Role of splanchnic circulation in the pathogenesis of heart failure: State-of-the-art review

A hallmark of heart failure (HF), whether it presents itself during rest or periods of physical exertion, is the excessive elevation of intracardiac filling pressures at rest or with exercise. Many mechanisms contribute to the elevated intracardiac filling pressures, and notably, the concept of volume redistribution has gained attention as a cause of the elevated intracardiac filling pressures in patients with HF, particularly HF with preserved ejection fraction, who often present without symptoms at rest, with shortness of breath and fatigue appearing only during exertion. This phenomenon suggests cardiopulmonary system non-compliance and inappropriate volume distribution between the stressed and unstressed blood volume components. A substantial proportion of the intravascular blood volume is in the splanchnic vascular compartment in the abdomen. Preclinical and clinical investigations support the critical role of the sympathetic nervous system in modulating the capacitance and compliance of the splanchnic vascular bed via modulation of the greater splanchnic nerve (GSN). The GSN activation by stressors such as exercise causes excessive splanchnic vasoconstriction, which may contribute to the decompensation of chronic HF via volume redistribution from the splanchnic vascular bed to the central compartment. Accordingly, for example, GSN ablation for volume management has been proposed as a potential therapeutic intervention to increase unstressed blood volume. Here we provide a comprehensive review of the role of splanchnic circulation in the pathogenesis of HF and potential novel treatment options for redistributing blood volume to improve symptoms and prognosis in patients with HF.

Effectiveness and safety of morphine administration for refractory dyspnoea among hospitalised patients with advanced heart failure: the Morphine-HF study

OBJECTIVES

Morphine is effective in alleviating dyspnoea in patients with cancer. We aimed to investigate the effectiveness and safety of morphine administration for refractory dyspnoea in patients with advanced heart failure (HF).

METHODS

We conducted a multicentre, prospective, observational study of hospitalised patients with advanced HF in whom morphine was administered for refractory dyspnoea. Morphine effectiveness was evaluated by dyspnoea intensity changes, assessed regularly by both a quantitative subjective scale (Visual Analogue Scale (VAS; graded from 0 to 100 mm)) and an objective scale (Support Team Assessment Schedule-Japanese (STAS-J; graded from 0 to 4 points)). Safety was assessed by vital sign changes and new-onset severe adverse events, including nausea, vomiting, constipation and delirium based on the Common Terminology Criteria for Adverse Events.

RESULTS

From 15 Japanese institutions between September 2020 and August 2022, we included 28 hospitalised patients with advanced HF in whom morphine was administered (mean age: 83.8±8.7 years, male: 15 (54%), New York Heart Association class IV: 26 (93%) and mean left ventricular ejection fraction: 38%±19%). Both VAS and STAS-J significantly improved from baseline to day 1 (VAS: 67±26 to 50±31 mm; p=0.02 and STAS-J: 3.3±0.8 to 2.6±1.1 points; p=0.006, respectively), and thereafter the improvements sustained through to day 7. After morphine administration, vital signs including blood pressure, pulse rate and oxygen saturation did not change, and no new-onset severe adverse events occurred through to day 7.

CONCLUSIONS

This study suggested acceptable effectiveness and safety for morphine administration in treating refractory dyspnoea in hospitalised patients with advanced HF.

The characteristics and outcomes in patients with acute heart failure who used tolvaptan: from KCHF registry

AIMS

The use of tolvaptan is increasing in clinical practice in Japan. However, the characteristics of patients who used tolvaptan and the timing of its use in patients with acute heart failure (AHF) are not fully elucidated.

METHODS AND RESULTS

Among consecutive 4056 patients in the Kyoto Congestive Heart Failure registry, we analysed 3802 patients after excluding patients on dialysis, prior or unknown tolvaptan use at admission, and unknown timing of tolvaptan use, and we divided them into two groups: tolvaptan use (N = 773) and no tolvaptan use (N = 3029). The prevalence of tolvaptan use varied widely from 48.7% to 0% across the participating centres. Factors independently associated with tolvaptan use were diabetes, poor medical adherence, oedema, pleural effusion, hyponatraemia, estimated glomerular filtration rate < 30 mL/min/1.73 m2 , moderate/severe tricuspid regurgitation, dobutamine infusion within 24 h, and additional inotropes infusion beyond 24 h after admission. The mortality rate at 90 days after admission was significantly higher in the tolvaptan use group than in the no tolvaptan use group (14.3% vs. 8.6%, P = 0.049). However, after adjustment, the excess mortality risk of tolvaptan use relative to no tolvaptan use was no longer significant (hazard ratio = 1.53, 95% confidence interval = 0.77-3.02, P = 0.22). Patients with tolvaptan use had a longer hospital stay [median (interquartile range): 22 (15-34) days vs. 15 (11-21) days, P < 0.0001] and a higher prevalence of worsening renal failure (47.0% vs. 31.8%, P < 0.0001) and worsening heart failure (24.8% vs. 14.4%, P < 0.0001) than those without.

CONCLUSIONS

AHF patients with tolvaptan use had more congestive status with poorer in-hospital outcomes and higher short-term mortality than those without tolvaptan use.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT02334891 (NCT02334891) and https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000017241 (UMIN000015238).

Prognostic Value of the Severity of Clinical Congestion in Patients Hospitalized for Decompensated Heart Failure: Findings From the Japanese KCHF Registry

BACKGROUND

Congestion is a leading cause of hospitalization and a major therapeutic target in patients with heart failure (HF). Clinical practice in Japan is characterized by a long hospital stay, which facilitates more extensive decongestion during hospitalization. We herein examined the time course and prognostic impact of clinical congestion in a large contemporary Japanese cohort of HF.

METHODS AND RESULTS

Peripheral edema, jugular venous pressure, and orthopnea were graded on a standardized 4-point scale (0-3) in 3787 hospitalized patients in a Japanese cohort of HF. Composite Congestion Scores (CCS) on admission and at discharge were calculated by summing individual scores. The primary outcome was a composite of all-cause death or HF hospitalization. The median admission CCS was 4 (interquartile range, 3-6). Overall, 255 patients died during the median hospitalization length of 16 days, and 1395 died or were hospitalized for HF over a median postdischarge follow-up of 396 days. The cumulative 1-year incidence of the primary outcome increased at higher tertiles of congestion on admission (32.5%, 39.3%, and 41.0% in the mild [CCS ≤3], moderate [CCS = 4 or 5], and severe [CCS ≥6] congestion groups, respectively, log-rank P < .001). The adjusted hazard ratios of moderate and severe congestion relative to mild congestion were 1.205 (95% confidence interval [CI], 1.065-1.365; P = .003) and 1.247 (95% CI, 1.103-1.410; P < .001), respectively. Among 3445 patients discharged alive, 85% had CCS of 0 (complete decongestion) and 15% had a CCS of 1 or more (residual congestion) at discharge. Although residual congestion predicted a risk of postdischarge death or HF hospitalization (adjusted hazard ratio, 1.314 [1.145-1.509]; P < .001), the admission CCS correlated with the risk of postdischarge death or HF hospitalization, even in the complete decongestion group. No correlation was observed for postdischarge death or HF hospitalization between residual congestion at discharge and admission CCS (P for the interaction = .316).

CONCLUSIONS

In total, 85% of patients were discharged with complete decongestion in Japanese clinical practice. Clinical congestion, on admission and at discharge, was of prognostic value. The severity of congestion on admission was predictive of adverse outcomes, even in the absence of residual congestion.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/ct2/show/NCT02334891 (NCT02334891) https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000017241 (UMIN000015238).

Weight loss during follow-up in patients with acute heart failure: From the KCHF registry

BACKGROUNDS

The prognostic implication of weight loss after discharge from acute heart failure (AHF) remains unclear. We sought to investigate the association of weight loss between discharge and 6-month visit with subsequent clinical outcomes in patients with AHF.

METHODS

We analyzed 686 patients with AHF in the prospective longitudinal follow-up study derived from the Kyoto Congestive Heart Failure registry, and divided them into 2 groups based on the weight loss at 6-month index visit. We defined the weight loss as ≥ 5% decrease in body weight from discharge to 6-month index visit.

RESULTS

There were 90 patients (13.1%) with a weight loss at 6-month visit. Patients in the weight loss group compared with those in the no weight loss group had higher body weight at discharge and lower body weight at 6-mont visit. Patients in the weight loss group had a lower systolic blood pressure, higher brain-type natriuretic peptide, lower serum albumin, lower hemoglobin, higher prevalence of heart failure with reduced ejection fraction at 6-month visit, and a lower prescription rate of inhibitors of renin-angiotensin system than those in the no weight loss group. The cumulative 6-month incidence of all-cause death was significantly higher in the weight loss group than in the no weight loss group (14.2% and 4.3%, log-rank P<0.001). The excess adjusted risk of the weight loss group relative to the no weight loss group remained significant for all-cause death (HR 2.39, 95%CI 1.01-5.65, P = 0.048).

CONCLUSION

Body weight loss of ≥5% at 6-month visit after discharge was associated with subsequent all-cause death in patients with AHF.

Rationale and study design of the GOREISAN for heart failure (GOREISAN-HF) trial: A randomized clinical trial

BACKGROUND

The decongestion strategy using loop diuretics is essential for improving signs and symptoms of heart failure (HF). However, chronic use of loop diuretics in HF has been linked to worsening renal function and adverse clinical outcomes in a dose-dependent manner. Goreisan, a traditional Japanese herbal medicine, has a long history of use in Japan for regulating body fluid homeostasis and has been recognized as causing less adverse outcomes such as dehydration in contrast to loop diuretics in clinical practice. Therefore, we designed the GOREISAN-HF trial to evaluate the long-term effects of a new decongestion strategy adding Goreisan to usual care in patients with HF and volume overload.

METHODS

The GOREISAN-HF trial is an investigator-initiated, multicenter, pragmatic, randomized, comparative effectiveness trial in which we will enroll 2,192 patients hospitalized for HF at 68 hospitals in Japan. All study participants will be randomly assigned to either a decongestion strategy that adds Goreisan at a dose of 7.5 g daily on top of usual care or usual care alone. Investigators have the flexibility to change the existing diuretic regimen in both groups. The primary end point is the improvement rate of cardiac edema at 12-month follow-up, and the co-primary end point is a composite of all-cause death or hospitalization up to the end of the planned follow-up period. Secondary end points include longitudinal changes in patient-reported outcomes, loop diuretics dose, and renal function.

CONCLUSIONS

The GOREISAN-HF is the first large-scale randomized pragmatic trial to assess the efficacy and safety of a new congestion control strategy adding Goreisan to usual care in patients with HF and volume overload.

