Super-resolution techniques for biomedical applications and challenges

Super-resolution (SR) techniques have revolutionized the field of biomedical applications by detailing the structures at resolutions beyond the limits of imaging or measuring tools. These techniques have been applied in various biomedical applications, including microscopy, magnetic resonance imaging (MRI), computed tomography (CT), X-ray, electroencephalogram (EEG), ultrasound, etc. SR methods are categorized into two main types: traditional non-learning-based methods and modern learning-based approaches. In both applications, SR methodologies have been effectively utilized on biomedical images, enhancing the visualization of complex biological structures. Additionally, these methods have been employed on biomedical data, leading to improvements in computational precision and efficiency for biomedical simulations. The use of SR techniques has resulted in more detailed and accurate analyses in diagnostics and research, essential for early disease detection and treatment planning. However, challenges such as computational demands, data interpretation complexities, and the lack of unified high-quality data persist. The article emphasizes these issues, underscoring the need for ongoing development in SR technologies to further improve biomedical research and patient care outcomes.

tFUSFormer: Physics-guided super-resolution Transformer for simulation of transcranial focused ultrasound propagation in brain stimulation

Transcranial focused ultrasound (tFUS) has emerged as a new mode of non-invasive brain stimulation (NIBS), with its exquisite spatial precision and capacity to reach the deep regions of the brain. The placement of the acoustic focus onto the desired part of the brain is critical for successful tFUS procedures; however, acoustic wave propagation is severely affected by the skull, distorting the focal location/shape and the pressure level. High-resolution (HR) numerical simulation allows for monitoring of acoustic pressure within the skull but with a considerable computational burden. To address this challenge, we employed a 4x super-resolution (SR) Swin Transformer method to improve the precision of estimating tFUS acoustic pressure field, targeting operator-defined brain areas. The training datasets were obtained through numerical simulations at both ultra-low (2.0 mm) and high (0.5 mm) resolutions, conducted on in vivo CT images of 12 human skulls. Our multivariable datasets, which incorporate physical properties of the acoustic pressure field, wave velocity, and skull CT images, were utilized to train three-dimensional SR models. We found that our method yielded 87.99?4.28% accuracy in terms of focal volume conformity under foreseen skull data, and accuracy of 82.32?5.83% for unforeseen skulls, respectively. Moreover, a significant improvement of 99.4% in computational efficiency compared to the traditional 0.5 mm HR numerical simulation was shown. The presented technique, when adopted in guiding the placement of the FUS transducer to engage specific brain targets, holds great potential in enhancing the safety and effectiveness of tFUS therapy.

Depth-of-interaction positron emission tomography detector with 45° tilted silicon photomultipliers using dual-ended signal readout

BACKGROUND

Small-animal positron emission tomography (PET) systems are widely used in molecular imaging research and drug development. There is also growing interest in organ-dedicated clinical PET systems. In these small-diameter PET systems, the measurement of the depth-of-interaction (DOI) of annihilation photons in scintillation crystals allows for the correction of parallax error in PET system, leading to an improvement on the spatial resolution uniformity. The DOI information is also useful for improving the timing resolution of PET system as it enables the correction of DOI-dependent time walk in the arrival time difference measurement of annihilation photon pairs. The dual-ended readout scheme is one of the most widely investigated DOI measurement methods, which collects visible photons using a pair of photosensors located at both ends of the scintillation crystal. Although the dual-ended readout allows for simple and accurate DOI estimation, it requires twice the number of photosensors compared to the single-ended readout scheme.

PURPOSE

To effectively reduce the number of photosensors in a dual-ended readout scheme, we propose a novel PET detector configuration that employs 45° tilted and sparsely arranged silicon photomultipliers (SiPMs). In this configuration, the angle between the scintillation crystal and SiPM is 45°. Therefore, and thus, the diagonal of the scintillation crystal matches one of the lateral sides of the SiPM. Accordingly, it allows for the use of SiPM device larger than the scintillation crystal, thereby improving light collection efficiency with a higher fill factor and reducing SiPM quantity. In addition, all scintillation crystals can achieve more uniform performance than other dual-ended readout methods with a sparse SiPM arrangement because 50% of the scintillation crystal cross section is commonly in contact with the SiPM.

METHODS

To demonstrate the feasibility of our proposed concept, we implemented a PET detector that employs a 4 × ${\rm{\;}} \times \;$ 4 LSO block with a single crystal dimension of 3.03 × 3.03 × 20 mm³ and a 45° tilted SiPM array. The 45° tilted SiPM array consists of 2 × 3 SiPM elements at the top ("Top SiPM") and 3 × 2 SiPM elements at the bottom ("Bottom SiPM"). Each crystal element of the 4 × 4 LSO block is optically coupled with each quarter section of the Top SiPM and Bottom SiPM pair. To characterize the performance of the PET detector, the energy, DOI, and timing resolution were measured for all 16 crystals. The energy data was obtained by summing all the charges from the Top SiPMs and Bottom SiPMs, and the DOI resolution was measured by irradiating the side of the crystal block at five different depths (2, 6, 10, 14, and 18 mm). The timing was estimated by averaging the arrival time of the annihilation photons measured at the Top SiPMs and Bottom SiPMs (Method 1). The DOI-dependent time-walk effect was further corrected by using DOI information and statistical variations in the trigger times at the Top SiPMs and Bottom SiPMs (Method 2).

RESULTS

The average DOI resolution of the proposed PET detector was 2.5 mm, thereby resolving the DOI at five different depths, and the average energy resolution was 16% full width at half maximum (FWHM). When Methods 1 and 2 were applied, the coincidence timing resolutions were 448 and 411 ps FWHM, respectively.

CONCLUSIONS

We expect that our novel low-cost PET detector design with 45° tilted SiPMs and a dual-ended readout scheme would be a suitable solution for constructing a high-resolution PET system with DOI encoding capability.

Performance evaluation of SimPET-L and SimPET-XL: MRI-compatible small-animal PET systems with rat-body imaging capability

BACKGROUND

SimPET-L and SimPET-XL have recently been introduced with increased transaxial fields of view (FOV) compared with their predecessors (SimPET™ and SimPET-X), enabling whole-body positron emission tomography (PET) imaging of rats. We conducted performance evaluations of SimPET-L and SimPET-XL and rat-body imaging with SimPET-XL to demonstrate the benefits of increased axial and transaxial FOVs.

PROCEDURES

The detector blocks in SimPET-L and SimPET-XL consist of two 4 × 4 silicon photomultiplier arrays coupled with 20 × 9 array lutetium oxyorthosilicate crystals. SimPET-L and SimPET-XL have an inner diameter (bore size) of 7.6 cm, and they are composed of 40 and 80 detector blocks yielding axial lengths of 5.5 and 11 cm, respectively. Each system was evaluated according to the National Electrical Manufacturers Association NU4-2008 protocol. Rat imaging studies, such as ¹⁸F-NaF and ¹⁸F-FDG PET, were performed using SimPET-XL.

RESULTS

The radial resolutions at the axial center measured using the filtered back projection, 3D ordered-subset expectation maximization (OSEM), and 3D OSEM with point spread functions correction were 1.7, 0.82, and 0.82 mm FWHM in SimPET-L and 1.7, 0.91, and 0.91 mm FWHM in SimPET-XL, respectively. The peak sensitivities of SimPET-L and SimPET-XL were 6.30% and 10.4% for an energy window of 100-900 keV and 4.44% and 7.25% for a window of 250-750 keV, respectively. The peak noise equivalent count rate with an energy window of 250-750 keV was 249 kcps at 44.9 MBq for SimPET-L and 349 kcps at 31.3 MBq for SimPET-XL. In SimPET-L, the uniformity was 4.43%, and the spill-over ratios in air- and water-filled chambers were 5.54% and 4.10%, respectively. In SimPET-XL, the uniformity was 3.89%, and the spill-over ratio in the air- and water-filled chambers were 3.56% and 3.60%. Moreover, SimPET-XL provided high-quality images of rats.

CONCLUSION

SimPET-L and SimPET-XL show adequate performance compared with other SimPET systems. In addition, their large transaxial and long axial FOVs provide imaging capability for rats with high image quality.

Relation of lymphopenia to comorbidity burden and its prognostic value in patients with acute decompensated heart failure with preserved left ventricular ejection fraction: a multicentre study

Background

Systemic inflammation resulting from comorbidities is postulated to play a central role in the pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF). Lymphopenia is a common manifestation of systemic inflammation and a prognostic factor in patients with HF. However, the association of lymphopenia with the comorbidity burden is unknown, and its prognostic value in patients with HFpEF admitted due to acute decompensated heart failure (ADHF) also remains elusive.

Purpose

We sought to clarify the relation of lymphopenia with the comorbidity burden, as well as its prognostic value and complementarity with the Get with the Guidelines-Heart Failure (GWTG-HF) risk score in ADHF patients with HFpEF.

Methods

Patients' data were extracted from the Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT-HFpEF), which is a prospective multicentre registry for patients with ADHF with a LVEF ≥50%. We analysed data of patients admitted between June 2016 and December 2020 who survived to discharge. The total lymphocyte count (per μL) and GWTG-HF risk score were obtained on admission, as previously reported. Comorbidity burden was defined as the number of comorbidities from the following: atrial fibrillation, hypertension, diabetes mellitus, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, anaemia, and obesity. The study endpoint was all-cause death.

Results

Over a median follow-up of 417 days, 181 of the 1013 included patients died. The proportion of patients with a total lymphocyte count in the lowest tertile was increasing with the increase in comorbidity burden (Figure 1). In the multivariate Cox analysis, a total lymphocyte count in the intermediate (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.00–2.41, p=0.0486) and lowest tertile (HR 2.23, 95% CI 1.47–3.38, p=0.0002) was independently associated with all-cause death. There was a significant difference in the all-cause death rate among the groups stratified by total lymphocyte count tertile (Figure 2). The total lymphocyte count had a higher C-statistic value (0.627) for the prediction of all-cause death than the GWTG-HF risk score, and the C-statistic value of the GWTG-HF risk score was improved when the total lymphocyte count was added (0.613 to 0.636, p=0.0260).

Conclusions

Lymphopenia was significantly associated with comorbidity burden. Furthermore, it was a useful marker of poor prognosis in hospitalised patients with acute HFpEF and was shown to be complementary to the contemporary HF prognostic score.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Roche Diagnostics K.K.Fuji Film Toyama Chemical Co. Ltd.

Clinical trajectory and outcomes of patients with heart failure with preserved ejection fraction with normal or indeterminate diastolic function

Background

Heart failure (HF) with preserved ejection fraction (HFpEF) is a chronic and progressive disease, but limited therapeutic strategies are currently available. Although left ventricular diastolic dysfunction (DD) is a prominent mechanism of HFpEF, a certain number of patients with HFpEF have a normal diastolic function (ND) or indeterminate diastolic function (ID). With the progressive nature of HFpEF, diastolic function may change over time. However, the change of diastolic function, its predictor and prognosis in patients with clinically established HFpEF remains unknown.

Purpose

To investigate the clinical trajectory and outcomes of patients with HFpEF with ND or ID and to identify factors associated with progression from ND or ID at discharge to DD at 1-year follow-up.

