or vascular kidney injury factors, and severe comorbidities than those in summer (all p < 0.05). In the multivariable analysis, winter was an independent risk factor for in-hospital mortality of patients with AKI [odds ratio (OR) = 1.22, 95% confidence interval (CI), 1.03-1.44, p = 0.02] after adjusting for demographic factors, medical history, comorbidity, and climatic confounders. Higher ambient temperature (OR = 0.91, 95% CI, 0.86-0.97, p = 0.002, per 10°C increase), higher relative humidity level (OR = 1.14, 95% CI, 1.04-1.25, p = 0.005, per 10% increase), and living in temperate continental region (OR = 2.18, 95% CI, 1.63-2.91, p < 0.001) were each independently associated with in-hospital mortality.

Conclusion

The detection rate and all-cause in-hospital mortality of AKI showed a winter predominance in patients with AKI in China. Winter appeared to be an independent risk factor for all-cause in-hospital mortality in patients with AKI. Environmental factors, including lower ambient temperature, higher relative humidity level, and living in temperate continental climatic regions, were each independently associated with increased risks of in-hospital mortality in patients with AKI.

Incidence Rate of Hospitalization for Heart Failure in a Japanese City ― An Updated Reference for Japan’s Aging Society ―

Background: The prevalence of heart failure (HF) is increasing in aging societies, such as Japan. The current incidence rate (IR) of HF hospitalization in Japan is unknown.

Methods and Results: We conducted a regional population-based study assessing the IR of HF hospitalization in Nobeoka City. Data were collected over a period of 3 years from all patients with HF admitted for the first time to hospitals and clinics. 406 HF hospitalizations were registered (54% female; mean age 82 years). The IR of HF hospitalization was 129/100,000 person-years. The difference in the IR between women and men was not significant (131 vs. 127/100,000 person-years, respectively; P=0.767). The age-adjusted IR in the 2015 Japanese population was 105/100,000 person-years. According to 5-year age bands, the IR of HF hospitalization gradually increased up to 60–70 years of age, then increased rapidly in those aged ≥95 years for both sexes. The IR ratio compared with age <65 years was higher in women than men in each older age group.

Conclusions: In this population-based study, the current IR of HF hospitalization in a region of Japan was higher than the IR from another study conducted in a different region in early 2000. By presenting detailed age-related data, the research findings will contribute to estimating the number of HF hospitalizations in other areas of Japan.

Low educational level increases functional disability risk subsequent to heart failure in Japan: On behalf of the Iwate KENCO study group

Objectives

The risk factors that contribute to future functional disability after heart failure (HF) are poorly understood. The aim of this study was to determine potential risk factors to future functional disability after HF in the general older adult population in Japan.

Methods

The subjects who were community-dwelling older adults aged 65 or older without a history of cardiovascular diseases and functional disability were followed in this prospective study for 11 years. Two case groups were determined from the 4,644 subjects: no long-term care insurance (LTCI) after HF (n = 52) and LTCI after HF (n = 44). We selected the controls by randomly matching each case of HF with three of the remaining 4,548 subjects who were event-free during the period: those with no LTCI and no HF with age +/-1 years and of the same sex, control for the no LTCI after HF group (n = 156), and control for the LTCI after HF group (n = 132). HF was diagnosed according to the Framingham diagnostic criteria. Individuals with a functional disability were those who had been newly certified by the LTCI during the observation period. Objective data including blood samples and several socioeconomic items in the baseline survey were assessed using a self-reported questionnaire.

Results

Significantly associated risk factors were lower educational levels (odds ratio (OR) [95% confidence interval (CI)]: 3.72 [1.63–8.48]) in the LTCI after HF group and hypertension (2.20 [1.10–4.43]) in no LTCI after HF group. Regular alcohol consumption and unmarried status were marginally significantly associated with LTCI after HF (OR [95% CI]; drinker = 2.69 [0.95–7.66]; P = 0.063; unmarried status = 2.54 [0.91–7.15]; P = 0.076).

Conclusion

Preventive measures must be taken to protect older adults with unfavorable social factors from disability after HF via a multidisciplinary approach.

Short-term exposure to air pollution and hospital admission for heart failure among older adults in metropolitan cities: a time-series study

PURPOSE

We aimed to investigate the association between air pollution concentration levels and hospital admissions for heart failure (HF) among older adults in metropolitan cities in South Korea.

METHODS

We used hospital admission data of 1.8 million older adults in seven metropolitan cities from 2008 to 2016, derived from the National Health Insurance Service of South Korea. Daily HF admission data were linked to air pollutants concentrations for the respective dates, including particulate matter less than 2.5 μm in size (PM_2.5), 10 μm (PM₁₀), sulfur dioxide (SO₂), nitrogen dioxide (NO₂), carbon monoxide (CO), and ozone. We estimated the association between air pollutants and daily HF admissions using quasi-Poisson generalized additive models for each city.