REGISTRATION NUMBER

NCT04691700.

Tricuspid regurgitation in elderly patients with acute heart failure: insights from the KCHF registry

AIMS

Several studies demonstrated that tricuspid regurgitation (TR) is associated with poor clinical outcomes. However, data on patients with TR who experienced acute heart failure (AHF) remains scarce. The purpose of this study is to evaluate the association between TR and clinical outcomes in patients admitted with AHF, using a large-scale Japanese AHF registry.

METHODS AND RESULTS

The current study population consisted of 3735 hospitalized patients due to AHF in the Kyoto Congestive Heart Failure (KCHF) registry. TR grades were assessed according to the routine clinical practice at each participating centre. We compared the baseline characteristics and outcomes according to the severity of TR. The primary outcome was all-cause death. The secondary outcome was hospitalization for heart failure (HF). The median age of the entire study population was 80 (interquartile range: 72-86) years. One thousand two hundred five patients (32.3%) had no TR, while mild, moderate, and severe TR was found in 1537 patients (41.2%), 776 patients (20.8%), and 217 patients (5.8%), respectively. Pulmonary hypertension, significant mitral regurgitation, and atrial fibrillation/flutter were strongly associated with the development of moderate/severe of TR, while left ventricular ejection fraction <50% was inversely associated with it. Among 993 patients with moderate/severe TR, the number of patients who underwent surgical intervention for TR within 1 year was only 13 (1.3%). The median follow-up duration was 475 (interquartile range: 365-653) days with 94.0% follow-up at 1 year. As the TR severity increased, the cumulative 1 year incidence of all-cause death and HF admission proportionally increased ([14.8%, 20.3%, 23.4%, 27.0%] and [18.9%, 23.0%, 28.5%, 28.4%] in no, mild, moderate, and severe TR, respectively). Compared with no TR, the adjusted risks of patients with mild, moderate, and severe TR were significant for all-cause death (hazard ratio [95% confidence interval]: 1.20 [1.00-1.43], P = 0.0498, 1.32 [1.07-1.62], P = 0.009, and 1.35 [1.00-1.83], P = 0.049, respectively), while those were not significant for hospitalization for HF (hazard ratio [95% confidence interval]: 1.16 [0.97-1.38], P = 0.10, 1.19 [0.96-1.46], P = 0.11, and 1.20 [0.87-1.65], P = 0.27, respectively). The higher adjusted HRs of all the TR grades relative to no TR were significant for all-cause death in patients aged <80 years, but not in patients aged ≥80 years with significant interaction.

CONCLUSIONS

In a large Japanese AHF population, the grades of TR could successfully stratify the risk of all-cause death. However, the association of TR with mortality was only modest and attenuated in patients aged 80 or more. Further research is warranted to evaluate how to follow up and manage TR in this elderly population.

Intracardiac energy inefficiency during atrial fibrillation rhythm with heart failure: Assessment by echo-vector flow mapping

AIMS

Intracardiac dynamics during atrial fibrillation(AF) complicated by heart failure(HF) are not fully understood. The aim of this study was to evaluate the impact of intracardiac dynamics assessed by echo-vector flow mapping on AF complicated by HF.

METHODS AND RESULTS

We enrolled 76 AF patients receiving sinus restoration therapy and assessed energy loss(EL) by echo-vector flow mapping during both AF rhythm and sinus rhythm. Patients were divided into 2 groups according to serum NT-proBNP level: high NT-proBNP group(≥1800 pg/ml during AF rhythm: N = 19), and low NT-proBNP group(N = 57). Outcome measures were average ELs/stroke volume(SV) in left ventricle(LV) and left atrium(LA). Average EL/SVs during AF rhythm in the LV and LA were significantly larger in the high NT-proBNP group than the low NT-proBNP group(54.2 mE/m·L versus 41.2 mE/m·L, P = 0.02; 3.2 mE/m·L versus 1.9 mE/m·L, P = 0.01). The significantly larger EL/SV in the high NT-proBNP group was recorded for maximum EL/SVs. In patients with high NT-proBNP, large vortex formation with extreme EL was detected in the LV and LA during the diastolic phase. After sinus restoration, the average decrease of EL/SV in the LV and LA was larger in the high NT-proBNP group(-21.4 mE/m·L versus +2.6 mE/m·L, P = 0.04; -1.6 mE/m·L versus -0.3 mE/m·L, P = 0.02). Average EL/SV during sinus rhythm did not significantly differ between the high and low NT-proBNP groups in the LV and LA.

CONCLUSIONS

High EL during AF rhythm as intracardiac energy inefficiency was associated with high serum NT-proBNP levels and improved after sinus restoration.

Association between changes in loop diuretic dose and outcomes in acute heart failure

AIMS

Little is known about the association between the starting of or dose changes in loop diuretics during acute heart failure (AHF) hospitalization and post-discharge outcomes. We investigated the clinical impact of starting loop diuretics and changing the loop diuretics dose during hospitalization on post-discharge outcomes.

METHODS AND RESULTS

From the Kyoto Congestive Heart Failure registry, 3665 consecutive patients hospitalized for HF and discharged alive were included in this study. We analysed 1906 patients without loop diuretics on admission and were discharged alive and 1759 patients who received loop diuretics on admission and were discharged alive. The primary outcome measure was all-cause death. Of the 1906 patients without loop diuretics on admission, 1366 (71.7%) patients started loop diuretics during the index AHF hospitalization. Starting loop diuretics was not associated with lower post-discharge mortality [adjusted hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.68-1.25]. Of the 1759 patients who received loop diuretics on admission, loop diuretic dose was decreased in 23.8%, unchanged in 44.6%, and increased in 31.6% of the patients. Changes in the dose at discharge compared with no change in dose were not associated with lower risk of post-discharge mortality (decrease relative to no change: adjusted HR 0.98, 95% CI 0.76-1.28; increase relative to no change: adjusted HR 1.00, 95% CI 0.78-1.27). Compared with no loop diuretics at discharge, a loop diuretics dose of ≥80 mg at discharge was associated with higher post-discharge mortality risk.

CONCLUSIONS

In patients with AHF, we found no association between the starting of loop diuretics and post-discharge outcomes and between dose changes and post-discharge outcomes.

Association of intravenous heparin administration with in-hospital clinical outcomes among hospitalized patients with acute heart failure

BACKGROUNDS

Patients with acute heart failure (AHF) possess a high risk for thromboembolism, and thromboembolism prophylaxis using heparin has been recommended by the guidelines.

METHODS

Among 4056 patients enrolled in the KCHF Registry, the current study population consisted of 2525 patients after excluding patients with acute coronary syndrome and oral anticoagulants on admission and those with mechanical circulatory supports. There were 789 patients (31%) with heparin administration within 24 h after admission, and 1736 patients (69%) without.

RESULTS

The baseline characteristics included mean age: 78 ± 13 years, New York Heart Association class IV: 51%, ischemic etiology: 30%, atrial fibrillation: 31% and mean left ventricular ejection fraction: 45%. During median hospitalization length of 16 days, 161 patients had all-cause death, 34 patients developed ischemic stroke, and 48 patients developed major bleeding. Multivariable logistic regression analyses demonstrated that heparin administration compared with no heparin administration was not associated with a lower risk for all-cause death (OR: 1.39, 95%CI: 0.90-2.15; P = 0.14), nor for ischemic stroke (OR: 1.14, 95%CI: 0.53-2.43; P = 0.74), but was associated with a higher risk for major bleeding (OR: 2.88, 95%CI: 1.54-5.41; P < 0.001).

CONCLUSIONS

In patients with AHF, heparin administration within 24 h after admission was not associated with a lower risk of all-cause death and ischemic stroke, but was associated with a higher risk of major bleeding during hospitalization. Our study raises questions about the routine use of heparin for thromboembolism prophylaxis in hospitalized patients with AHF. Further studies are warranted to address the utility of anticoagulant therapy in these patients.

A comparison between hospital follow-up and collaborative follow-up in patients with acute heart failure

AIMS

There are no previous studies focusing on collaborative follow-ups between hospitals and clinics for patients discharged after acute heart failure (AHF) in Japan. The purpose of this study was to determine the status of collaboration between hospitals and clinics for patients with AHF in Japan and to compare patient characteristics and clinical outcomes using a large Japanese observational database.

METHODS AND RESULTS

Of 4056 consecutive patients hospitalized for AHF in the Kyoto Congestive Heart Failure registry, we analysed 2862 patients discharged to go home, who were divided into 1674 patients (58.5%) followed up at hospitals with index hospitalization (hospital follow-up group) and 1188 (41.5%) followed up in a collaborative fashion with clinics or other general hospitals (collaborative follow-up group). The primary outcome was a composite of all-cause death or heart failure (HF) hospitalization within 1 year after discharge. Previous hospitalization for HF and length of hospital stay longer than 15 days were associated with hospital follow-up. Conversely, ≥80 years of age, hypertension, and cognitive dysfunction were associated with collaborative follow-up. The cumulative 1-year incidence of the primary outcome, all cause death, and cardiovascular death were similar between the hospital and collaborative follow-up groups (31.6% vs. 29.6%, P = 0.51, 13.1% vs, 13.9%, P = 0.35, 8.4% vs. 8.2%, P = 0.96). Even after adjusting for confounders, the difference in risk for patients in the hospital follow-up group relative to those in the collaborative follow-up group remained insignificant for the primary outcome, all-cause death, and cardiovascular death (HR: 1.11, 95% CI: 0.97-1.27, P = 0.14, HR: 1.10, 95% CI: 0.91-1.33, P = 0.33, HR: 0.96, 95% CI: 0.87-1.05, P = 0.33). The cumulative 1-year incidence of HF hospitalization was higher in the hospital follow-up group than in the collaborative follow-up group (25.5% vs. 21.3%, P = 0.02). The risk of HF hospitalization was higher in the hospital follow-up group than in the collaborative follow-up group (HR: 1.19, 95% CI: 1.01-1.39, P = 0.04).

CONCLUSIONS

In patients hospitalized for AHF, 41.5% received collaborative follow-up after discharge. The risk of HF hospitalization was higher in the hospital follow-up group than in the collaborative follow-up, although risk of the primary outcome, all-cause death, and cardiovascular death were similar between groups.

Percutaneous coronary intervention using new-generation drug-eluting stents versus coronary arterial bypass grafting in stable patients with multi-vessel coronary artery disease: From the CREDO-Kyoto PCI/CABG registry Cohort-3

Aims

There is a scarcity of studies comparing percutaneous coronary intervention (PCI) using new-generation drug-eluting stents (DES) with coronary artery bypass grafting (CABG) in patients with multi-vessel coronary artery disease.