Methods

Using data from a prospective multicenter observational study of patients with HFpEF, we extracted 289 patients with HFpEF with ND or ID at discharge who had echocardiographic data at 1-year follow-up for the re-evaluation of diastolic function. Diastolic function was assessed according to the 2016 American Society of Echocardiography recommendations. Patients were classified according to the absence or presence of progression from ND or ID to DD at 1 year. The primary endpoint was a composite of all-cause death and HF rehospitalization.

Results

Median age was 81 years, and 138 (47.8%) patients were female. At 1 year, 107 (37%) patients progressed to DD. During a median follow-up of 709 days, the composite endpoint occurred in 90 (31.1%) patients. Compared to patients without progression to DD, those with progression to DD had a significantly higher cumulative incidence rate of the composite endpoint (incidence rate: 11.7/100 person-year versus 23.3/100 person-year, P<0.001). Progression to DD (adjusted HR: 2.014, 95% CI: 1.239–3.273, P=0.005) was independently associated with the composite endpoint. Age (adjusted OR: 1.046, 95% CI: 1.008–1.087, P=0.018), body mass index (BMI) (adjusted OR: 1.107, 95% CI: 1.029–1.192, P=0.006), and serum albumin (adjusted OR: 0.459, 95% CI: 0.216–0.974, P=0.042) were independently associated with progression from ND or ID to DD at 1 year.

Conclusion

More than one-third of patients with HFpEF with ND or ID progressed to DD at 1 year and had poor clinical outcomes. Age, BMI, and serum albumin were independently associated with this progression.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by grants from Japan Society for the Promotion of Science KAKENHI (No. JP 17K09496) and Japan Agency for Medical Research and Development (No. JP16lk1010013).

The clinical relevance of quality of life in patients with acute decompensated heart failure with preserved ejection fraction: insights from the PURSUIT-HFpEF Registry

Background

Improvement of quality of life (QOL) is one of the most important therapeutic goals for patients with heart failure with preserved ejection fraction (HFpEF). It is, therefore, clinically relevant to comprehensively identify aggravating factors among cardiac factors, non-cardiac comorbidities, and social factors. The aim of this study was to elucidate determinant factors of impaired QOL and clarify the association between QOL and prognosis in patients with HFpEF.

Methods and results

Patient data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. EuroQol 5 dimensions 5-level (EQ-5D-5L) data were obtained at discharge to evaluate patients' health-related QOL. A total of 864 patients were enrolled in this study. Multivariable logistic regression analysis revealed that only non-cardiac factors such as age, female sex, frailty, malnutrition and inflammation were significantly associated with low EQ-5D-5L score, whereas cardiac factors showed no significant association after multivariable adjustment. A total of 206 patients died over a mean follow-up period of 2.0±1.2 years. Kaplan–Meier survival curve analysis demonstrated a significant increase in risk of mortality stratified by tertiles of EQ-5D-5L score (p<0.0001). Cox multivariable analysis revealed that patients with low EQ-5D-5L score had a significantly greater risk of mortality than those with high EQ-5D-5L score (adjusted hazard ratio: 2.20 (1.40–3.45), p=0.001).

Conclusion

Among patients with HFpEF, non-cardiac factors such as age, female sex, frailty, malnutrition and inflammation are significantly associated with impaired QOL. The QOL score itself also offers useful prognostic information in patients with HFpEF.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of the serial change of a systemic inflammation-nutrition index in patients with heart failure with preserved ejection fraction: insights from pursuit-hfpef registry

Background

Malnutrition and inflammation are associated with poor outcomes with heart failure (HF). It has been reported that advanced lung cancer inflammation index (ALI), calculated by body mass index × serum albumin level / neutrophil to lymphocyte ratio (NLR) can be useful for the risk stratification and predicting the post-discharge prognosis of the patients with acute decompensated heart failure (ADHF). However, there is no information available on the prognostic value of the serial ALI change in ADHF patients with preserved ejection fraction (HFpEF).

Methods and results

Patients' data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study, which is a prospective multicenter observational registry for ADHF-HFpEF in Osaka. Laboratory data and body weight measurements were performed at the discharge and 1 year after the discharge. We analyzed 527 patients after exclusion of patients on dialysis, in-hospital death, missing follow-up data, or missing data to calculate ALI. The study patients were categorized by the serial change from baseline to 1 year after the discharge (ΔALI) as follows: low tertile: ΔALI <−6.99 (n=176), middle tertile: −6.99 ≤ ALI <8.44 (n=176), and high tertile: 8.44 ≤ ΔALI (n=175). The endpoints of the present study were all-cause death (ACD) and cardiovascular death (CVD). During a mean follow-up period of 1.5±1.0 years, 94 patients had ACD and 40 patients had CVD. The Kaplan-Meier analysis revealed that the patients with middle and low ΔALI at 1 year after heart failure hospitalization had a significantly greater risk of reaching the ACD and CVD than those with high ΔALI (ACD: 22% vs 22% vs 10%, p=0.0011, CVD: 10% vs 9% vs 3%, p=0.014). On multivariate Cox analysis, ΔALI was significantly associated with ACD independently of age, gender, serum NT-proBNP level, and baseline ALI after adjustment for NYHA functional class, serum creatinine level, serum hemoglobin level, serum CRP level, serum sodium level and LVEF.

Conclusion

This study showed that patients with the increased ALI after the discharge had improved outcome in comparison to those without the increased ALI. The serial change of ALI, a systemic inflammation-nutrition index, might be useful for stratifying ADHF patients with HFpEF at risk for the total mortality and cardiovascular mortality.

Funding Acknowledgement

Type of funding sources: None.

Volumetric Measurement of Relative CBV Using T1-Perfusion-Weighted MRI with High Temporal Resolution Compared with Traditional T2*-Perfusion-Weighted MRI in Postoperative Patients with High-Grade Gliomas

BACKGROUND AND PURPOSE

T1-PWI with high temporal resolution may provide a reliable relative CBV value as a valid alternative to T2*-PWI under increased susceptibility. The purpose of this study was to assess the technical and clinical performance of T1-relative CBV in patients with postoperative high-grade gliomas.

MATERIALS AND METHODS

Forty-five MRIs of 34 patients with proved high-grade gliomas were included. In all MRIs, T1- and T2*-PWIs were both acquired and processed semiautomatically to generate relative CBV maps using a released commercial software. Lesion masks were overlaid on the relative CBV maps, followed by a histogram of the whole VOI. The intraclass correlation coefficient and Bland-Altman plots were used for quantitative and qualitative comparisons. Signal loss from both methods was compared using the Wilcoxon signed-rank test of zero voxel percentage. The MRIs were divided into a progression group (n = 20) and a nonprogression group (n = 14) for receiver operating characteristic curve analysis.

RESULTS

Fair intertechnique consistency was observed between the 90th percentiles of the T1- and T2*-relative CBV values (intraclass correlation coefficient = 0.558, P < .001). T2*-PWI revealed a significantly higher percentage of near-zero voxels than T1-PWI (17.7% versus 3.1%, P < .001). There was no statistically significant difference between the area under the curve of T1- and T2*-relative CBV (0.811 versus 0.793, P = .835). T1-relative CBV showed 100% sensitivity and 57.1% specificity for the detection of progressive lesions.

CONCLUSIONS

T1-relative CBV demonstrated exquisite diagnostic performance for detecting progressive lesions in postoperative patients with high-grade gliomas, suggesting the potential role of T1-PWI as a valid alternative to the traditional T2*-PWI.

Effects of Human Rights Sensitivity of case managers on the working relationships with people suffering from mental illness mediated by empathy

Introduction

It is critical to provide not only mental health services but also welfare services that meet the socioeconomic needs of people suffering from mental illnesses in order for them to recover. Case managers in the public sector who provide socioeconomic support to the low-income class, in particular, play critical roles in early detection of untreated mentally ill people, linking them to the mental health system, and providing various supports for their community integration. Positive working relationships are required to fulfill these roles.

Objectives

This study aims to analyze the effects of human rights sensitivity of case managers on the working relationships with the persons with mental illness mediated by empathy.

Methods

We evaluated overall human rights sensitivity, level of empathy(cognitive, affective, behavioral aspects) and working relationships with the mentally ill of 291 public sector case managers(Mean age = 40.52, SD=7.96, female 78.2%, male 21.8%).

Results

In research model analysis, the goodness-of-fit was evaluated to verify the effect of overall human rights sensitivity on the working relationships with the persons with mental illness mediated by empathy. Most of indices showed sufficient goodness-of-fit. In other words, the higher overall human rights sensitivity is, the higher the level of empathy is, and this has a positive effect on the working relationships with persons with mental illness.

Conclusions

To form positive working relationships with people suffering from mental illnesses, public sector case managers must be educated to increase their empathy by improving their overall human rights sensitivity.

Disclosure

No significant relationships.

Prognostic value of the combination of pulmonary-systemic pressure ratio and a new systemic inflammation-nutrition index in patients admitted for acute decompensated heart failure

Background

Concomitant presence of pulmonary hypertension in heart failure (HF) is associated with increased adverse events and may be related to interventricular uncoupling and impaired cardiac efficiency. It has recently been shown that an increased mean pulmonary artery pressure to mean systemic arterial pressure ratio (MPS ratio), a marker of interventricular coupling and efficiency, is associated with worse clinical outcomes in patients with advanced HF. On the other hand, systemic inflammation plays a critical role in the outcomes of heart failure, and malnutrition is also associated with poor outcome in heart failure patients It has been recently reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index × serum albumin / neutrophil to lymphocyte ratio (NLR), is an independent prognostic marker in several types of cancer. However, there is no information available on the prognostic value of the combination of MPS ratio and ALI in patients with acute decompensated HF (ADHF).

Methods and results

We studied 219 patients admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival. During a follow up period of 5.1±4.2 yrs, 57 had cardiovascular death (CVD). MPS ratio was significantly greater (0.401±0.107 vs 0.346±0.105, p=0.0009) and ALI was significantly smaller (34.2±18.7 vs 52.0±27.1, p&lt;0.0001) in patients with than without CVD At multivariate Cox analysis, MPS ratio and ALIwere significantly associated with CVD, independently of eGFR and prior heart failure hospitalization, after the adjustment with left ventricular end-diastolic dimension and serum sodium level. The patients with both greater MPS ratio&gt;0.350 (AUC 0.652 [0.569–0.735]) and smaller ALI &lt;35.767 (AUC 0.714 [0.636–0.792]) had a significantly increased risk of CVD than those with either greater MPS or smaller ALI and none of them (67% vs 22% vs 11%, p&lt;0.0001, respectively).

Conclusion

The combination of MPS ratio and ALI might be useful for stratifying ADHF patients at higher risk for CVD.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of sarcopenia and malnutrition in patients admitted for acute decompensated heart failure with reduced or preserved left ventricular ejection fraction

Background

Sarcopenia and malnutrition are associated with poor clinical outcome in patients with chronic heart failure. However, there is little information available on the prognostic significance of the combination of sarcopenia and malnutrition in patients with acute decompensated heart failure (ADHF), relating to reduced or preserved left ventricular ejection fraction (HFrEF or HFpEF).

Methods

We prospectively studied 543 consecutive ADHF patients who survived to discharge (HFrEF [LVEF &lt;45%] n=245 and HFpEF [LVEF≥45%] n=298). At the discharge, sarcopenia and malnutrition was evaluated by free-fat mass index (FFMI) and geriatric nutrition risk index (GNRI), respectively. FFMI was calculated as follows: FFMI = (7.38 + 0.02908 × urinary creatinine [mg/day])/ (height in meter)2. Sarcopenia was defined as FFMI &lt;17 kg/m2 in men and &lt;15 kg/m2 in women. GNRI was calculated as follows: 14.89 × serum albumin (g/dl) + 41.7 × BMI/22, and malnutrition was defined as GNRI&lt;92. The endpoint was all-cause death.