RESULTS

During the study period, 142,490 hospital admissions for HF were noted. Increases of 10 μg/m³ of PM_2.5 and PM₁₀, and 10 ppb of SO₂, NO₂, and CO were associated with an increased risk of HF admission by 0.93% ([95% confidence intervals 0.51-1.36], 0.55% [0.31-0.80], 6.04% [2.15-10.08], 1.10% [0.38-1.82], and 0.05% [0.01-0.09]), respectively, on the same day. Increases in mean exposure to PM_2.5, PM₁₀, and SO₂ for 8 days from the concurrent day were also significantly associated with HF admissions. During the warm season, the risk of HF admissions increased shortly after an increase in PM_2.5, whereas prolonged effects were observed during the cold season.

CONCLUSION

Our study suggests the adverse effects of air pollution on HF. Moreover, the evidence of seasonality may help tailor protection guidelines for older adults.

The Impact of Environmental Factors on the Mortality of Patients With Chronic Heart Failure

Outcomes of acute heart failure hospitalizations are worse during the winter than the rest of the year. Seasonality data are more limited for outcomes in chronic heart failure and the effect of environmental variables is unknown. In this population-level study, we merged 20-year data for 555,324 patients with heart failure from the national Veterans Administration database with data on climate from the National Oceanic and Atmospheric Administration and air pollutants by the Environmental Protection Agency. The outcome was the all-cause mortality rate, stratified by geographical location and each month. The impact of environmental factors was assessed through Pearson's correlation and multiple regression with a family-wise α = 0.05. The monthly all-cause mortality was 13.9% higher in the winter than the summer, regardless of gender, age group, and heart failure etiology. Winter season, lower temperatures, and higher concentrations of nitrogen dioxide were associated with a higher mortality rate in multivariate analysis of the overall population. Different environmental factors were associated in regions with similar patterns of temperature and precipitation. The only environmental factor associated with the mortality rate of patients dwelling in large urban centers was the air quality index. In conclusion, the mortality in chronic heart failure exhibits a seasonal pattern, regardless of latitude or climate. In this group of patients, particularly those of male gender, a higher mortality was associated with environmental factors and incorporating these factors in treatment plans and recommendations could have a favorable cost-benefit ratio.

Unraveling the Mystery of Cold Stress-Induced Myocardial Injury

Exposure to low ambient temperature imposes great challenge to human health. Epidemiological evidence has noted significantly elevated emergency admission and mortality rate in cold climate in many regions, in particular, adverse events in cardiovascular system. Cold stress is becoming one of the important risk factors for cardiovascular death. Through recent advance in echocardiography and myocardial histological techniques, both clinical and experimental experiments have unveiled that cold stress triggers a variety of pathological and pathophysiological injuries, including ventricular wall thickening, cardiac hypertrophy, elevated blood pressure, decreased cardiac function, and myocardial interstitial fibrosis. In order to examine the potential mechanism of action behind cold stress-induced cardiovascular anomalies, ample biochemical and molecular biological experiments have been conducted to denote a role for mitochondrial injury, intracellular Ca²⁺ dysregulation, generation of reactive oxygen species (ROS) and other superoxide, altered gene and protein profiles for apoptosis and autophagy, and increased adrenergic receptor sensitivity in cold stress-induced cardiovascular anomalies. These findings suggest that cold stress may damage the myocardium through mitochondrial injury, apoptosis, autophagy, metabolism, oxidative stress, and neuroendocrine pathways. Although the precise nature remains elusive for cold stress-induced cardiovascular dysfunction, endothelin (ET-_A) receptor, endoplasmic reticulum (ER) stress, transient receptor potential vanilloid, mitochondrial-related protein including NRFs and UCP-2, ROS, Nrf2-Keap1 signaling pathway, Bcl-2/Bax, and lipoprotein lipase (LPL) signaling may all play a pivotal role. For myocardial injury evoked by cold stress, more comprehensive and in-depth mechanisms are warranted to better define the potential therapeutic options for cold stress-associated cardiovascular diseases.

TMAO, a seafood-derived molecule, produces diuresis and reduces mortality in heart failure rats

Trimethylamine-oxide (TMAO) is present in seafood which is considered to be beneficial for health. Deep-water animals accumulate TMAO to protect proteins, such as lactate dehydrogenase (LDH), against hydrostatic pressure stress (HPS). We hypothesized that TMAO exerts beneficial effects on the circulatory system and protects cardiac LDH exposed to HPS produced by the contracting heart. Male, Sprague-Dawley and Spontaneously-Hypertensive-Heart-Failure (SHHF) rats were treated orally with either water (control) or TMAO. In vitro, LDH with or without TMAO was exposed to HPS and was evaluated using fluorescence correlation spectroscopy. TMAO-treated rats showed higher diuresis and natriuresis, lower arterial pressure and plasma NT-proBNP. Survival in SHHF-control was 66% vs 100% in SHHF-TMAO. In vitro, exposure of LDH to HPS with or without TMAO did not affect protein structure. In conclusion, TMAO reduced mortality in SHHF, which was associated with diuretic, natriuretic and hypotensive effects. HPS and TMAO did not affect LDH protein structure.