Methods and results

The CREDO-Kyoto PCI/CABG registry Cohort-3 enrolled 14927 consecutive patients who underwent first coronary revascularization with PCI or isolated CABG between January 2011 and December 2013. The current study population consisted of 2464 patients who underwent multi-vessel coronary revascularization including revascularization of left anterior descending coronary artery (LAD) either with PCI using new-generation DES (N = 1565), or with CABG (N = 899). Patients in the PCI group were older and more often had severe frailty, but had less complex coronary anatomy, and less complete revascularization than those in the CABG group. Cumulative 5-year incidence of a composite of all-cause death, myocardial infarction or stroke was not significantly different between the 2 groups (25.0% versus 21.5%, P = 0.15). However, after adjusting confounders, the excess risk of PCI relative to CABG turned to be significant for the composite endpoint (HR 1.27, 95%CI 1.04–1.55, P = 0.02). PCI as compared with CABG was associated with comparable adjusted risk for all-cause death (HR 1.22, 95%CI 0.96–1.55, P = 0.11), and stroke (HR 1.17, 95%CI 0.79–1.73, P = 0.44), but with excess adjusted risk for myocardial infarction (HR 1.58, 95%CI 1.05–2.39, P = 0.03), and any coronary revascularization (HR 2.66, 95%CI 2.06–3.43, P<0.0001).

Conclusions

In this observational study, PCI with new-generation DES as compared with CABG was associated with excess long-term risk for major cardiovascular events in patients who underwent multi-vessel coronary revascularization including LAD.

Insomnia in patients with acute heart failure: from the KCHF registry

AIMS

Insomnia is a known risk factor for heart failure (HF) and a predictor of cardiac events in HF patients, but the clinical significance of insomnia in patients with acute HF (AHF) is not adequately evaluated. This study aimed to investigate the association between insomnia and subsequent clinical outcomes in patients with AHF.

METHODS

From the Kyoto Congestive Heart Failure registry, consecutive 3414 patients hospitalized for HF who were discharged alive were divided into the 2 groups at discharge: insomnia group and non-insomnia group. We compared baseline characteristics and 1 year clinical outcomes according to the presence of insomnia. The primary outcome measure was all-cause death.

RESULTS

There were 330 patients (9.7%) and 3084 patients (90.3%) with and without insomnia, respectively. In the multivariable logistic regression analysis, brain-type natriuretic peptide above median value at discharge (OR = 1.50, 95% CI = 1.08-2.10, P = 0.02) and the presence of oedema at discharge (OR = 4.23, 95% CI = 2.95-6.07, P < 0.001) were positively associated with insomnia at discharge, whereas diuretics at discharge (OR = 0.60, 95% CI = 0.39-0.90, P = 0.01) were negatively associated with insomnia at discharge. The cumulative 1 year incidence of all-cause death was significantly higher in the insomnia group than in the non-insomnia group (25.1% vs. 16.2%, P < 0.001). Even after adjusting the confounders, the higher mortality risk of patients with insomnia relative to those without insomnia remained significant (HR = 1.55, 95% CI = 1.24-1.94; P < 0.001).

CONCLUSIONS

Patients with insomnia at discharge were associated with a higher risk of mortality than those without insomnia at discharge.

Reproducibility and stability of atrial fibrillation drivers identified by an automated algorithm: CARTOFINDER

BACKGROUND

The characteristics of atrial fibrillation (AF) drivers identified by CARTOFINDER have not been thoroughly evaluated. Therefore, the current study was sought to validate the reliability of AF drivers.

METHODS

The reliability of focal and rotational activation identified by CARTOFINDER during AF was assessed by the sequential recordings in each site before and after pulmonary vein isolation (PVI) in 27 persistent AF patients. The primary outcome measures were the reproducibility rate during the sequential recordings and the stability rate between pre- and post-PVI.

RESULTS

Among 32,135 points in 509 sites, focal activation was identified in 1775 points (5.5%) with a repetition of 11 (6-26) times during the recording. Rotational activation was identified in 132 points (0.4%) with a repetition number of 21 (14-21) times. AF drivers had significantly higher voltage and shorter AF cycle length than non-AF driver sites. The reproducibility rate of focal activation during the sequential recordings was 57.8% and increased with the repetition number. The reproducibility rate of rotational activation was 37.4%. The prevalence and the reproducibility rate of focal activation in post-PVI were significantly lower than pre-PVI (5.3% versus 6.0%, P = 0.02; 53.4% versus 63.6%, P < 0.001). The stability rate of focal activation between pre- and post-PVI was only 28.3% but increased with the repetition number. There was no stable rotational activation between pre- and post-PVI.

CONCLUSIONS

The reproducibility of AF drivers, especially focal activation, identified by CARTOFINDER is relatively favorable, but the stability between pre- and post-PVI was poor. These results depended on the repetition number during the recording.

Appetite loss at discharge from acute decompensated heart failure: Observation from KCHF registry

Objective

The complex link between nutritional status, protein and lipid synthesis, and immunity plays an important prognostic role in patients with heart failure. However, the association between appetite loss at discharge and long-term outcome remains unclear.

Methods

The Kyoto Congestive Heart Failure registry is a prospective cohort study that enrolled consecutive patients hospitalized for acute decompensated heart failure (ADHF) in Japan. We assessed 3528 patients alive at discharge, and for whom appetite and follow-up data were available. We compared one-year clinical outcomes in patients with and without appetite loss at discharge.

Results

In the multivariable logistic regression analysis using 19 clinical and laboratory factors with P value < 0.1 by univariate analysis, BMI < 22 kg/m² (odds ratio (OR): 1.57, 95% confidence interval (CI): 1.11–2.24, P = 0.01), CRP >1.0mg/dL (OR: 1.49, 95%CI: 1.04–2.14, P = 0.03), and presence of edema at discharge (OR: 4.30, 95%CI: 2.99–6.22, P<0.001) were associated with an increased risk of appetite loss at discharge, whereas ambulatory status (OR: 0.57, 95%CI: 0.39–0.83, P = 0.004) and the use of ACE-I/ARB (OR: 0.70, 95% CI: 0.50–0.98, P = 0.04) were related to a decreased risk in the presence of appetite loss. The cumulative 1-year incidence of all-cause death (primary outcome measure) was significantly higher in patients with appetite loss than in those without appetite loss (31.0% vs. 15.0%, P<0.001). The excess adjusted risk of appetite loss relative to no appetite loss remained significant for all-cause death (hazard ratio (HR): 1.63, 95%CI: 1.29–2.07, P<0.001).

Conclusions

Loss of appetite at discharge was associated with worse 1-year mortality in patients with ADHF. Appetite is a simple, reliable, and useful subjective marker for risk stratification of patients with ADHF.

Instability of rotational activation as atrial fibrillation drivers: assessment by ExTRa Mapping system

BACKGROUND

ExTRa Mapping™ has developed to visualize rotational activation as atrial fibrillation(AF) drivers. The current study was sought to evaluate the instability of AF drivers by ExTRa Mapping™.

METHODS

Variation of non-passively activated ratio(%NP) among 3-time repetitive recordings before and after pulmonary vein isolation(PVI) in left atrium was assessed in 26 persistent AF patients. The recoding time was set at 5 seconds or 8 seconds for the respective patients. The outcome measures included %NP at each recording, mean value of the 3-time recordings, and the instability index, which was defined as maximum difference per mean %NP×100 (%).

RESULTS

Total 683 sites 2049 recordings were assessed. Mean %NP was 33.3(23.3-42.7)%, and higher in sites with severe(≥50%) and patchy low voltage area than those without, but not in those with severe complex fractionated atrial electrogram area. There was significant correlation between actual and mean %NP (R = 0.86, P<0.001), but maximum difference among the repetitive recordings was 16(10-24) %. The instability index of %NP was 55.9(30.9-83.6)%, and significantly lower at the recordings of 8 seconds compared with 5 seconds (50.6[28.6-78.4]% versus 60.4[35.0-90.0]%, P = 0.004). Furthermore, it was higher at sites with lower reliability of the recordings. After PVI, mean %NP significantly decreased (28.7[18.3-36.7]% versus 37.7[28.7-45.7]%, P<0.001), but the instability index significantly increased compared with those before PVI (60.0[35.0-92.7]% versus 48.9[29.1-75.0]%, P = 0.001).

CONCLUSION

Rotational activation as AF drivers assessed by ExTRa Mapping™ is unstable, and repetitive and longer recording is required for the reliable assessment even after PVI. This article is protected by copyright. All rights reserved.

Public assistance in patients with acute heart failure: a report from the KCHF registry

Aims

There is a scarcity of data on the post‐discharge prognosis in acute heart failure (AHF) patients with a low‐income but receiving public assistance. The study sought to evaluate the differences in the clinical characteristics and outcomes between AHF patients receiving public assistance and those not receiving public assistance.

Methods and results

The Kyoto Congestive Heart Failure registry was a physician‐initiated, prospective, observational, multicentre cohort study enrolling 4056 consecutive patients who were hospitalized due to AHF for the first time between October 2014 and March 2016. The present study population consisted of 3728 patients who were discharged alive from the index AHF hospitalization. We divided the patients into two groups, those receiving public assistance and those not receiving public assistance. After assessing the proportional hazard assumption of public assistance as a variable, we constructed multivariable Cox proportional hazard models to estimate the risk of the public assistance group relative to the no public assistance group. There were 218 patients (5.8%) receiving public assistance and 3510 (94%) not receiving public assistance. Patients in the public assistance group were younger, more frequently had chronic coronary artery disease, previous heart failure hospitalizations, current smoking, poor medical adherence, living alone, no occupation, and a lower left ventricular ejection fraction than those in the no public assistance group. During a median follow‐up of 470 days, the cumulative 1 year incidences of all‐cause death and heart failure hospitalizations after discharge did not differ between the public assistance group and no public assistance group (13.3% vs. 17.4%, P = 0.10, and 28.3% vs. 23.8%, P = 0.25, respectively). After adjusting for the confounders, the risk of the public assistance group relative to the no public assistance group remained insignificant for all‐cause death [hazard ratio (HR), 0.97; 95% confidence interval (CI), 0.69–1.32; P = 0.84]. Even after taking into account the competing risk of all‐cause death, the adjusted risk within 180 days in the public assistance group relative to the no public assistance group remained insignificant for heart failure hospitalizations (HR, 0.93; 95% CI, 0.64–1.34; P = 0.69), while the adjusted risk beyond 180 days was significant (HR, 1.56; 95% CI, 1.07–2.29; P = 0.02).