Results

During a follow-up period of 2.8±1.4 years, 161 patients had all-cause death. Multivariate Cox analysis showed that both FFMI and GNRI were independently associated with all-cause death in both HFrEF (p=0.0064 and p&lt;0.0001, respectively) and HFpEF patients (p=0.0140 and p=0.0007, respectively) after adjustment for relevant baseline clinical and study characteristics. In HFrEF, patients with both sarcopenia and malnutrition had a significantly higher risk of the total mortality than those with either or none of them. On the other hand, in HFpEF, patients with both and either sarcopenia or malnutrition had a significantly higher risk of the total mortality than those with none of them, while there was no significant difference in the risk between both and either sarcopenia or malnutrition.

Conclusions

Sarcopenia or malnutrition at discharge was associated with all-cause death even in ADHF patients, irrespective of reduced or preserved LVEF. The combination of sarcopenia and malnutrition could provide prognostic information in ADHF patients with reduced LVEF.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Prognostic value of simple risk index and plasma volume status in patients with acute decompensated heart failure

Background

Increased heart rate (HR) and low systolic blood pressure (SBP) are associated with adverse clinical outcomes in patients admitted for acute decompensated heart failure (ADHF), and simple risk index (SRI) based on easily assessed clinical characteristics (age, HR, and SBP) provides prognostic information. On the other hand, plasma volume (PV) expansion plays an essential role in heart failure, and PV status is has been reported to be associated with adverse outcomes in ADHF patients. However, there is no information available on the value of the combination of SRI and PV status in patients admitted for ADHF.

Methods and results

We studied 301 patients admitted for ADHF. At the admission, SRI was calculated as (HR x [age/10]2)/SBP. PV status was calculated as the following: Actual PV = (1 − hematocrit) x [a + (b x body weight)] (a=1530 in males and a=864 in females, b=41 in males and b=47.9 in females), Ideal PV = c x body weight (c=39 in males and c=40 in females), and PV status = [(actual PV − ideal PV)/ideal PV] x 100(%). During a follow-up period of 4.3±3.2 yrs, 95 patients had all-cause death (ACD) and 68 patients had cardiovascular death (CVD). At multivariate Cox analysis, SRI and PV status were significantly associated with ACD and CVD, independently of the prior history of heart failure hospitalization and serum creatinine and sodium levels, after the adjustment with serum albumin level and anemia. Patients with both greater SRI (≥35.1 by ROC analysis; AUC 0.599 [0.524–0.674]) and greater PV status (≥8.1% by ROC analysis; AUC 0.625 [0.550–0.700]) had a significantly higher risk of ACD and CVD than those with either or none of them (ACD: 49% vs 27% vs 24%, p&lt;0.0001, CVD: 39% vs 18% vs 15%, p&lt;0.0001,respectively).

Conclusion

The combination of SRI and PV status might be useful for stratifying patients at risk for the total mortality and cardiovascular death in patients with ADHF.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of a new systemic inflammation-nutrition index in patients admitted with acute decompensated heart failure; a comparison with malnutrition

Background

Systemic inflammation plays a critical role in the outcomes of heart failure. Malnutrition is also associated with poor outcome in heart failure patients. It has been recently reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index × serum albumin / neutrophil to lymphocyte ratio (NLR), is an independent prognostic marker in several types of cancer. However, there is no information available on the prognostic impact of ALI in patients admitted with acute decompensated heart failure (ADHF), especially in comparison with malnutrition.

Methods and results

We studied 263 ADHF patients discharged with survival. At the discharge, we measured ALI. Malnutrition was assessed by prognostic nutritional index (PNI) and controlling nutritional status score (CONUT). During a follow up period of 5.1±4.3 yrs, 67 patients had cardiovascular death (CVD). ALI was significantly smaller in patients with than without CVD (32.5±18.2 vs 52.2±30.2, p&lt;0.0001). At multivariate Cox regression analysis, ALI was significantly associated with CVD, independently of prior heart failure hospitalization, systolic blood pressure and eGFR, although PNI and CONUT showed the association with CVD at unvariate analysis. By receiver-operator curve analysis, AUC of ALI was 0.733 (0.664–0.803), which was significantly greater than that of PNI (0.664 [0.590–0.739]) and CONUT (0.591 [0.509–0.672]). Patients with lowest tertile of ALI (&lt;32.0) had a increased risk of mortality than middle tertile (NLR=32.0–53.6; HR 2.06 [1.15–3.71]) and highest tertile (ALI&gt;53.6: HR 5.80 [2.60–12.94]) (48% vs 21% vs 9%, p&lt;0.0001, respectively).

Conclusion

ALI, a systemic inflammation-nutrition index, is more useful prognostic marker than malnutrition in patients admitted with ADHF.

Funding Acknowledgement

Type of funding sources: None.

Long-term prognostic value of the combination of malnutrition and fib-4 index in patients admitted with acute decompensated heart failure

Background

Malnutrition is associated with increased mortality risk in patients with acute decompensated heart failure (ADHF). Cardiohepatic interactions have been a focus of attention among heart failure. It was reported that liver stiffness assessed by non-invasive fibrosis marker such as Fibrosis-4 (FIB4) index provide prognostic information in ADHF patients. However, there is no information available on the long-term prognostic value of the combination of malnutrition and FIB4 index in patients admitted for ADHF.

Methods and results

We studied 294 patients admitted for ADHF, who were discharged with survival. Nutritional status was evaluated by Geriatric Nutritional Risk Index (GNRI) calculated as follows: 14.89 × serum albumin (g/dl) + 41.7 × BMI/22, and malnutrition was defined as GNRI &lt;92. FIB4 index was calculated by the formula: age (yrs) × AST[U/L] / (platelets [103/μL] × (ALT[U/L])1/2), and abnormal FIB4 index was defined as &gt;2.67. During a mean follow-up period of 4.3±3.3 yrs, 94 patients had all-cause death. At multivariate Cox regression analysis, GNRI and FIB4 index were significantly associated with the total mortality, independently of prior heart failure hospitalization, systolic blood pressure, and serum creatinine level. Patients with malnutrition and abnormal FIB4 index had a significantly higher risk of the total mortality than those with either and none of them (49% vs 32% vs 20%, p&lt;0.0001, respectively).

Conclusions

The combination of malnutrition and FIB4 index might be useful for stratifying ADHF patients at higher risk for the total mortality.

Funding Acknowledgement

Type of funding sources: None.

A prospective, randomized, comparison of the coronary vasomotion associated with drug-coated balloon versus drug-eluting stent

Background

It is widely known that even new-generation drug-eluting stent (DES) induce coronary vasomotion abnormality. On the other hand, recent studies reported that drug-coated balloon (DCB) for native coronary artery was non-inferior to DES in medium term outcomes. However, there is no available information about vasomotion after treatment with DCB.

Purpose

The aim of this study was to prospectively compare coronary vasomotion in patients treated with DCB versus new-generation DES.

Methods

Twenty-seven patients were randomly treated with angioplasty with DCB (n=12) versus implantation of bioabsorbable polymer everolimus-eluting stent (BP-EES, n=15) after successful predilation. At 8 months after treatment, endothelium-dependent and -independent vasomotion were evaluated by intracoronary infusion of incremental doses of acetylcholine (for right coronary artery: low-dose 5μg, high-dose 50μg and for left coronary artery: low-dose 10μg, high-dose 100μg) and nitroglycerine (200μg). Mean luminal diameter of the distal segments, beginning 5 mm and ending 15 mm distal to the edge of the treated segment was quantitatively measured by angiography.

Results

Clinical and procedural characteristics were not different between two groups. Vasoconstriction after acetylcholine infusion was less pronounced in the DCB group than the BP-EES group (low-dose: 4±13% vs −4±14%, p=0.158, high-dose: −2±14% vs −28±30%, p=0.013). The response to nitroglycerin was not different between two groups (17±13% vs 18±24%, p=0.838).

Conclusion

Vasoconstriction after acetylcholine infusion in the peri-treated region was more pronounced in the BP-EES group than in the DCB group, which suggests that endothelial function of coronary vessel treated by DCB can be more preserved than new-generation DES.

Figure 1

Funding Acknowledgement

Type of funding source: None

Predictors of silent cerebral infarction associated with catheter ablation for atrial fibrillation

Introduction

Cather ablation (CA) has been identified as an effective and safe treatment option for patients with atrial fibrillation (AF). One of the serious complications associated AF is cerebral infarction (CI). Recent studies reported that CA was associated with lower incidence of ischemic stroke in patients with AF. However, CA for AF itself has a potential risk of CI. Several previous studies showed that the incidence of silent CI (SCI) assessed by magnetic resonance imaging (MRI) of the brain occurred 5 to 18% during CA for AF. Recently, CA for AF made a remarkable progress in technology. However, there are few information available that the impact of 3-dimensional electroanatomical mapping system on the incidence of SCI. This study aimed to clarify the prevalence and predictors of SCI during CA for AF.

Methods

We enrolled 893 consecutive patients (male 534, age 71±10 years), who underwent CA for AF and MRI of brain 1 day after the procedure. We collected patients data such as physical examinations, blood sampling, echo cardiography, and CA data. A brain MRI was performed the next day following the procedure to identify any CIs. One-hundred and forty-six of patients used the Rhythmia® mapping system catheter, and the other mapping system such as CARTO or EnSite system used in the remaining 747 patients.

Results

The MRI depicted acute micro-CIs in 144 (16%) patients, but neither symptoms nor abnormal neurological findings were present in these patients. Patients with SCI had significantly higher prevalence of persistent AF (60 vs 43%, p=0.0002), CHADS2 Score (2 (1–3) vs 1 (1–2), p=0.0001), higher prevalence of previous stroke (19 vs 12%, p=0.02), larger left atrial (LA) diameter (43.2±6.4 vs 41.7±6.5mm, p=0.01), lower left ventricular ejection fraction (LVEF) (59.0±13.2 vs 64.2±11.3%, p≤0.0001), higher B-type natriuretic peptide level (221±236 vs 163±225 pg/dl, p≤0.0001), more Rhythmia® mapping system use (30 vs 8%, p&lt;0.0001), and longer procedure time (129±46 vs 108±39 min, p≤0.0001) than those without SCI, while there were no significant differences in age, LA appendage flow velocity, kind of anti-coagulant agent between the two groups. Multivariate regression analysis identified Rhythmia® use [odds ratio (OR) 4.26, (95% CI 2.32–7.84), p=0.0001], LVEF (OR 1.02, p=0.0059), CHADS2 score (OR 1.27, p=0.009), and procedure time (OR 1.005, p=0.04) as independent risk factors of acute SCI during CA for AF.

Conclusion

Acute SCI occurred about 16% after CA for AF. Rhythmia® mapping system use exhibited a higher incidence of acute SCI after catheter ablation for AF than the other mapping system use. Rhythmia® mapping system use, LVEF, CHADS2 score, and procedure time are associated with SCI relating CA for AF.