Heart failure is a common cause of death in industrialized countries with aging populations. Japan, however, has lower rates of heart failure and fewer deaths linked to this disease than the United States or Europe, despite having the highest proportion of elderly people in the world. Dietary differences between these regions may explain the lower rate of heart failure in Japan. The Japanese diet is rich in seafood, which contains nutrients that promote heart health, such as omega-3 fatty acids.

Seafood also contains other compounds, including trimethylamine oxide (TMAO). Fish that live in deep waters undergo high pressures, which can damage their proteins, but TMAO seems to protect the proteins from harm. In humans, eating seafood increases TMAO levels in the blood and urine, but it is unclear what effects this has on heart health. Increased levels of TMAO in the blood are associated with cardiovascular diseases, but scientists are not sure whether TMAO itself harms the heart. A toxic byproduct of gut bacteria called TMA is converted in TMAO in the body, so it is possible that TMA rather than TMAO is to blame.

To assess the effects of dietary TMAO on heart failure, Gawrys-Kopczynska et al. fed the compound to healthy rats and rats with heart failure for one year. TMAO had no effects on the healthy rats. Of the rats with heart failure that were fed TMAO, all of them survived the year, while one third of rats with heart failure that were not fed TMAO died. TMAO-treated rats with heart failure had lower blood pressure and urinated more than untreated rats with the condition.

The experiments suggest that dietary TMAO may mimic the effects of heart failure treatments, which remove excess water and salt and lower pressure on the heart. More studies are needed to confirm whether TMAO has this same effect on humans.

Seasonality of acute kidney injury incidence and mortality among hospitalized patients

Background

Understanding disease seasonality is important for improving clinical practice, hospital resource utilization and community-based preventive care. However, no studies have investigated the seasonality of acute kidney injury (AKI).

Methods

In the Tokushukai Medical Database, which includes 38 Japanese community hospitals, we identified hospitalized patients with AKI based on the Kidney Disease: Improving Global Outcomes serum creatinine criteria from January 2012 to December 2014. We plotted the number and proportion of patients with AKI among hospitalized patients by month of hospital admission. Subgroup analyses were conducted by the admission diagnosis category, timing of AKI diagnosis and age. We also examined the association between month of hospital admission and AKI, adjusting for patient characteristics and AKI risk factors. Finally, we assessed seasonal variations in disease severity and 30-day mortality of patients with AKI.

Results

We identified 81 279 (14.6%) patients with AKI among 555 940 hospitalized patients. The proportion of patients with AKI was highest in January (16.7%) and lowest in June (13.4%). Subgroup analyses suggested that the seasonality of AKI incidence was driven by community-acquired AKI associated with the admission diagnosis of cardiovascular and pulmonary diseases among older patients. The adjusted odds ratio for AKI (January versus June) was 1.24 (95% confidence interval, 1.17-1.31). Patients with AKI showed a larger number of failing organs in winter, and their 30-day mortality was 16.4% in spring, 14.5% in summer, 15.6% in autumn and 18.4% in winter.

Conclusion

AKI is more common among hospitalized patients and patients with AKI are more severely ill in winter.

Seasonal variation in hospitalization outcomes in patients admitted for heart failure in the United States

BACKGROUND

There is lack of evidence of the impact of varying season on heart failure (HF) hospitalization outcomes in the U.S.

HYPOTHESIS

HF hospitalization outcomes exhibit significant seasonal variation in the U.S.

METHODS

Using data from the National Inpatient Sample (2011-2013), seasonal variation was classified based on meteorological classification of Northern Hemisphere-Spring, Summer, Fall, & Winter-and analysis was conducted via multivariable-adjusted mixed-effect model.

RESULTS

An estimated 2.8 million adults were hospitalized for HF in the U.S. from 2011 to 2013. Of all hospitalizations, admissions were highest in Winter (27%), followed by Spring (26%), Fall (24%), and Summer (23%). The overall mortality rate was 3.1%. Compared with Spring, there was significantly lower mortality in Summer (odds ratio [OR]: 0.95, 95% CI: 0.91-0.99) and Fall (OR: 0.94, 95% CI: 0.89-0.98), but the highest mortality was in Winter (OR: 1.06, 95% CI: 1.02-1.11). In addition, mean length of stay and median cost of hospitalization were highest in Winter (5.3 days, USD7459, respectively) and lowest in Summer (5.1 days, USD7181, respectively). However, age and sex differences existed (e.g. seasonal variation in inpatient mortality was only significant for patients age ≥65 years, and, compared with the Spring season, males had higher risk of inpatient mortality in Winter (OR: 1.10, 95% CI: 1.04-1.17) and females had lower risk of inpatient mortality in Summer (OR: 0.94, 95% CI: 0.88-1.00) and Fall (OR: 0.92, 95% CI: 0.87-0.98).