Conclusions

The AHF patients receiving public assistance as compared with those not receiving public assistance had no significant excess risk for all‐cause death at 1 year after discharge or a heart failure hospitalization within 180 days after discharge, while they did have a significant excess risk for heart failure hospitalizations beyond 180 days after discharge.

Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT02334891 (NCT02334891) and https://upload.umin.ac.jp/cgi‐open‐bin/ctr_e/ctr_view.cgi?recptno=R000017241 (UMIN000015238)

Changes in BNP levels from discharge to 6-month visit predict subsequent outcomes in patients with acute heart failure

Background

This study aimed to investigate the association between changes in brain natriuretic peptide (BNP) from discharge to 6-month visit and subsequent clinical outcomes in patients with acute heart failure (AHF).

Methods

Among 1246 patients enrolled in the prospective longitudinal follow-up study nested from the Kyoto Congestive Heart Failure registry, this study population included 446 patients with available paired BNP data at discharge and 6-month index visit. This study population was classified into 3 groups by percent change in BNP from discharge to 6-month visit; the low tertile (≤-44%, N = 149), the middle tertile (>-44% and ≤22%, N = 149) and the high tertile (>22%, N = 148).

Findings

The cumulative 180-day incidence after the index visit of the primary outcome measure (a composite endpoint of all-cause death or hospitalization for HF) was significantly higher in the high and middle tertiles than in the low tertile (26.8% and 14.4% versus 6.9%, log-rank P<0.0001). The adjusted excess risk of the high tertile relative to the low tertile remained significant for the primary outcome measure (hazard ratio: 3.43, 95% confidence interval: 1.51–8.46, P = 0.003).

Conclusions

Percent change in BNP was associated with a subsequent risk for a composite of all-cause death and hospitalization for HF after adjustment of the absolute BNP values, suggesting that observing the change in BNP levels, in addition to absolute BNP levels themselves, helps us to manage patient with HF.

Current use of inotropes according to initial blood pressure and peripheral perfusion in the treatment of congestive heart failure: findings from a multicentre observational study

OBJECTIVES

Current guidelines restrict the use of inotropes for the treatment for heart failure (HF) unless the patients are hypotensive or hypoperfused because of safety concerns. This study sought to characterise the contemporary real-world use of inotropes and associated long-term outcomes according to systolic blood pressure (sBP) and perfusion status.

DESIGN

A multicentre prospective cohort study.

SETTING

This study was nested from the Kyoto Congestive Heart Failure registry, which included consecutive Japanese patients admitted for HF.

PARTICIPANTS

We categorised 3995 patients into two groups: sBP ≥90 mm Hg and warm profile group, and sBP <90 mm Hg or cold profile group. In each group, patients were stratified across the use of inotropes within 24 hours of hospital presentation.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was all-cause death throughout follow-up. Secondary outcomes included cardiovascular death throughout follow-up, all-cause death during index hospitalisation and after discharge, and HF hospitalisation.

RESULTS

A total of 793 patients (20%) presented with sBP <90 mm Hg or cold profile, whereas 3202 patients had sBP ≥90 mm Hg and warm profile; 276 patients (35%) in the sBP <90 mm Hg/cold group and 312 patients (10%) in the sBP ≥90 mm Hg/warm group received initial inotropic treatment. Adjusted excess risk of inotrope use relative to no inotrope for the primary outcome measure was significant in the sBP ≥90 mm Hg/warm group (adjusted HR), 1.36; 95% CI 1.09 to 1.72, p=0.006) but not in the sBP <90 mm Hg/cold group (adjusted HR, 1.28, 95% CI 0.96 to 1.69, p=0.09). Risk for postdischarge all-cause death and HF hospitalisation was not significantly different between the patients with inotropes and no inotropes in both groups.

CONCLUSION

Inotrope use in the absence of hypotension and hypoperfusion is still common, but associated with a worse long-term prognosis.

TRIAL REGISTRATION NUMBER

UMIN000015238.

Kampo medicine for the holistic approach to older adults with heart failure

Heart failure (HF) is a leading cause of hospitalization, morbidity, and mortality in older adults and represents a significant clinical and economic burden on the health care system. However, there are many challenges in assessing and managing HF in elderly patients, who often have coexisting multimorbidity, frailty, and malnutrition. Therefore, it is often difficult to solve these problems with Western medicine alone, and a holistic approach, including Kampo medicine, can be helpful. In particular, managing volume control and frailty by adding Kampo formulas may help improve health-related quality of life and substantially impact prognosis in HF. This review article summarizes the role of Kampo medicine for older patients with HF and frailty.

Different Kinetics of Activated Clotting Time among Uninterrupted Oral Anticoagulants during Catheter Ablation Procedure

Activated clotting time (ACT) kinetics under uninterrupted oral anticoagulants (OACs) has not been fully evaluated. The present study is sought to validate ACT kinetics including stability under uninterrupted use of OACs during ablation procedure in daily clinical practice. We prospectively enrolled consecutive 554 atrial fibrillation patients who underwent catheter ablation procedure under uninterrupted OACs. We evaluated ACT kinetics at an interval of 15 minutes during the procedure and periprocedural complications among five OACs (dabigatran [N = 46], rivaroxaban [N = 125], apixaban [N = 129], edoxaban [N = 184], and warfarin [N = 70]). Compared with the dabigatran group, time to achieve target ACT was significantly longer in the rivaroxaban and apixaban groups, but not in the edoxaban and warfarin groups (8.7 minutes versus 11.7 minutes, P <0.001; 13.3 minutes, P <0.001; 8.8 minutes, P = 0.64; 10.3 minutes, P = 0.19, respectively). Heparin dose to achieve target ACT was comparable except for the warfarin group. Whereas, compared with the dabigatran group, time in therapeutic range of ACT (ACT-TTR) within the first 1 hour was comparable in the rivaroxaban and apixaban group, but significantly lower in the edoxaban and warfarin groups (73.7 % versus 63.0%, P = 0.06; 67.0 %, P = 0.16; 59.2 %, P = 0.001; 58.2%, P = 0.004, respectively). In multiple regression analysis, low body weight, rivaroxaban, apixaban, and AM session had significant associations with time and heparin dose to achieve target ACT, and there were positive associations of dabigatran and apixaban with ACT-TTR within the first 1 hour. The incidence of periprocedural complications did not significantly differ among the five groups. Under uninterrupted OAC use in daily clinical practice, dabigatran showed faster achievement of target ACT and higher stability of ACT than other OACs. This article is protected by copyright. All rights reserved.

Coronary angiography in patients with acute heart failure: from the KCHF registry

Aims

Little is known about the characteristics and outcomes of patients who undergo coronary angiography during heart failure (HF) hospitalization, as well as those with coronary stenosis, and those who underwent coronary revascularization.

Methods and results

We analysed 2163 patients who were hospitalized for HF without acute coronary syndrome or prior HF hospitalization. We compared patient characteristics and 1 year clinical outcomes according to (i) patients with versus without coronary angiography, (ii) patients with versus without coronary stenosis, and (iii) patients with versus without coronary revascularization. The primary outcome measure was the composite of all‐cause death or HF hospitalization. Coronary angiography was performed in 37.0% of patients. In the multivariable logistic regression analysis, factors independently associated with coronary angiography were age < 80 years [adjusted odds ratio (OR) = 1.76, 95% confidence interval (CI) = 1.41–2.20, P < 0.001], men (adjusted OR = 1.28, 95% CI = 1.03–1.59, P = 0.02), diabetes (adjusted OR = 1.27, 95% CI = 1.02–1.60, P = 0.04), no atrial fibrillation or flutter (adjusted OR = 1.45, 95% CI = 1.17–1.82, P < 0.001), no prior device implantation (adjusted OR = 1.81, 95% CI = 1.13–2.91, P = 0.01), current smoking (adjusted OR = 1.40, 95% CI = 1.05–1.87, P = 0.02), no cognitive dysfunction (adjusted OR = 1.90, 95% CI = 1.34–2.69, P < 0.001), ambulatory status (adjusted OR = 2.89, 95% CI = 2.03–4.10, P < 0.001), HF with reduced ejection fraction (adjusted OR = 1.55, 95% CI = 1.24–1.93, P < 0.001), estimated glomerular filtration rate ≥ 30 mL/min/1.73 m² (adjusted OR = 1.93, 95% CI = 1.45–2.58, P < 0.001), no anaemia (adjusted OR = 1.27, 95% CI = 1.02–1.59, P = 0.04), and no prescription of β‐blockers prior to admission (adjusted OR = 1.32, 95% CI = 1.03–1.68, P = 0.03). Patients who underwent coronary angiography had a lower risk of the primary outcome [adjusted hazard ratio (HR) = 0.70, 95% CI = 0.58–0.85, P < 0.001]. Among the patients who underwent coronary angiography, those with coronary stenosis (38.9%) did not have lower risk of the primary outcome measure than those without coronary stenosis (adjusted HR = 0.93, 95% CI = 0.65–1.32, P = 0.68). Among the patients with coronary stenosis, those with coronary revascularization (54.3%) did not have higher risk of the primary outcome measure than those without coronary revascularization (adjusted HR = 1.36, 95% CI = 0.84–2.21, P = 0.22).

Conclusions

In patients with acute HF, patients who underwent coronary angiography had a lower risk of clinical outcomes and were significantly different from those who did not undergo coronary angiography.

Newly Diagnosed Infection After Admission for Acute Heart Failure: From the KCHF Registry

Background

No studies have explored the association between newly diagnosed infections after admission and clinical outcomes in patients with acute heart failure. We aimed to explore the factors associated with newly diagnosed infection after admission for acute heart failure, and its association with in‐hospital and post‐discharge clinical outcomes.

Methods and Results

Among 4056 patients enrolled in the Kyoto Congestive Heart Failure registry, 2399 patients without any obvious infectious disease upon admission were analyzed. The major in‐hospital and post‐discharge outcome measures were all‐cause deaths. There were 215 patients (9.0%) with newly diagnosed infections during hospitalization, and 2184 patients (91.0%) without infection during hospitalization. The factors independently associated with a newly diagnosed infection were age ≥80 years, acute coronary syndrome, non‐ambulatory status, hyponatremia, anemia, intubation, and patients who were not on loop diuretics as outpatients. The newly diagnosed infection group was associated with a higher incidence of in‐hospital mortality (16.3% and 3.2%, P<0.001) and excess adjusted risk of in‐hospital mortality (odds ratio, 6.07 [95% CI, 3.61–10.19], P<0.001) compared with the non‐infection group. The newly diagnosed infection group was also associated with a higher 1‐year incidence of post‐discharge mortality (19.3% in the newly diagnosed infection group and 13.6% in the non‐infection group, P<0.001) and excess adjusted risk of post‐discharge mortality (hazard ratio, 1.49 [95% CI, 1.08–2.07], P=0.02) compared with the non‐infection group.