Funding Acknowledgement

Type of funding source: None

Impact of simple nutrition index on the long-term mortality of acute decompensated heart failure patients with preserved left ventricular ejection fraction: insight from PURSUIT-HFpEF registry

Background

The novel nutrition index; triglyceride (TG) × total cholesterol (TG) × body weight (BW) index (TCBI) has been reported to be an easy and useful predictor for patients with coronary artery disease. However, there is no information available on the prognostic value of TCBI in patients with heart failure with preserved LVEF (HFpEF) who admitted with acute decompensated heart failure (ADHF).

Methods and results

Data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. PURSUIT-HFpEF study is a prospective multicenter observational study in which collaborating hospitals recorded clinical, echocardiographic, and outcome data of ADHF pts with HFpEF. We enrolled consecutive 757 HFpEF patients who admitted with ADHF from June 2016 to June 2019. TCBI was calculated by the formula; TG × TC × BW / 1000 at the discharge. After we excluded patients with in-hospital death or without sufficient data, we analyzed 419 patients. The primary endpoint was all-cause mortality. During a median follow up period of 1.1 (0.9–1.9) years, 59 patients died. ROC analysis revealed that TCBI at discharge was a fair discriminator for predicting all-cause mortality (AUC 0.676, sensitivity 53%, specificity 78%). Multivariate Cox proportional analysis showed that TCBI (p=0.002) was an independent predictor for all cause death after adjustment with major confounders such as age, gender, NT-proBNP, hemoglobin and serum creatinine level. We divided patients into 4 groups according to quartiles of TCBI. Kaplan-Meier analysis showed a significantly higher risk of all-cause death in relation to the decrease in TCBI.

Conclusion

TCBI, a simple and novel nutrition index, is a useful and strong long-term prognostic indicator in ADHF patients with HFpEF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnositics K.K.; Fuji Film Toyoma Chemical Co. Ltd.

Effect of empagliflozin as add-on therapy on transtubular potassium concentration gradient in patients with type 2 diabetes hospitalized for acute decompensated heart failure

Background

The transtubular potassium concentration gradient (TTKG) has been reported to be a marker of renal aldosterone bioactivity, and has been shown to be a surrogate of arterial underfilling in patients with acute decompensated heart failure (ADHF). Moreover, high TTKG at discharge has been shown to be associated with poor prognosis in ADHF patients. Empagliflozin, one of the sodium glucose cotransporter 2 inhibitors, has been shown to reduce the risk of cardiovascular mortality in patients with type 2 diabetes mellitus (T2D) and cardiovascular disease. However, little is known about the effect of empagliflozin as add-on therapy on TTKG in T2D patients with ADHF.

Purpose

We sought to elucidate the effect of empagliflozin as add-on therapy on TTKG in T2D patients with ADHF.

Methods

We enrolled 58 consecutive T2D patients admitted for ADHF. On admission, enrolled patients were randomly assigned in a 1:1 ratio to either empagliflozin add-on therapy (EMPA(+)) or conventional glucose-lowering therapy (EMPA(−)). All patients in EMPA(+) group received empagliflozin (10 mg/day) throughout the study period. Left ventricular ejection fraction (LVEF) was measured at baseline using echocardiography. Body weight and vital signs, such as blood pressure and heart rate, were measured, and blood and urine samples were collected at baseline and 1, 2, 3 and 7 days after randomization. The TTKG was measured using the first morning urine samples collected on each day. TTKG was calculated according to the following equation: TTKG = (Ku/Ks)×(plasma osmolality/urine osmolality), where Ku is urine potassium concentration and Ks is serum potassium concentration, as previously reported.

Results

Thirty patients were assigned to the EMPA(+) group, and 28 patients were assigned to the EMPA(−) group. There were no significant baseline differences in LVEF, plasma B-type natriuretic peptide (BNP) level, body mass index, or serum creatinine level between the EMPA(+) and EMPA(−) groups. TTKG did not significantly differ between the two groups at baseline. However, seven days after randomization, plasma BNP level was significantly lower in the EMPA(+) group than in the EMPA(−) group (median 227 [IQR 114–381] pg/mL vs 362 [227–554] pg/mL, p=0.0294). Furthermore, TTKG of the EMPA(+) group was significantly lower at 2, 3 and 7 days after randomization (Figure).

Conclusions

This study demonstrated that empagliflozin as add-on therapy can lower TTKG in T2D patients with ADHF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Role of diuretics on long-term mortality may differ in volume status in patients with acute myocardial infarction

Background

Diuretics has been reported to have a potential for an activation of the renin-angiotensin-aldosterone system and the sympathetic nervous system, leading to a possibility of poor clinical outcome in patients with cardiovascular disease. However, few data are available on clinical impact of diuretics on long-term outcome in patients with acute myocardial infarction (AMI) based on plasma volume status.

Methods

To address the issue, a total of 3,416 survived patients with AMI who were registered to a large database of the Osaka Acute Coronary Insufficiency Study (OACIS) were studied. Plasma volume status was assessed with the estimated plasma volume status (ePVS) that was calculated at discharge as follows: actual PV = (1 − hematocrit) × [a + (b × body weight)] (a=1530 in males and a=864 in females, b=41.0 in males and b=47.9 in females); ideal PV = c × body weight (c=39 in males and c=40 in females), and ePVS = [(actual PV − ideal PV)/ideal PV] × 100 (%). Multivariable Cox regression analysis and propensity score matching were performed to account for imbalances in covariates. The endpoint was all-cause of death (ACD) within 5 years.

Results

During a median follow-up period of 855±656 days, 193 patients had ACD. In whole population, there was no significant difference in long-term mortality risk between patients with and without diuretics in both multivariate cox regression model and propensity score matching population. When patients were divided into 2 groups according to ePVS with a median value of 4.2%, 46 and 147 patients had ACD in groups with low ePVS and high ePVS, respectively. Multivariate Cox analysis showed that use of diuretics was independently associated with an increased risk of ACD in low ePVS group, (HR: 2.63, 95% confidence interval [CI]: 1.22–5.63, p=0.01), but not in high ePVS group (HR: 0.70, 95% CI: 0.44–1.10, p=0.12). These observations were consistent in the propensity-score matched cohorts; the 5-year mortality rate was significantly higher in patients with diuretics than those without among low ePVS group (4.7% vs 1.7%, p=0.041), but not among high ePVS group (8.0% vs 10.3%, p=0.247).

Conclusion

Prescription of diuretics at discharge was associated with increased risk of 5-year mortality in patients with AMI without PV expansion, but not with PV expansion. The role of diuretics on long-term mortality may differ in plasma volume status. Therefore, prescription of diuretics after AMI may be considered based on plasma volume status.

Funding Acknowledgement

Type of funding source: None

Comparative prognostic impact of ACCI and AHEAD risk score in heart failure with reduced, mid-range and preserved left ventricular ejection fraction admitted for acute decompensated heart failure

Background

Comorbidities are strongly associated with poor clinical outcome in heart failure patients (pts). The Age-adjusted Charlson comorbidity index (ACCI), which is well-known widely used comorbidity index, recently has been used as a robust prognostic model in heart failure pts. On the other hand, AHEAD risk score has been recently reported as a useful long-term risk stratification score in acute decompensated heart failure (ADHF) pts. Recently, a new group of heart failure pts with mid-range ejection fraction (HFmrEF) has been defined, separated from reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). We sought to compare the prognostic value of ACCI and AHEAD score in ADHF pts, relating to HFrEF, HFmrEF and HFpEF.

Methods

We prospectively studied 410 consecutive ADHF pts (HFrEF [n=143], HFmrEF [n=99] and HFpEF [n=168]) with survival discharge. ACCI contains 19 issues which was weighted according to their potential influence on mortality. AHEAD risk score is a simple index, which is range 0–5; atrial fibrillation, hemoglobin &lt;13 mg/dL for men and 12 mg/dL for women, age &gt;70 years, creatinine &gt;130 μmol/L, and diabetes mellitus. The endpoint of this study was all cause death (ACD).

Results

During a follow-up period of 2.4±1.4 years, 119 pts had ACD (42, 29 and 48 pts in HFrEF, HFmrEF and HFpEF, respectively). At univariate Cox analysis, ACCI and AHEAD risk score were significantly associated with ACD in each subgroup. At multivariate Cox analysis, in HFrEF pts, ACCI, but not AHEAD risk score, showed the significant and independent association with ACD. In HFmrEF, both ACCI and AHEAD risk score was significantly and independently associated with ACD and ROC analysis showed AUC of ACCI was greater than that of AHEAD risk score (0.778 [0.683–0.855] vs 0.637 [0.572–0.764], p=0.07). On the other hand, in HFpEF pts, AHEAD risk score, but not ACCI, showed the significant and independent association ACD.

Conclusion

ACCI provides more prognostic value in HFrEF pts, and AHEAD risk score has more prognostic value in HFpEF pts. In HFmrEF pts, both ACCI and AHEAD score might have prognostic values, although ACCI tends to be more associated with ACD than AHEAD score.

Funding Acknowledgement

Type of funding source: None

Prognostic significance of cardiac 123I-MIBG SPECT imaging in patients with acute decompensated heart failure with preserved left ventricular ejection fraction

Background

Cardiac sympathetic nerve dysfunction, which is assessed by I-123 metaiodobenzylguanidine (MIBG) imaging, is associated with the poor outcomes in patients with heart failure (HF). Most of the literature on the use of 123I-MIBG imaging is based on planar images in patients with chronic HF and reduced left ventricular ejection fraction (HFrEF), because It is technically challenging to conduct precise 123I-MIBG SPECT analysis in globally denervated heart, which is frequently observed in HFrEF patients. There was no information available on cardiac sympathetic nerve dysfunction evaluated by cardiac MIBG SPECT imaging in acute decompensated HF (ADHF) patients with preserved left ventricular ejection fraction (HFpEF).

Purpose

We aimed to clarify the prognostic significance of 123I-MIBG SPECT myocardial imaging in ADHF patients with HFpEF.

Methods

We enrolled 183 patients who were admitted for ADHF with HFpEF, discharged with survival. All patients underwent cardiac MIBG imaging at the timing of discharge. The cardiac MIBG heart to mediastinum ratio (H/M) was calculated on the early image and the delayed image (late H/M). We studied 156 patients after excluding 27 patients whose MIBG SPECT reconstruction was difficult due to too low MIBG uptake or extracardiac accumulation interference. SPECT analysis on the delayed image was conducted by using CardioBull, a fully automated software for the quantification of I-123 MIBG SPECT. All of 17 regional tracer uptake were compared with normal control database. A scoring algorithm for the evaluation of low uptake employs a 5-point scoring system as 0–4 for normal, mildly abnormal, moderately abnormal, severe abnormal, and perfusion defect, respectively. The summed severity (SSS) scores were obtained by summing the score for all segments. SSS could range from 0 to 68. The endpoint of this study is cardiac events defined as the composite of unplanned heart failure hospitalization and cardiac death.

Results

During a mean follow up period of 2.4±1.6 years, 60 patients reached cardiac events. SSS was significantly high in patients with than without cardiac events (20 [10–27] vs 7 [4–16], p&lt;0.0001). SSS (p&lt;0.0001) was significantly associated with cardiac events after multivariable Cox adjustment of age, sex, creatinine and log-transformed BNP level, although late H/M showed the significant association with the endpoint at the univariate Cox analysis. Kaplan-Meier analysis showed that patients with high SSS (&gt;10, defined by median) had significantly greater risk of cardiac event (56% vs 21%, Hazard ratio: 3.56 (2.00–6.33, p&lt;0.0001). ROC curve analysis showed that area under the curve (AUC) of SSS was 0.746 [95% CI:0.670, 0.812], which was significantly higher than that of late H/M (0.618 [95% CI:0.537, 0.695]) (p=0.0159).