CONCLUSIONS

Among HF patients in the U.S., hospitalization outcomes were worse in Winter but better in Summer.

Effects of climate and fine particulate matter on hospitalizations and deaths for heart failure in elderly: A population-based cohort study

BACKGROUND

There are limited data on the effects of climate and air pollutant exposure on heart failure (HF) within taking into account individual and contextual variables.

OBJECTIVES

We measured the lag effects of temperature, relative humidity, atmospheric pressure and fine particulate matter (PM_2.5) on hospitalizations and deaths for HF in elderly diagnosed with this disease on a 10-year period in the province of Quebec, Canada.

METHODS

Our population-based cohort study included 112,793 elderly diagnosed with HF between 2001 and 2011. Time dependent Cox regression models approximated with pooled logistic regressions were used to evaluate the 3- and 7-day lag effects of daily temperature, relative humidity, atmospheric pressure and PM_2.5 exposure on HF morbidity and mortality controlling for several individual and contextual covariates.

RESULTS

Overall, 18,309 elderly were hospitalized and 4297 died for the main cause of HF. We observed an increased risk of hospitalizations and deaths for HF with a decrease in the average temperature of the 3 and 7days before the event. An increase in atmospheric pressure in the previous 7days was also associated with a higher risk of having a HF negative outcome, but no effect was observed in the 3-day lag model. No association was found with relative humidity and with PM_2.5 regardless of the lag period.

CONCLUSIONS

Lag effects of temperature and other meteorological parameters on HF events were limited but present. Nonetheless, preventive measures should be issued for elderly diagnosed with HF considering the burden and the expensive costs associated with the management of this disease.

Seasonality and Readmission after Heart Failure, Myocardial Infarction, and Pneumonia

OBJECTIVE

To investigate whether hospital readmission after admission for heart failure (HF), myocardial infarction (MI), and pneumonia varies by season.

DATA SOURCES

All patients in 2005-2009 Healthcare Cost and Utilization Project State Inpatient Databases for New York and California hospitalized for HF, MI, or pneumonia.

STUDY DESIGN

The relationship between discharge season and unplanned readmission within 30 days was evaluated using multivariate modified Poisson regression.

PRINCIPAL FINDINGS

Cohorts included 869,512 patients with HF, 448,945 patients with MI, and 813,593 patients with pneumonia. While admissions varied widely by season, readmission rates only ranged from 25.0 percent (spring) to 25.6 percent (winter) for HF (p > .05), 18.9 percent (summer) to 20.0 percent (winter) for MI (p < .001), and 19.4 percent (spring) to 20.3 percent (summer) for pneumonia (p < .001). In adjusted models, in New York, there was lower readmission in spring and fall (RR: 0.98, 95% CI: 0.96-0.99 for both) after admission for HF and higher readmission in spring (RR: 1.04, 95% CI: 1.01-1.07) after MI. In California, there was lower readmission in spring and winter (RR: 0.95, 95% CI: 0.93-0.96 and RR: 0.96, 95% CI: 0.94-0.98, respectively) after pneumonia.

CONCLUSIONS

Given marked seasonality in incidence and mortality of HF, MI, and pneumonia, the modest seasonality in readmissions suggests that readmissions may be more related to non-seasonally dependent factors than to the seasonal nature of these diseases.

Seasonal Periodicity of Ischemic Heart Disease and Heart Failure

Seasonal variation for ischemic heart disease and heart failure is known. The interplay of environmental, biological, and physiologic changes is fascinating. This article highlights the seasonal periodicity of ischemic heart disease and heart failure and examines some of the potential reasons for these unique observations.

Risk of stroke and heart failure attributable to atrial fibrillation in middle-aged and elderly people: Results from a five-year prospective cohort study of Japanese community dwellers

Background

The relative and absolute risks of stroke and heart failure attributable to atrial fibrillation (AF) have not been sufficiently examined.

Methods

A prospective study of 23,731 community-dwelling Japanese individuals was conducted. Participants were divided into two groups based on the presence or absence of prevalent AF (n = 338 and n = 23,393, respectively). Excess events (EE) due to AF and relative risks (RRs) determined using the non-AF group as the reference for incident stroke and heart failure were estimated using Poisson regression stratified by age groups (middle-aged: 40–69 years old; elderly: 70 years of age or older) after adjustment for sex and age.