Conclusions

Elderly patients with multiple comorbidities were associated with the development of newly diagnosed infections after admission for acute heart failure. Newly diagnosed infections after admission were associated with higher in‐hospital and post‐discharge mortality in patients with acute heart failure.

Registration

URL: https://clinicaltrials.gov; Unique identifier: NCT02334891.

Ischemic Stroke in Acute Decompensated Heart Failure: From the KCHF Registry

Background Heart failure (HF) is a known risk factor for ischemic stroke, but data regarding ischemic stroke during hospitalization for acute decompensated HF (ADHF) are limited. Methods and Results We analyzed the data from a multicenter registry (Kyoto Congestive Heart Failure [KCHF] Registry) that enrolled 4056 consecutive patients with ADHF in Japan (mean age, 78 years; men, 2238 patients [55%]; acute coronary syndrome [ACS], 239 patients [5.9%]). We investigated the incidence and predictors of ischemic stroke during hospitalization for ADHF. During the hospitalization, 63 patients (1.6%) developed ischemic stroke. The median interval from admission to the onset of ischemic stroke was 7 [interquartile range: 2-14] days, and the most common underlying cause was cardioembolism (64%). Men (OR, 1.87; 95%CI, 1.11-3.24), ACS (OR, 2.31; 95%CI, 1.01-4.93), absence of prior HF hospitalization (OR, 2.21; 95%CI, 1.24-4.21), and high B-type natriuretic peptide (BNP)/N-terminal proBNP (NT-proBNP) levels (above the median) at admission (OR, 3.15; 95%CI, 1.84-5.60) were independently associated with ischemic stroke. In patients without ACS, the independent risk factors for ischemic stroke were fully consistent with those in the main analysis. Higher quartiles of BNP/NT-proBNP levels were significantly associated with higher incidence of ischemic stroke (P for trend, <0.001). Patients with ischemic stroke showed higher in-hospital mortality, longer length of hospital stay, and poorer functional status at discharge. Conclusions During hospitalization for ADHF, 1.6% of the patients developed ischemic stroke. Men, ACS, absence of prior HF hospitalization, and high BNP/NT-proBNP levels at admission were independently associated with ischemic stroke.

Starting Neurohormonal Antagonists in Patients with Acute Heart Failure with Mid-Range and Preserved Ejection Fraction

Background

The clinical benefits of neurohormonal antagonist in patients with heart failure (HF) with mid-range and preserved ejection fraction (HFmrEF and HFpEF) were uncertain. This study aimed to evaluate the prognostic effect of starting angiotensin-converting enzyme inhibitors (ACE-I) / angiotensin II receptor blockers (ARB) and β-blocker during HF hospitalization in these patients.

Methods

We analyzed 858 consecutive patients with HFmrEF (EF:40–49%) or HFpEF (EF≥50%), who were hospitalized for acute decompensated HF, were discharged alive, and were not taking ACE-I/ARB or β-blockers at admission. The study population was classified into four groups according to the status of prescription of ACE-I/ARB and β-blocker at discharge: no neurohormonal antagonist (N=342, 39.9%), ACE-I/ARB only (N=128, 14.9%), β-blocker only (N=189, 22.0%), and both ACE-I/ARB and β-blocker (N=199, 23.2%) groups. The primary outcome measure was a composite of all-cause death or HF hospitalization.

Results

The cumulative 1-year incidence of the primary outcome measure was 41.2% in the no neurohormonal antagonist group, 34.0% in the ACE-I/ARB only group, 28.6% in the β-blocker only group, and 16.4% in the both ACE-I/ARB and β-blocker group (P&lt;0.001). Compared with the no neurohormonal antagonist group, the both ACE-I/ARB and β-blocker group were associated with a significantly lower risk for a composite of all-cause death or HF hospitalization (HR: 0.59, 95% CI: 0.38–0.91, P=0.02).

Conclusions

In hospitalized patients with HFmrEF and HFpEF, starting both ACE-I/ARB and β-blocker was associated with a reduced risk of a composite of all-cause death or HF hospitalization compared with not starting ACE-I/ARB or β-blocker.

Funding Acknowledgement

Type of funding sources: None.

Impact of decreased lymphocyte, total cholesterol, and albumin levels at discharge on all-cause death in patients with acute heart failure

Background

Lymphocyte, total cholesterol, and albumin levels consist of Controlling Nutritional Status (CONUT) score, which has been reported to prognosticate patients with acute heart failure (AHF). However, the influence of each component of CONUT score on outcomes in patients with AHF was not fully elucidated.

Purpose

We aimed to evaluate the prognostic implication of the decrease in lymphocyte, total cholesterol, and albumin levels in patients with AHF.

Methods

We analyzed 1812 AHF patients in whom data at discharge were available from a multicenter registry. The decrease of lymphocyte (Ly) count was assigned with Ly≥1600/mL (31.0%), 1200≤ Ly &lt;1600 (26.9%), 800≤ Ly &lt;1200 (28.6%), Ly &lt;800 (13.5% of patients). The decrease of total cholesterol (TC) was assigned with TC≥180mg/dL (28.9%), 140≤ TC &lt;180 (42.2%), 100≤ TC &lt;140 (26.7%), TC &lt;100 (2.1% of patients). The decrease of albumin (Alb) was assigned and doubled with Alb≥3.5g/dL (45.7%), 3≤ Alb &lt;3.5 (35.1%), 2.5≤ Alb &lt;3 (15.2%), Alb &lt;2.5 (3.9% of patients). The primary outcome measure was all-cause death after discharge from the index hospitalization. Cumulative incidences were estimated by the Kaplan-Meier method and differences were assessed with the log-rank test. We constructed multivariable Cox proportional hazard models to estimate the risk of the decrease in each value per grade, with the results expressed as the hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

Cumulative one-year incidence of the all-cause death was higher with decreasing Ly, TC, and Alb levels (P&lt;0.0001, P&lt;0.0001, and P=0.02, respectively) (Figure 1). The adjusted hazard ratio for all-case death per grade decrease is most prominent in albumin (HR: 1.36, 95% CI: 1.20–1.54), followed by lymphocyte count (HR: 1,23, 95% CI: 1.10–1.38), whereas it became insignificant in total cholesterol (HR: 1.05, 95% CI: 0.91–1.21).

Conclusions

The prognostic implications after discharge were different in albumin, lymphocyte count, and total cholesterol in patients with AHF.

Funding Acknowledgement

Type of funding sources: None. Figure 1

The impact of current strategy using intracardiac echocardiography, lesion index, and minimum substrate ablation on clinical outcomes after catheter ablation procedure for atrial fibrillation

PURPOSE

We developed the intracardiac echocardiography (ICE) technique to minimize radiation exposure and other recent technology during ablation procedure for atrial fibrillation (AF). The aim of this study was to validate the impact of the current strategy using the recent technology for AF ablation on outcomes after procedure.

METHODS

We evaluated the safety and efficacy of the current strategy in consecutive set of patients undergoing first-time ablation for AF (N = 233) compared with the conventional strategy in earlier consecutive set of patients (N = 223). The current strategy included the technique of ICE to reduce radiation exposure, Ablation Index®-guided pulmonary veins isolation, and minimum substrate ablation targeting only for induced AF. Outcome measures were radiation exposure, procedure time, in-hospital adverse outcomes, and event-free survival from tachyarrhythmias.

RESULTS

Puncture-to-ablation time was slightly, but significantly increased in the current strategy than in the conventional strategy (48.0 minutes vs 44.7 minutes, P = .002), although total procedure time was significantly decreased in the current strategy (143.9 minutes vs 156.9 minutes, P < .001). Likewise, radiation time and absorbed dose were significantly decreased in the current strategy (9.8 minutes vs 38.8 minutes, P < .001; 102.3 mGy vs 490.5 mGy, P < .001). The incidence of overall in-hospital adverse outcomes was 3.9% in the current strategy and each complication rate was comparable with the conventional protocol. The event-free survival from recurrent atrial tachyarrhythmias was not significantly different between two groups (72.3% vs 77.1% at 2-year, P = .32).

CONCLUSION

The current strategy using the recent technology with ICE, lesion index, and minimum substrate ablation was feasible and reduced total procedure time and radiation exposure. However, the arrhythmia-free survival could not be improved.

Improved and new-onset anemia during follow-up in patients with acute decompensated heart failure: Characteristics and outcomes

There was no previous report on the prognostic impact of new-onset or improved anemia after discharge from acute decompensated heart failure (ADHF).We analyzed 771 patients with ADHF and who were followed in multicenters in Japan was divided into 4 groups based on the hemoglobin values at discharge and 6-month index visit: 373 patients (48.4%) with persistent anemia, 87 patients (11.3%) with new-onset anemia, 91 patients (11.8%) with improved anemia, and 220 patients (28.5%) without anemia.The primary outcome measure was a composite of all-cause death or HF hospitalization after index visit. The cumulative 6-month incidences of the primary outcome measure were 25.2% for persistent anemia, 18.5% for new onset anemia, 9.0% for improved anemia, and 9.2% for no anemia (log-rank P < .001). Compared with the no anemia group, the excess risk for the primary outcome measure remained significant in the persistent anemia group [hazard ratio (HR) 2.70, 95% confidence interval (95% CI), 1.45-5.44, P = .001] and in the new-onset anemia group (HR 2.73, 95% CI 1.19-6.25, P = .02), while it was not significant in the improved anemia group (HR 1.69, 95% CI 0.68-4.03, P = .25).Persistent and new-onset anemia at 6-month visit were associated with a subsequent higher risk for all-cause death or HF hospitalization in patients with ADHF, suggesting the importance of detecting anemia during follow-up.

Risk Factors and Clinical Outcomes of Nonhome Discharge in Patients With Acute Decompensated Heart Failure: An Observational Study

Background

No clinical studies have focused on the factors associated with discharge destination in patients with acute decompensated heart failure.