Conclusion

Cardiac MIBG SPECT imaging was useful for risk stratification in ADHF patients with HFpEF.

Funding Acknowledgement

Type of funding source: None

Impact of comorbidity on the predictive value of cystatin-C in patients admitted for acute decompensated heart failure: insights from a prospective study

Background

Comorbidities are strongly associated with poor clinical outcome in heart failure patients. The Age-adjusted Charlson comorbidity index (ACCI), which is well-known widely used comorbidity index, recently has been used as a robust prognostic model in heart failure patients. On the other hand, Cystatin C, as a novel and important biomarker of renal function, has been recently reported as a useful long-term risk stratification score in heart failure patients. However, there is no information available on the impact of comorbidities on the prognostic value of cystatin-C in patients admitted for acute decompensated heart failure (ADHF).

Methods

We prospectively studied 458 consecutive ADHF patients with survival discharge. Patients with hemodialysis were excluded. Echocardiography and venous blood sampling were performed just before discharge and serum cystatin-C level was measured. Comorbidity was measured with the Age-adjusted Charlson comorbidity index (ACCI). ACCI was commonly used for the evaluation of the comorbid condition which is weighted and scored, with additional points added for age. The endpoint was all-cause death (ACD).

Results

During a follow-up period of 2.8±1.5 years, 132 patients had ACD. At multivariate Cox analysis, ACCI (p=0.0015) and cystatin-C level (p=0.0145) were significantly and independently associated with ACD. Patients with high ACCI (≥6: determined by ROC analysis) had a significantly greater risk of ACD (37.2% vs 17.8%, p&lt;0.0001, HR 2.45 [1.61–3.70]). In the subgroup of higher ACCI, patients with higher cystatin-C level (≥1.56: determined by ROC analysis) had a significantly higher risk of ACD (50.3% vs 23.4%). Furthermore, in the subgroup of lower ACCI, patients with higher cystatin-C level had also significantly higher risk of ACD (34.2% vs 12.1%).

Conclusions

The prognostic value of cystatin-C is not affected by comorbidities and cystatin-C provide prognostic information even in patients admitted for ADHF, irrespective of comorbid burden.

All-cause death-free rate in ADHF pts

Funding Acknowledgement

Type of funding source: None

Prognostic value of nutritional status in patients with heart failure with preserved ejection fraction, with and without atrial fibrillation: insights From PURSUIT-HFpEF Registry

Background

Malnutrition is one of the most important comorbidities among heart failure (HF) patients, and serum cholinesterase (CHE) has been reported to be a prognostic factor in HF patients. On the other hand, atrial fibrillation (AF) is frequently observed in patients with HF with preserved ejection fraction (HFpEF). However, there is little information available on the prognostic value of nutritional status in HFpEF patients, with and without AF. We sought to clarify the prognostic value of CHE in HFpEF with and without AF and compare it with that of other nutrition indices such as gastric nutritional risk index (GNRI), controlling nutritional status (CONUT), and the prognostic nutritional index (PNI).

Methods and results

Patients data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study, which is a prospective multicenter observational registry for acute decompensated heart failure patients with left ventricular ejection fraction ≥50% in Osaka. We analyzed 380 patients (median age: 80 [75–87] years, male: 46%) after exclusion of patients with in-hospital death, missing follow-up data, or missing data to calculate nutritional indices. On admission, 155 patients had AF. Laboratory data were obtained at discharge. During a mean follow up period of 1.1±0.6 years, 131 patients had a composite endpoint (CE) of all-cause death and hospitalization for worsening heart failure or cerebrovascular disorder. In multivariate Cox analysis, in patients with AF, CHE was significantly associated with CE independently of age, gender and body mass index after the adjustment with serum albumin, total cholesterol levels and total lymphocyte count, while it was not significantly associated with CE in patients without AF. C-index of CHE (0.708) was higher than that of GNRI (0.555, p=0.0028), CONUT (0.651, p=0.208) and PNI (0.635, p=0.208) in AF patients, while there were no significant differences in those nutritional indices in patients without AF. Kaplan-Meier curve analysis revealed that AF patients with lower CHE (&lt;208 U/L = median value) had higher risk of CE than those with higher CHE (44% vs 18%, adjusted HR 3.26 95% CI [1.66–6.67], p=0.0005), while there was no significant difference in the occurrence rate of CE between patients with and without higher CHE in non-AF group (42% vs 31%, adjusted HR 1.28 95% CI [0.78–2.13], p=0.33).

Conclusions

Prognostic value of CHE would be stronger than other nutritional indices in HFpEF patients with AF, while it would be weak in HFpEF patients without AF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd.

Long-term serial changes of cardiac sympathetic nerve dysfunction in acute decompensated heart failure patients with reduced, mid-range and preserved left ventricular ejection fraction

Background

Cardiac sympathetic nerve dysfunction, which is assessed by I-123 metaiodobenzylguanidine (MIBG) imaging, is associated with the poor outcomes in patients with chronic heart failure (CHF). Serial evaluation of cardiac MIBG imaging was shown to be useful for predicting adverse outcome in CHF. However, there was no information available on long-term serial changes of cardiac sympathetic nerve dysfunction after discharge of acute decompensated heart failure (ADHF) hospitalization.

Purpose

We aimed to clarify the serial change of cardiac MIBG imaging parameter in long-term after discharge of heart failure hospitalization, especially relating to HFrEF (LVEF&lt;40%), HFmrEF (40%≤LVEF&lt;50%) and HFpEF (LVEF≥50%).

Methods

We studied 112 patients (HFrEF; n=44, HFmrEF; n=23 and HFpEF; n=45) who were admitted for ADHF, discharged with survival and without heart failure hospitalization during follow-up period. All patients underwent cardiac MIBG imaging at the timing of discharge, in 6–12 months and in 18–24 months after discharge. The cardiac MIBG heart to mediastinum ratio (H/M) was calculated on the early image and the delayed image (late H/M). The cardiac MIBG washout rate (WR) was calculated from the early and delayed planar images after taking radioactive decay of I-123 into consideration.

Results

In HFrEF patients, late H/M was significantly improved from discharge to 6–12 months data (1.60±0.24 vs 1.75±0.31, p&lt;0.0001). Late H/M of HFmrEF patients was also significantly improved from discharge to 18–24 months data (1.71±0.27 vs 1.84±0.29 p=0.043). On the other hand, late H/M of HFpEF patients was not significantly changed. As for WR, WR in HFrEF and HFmrEF patients was significantly improved from discharge to 18–24 months data, although WR of HFpEF was not significantly changed.

Conclusion

The improvement in cardiac sympathetic nerve dysfunction was observed in patients with HFrEF and HFmrEF, not in HFpEF, after the discharge of acute heart failure hospitalization.

Funding Acknowledgement

Type of funding source: None

Long-term prognostic value of the combination of malnutrition and pulmonary-systemic pressure ratio in patients admitted with acute decompensated heart failure

Background

Malnutrition is associated with increased mortality risk in patients (pts) with acute decompensated heart failure (ADHF). On the other hand, concomitant presence of pulmonary hypertension in heart failure is associated with increased adverse events and may be related to interventricular uncoupling and impaired cardiac efficiency. It has recently been shown that an increased mean pulmonary artery pressure to mean systemic arterial pressure ratio (MPS ratio), a marker of interventricular coupling and efficiency, is associated with worse clinical outcomes in patients with advanced heart failure. However, there is no information available on the long-term prognostic value of the combination of malnutrition and MPS ratio in pts admitted for ADHF.

Methods and results

We studied 248 pts admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival. Malnutrition was assessed by geriatric nutritional risk index (GNRI), prognostic nutritional index (PNI) and controlling nutritional status score (CONUT). During a mean follow-up period of 5.2±4.4 yrs, 62 pts had cardiovascular death (CVD). MPS ratio was significantly greater in pts with than without CVD (0.408±0.114 vs 0.347±0.102, p=0.0001). GNRI and PNI were significantly lower, CONUT was significantly greater in pts with than without CVD. At multivariate Cox regression analysis, GNRI and MPS ratio were significantly associated with CVD, independently of prior heart failure hospitalization, eGFR, and serum sodium level and anemia, although PNI and CONUT showed the association with CVD at unvariate analysis. Pts with malnutrition (GNRI≤median value=96.5) and greater MPS ratio (≥median value=0.346) had a significantly higher CVD risk than those with either and none of them (51% vs 20% vs 12%, p&lt;0.0001, respectively).

Conclusions

The combination of malnutrition and MPS ratio might be useful for stratifying pts at risk for CVD in patients with ADHF.

Funding Acknowledgement

Type of funding source: None

Full-Color-Tunable Nanophotonic Device Using Electrochromic Tungsten Trioxide Thin Film

Color generation based on strategically designed plasmonic nanostructures is a promising approach for display applications with unprecedented high-resolution. However, it is disadvantageous in that the optical response is fixed once the structure is determined. Therefore, obtaining high modulation depth with reversible optical properties while maintaining its fixed nanostructure is a great challenge in nanophotonics. In this work, dynamic color tuning and switching using tungsten trioxide (WO₃), a representative electrochromic material, are demonstrated with reflection-type and transmission-type optical devices. Thin WO₃ films incorporated in simple stacked configurations undergo dynamic color change by the adjustment of their dielectric constant through the electrochromic principle. A large resonance wavelength shift up to 107 nm under an electrochemical bias of 3.2 V could be achieved by the reflection-type device. For the transmission-type device, on/off switchable color pixels with improved purity are demonstrated of which transmittance is modulated by up to 4.04:1.

The Association of Gait Speed and Frontal Lobe among Various Cognitive Domains: The Korean Frailty and Aging Cohort Study (KFACS)

OBJECTIVE

The aim of this study was to determine how gait speed and frontal lobe functionsin community-dwelling older adults in Korea.

DESIGN

This was a cross-sectional study.

SETTING

The study used data from the Korean Frailty and Aging Cohort Survey (KFACS), a multi-center longitudinal study addressing 10 centers across urban, rural, and suburban communities in Korea, between 2016 and 2017.

PARTICIPANTS

A total of 1552 older adults who underwent both gait speed tests and cognitive functions tests during the investigation of the KFACS.

MEASUREMENTS

Gait speed was assessed by asking participants to walk from a starting point to a point 4 meters away at a normal gait. Cognitive functions were evaluated using various standardized cognitive functions tests.

RESULTS

Gait speed was slower when participants were older or less educated The percentage of women, higher BMI, people with lower incomes, singles, smokers, and drinkers was high in the slower gait group. Also, all cognitive function scores were low and depression score was high in the group with slower walking speed. The slower walking speed showed low physical activity score and high prevalence of hypertension, osteoarthritis and osteoporosis. Among the seven cognitive functions (MMSE, memory, TMT, Recall, Recognition, digit span, and Fab), only TMT showed no significant difference between different gait speed groups. The other six cognitive functions showed higher results in the fastest gait speed group (T3), Participants in middle gait speed group (T2) also showed higher results in five of the seven cognitive function scores as well (Memory, Recall, Recognition, digit span, and Fab).