Results

There were 611 cases of stroke and 98 cases of heart failure during the observation period (131,088 person-years). AF contributed to a higher risk of stroke both in middle-aged individuals (EE 10.4 per 1000 person-years; RR 4.88; 95% confidence interval [CI], 2.88–8.29) and elderly individuals (EE 18.3 per 1000 person-years; RR 3.05; 95% CI, 2.05–4.54). AF also contributed to a higher risk of heart failure in middle-aged individuals (EE 3.7 per 1000 person-years; RR 8.18; 95% CI, 2.41–27.8) and elderly individuals (EE 15.4 per 1000 person-years; RR 7.82; 95% CI, 4.11–14.9). Results obtained from multivariate-adjusted analysis were similar (stroke: EE 8.9 per 1000 person-years; RR 4.40; 95% CI, 2.57–7.55 in middle-aged and EE 17.4 per 1000 person-years; RR 2.97; 95% CI, 1.99–4.43 in elderly individuals; heart failure: EE 3.1 per 1000 person-years; RR 7.22; 95% CI, 2.06–25.3 in middle-aged and EE 14.1 per 1000 person-years; RR 7.41; 95% CI, 3.86–14.2 in elderly individuals).

Conclusions

AF increased the risk of stroke by the same magnitude as that reported previously in Western countries. AF increased the RR of heart failure more than that in Western populations.

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Incidence rates for stroke and HF were estimated in Japanese community dwellers.

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Subjects were divided into AF and non-AF groups separately by age (40–69 and ≥70).

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AF increased the risk of stroke by the same magnitude as in Western populations.

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AF increased the risk of HF more than that in Western populations.

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The absolute risk differences of outcomes were larger in the elderly individuals.

Is Vitamin D Deficiency Associated With Heart Failure? A Review of Current Evidence

An estimated 1 billion people worldwide have deficient or insufficient levels of vitamin D. Even more alarming is the association of vitamin D deficiency with many types of diseases, particularly heart failure (HF). Hypovitaminosis D has been observed to be highly prevalent in the HF community with rates varying from approximately 80% to 95%. Higher rates of deficiency have been linked to winter months, in patients with protracted decompensated HF, darker skin pigmentation, and higher New York Heart Association (NYHA) classes. In fact, some data suggest vitamin D deficiency may even be an independent predictor of mortality in patients with HF. Traditionally obtained through UV exposure and activated in the liver and then the kidneys, vitamin D is classified as a vitamin but functions as a steroid hormone. The hormone acts through the vitamin D receptor (VDR), which is expressed in vascular smooth muscle cells, renal juxtaglomerular cells, and most interestingly, cardiac myocytes. Studies have shown that the association between vitamin D deficiency and HF often manifests in the structural components of cardiac myocytes and/or through alterations of the neurohormonal cascade. In addition, vitamin D may also act rapidly through intracellular nongenomic receptors that alter cardiac contractility. Unfortunately, prospective vitamin D supplementation trials show mixed results. In rat models, successful correction of deficiency was associated with reductions in ventricular hypertrophy. In humans, however, echocardiographic dimensions did not change significantly. These results bring into questions whether vitamin D is a risk factor for HF, a marker of HF disease severity, or has a true pathologic role. This article provides a thorough review of vitamin D deficiency etiology, prevalence, and possible pathophysiologic role in HF. Furthermore, we carefully review prospective trials on vitamin D therapy in HF. We believe more trials on vitamin D therapy in HF need to be conducted before any conclusions can be drawn.

Relationships of physiologically equivalent temperature and hospital admissions due to I30-I51 other forms of heart disease in Germany in 2009-2011

We aimed to understand relationships of the weather as biometeorological and hospital admissions due to other forms of heart disease by subtypes, which have been paid less attention, in a national setting in recent years. This is an ecological study. Ten percent of daily hospital admissions of the included hospitals (n = 1618) across Germany that were available between 1 January 2009 and 31 December 2011 (n = 5,235,600) were extracted from Statistisches Bundesamt, Germany. We identified I30-I51 other forms of heart disease by the International Classification of Diseases version 10 as the study outcomes. Daily weather data from 64 weather stations that have covered 13 German states, including air temperature, humidity, wind speed, cloud cover, radiation flux and vapour pressure, were obtained and generated into physiologically equivalent temperature (PET). Admissions due to other diseases of pericardium, nonrheumatic mitral valve disorders, nonrheumatic aortic valve disorders, cardiomyopathy, atrioventricular and left bundle-branch block, other conduction disorders, atrial fibrillation and flutter, and other cardiac arrhythmias peaked when PET was between 0 and 10 °C. Complications and ill-defined descriptions of heart disease admissions peaked at PET 0 °C. Cardiac arrest and heart failure admissions peaked when PET was between 0 and -10 °C while the rest did not vary significantly. A common drop of admissions was found when PET was above 10 °C. More medical resources could have been needed for heart health on days when PETs were <10 °C than on other days. Adaptation to such weather change for medical professionals and the general public would seem to be imperative.