Methods and Results

Of 4056 consecutive patients hospitalized for acute decompensated heart failure in the KCHF (Kyoto Congestive Heart Failure) registry, we analyzed 3460 patients hospitalized from their homes and discharged alive. There were 3009 and 451 patients who were discharged to home and nonhome, respectively. We investigated the factors associated with nonhome discharge and compared the outcomes between home discharge and nonhome discharge. Factors independently and positively associated with nonhome discharge were age ≥80 years (odds ratio [OR],1.76; 95% CI,1.28–2.42), body mass index ≤22 kg/m² (OR,1.49; 95% CI,1.12–1.97), poor medication adherence (OR, 2.08; 95% CI,1.49–2.88), worsening heart failure (OR, 2.02; 95% CI, 1.46–2.82), stroke during hospitalization (OR, 3.74; 95% CI, 1.75–8.00), functional decline (OR, 12.24; 95% CI, 8.74–17.14), and length of hospital stay >16 days (OR, 4.14; 95% CI, 3.01–5.69), while those negatively associated were diabetes mellitus (OR, 0.69; 95% CI, 0.51–0.94), cohabitants (OR, 0.62; 95% CI, 0.46–0.85), and ambulatory state before admission (OR, 0.25; 95% CI, 0.18–0.36). The cumulative 1‐year incidence of all‐cause death was significantly higher in the nonhome discharge group than in the home discharge group. The nonhome discharge group compared with the nonhome discharge group was associated with a higher adjusted risk for all‐cause death (hazard ratio, 1.66; P<0.001).

Conclusions

The discharge destination of patients with acute decompensated heart failure is influenced by factors such as prehospital social background, age, body mass index, low self‐care ability, events during hospitalization (worsening heart failure, stroke, etc), functional decline, and length of hospital stay; moreover, the prognosis of nonhome discharge patients is worse than that of home discharge patients.

Registration Information

clinicaltrials.gov. Identifier: NCT02334891.

Admission systolic blood pressure as a prognostic predictor of acute decompensated heart failure: A report from the KCHF registry

Background

Admission systolic blood pressure has emerged as a predictor of postdischarge outcomes of patients with acute decompensated heart failure; however, its validity in varied clinical conditions of this patient subset is unclear. The aim of this study was to further explore the prognostic value of admission systolic blood pressure in patients with acute decompensated heart failure.

Methods

The Kyoto Congestive Heart Failure (KCHF) registry is a prospective, observational, multicenter cohort study enrolling consecutive patients with acute decompensated heart failure from 19 participating hospitals in Japan. Clinical characteristics at baseline and prognosis were examined by the following value range of admission systolic blood pressure: <100, 100–139, and ≥140 mmHg. The primary outcome measure was defined as all-cause death after discharge. Subgroup analyses were done for prior hospitalization for heart failure, hypertension, left ventricular ejection fraction, and medications at discharge. We excluded patients with acute coronary syndrome or insufficient data.

Results

We analyzed 3564 patients discharged alive out of 3804 patients hospitalized for acute decompensated heart failure. In the entire cohort, lower admission systolic blood pressure was associated with poor outcomes (1-year cumulative incidence of all-cause death: <100 mmHg, 26.8%; 100–139 mmHg, 20.2%; and ≥140 mmHg, 15.1%, p<0.001). The magnitude of the effect of lower admission systolic blood pressure for postdischarge all-cause death was greater in patients with prior hospitalization for heart failure, heart failure with reduced left ventricular ejection fraction, and β-blocker use at discharge than in those without.

Conclusions

Admission systolic blood pressure is useful for postdischarge risk stratification in patients with acute decompensated heart failure. Its magnitude of the effect as a prognostic predictor may differ across clinical conditions of patients.

Lower In-Hospital Mortality With Beta-Blocker Use at Admission in Patients With Acute Decompensated Heart Failure

Background

It remains unclear whether beta‐blocker use at hospital admission is associated with better in‐hospital outcomes in patients with acute decompensated heart failure.

Methods and Results

We evaluated the factors independently associated with beta‐blocker use at admission, and the effect of beta‐blocker use at admission on in‐hospital mortality in 3817 patients with acute decompensated heart failure enrolled in the Kyoto Congestive Heart Failure registry. There were 1512 patients (39.7%) receiving, and 2305 patients (60.3%) not receiving beta‐blockers at admission for the index acute decompensated heart failure hospitalization. Factors independently associated with beta‐blocker use at admission were previous heart failure hospitalization, history of myocardial infarction, atrial fibrillation, cardiomyopathy, and estimated glomerular filtration rate <30 mL/min per 1.73 m². Factors independently associated with no beta‐blocker use were asthma, chronic obstructive pulmonary disease, lower body mass index, dementia, older age, and left ventricular ejection fraction <40%. Patients on beta‐blockers had significantly lower in‐hospital mortality rates (4.4% versus 7.6%, P<0.001). Even after adjusting for confounders, beta‐blocker use at admission remained significantly associated with lower in‐hospital mortality risk (odds ratio, 0.41; 95% CI, 0.27–0.60, P<0.001). Furthermore, beta‐blocker use at admission was significantly associated with both lower cardiovascular mortality risk and lower noncardiovascular mortality risk. The association of beta‐blocker use with lower in‐hospital mortality risk was relatively more prominent in patients receiving high dose beta‐blockers. The magnitude of the effect of beta‐blocker use was greater in patients with previous heart failure hospitalization than in patients without (P for interaction 0.04).

Conclusions

Beta‐blocker use at admission was associated with lower in‐hospital mortality in patients with acute decompensated heart failure.

Registration

URL: https://www.upload.umin.ac.jp/; Unique identifier: UMIN000015238.

Serum cholinesterase as a prognostic biomarker for acute heart failure

AIMS

The association between serum cholinesterase and prognosis in acute heart failure (AHF) remains to be elucidated. We investigated the serum cholinesterase level at discharge from hospitalization for AHF and its association with clinical outcomes in patients with AHF.

METHODS AND RESULTS

Among 4056 patients enrolled in the Kyoto Congestive Heart Failure multicentre registry, we analysed 2228 patients with available serum cholinesterase data. The study population was classified into three groups according to serum cholinesterase level at discharge: low tertile (<180 U/L, N = 733), middle tertile (≥180 U/L and <240 U/L, N = 746), and high tertile (≥240 U/L, N = 749). Patients in the low tertile had higher tricuspid pressure gradient, greater inferior vena cava diameter, and higher brain natriuretic peptide (BNP) levels than those in the high tertile. The cumulative 1-year incidence of the primary outcome measure (a composite endpoint of all-cause death and hospitalization for HF) was higher in the low and middle tertiles than in the high tertile [46.5% (low tertile) and 31.4% (middle tertile) vs. 22.1% (high tertile), P < 0.0001]. After adjustment for 26 variables, the excess risk of the low tertile relative to the high tertile for the primary outcome measure remained significant (hazard ratio 1.37, 95% confidence interval 1.10-1.70, P = 0.006). Restricted cubic spline models below the median of cholinesterase demonstrated incrementally higher hazards at low cholinesterase levels.

CONCLUSIONS

Low serum cholinesterase levels are associated with congestive findings on echocardiography, higher BNP, and higher risks for a composite of all-cause death and HF hospitalization in patients with AHF.

A decrease in tricuspid regurgitation pressure gradient associates with favorable outcome in patients with heart failure

Aims

Although the prognostic impact of the high tricuspid regurgitation pressure gradient (TRPG) has been investigated, the association of the decrease in TRPG during follow‐up with clinical outcomes in heart failure (HF) has not been previously studied. The aim of this study was to investigate the association of a decrease in TRPG between hospitalization and 6 month visit with subsequent clinical outcomes in patients with acute decompensated HF (ADHF).

Methods and results

Among 721 patients with available TRPG data both during hospitalization and a subsequent 6 month visit, the study population was divided into two groups: a decrease in TRPG group (>10 mmHg decrease at 6 month visit) (N = 179) and no decrease in TRPG group (N = 542). The primary outcome measure was a composite of all‐cause death or HF hospitalization. The cumulative 6 month incidence of primary outcome measure was significantly lower in the decrease in TRPG group than in the no decrease in TRPG group (12.2% vs. 18.7%, P = 0.02). After adjusting for confounders, there was a significantly lower risk in decrease in TRPG group than in the no decrease in TRPG group for the measured primary outcome (hazard ratio: 0.56, 95% confidence interval 0.32–0.93, P = 0.02). The lower risk in decrease in TRPG group was not different among the basal TRPG values.

Conclusions

Heart failure patients with a decrease in TRPG at 6 months after discharge from ADHF hospitalization had lower subsequent risk of all‐cause death and HF hospitalization than those without a decrease in TRPG, regardless of TRPG values.

Changes in demographics, clinical practices and long-term outcomes of patients with ST segment-elevation myocardial infarction who underwent coronary revascularisation in the past two decades: cohort study

OBJECTIVE

To evaluate changes in demographics, clinical practices and long-term clinical outcomes of patients with ST segment-elevation myocardial infarction (STEMI) before and beyond 2010.

DESIGN

Multicentre retrospective cohort study.

SETTING

The Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) AMI Registries Wave-1 (2005-2007, 26 centres) and Wave-2 (2011-2013, 22 centres).

PARTICIPANTS

9001 patients with STEMI who underwent coronary revascularisation (Wave-1: 4278 patients, Wave-2: 4723 patients).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause death at 3 years. The secondary outcomes were cardiovascular death, cardiac death, sudden cardiac death, non-cardiovascular death, non-cardiac death, myocardial infarction, definite stent thrombosis, stroke, hospitalisation for heart failure, major bleeding, target vessel revascularisation, ischaemia-driven target vessel revascularisation, any coronary revascularisation and any ischaemia-driven coronary revascularisation.

RESULTS

Patients in Wave-2 were older, more often had comorbidities and more often presented with cardiogenic shock than those in Wave-1. Patients in Wave-2 had shorter onset-to-balloon time and door-to-balloon time, were more frequently implanted drug-eluting stents, and received guideline-directed medication than those in Wave-1. The cumulative 3-year incidence of all-cause death was not significantly different between Wave-1 and Wave-2 (15.5% and 15.7%, p=0.77). The adjusted risk of all-cause death in Wave-2 relative to Wave-1 was not significant at 3 years (HR 0.92, 95% CI 0.83 to 1.03, p=0.14), but lower beyond 30 days (HR 0.86, 95% CI 0.75 to 0.98, p=0.03). The adjusted risks of Wave-2 relative to Wave-1 were significantly lower for definite stent thrombosis (HR 0.59, 95% CI 0.43 to 0.81, p=0.001) and for any coronary revascularisation (HR 0.75, 95% CI 0.69 to 0.81, p<0.001), but higher for major bleeding (HR 1.34, 95% CI 1.20 to 1.51, p=0.005).

CONCLUSIONS

We could not demonstrate improvement in 3-year mortality risk from Wave-1 to Wave-2, but we found reduction in mortality risk beyond 30 days. We also found risk reduction for definite stent thrombosis and any coronary revascularisation, but an increase in the risk of major bleeding from Wave-1 to Wave-2.

Prognostic value of reduction in left atrial size during a follow-up of heart failure: an observational study

OBJECTIVE

The association between sequential changes in left atrial diameter (LAD) and prognosis in heart failure (HF) remains to be elucidated. The present study aimed to investigate the link between reduction in LAD and clinical outcomes in patients with HF.