CONCLUSION

In this study, we found correlation between the slower gait speeds and the decrease in cognitive function, and especially the frontal lobe dysfunction was most prominent of all cognitive dysfunctions.

P794Long-term prognostic value of the combination of AHEAD score and wasting syndrome in patients admitted for acute decompensated heart failure with reduced or preserved LV ejection fraction

Background

Comorbidities are associated with poor clinical outcome in heart failure patients (pts). AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) score has been related to clinical outcomes in acute decompensated heart failure (ADHF) pts. On the other hand, heart failure is one of a number of disorders associated with the development of wasting syndrome. Previous studies have reported reduced mortality rates in heart failure patients with increased body mass index (BMI), so-called, obesity paradox. We sought to investigate the prognostic value of the combination of AHEAD score and the cachectic state in ADHF pts, relating to reduced or preserved LVEF (HFrEF or HFpEF).

Methods and results

We studied 303 pts admitted for ADHF and discharged with survival (HFrEF (LVEF <50%); n=163, HFpEF (LVEF ≥50%; n=140). We evaluated AHEAD score (range 0–5, atrial fibrillation, hemoglobin <13 mg/dL for men and 12 mg/dL for women, age >70 years, creatinine >130 μmol/L, and diabetes mellitus) and wasting syndrome was defined as BMI <20 kg/m2 and serum albumin level (Alb) <3.2 g/dl at the discharge. During a follow-up period of 5.1±4.2 years, 121 pts died. At multivariate Cox analysis, AHEAD score and wasting syndrome was significantly and independently associated with the total mortality, in pts with not only HFrEF but also HFpEF. Pts with both high AHEAD score (≥3: AUC 0.625 [0.542–0.709] in HFrEF and ≥3: AUC 0.611 [0514–0.708] in HFpEF, by ROC curve analysis) and wasting syndrome had a higher risk of mortality than those with either and none of them in HFrEF (71% vs 51% vs 40%, p<0.0001, respectively) and HFpEF (78% vs 33% vs 24%, p<0.0001, respectively).

Conclusion

The combination of AHEAD score and wasting syndrome would be useful for stratifying patients at risk for the mortality in ADHF pts, regardless of HFrEF or HFpEF.

P787Long-term prognostic value of the combination of fibrosis-4 index and acute kidney injury in patients with admitted for acute decompensated heart failure

Background

Liver dysfunction in patients with heart failure (HF) is caused by liver congestion, which is related to liver stiffness. It was reported that liver stiffness assessed by non-invasive fibrosis marker such as Fibrosis-4 (FIB4) index (based on age, aspartate aminotransferase [AST] and alanine aminotransferase [ALT] levels, and platelet counts) predicts mortality in HF pts. Acute kidney injury (AKI) during HF treatment is associated with poor outcome in pts admitted for acute decompensated heart failure (ADHF). However, there is no information available on the long-term prognostic significance of the combination of FIB4 index and AKI in ADHF pts.

Methods and results

We studied 299 ADHF pts with survival discharge. FIB4 index was calculated by the formula: age (yrs) × AST[U/L]/(platelets [103/μL] × (ALT[U/L])1/2). AKI during ADHF treatment was defined according to AKI Network criteria (stage 1: mild, stage 2: moderate, stage 3: severe). During a follow-up period of 4.3±3.3 yrs, 94 pts died. At multivariate Cox analysis, FIB4 index and stage2/3 AKI, but not stage1 AKI, significantly associated with total mortality, independently of prior HF hospitalization and serum sodium and blood urea nitrogen levels after adjustment with BMI, systolic blood pressure, hemoglobin, serum creatinine and albumin levels, left ventricular end-diastolic and left atrial dimension indexes. Pts with both greater FIB4 index (&gt;2.674: median) and stage 2/3 AKI had a significantly higher risk of total mortality than those with none of them. Adjusted hazard ratio in pts with both greater FIB4 index and stage 2/3 AKI was 3.5 (95% CI 1.6–7.7), which was two-fold of that in pts with either of them (1.7 [95% CI 1.1–2.7]).

Conclusion

The combination of FIB4 index and moderate to severe AKI might identify higher risk subset for total mortality in ADHF pts.

P762Usefulness of 2-year iodine-123 metaiodobenzylguanidine-based risk model for the post-discharge risk stratification in patients with acute decompensated heart failure

Background

A four-parameter risk model including cardiac iodine-123 metaiodobenzylguanidine (MIBG) imaging and readily available clinical parameters has been recently developed for the prediction of 2-year cardiac mortality risk in patients with chronic heart failure (CHF) using a Japanese CHF database consisting of 1322 patients. On the other hand, the Acute Decompensated Heart Failure National Registry (ADHERE) and Get With The Guidelines-Heart Failure (GWTG-HF) risk scores, simple tools to predict risk of in-hospital mortality, have been reported to be predictive of post-discharge outcome in patients with acute decompensated heart failure (ADHF). However, there is no information available on the usefulness of 2-year MIBG-based cardiac mortality risk score for the prediction of post-discharge prognosis in ADHF patients and its comparison with the ADHERE and GWTG-HF risk scores.

Purpose

We sought to validate the predictability of the 2-year MIBG-based cardiac mortality risk score for post-discharge clinical outcome in ADHF patients, and to compare its prognostic value with those of ADHERE and GWTG-HF risk scores.

Methods

We studied 297 consecutive patients who were admitted for ADHF, survived to discharge, and had definitive 2-year outcomes. Venous blood sampling was performed on admission, and echocardiography and cardiac MIBG imaging were performed just before discharge. In cardiac MIBG imaging, the cardiac MIBG heart-to-mediastinum ratio (HMR) was measured from the chest anterior view images obtained at 20 and 200 min after isotope injection. The 2-year cardiac mortality risk score was calculated using four parameters, including age, left ventricular ejection fraction, NYHA functional class, and HMR on delayed image. The patients were stratified into three groups based on the 2-year cardiac mortality risk score: low- (<4%), intermediate- (4–12%), and high-risk (>12%) groups. The ADHERE and GWTG-HF risk scores were also calculated from admission data as previously reported. The predictive ability of the scores was compared using receiver operating characteristic curve analysis. The endpoint was a composite of all-cause mortality and unplanned hospitalization for worsening heart failure.

Results

During a follow-up period, 110 patients reached the primary endpoint. There was significant difference in the rate of primary endpoint among the three groups stratified by 2-year cardiac mortality risk score (low-risk group: 18%, intermediate-risk group: 36%, high-risk group: 64%, Figure 1A). The 2-year cardiac mortality risk score demonstrated a greater area under the curve for the primary endpoint compared to the ADHERE and the GWTG-HF risk scores (Figure 1B).

Figure 1

Conclusions

The 2-year MIBG-based cardiac mortality risk score is also useful for the prediction of post-discharge clinical outcome in ADHF patients, and its prognostic value is superior to those of the ADHERE and the GWTG-HF risk scores.

P4552The prognostic impact of worsening and improved renal function in acute decompensated heart failure with and without plasma volume expansion

Background

Recent studies showed that both worsening renal function (WRF) and improved renal function (IRF) during hospitalization are associated with poor prognosis in patients with acute decompensate heart failure (ADHF). On the other hand, plasma volume (PV) expansion plays an essential role in ADHF. However, there is little information about the difference of prognostic impact of WRF and IRF in ADHF patients, relating to PV status (PVS).

Methods

We prospectively studied 348 patients admitted for ADHF. PVS was defined as follows: actual PV = (1 - hematocrit) × [a + (b × body weight)] (a=1530 in males and a=864 in females, b=41.0 in males and b=47.9 in females); ideal PV = c × body weight (c=39 in males and c=40 in females); and PVS = [(actual PV - ideal PV)/ideal PV] × 100 (%). WRF and IRF were defined as an increase and a decrease in serum creatinine of ≥0.3 mg/dl from admission to discharge, respectively. The endpoint was readmission for worsening heart failure (WHF) within 1 year.

Result

Median PVS was 6.7% (IQR: −4.1%–16.7%). 43 and 21 patients had WHF in groups with high PVS (PVS ≥ median) and low PVS (PVS > median), respectively. In high PVS group, multivariate Cox analysis showed that IRF was independently and significantly associated with WHF (p=0.016, HR: 2.4 [1.2–4.8]), but WRF was not (p=0.55, HR: 0.7 [0.3–2.1]). On the other hand, in low PVS group, WRF was independently associated with WHF (p=0.035, HR: 3.0 [1.1–8.1]), but IRF was not (p=0.27, HR: 2.1 [0.6–8.0]). Kaplan-Meier analysis revealed that only patients with IRF had a significantly higher risk of WHF than those with stable renal function (SRF) in high PVS group, while patients with WRF had a significantly higher risk of WHF than those with SRF in low PVS group.

Worsening heart failure-free rate curves

Conclusion

In ADHF patients with PV expansion, IRF during hospitalization could predict poor outcomes, but WRF could not. On the other hand, in ADHF patients without PV expansion, not IRF but WRF could predict poor outcomes. PVS guided-therapy may be considered in secondary prevention for WHF.

P793Prediction of prognosis using combined objective nutritional score in the patients with acute decompensated heart failure

Background

It has been reported that the objective nutritional indices such as the Controlling Nutritional Status (CONUT) score, Geriatric Nutritional Risk Index (GNRI) and Prognostic Nutritional Index (PNI) are useful for the prediction of prognosis in patients with heart failure. However, there is no information available on the prognostic value of the combination of these objective nutritional indices in patients with acute decompensated heart failure (ADHF).

Purpose

We sought to assess the usefulness of the Combined Objective Nutritional Score for the prediction of post-discharge clinical outcome in ADHF patients.

Methods

We studied 361 consecutive patients who were admitted for ADHF and survived to discharge. Venous blood sampling, echocardiography, and measurement of body weight were performed just before discharge. CONUT score, GNRI and PNI were calculated as previously reported. We determined the Combined Objective Nutritional Score by assigning 1 point each for high CONUT score (2–12), low GNRI (≤98) or low PNI (≤38). Patients were followed-up for up to 5 years. The study endpoint was all-cause death.

Results

During a follow-up period of 2.4±1.3 years, 106 patients had all-cause death. Multivariate Cox analysis showed that the Combined Objective Nutritional Score was independently associated with all-cause death after adjustment for age, gender, history of coronary artery disease, left ventricular ejection fraction, brain natriuretic peptide level and estimate glomerular filtration rate (p<0.0001). When the patients were stratified into the three groups based on the Combined Objective Nutritional Score (normal nutritional status: 0 point, mild-to-moderate malnutrition: 1–2 points, severe malnutrition: 3 points), the incidence of all-cause death appeared to increase in relation to the Combined Objective Nutritional Score (normal: 0%, mild-to moderate: 23%, severe: 52%, p<0.0001, Figure). Patients with severe malnutrition showed 2.9 fold (95% CI 1.8–4.6) increase in the total mortality in comparison to patients with mild-to-moderate malnutrition.

Figure 1

Conclusion

This study showed that the Combined Objective Nutritional Score is a useful tool to risk stratify the patients hospitalized with ADHF.