Assessment of transthyretin combined with mini nutritional assessment on admission provides useful prognostic information in patients with acute decompensated heart failure

Decreased Transthyretin (TTR) can be observed in heart failure patients with malnutrition evaluated by the Mini Nutritional Assessment (MNA). This study investigated whether a combination of different nutritional assessment methods would be useful for assessing prognosis in patients with acute decompensated heart failure (ADHF).This prospective study included 52 patients with ADHF (mean age, 71.1 ± 14.7 years; men 55.8%) who were admitted to our hospital between June 2012 and August 2013. On admission, nutritional status was evaluated according to levels of TTR and the MNA. Of 52 patients, 28 (53.8%) had TTR < 15 mg/dL, 39 (75.0%) had malnutrition or were at risk of malnutrition (MNA score ≤ 23.5), and 21 (40.4%) were categorized into group L (MNA score ≤ 23.5 and TTR < 15 mg/dL). Readmission due to worsening heart failure occurred in 12 patients (23.1%), and there were 4 (7.7%) allcause deaths. The 1-year event-free survival rates in group L and the remaining patients (group O) were 27.7% and 85.6%, respectively (P = 0.001). Using Cox multivariate analysis, group L also had a poorer prognosis (hazard ratio 4.35, 95% confidence interval 1.26-17.74, P = 0.020).MNA revealed that 75% of patients with ADHF had malnutrition or were at risk of malnutrition. The combination of low MNA and low TTR on admission can predict the prognosis of patients with ADHF.

Clinical scenario 1 is associated with winter onset of acute heart failure

BACKGROUND

Several reports have evaluated the association between seasonal variation and acute heart failure (AHF) onset. Cold weather may induce AHF, but the clinical characteristics of patients susceptible to AHF during winter have not been established. Clinical Scenario (CS) is used in the early clinical management of AHF, so we investigated the relationship between CS classification and winter onset of AHF in Japan.

METHODS AND RESULTS

We enrolled 582 patients hospitalized for AHF and compared the frequency of AHF among the 4 seasons in each CS group to clarify the clinical characteristics of the winter onset group. Significant increase of AHF during winter was seen in CS1 (systolic blood pressure [SBP] (>140 mmHg) (P=0.01) but not in CS2 (SBP ≥ 100 and ≤ 140 mmHg) or CS3 (SBP <100 mmHg). CS1 patients were divided into winter and other season admission groups. In multivariate analysis, only lack of loop diuretic use was associated with winter admission of CS1 patients (odds ratio 0.562, 95% confidence interval: 0.256-0.798, P=0.006).

CONCLUSIONS

Winter predominance of AHF was seen only in CS1, and lack of loop diuretic use was a risk factor for winter onset. Future studies are necessary to confirm whether loop diuretics are useful in preventing AHF with CS1 in winter.

Clinical and seasonal variations of nutritional risk screening in patients scheduled for rehabilitation after heart surgery

BACKGROUND

Current knowledge on the pervasiveness of increased nutritional risk in cardiovascular diseases is limited. Our aim was to analyze the characteristics of nutritional risk screening in patients scheduled for rehabilitation after heart surgery. Prevalence and extent of nutritional risk were studied in connection with patients' characteristics and seasonal climate effects on weight loss dynamics.

METHODS

The cohort included 65 consecutive patients with an age range of 25-84 years, 2-6 months after surgical treatment for ischemic or valvular heart disease. Nutritional risk screening was appraised using a standardized NRS-2002 questionnaire. Groups were analyzed according to a timeline of rehabilitation according to the "cold" and "warm" seasons of the moderate Mediterranean climate in Opatija, Croatia.

RESULTS

Increased nutritional risk scores (NRS-2002) of >3 were found in 96% of studied patients. Mean NRS-2002 of patients was 5.0 ± 1.0, with a percentage weight loss history of 11.7% ± 2.2% (4.6-19.0). Risk was found to be more pronounced during the warmer season, with NRS-2002 scores of 5.3 ± 0.7 versus 4.8 ± 1.1 (P = 0.136) and greater loss of weight of 13.0% ± 3.2% versus 10.6% ± 3% (P = 0.005), respectively. Increased nutritional risk correlated significantly with creatinine concentrations (rho = 0.359; P = 0.034 versus 0.584; P = 0.001, respectively). Significant discordance in correlations was found between NRS-2002 and the decrease in left ventricle systolic function (rho correlation coefficient [rho-cc] = -0.428; P = 0.009), the increase in glucose concentrations (cc = 0.600; P < 0.001), and the decrease in erythrocyte counts (cc = -0.520; P = 0.001) during the colder season.