DESIGN

A multicentre prospective cohort study.

SETTING

This study was nested from the Kyoto Congestive Heart Failure registry including consecutive patients admitted for acute decompensated heart failure (ADHF) in 19 hospitals throughout Japan.

PARTICIPANTS

The current study population included 673 patients with HF who underwent both baseline and 6-month follow-up echocardiography with available paired LAD data. We divided them into two groups: the reduction in the LAD group (change <0 mm) (n=398) and the no-reduction in the LAD group (change ≥0 mm) (n=275).

PRIMARY AND SECONDARY OUTCOMES

The primary outcome measure was a composite of all-cause death or hospitalisation for HF during 180 days after 6-month follow-up echocardiography. The secondary outcome measures were defined as the individual components of the primary composite outcome measure and a composite of cardiovascular death or hospitalisation for HF.

RESULTS

The cumulative 180-day incidence of the primary outcome measure was significantly lower in the reduction in the LAD group than in the no-reduction in the LAD group (13.3% vs 22.2%, p=0.002). Even after adjusting 15 confounders, the lower risk of reduction in LAD relative to no-reduction in LAD for the primary outcome measure remained significant (HR 0.59, 95% CI 0.36 to 0.97 p=0.04).

CONCLUSION

Patients with reduction in LAD during follow-up after ADHF hospitalisation had a lower risk for a composite endpoint of all-cause death or HF hospitalisation, suggesting that the change of LAD might be a simple and useful echocardiographic marker during follow-up.

C-reactive protein at discharge and 1-year mortality in hospitalised patients with acute decompensated heart failure: an observational study

OBJECTIVES

To examine the association of a high C-reactive protein (CRP) level at discharge from an acute decompensated heart failure (ADHF) hospitalisation with the 1-year clinical outcomes.

DESIGN

A post-hoc subanalysis of a prospective cohort study of patients hospitalised for ADHF (using the Kyoto Congestive Heart Failure (KCHF) registry) between October 2014 and March 2016 with a 1-year follow-up.

SETTING

A physician-initiated multicentre registry enrolled consecutive hospitalised patients with ADHF for the first time at 19 secondary and tertiary hospitals in Japan.

PARTICIPANTS

Among the 4056 patients enrolled in the KCHF registry, the present study population consisted of 2618 patients with an available CRP value both on admission and at discharge and post-discharge clinical follow-up data. We divided the patients into two groups, those with a high CRP level (>10 mg/L) and those with a low CRP level (≤10 mg/L) at discharge from the index hospitalisation.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was all-cause death after discharge from the index hospitalisation. The secondary outcome measures were heart failure hospitalisations, cardiovascular death and non-cardiovascular death.

RESULTS

The high CRP group and low CRP group included 622 patients (24%) and 1996 patients (76%), respectively. During a median follow-up period of 468 days, the cumulative 1-year incidence of the primary outcome was significantly higher in the high CRP group than low CRP group (24.1% vs 13.9%, log-rank p<0.001). Even after a multivariable analysis, the excess mortality risk in the high CRP group relative to the low CRP group remained significant (HR, 1.43; 95% CI, 1.19 to 1.71; p<0.001). The excess mortality risk was consistent regardless of the clinically relevant subgroup factors.

CONCLUSIONS

A high CRP level (>10 mg/L) at discharge from an ADHF hospitalisation was associated with an excess mortality risk at 1 year. TRIAL REGISTRATION DETAILS: https://clinicaltrials.gov/ct2/show/NCT02334891 (NCT02334891) https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000017241 (UMIN000015238).

Association of an increase in serum albumin levels with positive 1-year outcomes in acute decompensated heart failure: A cohort study

BACKGROUND

Despite the prognostic importance of hypoalbuminemia, the prognostic implication of a change in albumin levels has not been fully investigated during hospitalization in patients with acute decompensated heart failure (ADHF).

METHODS

Using the data from the Kyoto Congestive Heart Failure registry on 3160 patients who were discharged alive for acute heart failure hospitalization and in whom the change in albumin levels was calculated at discharge, we evaluated the association with an increase in serum albumin levels from admission to discharge and clinical outcomes by a multivariable Cox hazard model. The primary outcome measure was a composite of all-cause death or hospitalization for heart failure.

FINDINGS

Patients with increased albumin levels (N = 1083, 34.3%) were younger and less often had smaller body mass index and renal dysfunction than those with no increase in albumin levels (N = 2077, 65.7%). Median follow-up was 475 days with a 96% 1-year follow-up rate. Relative to the group with no increase in albumin levels, the lower risk of the increased albumin group remained significant for the primary outcome measure (hazard ratio: 0.78, 95% confidence interval: 0.69-0.90: P = 0.0004) after adjusting for confounders including baseline albumin levels. When stratified by the quartiles of baseline albumin levels, the favorable effect of increased albumin was more pronounced in the lower quartiles of albumin levels, but without a significant interaction effect (interaction P = 0.49).

CONCLUSIONS

Independent of baseline albumin levels, an increase in albumin during index hospitalization was associated with a lower 1-year risk for a composite of all-cause death and hospitalization in patients with acute heart failure.

Influence of low body weight on long-term clinical outcomes in patients with venous thromboembolism: From the COMMAND VTE registry

INTRODUCTION

There is a paucity of data on the influence of low body weight on clinical outcomes in patients with acute venous thromboembolism (VTE).

MATERIALS AND METHODS

The COMMAND VTE registry is a multicenter cohort study enrolling 3027 consecutive patients with acute symptomatic VTE. The current study population consisted of 2778 patients with available body weight value, who were divided into 2 groups; 1705 patients with lower body weight (≤60 kg) and 1073 patients with higher body weight (>60 kg).

RESULTS

Patients with lower body weight were older (70.8 versus 60.9 years, P < 0.001), and more often women (75% versus 38%, P < 0.001), and more often had active cancer (27% versus 19%, P < 0.001) than those with higher body weight. The cumulative 5-year incidence of recurrent VTE was not significantly different between the 2 groups (10.6% versus 10.7%, P = 0.51). The cumulative 5-year incidences of major bleeding and all-cause death were significantly higher in patients with lower body weight than in those with higher body weight (14.6% versus 9.6%, P < 0.001, and 35.8% versus 19.8%, P < 0.001, respectively). The excess adjusted risk of patients with lower body weight relative to those with higher body weight remained significant for major bleeding and all-cause death (HR 1.57, 95%CI: 1.16-2.12, P = 0.003, and HR 1.50, 95%CI: 1.24-1.81, P < 0.001, respectively).

CONCLUSIONS

In the current Japanese real-world registry, there were a high proportion of patients with low body weight, who had a higher risk for major bleeding and mortality without significant excess risk for recurrent VTE.

A decrease in tricuspid regurgitation pressure gradient during follow-up in patients with heart failure

Objective

This study aimed to investigate the prognostic impact of the decrease in tricuspid regurgitation pressure gradient (TRPG) at 6-month follow-up in patients after discharge with heart failure (HF).

Background

No previous study has reported the association between TRPG decrease during follow-up and clinical outcomes in HF.

Methods

Among 748 patients with 6-months follow-up echocardiography after discharge from the acute decompensated heart failure in 19 centers in Japan, we analyzed 721 patients with available TRPG data and divided into two groups: the decrease in TRPG group (N=179) and no decrease in TRPG group (N=542). We defined the decrease in TRPG as &gt;10mmHg decrease compared in the initial hospitalization. The primary outcome measure was a composite of all cause deaths and hospitalization due to HF.

Results

The patients in the decrease in TRPG group had a lower prevalence of hypertension, dyslipidemia, atrial fibrillation, and a reduced EF, higher levels of blood albumin and lower levels of sodium than those in no decrease in TRPG group. The median follow-up duration after the follow up echocardiography was 302 (inter quartile range: 206–490), with a 90.9% follow up rate at 6-month. The cumulative 6-month incidence of the primary outcome measure was significantly lower in the decrease in TRPG group than in no decrease in TRPG group (12.2% vs. 18.9%, P=0.0011). After adjusting confounders, the excess risk of the decrease in TRPG relative to no decrease in TRPG for the primary outcome measure remained significant (HR: 0.60, 95% CI 0.34–0.99). There were no significant interactions between the subgroup factors and the effect of the decrease in TRPG for primary outcomes.

Conclusions

HF patients with the decrease in TRPG at 6-month after discharge had a lower risk of clinical outcome than those without decrease in TRPG.

Funding Acknowledgement

Type of funding source: None

Long-term outcomes evaluated by device-monitored physical activity in patients with implantable cardiac defibrillator or cardiac resynchronization therapy device

Background

The patients with implantable cardiac defibrillator (ICD) or cardiac resynchronization therapy device (CRT) have high risk of cardiac events, and lower physical activity has been thought to be associated with higher rate of cardiac events. On the other hand, cardiovascular implantable electronic devices can monitor physical activity through a built-in accelerometer. This study aimed to analyze long-term outcomes by device-based monitoring of physical activity in patients with ICD or CRT.

Methods

We retrospectively reviewed 89 patients with ICD/CRT, (56 males, 66.5 years old; ICD 45, CRT-D 42, CRT-P 2) who survived longer than 6 months after implantation in our institution. We analyzed physical activity by devices at 6th month and divided to 2 groups; In Low activity group (group L; n=38), their physical activity (moving time above 70 steps/min walk level) is less than 2 hours/day, and in Normal activity group (group N; n=51), physical activity is more than 2 hours/day. We evaluated their background characteristics in each group, physical activity at 12th month, and composite outcomes of hospitalization due to worsening of heart failure (HF) and death of any cause.

Results

Mean follow-up period was 57.4 months (median 40 months). In group L, they had higher age (71.1 y.o. vs. 63.2 y.o.; p=0.0003), higher rate of low EF (76.3% vs. 54.9%; p=0.035), and lower rate of attendance to outpatient cardiac rehabilitation program (10.5% vs 27.5%; p=0.043) compared with group N. 85.7% of patients in group L stayed in low physical activity at 12th month, and 87.8% of patient in group N stayed in normal physical activity. Composite outcomes of HF hospitalization and death occurred significantly higher in group L (Log-rank p&lt;0.0001; 29.0% vs. 5.9% at 1 year, and 68.7% vs. 16.2% at 3 year: Figure 1) than in group N. Each event, HF hospitalization and death of any cause were shown significantly higher in group L (Log-rank p&lt;0.0001). In group L, mortality rate of patients who could improve their physical activity from 6th month to 12th month was significantly lower than patients who stayed in low physical activity (Log-rank p=0.038).