P791Long-term prognostic value of pulmonary-systemic pressure ratio in patients admitted for acute decompensated heart failure with reduced or preserved left ventricular ejection fraction

Background

Concomitant presence of pulmonary hypertension in heart failure is associated with increased adverse events and may be related to interventricular uncoupling and impaired cardiac efficiency. It has recently been shown that an increased mean pulmonary artery pressure to mean systemic arterial pressure ratio (MPS ratio), a marker of interventricular coupling and efficiency, is associated with worse clinical outcomes in patients with advanced heart failure. However, there is little information available on the long-term prognostic value of MPS ratio in patients with acute decompensated heart failure (ADHF), relating to reduced or preserved left ventricular ejection fraction (HFrEF or HFpEF).

Methods and results

We studied 240 patients admitted for ADHF, who underwent right heart catheterization and were discharged with survival (HFrEF (LVEF≤40%); n=110, HFpEF (LVEF>40%); n=130). MPS ratio was obtained at the admission. During a mean follow-up period of 5.2±4.4 yrs, 59 patients had cardiovascular death (CVD). In both groups with HFrEF and HFpEF, MPS ratio was significantly greater in patients with than without CVD (HFrEF; 0.453±0.101 vs 0.382±0.116, p=0.0035, HFpEF; 0.374±0.118 vs 0.323±0.083, p=0.0091). At multivariate Cox regression analysis, MPS ratio was significantly associated with CVD, independently of eGFR and serum sodium level in HFrEF and HFpEF groups. Patients with high MPS ratio (>0.386 in HFrEF and >0.415 in HFpEF determined by ROC curve analysis) had a significantly increased risk of CVD than those with low MPS ratio in both groups.

Conclusions

MPS ratio could provide the long-term prognostic information in patients admitted for ADHF, regardless of reduced or preserved LVEF.

P5406Impact of the albumin level on the prognostic value of diuretic response in patients admitted for acute decompensated heart failure: a prospective study

Background

The reduced diuretic response (DR) has been shown to be associated with poor clinical outcome in patients with acute decompensated heart failure (ADHF). In addition, hypoalbuminemia, which is related to DR, has been also reported to predict poor prognosis in ADHF patients. However, there is no information available on the impact of albumin level on the prognostic value of DR in patients with ADHF.

Methods

We prospectively studied 296 consecutive patients who were admitted for ADHF and survived to discharge. The patients were divided into 2 groups according to the presence or absence of hypoalbuminemia at the admission, defined as the serum level of albumin at admission <3.5g/dl, and DR was defined as weight loss per 40mg intravenous dose and 80mg oral dose of furosemide up to day 4. The endpoint was a composite of all-cause mortality and unplanned hospitalization for worsening heart failure.

Results

There were 144 patients with hypoalbuminemia and 152 patients without hypoalbuminemia. During a mean follow-up period of 2.2±1.5 years, 88 patients with hypoalbuminemia and 53 patients without hypoalbuminemia reached the endpoint. In group with hypoalbuminemia, DR was significantly smaller in patients with than without the endpoint (0.85 [0.50–1.50] vs 1.60 [0.76–2.70] kg/40mg furosemide, p=0.003), while there was no significant difference in DR between them in group without hypoalbuminemia (1.17 [0.59–1.66] vs 1.07 [0.75–1.88] kg/40mg furosemide, p=0.381). At multivariate Cox analysis, in group with hypoalbuminemia, DR was significantly associated with the endpoint, independently of age, left ventricular ejection fraction, and serum creatinine and plasma BNP levels. On the other hand, in group without hypoalbuminemia, DR showed no significant association with the endpoint at univariate Cox analysis. Kaplan-Meier analysis showed that patients with poor DR (≤1.08 kg/40mg furosemide: median value) had a significantly higher risk of the endpoint in group with hypoalbuminemia, but not in group without hypoalbuminemia (Figure).

Figure 1

Conclusion

Our results suggested that prognostic value of DR in ADHF patients is affected by the presence or absence of hypoalbuminemia.

P5409Plasma volume status provides the additional prognostic information to the Get With the Guidelines-Heart Failure risk score in acute decompensated heart failure patients

Background

The Get with The Guidelines (GWTG) heart failure (HF) risk score was developed in the GWTG inpatient HF registry to predict in-hospital mortality and also reported to be associated with post-discharge long-term outcomes. Plasma volume (PV) expansion plays an essential role in HF. Recently, it has been reported that PV is estimated by a simple formula based on hematocrit and body weight, not using radioisotope assays, and PV status provides prognostic information in patients (pts) with acute decompensated heart failure (ADHF). However, there is no information available on the long-term prognostic value of the combination of PV status and GWTG-HF risk score in pts admitted for ADHF.

Methods and results

We studied 301 ADHF pts discharged with survival. Variables required for the GWTG-HF risk score were race, age, systolic blood pressure, heart rate, serum levels of blood urea nitrogen and sodium, and the presence of chronic obstructive pulmonary disease. PV status was calculated as the following: Actual PV = (1 − hematocrit) x [a + (b x body weight)] (a=1530 in males and a=864 in females, b=41 in males and b=47.9 in females), Ideal PV = c x body weight (c=39 in males and c=40 in females), and PV status = [(actual PV − ideal PV)/ideal PV] x 100(%). During a follow-up period of 4.3±3.2 yrs, 95 pts had all-cause death (ACD). At multivariate Cox analysis, GWTG-HF risk score and PV status were significantly associated with the total mortality, independently of eGFR and the prior history of heart failure hospitalization, after the adjustment with serum albumin level and anemia. Pts with both high GWTG-HF risk score (≥39 by ROC analysis; AUC 0.655 [0.586–0.724]) and greater PV status (≥8.1% by ROC analysis; AUC 0.624 [0.566–0.692]) had a significantly higher risk of ACD than those with either or none of them (58% vs 30% vs 21%, p<0.0001, respectively).

Conclusion

PV status would provide the additional long-term prognostic information to GWTG-HF risk score in ADHF pts.

P4523Impact of comorbiditity on the predictive value of acute kidney injury in patients admitted for acute decompensated heart failure: a prospective study

Background

Comorbidities are associated with poor clinical outcome in patients with chronic heart failure, and acute kidney injury (AKI) also provides prognostic information in patients with heart failure. However, there is no information available on the impact of comorbidities on the prognostic value of AKI in patients admitted for acute decompensated heart failure (ADHF).

Methods

We prospectively studied 357 consecutive ADHF patients with survival discharge. Patients with hemodialysis were excluded. Comorbidity was measured with the Age-adjusted Charlson comorbidity index (ACCI) which is commonly used for the evaluation of the comorbid condition which is weighted and scored, with additional points added for age. AKI was defined as an absolute increase in serum creatinine of 0.3mg/dl or more during hospitalization. The endpoint was all-cause death (ACD).

Results

During a follow-up period of 2.2±1.4 years, 97 patients had ACD. At multivariate Cox analysis, ACCI (p<0.0001) and AKI (p=0.0061) were significantly and independently associated with ACD. Patients with high ACCI (≥5: determined by ROC analysis) had a significantly greater risk of ACD (39% vs 16%). In the subgroup of high ACCI, patients with AKI had a significantly higher risk of ACD (60% vs 35%), whereas there was no significant difference in the risk of ACD between with and without AKI (15% vs 16%) in the subgroup of low ACCI.

Conclusions

The presence of AKI was associated with the increased risk of mortality in ADHF patients with higher comorbidity burden but not in those without them.

P1649Prognostic significance of serum cholinesterase in patients with acute decompensated heart failure with preserved ejection fraction: insights from PURSUIT-HFpEF registry

Background

Comorbidities strongly influence the prognosis in heart failure with preserved ejection fraction (HFpEF). Malnutrition is one of the most important comorbidities among heart failure patients. Serum cholinesterase (CHE), one of the markers of malnutrition, was reported to be a prognostic factor in patients with chronic heart failure. In addition, we previously reported prognostic significance of CHE from a single center registry data of acute decompensated heart failure (ADHF). The aim of this study is to conduct external validation of the prognostic role of CHE using multi-center HFpEF registry.

Methods and results

Patients data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. PURSUIT-HFpEF study is a prospective multicenter observational study in which collaborating hospitals in Osaka recorded clinical, echocardiographic, and outcome data of patients with ADHF and preserved ejection fraction. Between June 2016 and January 2018, 381 patients were enrolled and we excluded patients without sufficient laboratory data and in-hospital death. Finally, we analyzed 204 patients with survival discharge. Laboratory data including CHE and echocardiography were obtained just before discharge. The endpoint of this study is the composite of all-cause death and worsening heart failure re-admission (cardiac event). During a follow up period of 0.92±0.37 years, 49 patients had cardiac event. CHE was significantly lower in patients with than without cardiac event (183±67 vs 223±71 U/L, p<0.0001). At multivariate Cox analysis, CHE (p=0.0020) was significantly associated with cardiac event, independently of NT-pro BNP after adjustment of age, sex, eGFR and hemoglobin. ROC curve analysis showed that AUC of CHE for the prediction of cardiac event was 0.706 (95% CI 0.638–0.768). Kaplan-Meier analysis showed that patients with low CHE (<211U/L defined by median) had a significantly greater risk of cardiac event (35% vs 13% p=0.0002).

Figure 1

Conclusion

Serum cholinesterase level is the useful prognostic marker for the prediction of cardiac event in patients with ADHF with preserved ejection fraction.

Acknowledgement/Funding

Roche diagnostics, FUJIFILM Toyama Chemical

P795Long-term prognostic value of the combination of plasma volume status and pulmonary-systemic pressure ratio in patients admitted with acute decompensated heart failure

Background

Plasma volume (PV) expansion plays an essential role in heart failure and PV status provides prognostic information in patients (pts) with acute decompensated heart failure (ADHF). On the other hand, concomitant presence of pulmonary hypertension in heart failure is associated with increased adverse events and may be related to interventricular uncoupling and impaired cardiac efficiency. It has recently been shown that an increased mean pulmonary artery pressure to mean systemic arterial pressure ratio (MPS ratio), a marker of interventricular coupling and efficiency, is associated with worse clinical outcomes in patients with advanced heart failure. However, there is no information available on the long-term prognostic value of the combination of PV status and MPS ratio in pts admitted for ADHF.

Methods

We studied 248 pts admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival. PV status and MPS ratio were obtained at the admission. PV status was calculated as the following: Actual PV = (1 − hematocrit) x [a + (b x body weight)] (a=1530 in males and a=864 in females, b=41 in males and b=47.9 in females), Ideal PV = c x body weight (c=39 in males and c=40 in females), and PV status = [(actual PV − ideal PV)/ideal PV] x 100(%). The study endpoint was cardiovascular death (CVD).

Results

During a mean follow-up period of 5.2±4.4 yrs, 62 pts had CVD. PV status (10.0±16.2 vs 5.0±15.3%, p=0.03) and MPS ratio (0.408±0.114 vs 0.347±0.102, p=0.0001) were significantly greater in patients with than without CVD. At multivariate Cox regression analysis, PV status and MPS ratio were significantly associated with CVD, independently of prior heart failure hospitalization, eGFR, and serum sodium level and anemia. Patients with greater PV status (> median value = 4.6%) and MPS ratio (> median value = 0.346) had a significantly higher CVD risk than those with either and none of them (44% vs 22% vs 14%, p<0.0001, respectively).

Conclusions

The combination of PV status and MPS ratio might be useful for stratifying patients at risk for CVD in patients with ADHF.