CONCLUSION

Increased nutritional risk was found to be frequently expressed in the course of rehabilitation after heart surgery. Although seasonal climate effects influenced the weight loss dynamics, the impact on reproducibility of NRS-2002 was clinically less important. Further studies on the connection of nutritional risk with composited end points might offer improvements in overall quality of treatment.

Cold stress accentuates pressure overload-induced cardiac hypertrophy and contractile dysfunction: role of TRPV1/AMPK-mediated autophagy

Severe cold exposure and pressure overload are both known to prompt oxidative stress and pathological alterations in the heart although the interplay between the two remains elusive. Transient receptor potential vanilloid 1 (TRPV1) is a nonselective cation channel activated in response to a variety of exogenous and endogenous physical and chemical stimuli including heat and capsaicin. The aim of this study was to examine the impact of cold exposure on pressure overload-induced cardiac pathological changes and the mechanism involved. Adult male C57 mice were subjected to abdominal aortic constriction (AAC) prior to exposure to cold temperature (4 °C) for 4 weeks. Cardiac geometry and function, levels of TRPV1, mitochondrial, and autophagy-associated proteins including AMPK, mTOR, LC3B, and P62 were evaluated. Sustained cold stress triggered cardiac hypertrophy, compromised depressed myocardial contractile capacity including lessened fractional shortening, peak shortening, and maximal velocity of shortening/relengthening, enhanced ROS production, and mitochondrial injury, the effects of which were negated by the TRPV1 antagonist SB366791. Western blot analysis revealed upregulated TRPV1 level and AMPK phosphorylation, enhanced ratio of LC3II/LC3I, and downregulated P62 following cold exposure. Cold exposure significantly augmented AAC-induced changes in TRPV1, phosphorylation of AMPK, LC3 isoform switch, and p62, the effects of which were negated by SB366791. In summary, these data suggest that cold exposure accentuates pressure overload-induced cardiac hypertrophy and contractile defect possibly through a TRPV1 and autophagy-dependent mechanism.

Winter cardiovascular diseases phenomenon

This paper review seasonal patterns across twelve cardiovascular diseases: Deep venous thrombosis, pulmonary embolism, aortic dissection and rupture, stroke, intracerebral hemorrhage, hypertension, heart failure, angina pectoris, myocardial infarction, sudden cardiac death, venricular arrythmia and atrial fibrillation, and discuss a possible cause of the occurrence of these diseases. There is a clear seasonal trend of cardiovascular diseases, with the highest incidence occurring during the colder winter months, which have been described in many countries. This phenomenon likely contributes to the numbers of deaths occurring in winter. The implications of this finding are important for testing the relative importance of the proposed mechanisms. Understanding the influence of season and other factors is essential when seeking to implement effective public health measures.

Poor self-rated health is significantly associated with elevated C-reactive protein levels in women, but not in men, in the Japanese general population

OBJECTIVE

Self-rated health (SRH) is associated with risk for mortality, but its biological basis is poorly understood. We examined the association between SRH and low-grade inflammation in a Japanese general population.

METHODS

A total of 5142 men and 11,114 women aged 40 to 69years were enrolled. SRH was assessed by a single question and classified into four categories: good, rather good, neither good nor poor, and poor. Serum high-sensitivity C-reactive protein (hsCRP) levels were measured by the latex-enhanced immunonephelometric method. Elevated CRP was defined as hsCRP level of 1.0mg/L or higher. The association between SRH and elevated CRP was evaluated by using logistic regression with adjustment for age, socioeconomic status (job status, education and marital status), health-related behaviors (smoking status, drinking status, exercise habits and sleep duration), and cardiovascular risk factors (body mass index, systolic blood pressure, total- and HDL-cholesterol, HbA1c and prevalent stroke and/or myocardial infarction).

RESULTS

Compared to persons with good SRH, persons with poor SRH had significantly higher risk for elevated CRP: age-adjusted ORs (95% CIs) were 1.33 (1.01-1.76) in men and 1.66 (1.36-2.02) in women. The significant association remained even after adjustment for socioeconomic status, health-related behaviors and cardiovascular risk factors in women, whereas the significance disappeared in men.

CONCLUSION

Poor SRH is associated with low-grade inflammation in both sexes. In women, but not in men, the association is independent of potential confounders. These findings provide an insight into the biological background of SRH in a general population.

Seasonal variation in heart failure hospitalization

BACKGROUND

A seasonal variation has been reported for occurrence of acute cardiovascular events, such as myocardial infarction, sudden death, and rupture/dissection of aortic aneurysms.

HYPOTHESIS

The aim of this study was to determine whether a seasonal variation exists for heart failure (HF) hospitalization.