Conclusions

Lower level of device-monitored physical activity was associated with higher mortality and higher rate of HF hospitalization in patients with ICD or CRT. Most of the patient in lower physical activity could not improve their activity from 6th month to 12th month. Early and continuous intervention is necessary especially for high risk patients such as high age or low EF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Prognostic value of cardiac 123I-metaiodobenzylguanidine imaging for predicting cardiac events after transcatheter aortic valve replacement

Background

In patients with aortic valve stenosis (AS), cardiac sympathetic nervous (CSN) dysfunction and its improvement after TAVR have been reported; however, the prognostic impact of CSN function remains unclear. This study investigated the prognostic value of cardiac 123I-metaiodobenzylguanidine (MIBG) imaging for the prediction of cardiac events after transcatheter aortic valve replacement (TAVR).

Methods

This study was a single-center prospective observational study that enrolled patients with AS or failed surgical bioprostheses between July 2017 and May 2019. MIBG scintigraphy was performed before and after TAVR to evaluate the delayed heart–mediastinum ratio (d-H/M). Patients were classified into three pairs of groups based on the baseline and post-TAVR d-H/M (≥2.0 or &lt;2.0) and on the presence of TAVR-related improvement of d-H/M. The study endpoints were major adverse cardiac events (MACE), including all-cause death, myocardial infarction, and hospitalization due to heart failure. The association of d-H/M with MACE following TAVR was based on a Cox proportional hazards ratio model adjusted for multiple prognostic variables.

Results

Of 187 consecutive patients who underwent TAVR, 111 (31 men; median age: 86 years) were evaluated. Over a median follow-up of 366 days, 16 (14.4%) patients had MACE. The incidence of MACE was significantly lower in patients with d-H/M improvement and/or the high post-TAVR d-H/M (≥2.0). Post-TAVR d-H/M had significant impacts on MACE, with an adjusted hazard ratio of 1.326 (95% confidence interval, 0.139–2.515; p=0.027).

Conclusions

Both d-H/M improvement and high post-TAVR d-H/M were associated with better prognosis in patients who underwent TAVR. Cardiac MIBG imaging was useful for predicting cardiac events after TAVR.

Funding Acknowledgement

Type of funding source: None

Association between body mass index and prognosis of patients hospitalized with heart failure

The prognostic implications of very low body mass index (BMI) values remain unclear in patients with acute decompensated heart failure (ADHF). This study aimed to investigate the prognostic impact of BMI classification based on the World Health Organization criteria in patients with ADHF. Among 3509 patients with ADHF and available BMI data at discharge in 19 participating hospitals in Japan between October 2014 and March 2016, the study population was divided into five groups; (1) Severely underweight: BMI < 16 kg/m2, (2) Underweight: BMI ≥ 16 kg/m2 and < 18.5 kg/m2, (3) Normal weight: BMI ≥ 18.5 kg/m2 and < 25 kg/m2, (4) Overweight: BMI ≥ 25 kg/m2 and < 30 kg/m2 (5) Obese: BMI ≥ 30 kg/m2. The primary outcome measure was all-cause death. The median follow-up duration was 471 days, with 96.4% follow up at 1-year. The cumulative 1-year incidence of all-cause death was higher in underweight groups, and lower in overweight groups (Severely underweight: 36.3%, Underweight: 23.9%, Normal weight: 14.4%, Overweight: 7.9%, and Obese: 9.0%, P < 0.001). After adjusting confounders, the excess mortality risk remained significant in the severely underweight group (HR, 2.32; 95%CI, 1.83-2.94; P < 0.001), and in the underweight group (HR, 1.31; 95%CI, 1.08-1.59; P = 0.005) relative to the normal weight group, while the lower mortality risk was no longer significant in the overweight group (HR, 0.82; 95%CI, 0.62-1.10; P = 0.18) and in the obese group (HR, 1.09; 95%CI, 0.65-1.85; P = 0.74). Very low BMI was associated with a higher risk for one-year mortality after discharge in patients with ADHF.

Impact of left ventricular ejection fraction on the effect of renin-angiotensin system blockers after an episode of acute heart failure: From the KCHF Registry

Objective

This observational study aimed to examine the prognostic association of angiotensin-converting enzyme inhibitors (ACE-I)/angiotensin receptor blockers (ARB) in different left ventricular ejection fraction (LVEF) categories.

Methods

In 3717 patients enrolled in the KCHF Registry, a multicentre registry including consecutive patients hospitalized for acute heart failure (HF), we assessed patient characteristics and association between ACE-I/ARB and clinical outcomes according to LVEF. In the three LVEF categories (reduced LVEF [HFrEF], mid-range LVEF [HFmrEF] and preserved LVEF [HFpEF]), we compared the patients with ACE-I/ARB as discharge medication and those without, and assessed their 1-year clinical outcomes. We defined the primary outcome measure as a composite of all-cause death and HF hospitalization.

Results

The 1-year cumulative incidences of the primary outcome measure were 36.3% in HFrEF, 30.1% in HFmrEF and 33.8% in HFpEF (log-rank P = 0.07). The adjusted risks of the ACE-I/ARB group relative to the no ACE-I/ARB group for the primary outcome measure were significantly lower in HFrEF and HFmrEF (HR 0.66 [95%CI 0.54–0.79], P<0.001, and HR 0.61 [0.45–0.82], P = 0.001, respectively), but not in HFpEF (HR 0.95 [0.80–1.14], P = 0.61). There was a significant interaction between the LVEF category and the ACE-I/ARB use on the primary outcome measure (P_interaction = 0.01).

Conclusions

ACE-I/ARB for patients who were hospitalized for acute HF was associated with significantly lower risk for a composite of all-cause death and HF hospitalization in HFrEF and HFmrEF, but not in HFpEF. ACE-I/ARB might be a potential treatment option in HFmrEF as in HFrEF.

Sex differences in patients with acute decompensated heart failure in Japan: observation from the KCHF registry

Aims

The association between sex and long‐term outcome in patients hospitalized for acute decompensated heart failure (ADHF) has not been fully studied yet in Japanese population. The aim of this study was to determine differences in baseline characteristics and management of patients with ADHF between women and men and to compare 1‐year outcomes between the sexes in a large‐scale database representing the current real‐world clinical practice in Japan.

Methods and results

Kyoto Congestive Heart Failure registry is a prospective cohort study enrolling consecutive patients hospitalized for ADHF in Japan among 19 centres. Baseline characteristics, clinical presentation, management, and 1‐year outcomes were compared between men and women. A total of 3728 patients who were alive at discharge constituted the current study population. There were 1671 women (44.8%) and 2057 men. Women were older than men [median (IQR): 83 (76–88) years vs. 77 (68–84) years, P < 0.0001]. Hypertensive and valvular heart diseases were more prevalent in women than in men (28.0% vs. 22.5%, P = 0.0001; and 26.9% vs. 14.0%, P < 0.0001, respectively), whereas ischaemic aetiology was less prevalent in women than in men (20.0% vs. 32.5%, P < 0.0001). Women less often had reduced left ventricular ejection fraction (<40%) than men (27.5% vs. 45.1%, P < 0.0001). The cumulative incidence of all‐cause death or hospitalization for heart failure was not significantly different between women and men (33.6% vs. 34.3%, P = 0.71), although women were substantially older than men. After multivariable adjustment, the risk of all‐cause death or hospitalization for heart failure was significantly lower among women (adjusted hazard ratio: 0.84, 95% confidence interval: 0.74–0.96, P = 0.01).

Conclusions

Women with heart failure were older and more often presented with preserved EF with a non‐ischaemic aetiology and were associated with a reduced adjusted risk of 1‐year mortality compared with men in the Japanese population.

Mode of Death Among Japanese Adults With Heart Failure With Preserved, Midrange, and Reduced Ejection Fraction

IMPORTANCE

Despite intensive treatment, hospitalized patients with acute decompensated heart failure (ADHF) have a substantial risk of postdischarge mortality. Limited data are available on the possible differences in the incidence and mechanisms of death among patients with heart failure with reduced ejection fraction (HFrEF), heart failure with midrange ejection fraction (HFmrEF), and heart failure with preserved ejection fraction (HFpEF).

OBJECTIVES

To examine the incidences and mode of postdischarge mortality among patients with ADHF and to compare the risk profile among patients with HFrEF, HFmrEF, and HFpEF.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study of 4056 patients hospitalized for ADHF analyzed data from 3717 patients who were discharged from October 1, 2014, to March 31, 2016. Data analysis was performed from April 1 to August 31, 2019.

EXPOSURES

Death among patients with ADHF after hospital discharge.

MAIN OUTCOMES AND MEASURES

All-cause death and cause of postdischarge mortality after the index hospitalization by left ventricular ejection fraction (LVEF) subgroup.

RESULTS

A total of 3717 patients (mean [SD] age, 77.7 [12.0] years; 2049 [55.1%] male) were included in the study. The mean (SD) LVEF at baseline was 46.4% (16.2%). Among 3717 enrolled patients, 1383 (37.2%) were categorized as having HFrEF (LVEF, <40%), 703 (18.9%) as having HFmrEF (LVEF, 40%-49%), and 1631 (43.9%) as having HFpEF (LVEF, ≥50%). The incidence and causes of death were evaluated after discharge from the index hospitalization. The median follow-up period was 470 days (interquartile range, 357-649 days), and the 1-year follow-up rate was 96%. During follow-up, all-cause death occurred in 848 patients (22.8%; HFrEF group: 298 [21.5%; 95% CI, 19.5%-23.8%]; HFmrEF group: 158 [22.5%; 95% CI, 19.5%-25.7%]; and HRpEF group: 392 [24.0%; 95% CI, 22.0%-26.2%]; P = .26), cardiovascular deaths occurred in 523 patients (14.1%; HFrEF group: 203 [14.7%; 95% CI, 12.9%-16.6%]; HFmrEF group: 97 [13.8%; 95% CI, 11.4%-16.5%]; and HFpEF group: 223 [13.7%; 95% CI, 12.1%-15.4%]; P = .71), and sudden cardiac death occurred in 98 patients (2.6%; HFrEF group: 44 [3.2%; 95% CI, 2.4%-4.2%]; HFmrEF group: 14 [2.0%; 95% CI, 1.2%-3.3%]; and HFpEF group: 40 [2.5%; 95% CI, 1.8%-3.3%]; P = .23). The risks of causes of death were similar among the subtypes.

CONCLUSIONS AND RELEVANCE

The mode of death was similar among the heart failure subtypes. Given the nonnegligible incidence of sudden cardiac death in patients with HFpEF found in this study, further studies appear to be warranted to identify a high-risk subset in this population.