METHODS

The study included all cases of HF admissions to Ferrara Hospital between January 2002 and December 2009. The sample was divided into subgroups by gender, age, cardiovascular risk factors, patients' outcome, and order of ICD-9 codes (first diagnosis, accessory diagnosis). On the basis of date of admission, cases have been analyzed for seasonal variation and annual frequency. For seasonal analysis, monthly cases were categorized into four 3-month intervals by seasons. Moreover, monthly admissions have been also adjusted for number of days, and the average number of admissions per month has been used.

RESULTS

The database included 15,954 patients with the ICD-9-CM codes of HF (420-429). Hospital admissions for HF were most frequent in winter (28.4%) and least in summer (20.4%). Chronobiological analysis yielded a significant peak in January for total cases and all subgroups considered. No differences were found for subgroups by gender, age, fatal cases, presence of hypertension and diabetes mellitus, patients' outcome, and order of ICD-9 codes (first diagnosis, accessory diagnosis).

CONCLUSIONS

A seasonal periodicity for HF hospitalization was demonstrated, with a peak in winter months, independent of gender, age, major cardiovascular risk factor, and patients' outcome. These data could be useful for practitioners to improve causative prevention measures, therapeutic management, and educational strategies.

Seasonal variation in hospital admission in patients with heart failure and its effect on prognosis

BACKGROUND

A seasonal variation in hospital admissions in patients with heart failure (HF) has been described and most admissions occur during the winter season. The effect of this seasonal variation on prognosis is less clear.

OBJECTIVES

To evaluate the effect of the seasonal timing of hospital admission on clinical outcome in patients with HF.

METHODS

We prospectively enrolled 362 consecutive patients hospitalized with a definite clinical diagnosis of HF during a 2-year period. Patients were followed clinically for a period of 1 year.

RESULTS

There was a prominent seasonal variation in hospital admissions in patients with HF with peak admissions during the winter. The admission rate inversely correlated with the average monthly temperature. Admission during the summer season was a significant predictor of reduced survival (59 vs. 75%, p < 0.01). Cox regression analysis demonstrated that independent predictors of reduced survival after adjustment for other predictors were admission during the hottest 6 months or admission during the summer. In addition, increased mean environmental admission temperature was an independent predictor of reduced survival.

CONCLUSIONS

Seasonal temperature has a significant effect on the rate of hospital admission in patients with HF. Admission during warmer weather is a sign of a poor prognosis.

Plasma B-type natriuretic peptide level and cardiovascular events in chronic kidney disease in a community-based population

BACKGROUND

Plasma B-type natriuretic peptide (BNP) levels are confounded by renal dysfunction, so this study examined whether plasma BNP might be a reliable biomarker of the onset of cardiovascular (CV) events in a population-based cohort with impaired renal function.

METHODS AND RESULTS

Baseline data, including plasma BNP, serum creatinine, and urinary protein levels, were determined in participants from a community-based population. Estimated glomerular filtration rate (eGFR) was calculated, and chronic kidney disease (CKD) was defined as either: eGFR <60 mlxmin(-1)x1.73 m(-2) and/or proteinuria (CKD definition-1) or GFR <60 mlxmin(-1)x1.73 m(-2) (CKD definition-2). The CV endpoint was surveyed prospectively. The cohorts were followed for 5,275 person-years for CKD definition-1, and for 4,350 person-years for CKD definition-2. The CV event-free survival rate in the highest BNP quartile in either CKD definition was the lowest among the quartile groups (P<0.001). In multivariate Cox regression models adjusted by traditional CV risk factors and atrial fibrillation, relative risk (RR) for CV events was significantly higher in the highest BNP quartile compared with the lowest BNP quartile (CKD definition-1, RR 3.51, P<0.01: CKD definition-2, RR 4.67, both P<0.01).

CONCLUSIONS

Plasma BNP level provides strong predictive information about the future onset of CV events in CKD subjects selected from the general population.

The seasonality in heart failure deaths and total cardiovascular deaths

OBJECTIVES

To examine the seasonal pattern in heart failure (HF) and cardiovascular disease (CVD) by climate and cause of death in Australia.

METHODS

A retrospective analysis of a national database of deaths in the eight Australian State and Territory capitals between January 1997 and November 2004. We examined the seasonal pattern in HF and CVD deaths, we identified variations in the pattern by: sex, age, time, climate and cause of death (for total CVD using seven groups determined by ICD-10 code).

RESULTS

Deaths in all seven groups of CVD significantly increased in winter. The largest increase in mortality rates was 23.5% observed for HF. The magnitude of this increase varied greatly between cities, with the lowest winter mortality rates in the coldest (Hobart) and warmest (Darwin) cities. The pattern in CVD deaths showed a clearer correlation with climate than HF deaths.

CONCLUSION AND IMPLICATIONS

Winters in Australia are mild but winter increases in HF and CVD are a significant problem. Increased blood pressure and lack of vitamin D in winter are the most likely causes of the increase. Reducing exposure to cold, particularly in the elderly, should reduce the number of winter CVD deaths in Australia.