P842Calculated plasma volume status provides additional prognostic value to global registry of acute coronary event (GRACE) score in patients with acute myocardial infarction

Background

Plasma volume status (PVS) has been shown to be a well-validated prognostic indicator which relate to morbidity and mortality in heart failure. However, it remains unclear whether PVS would have the prognostic significance in patients with acute myocardial infarction (AMI). Global Registry of Acute Coronary Events (GRACE) risk score is a powerful predictor of prognosis after acute coronary event, but there is no information available on the additional prognostic value of PVS to GRACE in AMI patients.

Methods

We retrospectively studied 3930 AMI patients. GRACE score and PVS was obtained on the admission. PVS was calculated as follows: actual PV = (1 - hematocrit) × [a + (b × body weight)] (a=1530 in males and a=864 in females, b=41.0 in males and b=47.9 in females); ideal PV = c × body weight (c=39 in males and c=40 in females); and PVS = [(actual PV - ideal PV)/ideal PV] × 100 (%). The endpoint was All cause of death (ACD) within 5 years.

Results

During a mean follow-up period of 2.4±1.9 years, 406 patients had ACD. PVS was significantly greater in patients with ACD than without ACD (8.1±14.9% vs −1.7±13.3%, p<0.001). Each 5% increase in PVS was linked to a 27% estimated risk of 5-year mortality (p<0.001, HR: 1.05 [1.03–1.08]). PVS was still independently associated with ACD, after adjustment with GRACE score as a potential confounding factor. Kaplan-Meier analysis revealed that patients with PV expansion (PVS>0%) were significantly higher risk of ACD than those without PV expansion in patients both with high risk in GRACE score (>140) (28% (225/803) vs 19% (78/412), p=0.01, HR: 7.5) and with low risk in GRACE score (≤140) (6% (52/894) vs 3% (51/1821), p=0.009, HR: 6.2).

Survival rate curves

Conclusion

PVS, which represents intravascular compartment and congestion, could identify poor prognosis in patients with AMI. In addition, PVS would provide additional prognostic information to GRACE score.

P1031The impact of the duration of atrial fibrillation persistence for arrhythmia free survival in patients undergoing catheter ablation

Background

Catheter ablation (CA) for atrial fibrillation (AF) is a curable treatment option. However, AF recurrence after CA remains an important problem. Although the success rate has been improved after catheter ablation (CA) in patients with paroxysmal AF (PAF), outcome data after CA for persistent AF (PeAF) are highly variable. Previous studies showed the PeAF is one of independent predictors for AF recurrence in comparison to PAF. However, there are little information available on the prognostic significance of AF duration after CA for AF. The aim of this study is to evaluate the impact of AF duration on long-term outcomes of AF ablation in patients with PeAF compared with PAF.

Methods

We enrolled 778 consecutive patients, who were referred our institution between August 2015 and December 2017 for undergoing the first time CA for AF. We divided 5 groups (Group 1; PAF (n=442), Group 2; PeAF duration ≤6 months (n=198), Group 3; PeAF duration of 6 months to 2 years (n=87), Group 4; PeAF duration of 2–5 years (n=30) and Group 5; PeAF duration ≥5 years (n=21)). All patients followed up for at least 1 year. Outcome data on recurrence of AF after ablation were collected.

Results

There were no significant differences in baseline clinical characteristics before CA among 5 groups, except for the prevalence of congestive heart failure, left atrial diameter and left ventricular ejection fraction. During a mean follow-up period of 511±298 days, 217 patients had AF recurrence. Kaplan-Meier analysis revealed that AF recurrence was significantly higher in group 2 compared to group 1 (31% vs 20%, p=0.002) and in group 4 compared to group 3 (83% vs 30%, p<0.0001). However, AF recurrence was no significantly differences between groups 2 and 3 (31% vs 30%, p=0.76) and between groups 4 and 5 (83% vs 81%, p=0.45). Of 217 patients with AF recurrence, 154 patients had undergone multiple procedures. After last procedures, during a mean follow-up period of 546±279 days, 61 patients had AF recurrence. Kaplan-Meier analysis revealed that AF recurrence was significantly higher in group 2 compared to group 1 (10% vs 3%, P=0.0005) and in group 4 compared with group 3 (35% vs 10%, p=0.0001). However, AF recurrence was no significantly difference between groups 2 and 3 (10% vs 10%, p=0.91) and between groups 4 and 5 (47% vs 35%, p=0.47).

AF Free Survival Curve

Conclusion

Although patients with PeAF within 2 years had significantly higher AF recurrence compared to PAF, AF ablation might still be a good contributor as the first line approach to improve outcomes in patient with PeAF within 2 years.

P5413Effect of empagliflozin as add-on therapy on serum uric acid level in patients with type 2 diabetes hospitalized for acute decompensated heart failure: a prospective randomized controlled study

Background

Elevated serum uric acid (UA) level has been shown to be associated with reduced survival among patients (pts) with heart failure. Sodium glucose cotransporter 2 (SGLT2) inhibitors have been reported to lower serum uric acid level in pts with type 2 diabetes mellitus (T2D). Empagliflozin, one of the SGLT2 inhibitors, has been shown to reduce the risk of cardiovascular mortality in T2D pts with cardiovascular disease, and involvement of UA lowering effect by empagliflozin in the reduction of cardiovascular mortality has been suggested. However, little is known about the effect of empagliflozin as add-on therapy on serum UA level in T2D pts with acute decompensated heart failure (ADHF).

Purpose

We sought to elucidate the effect of empagliflozin as add-on therapy on serum UA level in T2D pts with ADHF.

Methods

We enrolled 38 consecutive T2D pts admitted for ADHF. On admission, enrolled pts were randomly assigned in a 1:1 ratio to either empagliflozin add-on therapy (EMPA(+)) or conventional glucose-lowering therapy (EMPA(−)). All pts in EMPA(+) group received empagliflozin (10 mg/day) throughout the study period. Left ventricular ejection fraction (LVEF) was measured at baseline using echocardiography. Body weight and vital signs, such as blood pressure and heart rate, were measured, and blood and urine samples were collected at baseline and 1, 2, 3 and 7 days after randomization. Renal handling of UA was evaluated by fractional excretion of UA (FEUA).

Results

Twenty pts were assigned to the EMPA(+) group, and 18 pts were assigned to the EMPA(−) group. There were no significant baseline differences in LVEF, plasma brain natriuretic peptide level, body mass index, or serum creatinine level between the EMPA(+) and EMPA(−) groups. In addition, prevalence rate of hyperuricemia, serum UA level, and FEUA did not significantly differ between the two groups at baseline. However, there was significant difference in the change in serum UA level from baseline at 2, 3 and 7 days after randomization between the two groups (Figure A). As a result, serum UA level was significantly lower in the EMPA(+) group than in the EMPA(−) group at 7 days after randomization (6.2±1.8 mg/dL vs 7.8±1.8 mg/dL, p=0.0127). Moreover, FEUN of the EMPA(+) group was significantly higher at 1, 2 and 7 days after randomization (Figure B), which suggested that serum UA level was lowered in the EMPA(+) group by increased urinary excretion of UA.

Figure 1

Conclusions

This study demonstrated that empagliflozin as add-on therapy can lower serum UA level in T2D pts with ADHF through the effect on the urinary excretion rate of UA.

4330Effect of empagliflozin as add-on therapy on decongestion and renal function in diabetic patients hospitalized for acute decompensated heart failure: a prospective randomized controlled study

Background

The mainstay of treatment of acute decompensated heart failure (ADHF) is decongestion by diuretic therapy. Empagliflozin has been shown to reduce the risk of hospitalization for heart failure in patients (pts) with type 2 diabetes mellitus (T2D) and cardiovascular disease. This may be explained by natriuresis and osmotic diuresis caused by empagliflozin, leading to plasma volume (PV) contraction and decongestion. However, little is known about the therapeutic effect of empagliflozin on decongestion and its association with renal function in T2D pts with ADHF.

Purpose

We sought to elucidate the effect of empagliflozin as add-on therapy on plasma B-type natriuretic peptide (BNP) level, hemoconcentration, PV contraction and renal function in T2D pts with ADHF.

Methods

We enrolled 38 consecutive T2D pts admitted for ADHF. On admission, enrolled pts were randomly assigned in a 1:1 ratio to either empagliflozin add-on therapy (EMPA(+)) or conventional glucose-lowering therapy (EMPA(−)). All pts in EMPA(+) group received empagliflozin (10mg/day) throughout the study period. Left ventricular ejection fraction (LVEF) was measured at baseline using echocardiography. Body weight and vital signs, such as blood pressure and heart rate, were measured, and blood and urine samples were collected at baseline and 1, 2, 3 and 7 days after randomization. Hemoconcentration was defined as a ≥3% absolute increase in hematocrit (Hct). Percent change in PV between admission and subsequent timepoints (%ΔPV) was calculated using the Strauss formula as follows: %ΔPV = ([(Hb1/Hb2) × ((100 − Hct2)/(100 − Hct1))] − 1) × 100 (%), where 1 = baseline values and 2 = subsequent values. Worsening renal function (WRF) was defined as an increase in serum creatinine ≥0.3 mg/dL above baseline within 7 days of randomization.

Results

Twenty pts were assigned to the EMPA(+) group, and 18 pts were assigned to the EMPA(−) group. There were no significant baseline differences in LVEF, plasma BNP level, Hct or serum creatinine level between the EMPA(+) and EMPA(−) groups. Seven days after randomization, plasma BNP level was significantly lower in the EMPA(+) group than in the EMPA(−) group (median 213 [IQR 116–360] pg/mL vs 362 [226–776] pg/mL, p=0.0437) and hemoconcentration was more frequently observed in the EMPA(+) group than in the EMPA(−) group (53% vs 12%, p=0.0105). The decrease in %ΔPV was larger in the EMPA(+) group than in the EMPA(−) group 2 days (−8.74±9.92% vs 1.14±14.71%, p=0.0228), 3 days (−11.28±10.65% vs −0.02±14.70%, p=0.0121) and 7 days after randomization (−10.62±14.89% vs 0.97±13.72%, p=0.0211). The incidence of WRF did not significantly differ between the EMPA(+) and EMPA(−) groups (15% vs 22%).

Conclusions

This study demonstrated that empagliflozin as add-on therapy can achieve effective decongestion without an increased risk of WRF in T2D pts with ADHF.

Utility of the laryngeal handshake method for identifying the cricothyroid membrane

BACKGROUND

The cricothyroid membrane is the most commonly accessed location for invasive surgical airway. Although the laryngeal handshake method is recommended for identifying the cricothyroid membrane, there is no clinical data regarding the utility of the laryngeal handshake method in cricothyroid membrane identification. The objective of this study was to compare the accuracy of cricothyroid membrane identification between the laryngeal handshake method and simple palpation.

METHODS

After anaesthesia induction, the otorhinolaryngology resident and anaesthesia resident identified and marked the needle insertion point for cricothyroidotomy using simple palpation and the laryngeal handshake method, respectively. The cricothyroid membrane was confirmed with ultrasonography. Identification was determined successful if the marked point was placed within the longitudinal area of the cricothyroid membrane and within 5 mm from midline transversely. The accuracy of cricothyroid membrane identification using the laryngeal handshake method and simple palpation was compared.

RESULTS

A total of 123 patients were enrolled. The cricothyroid membrane was correctly identified in 87 (70.7%, 95% confidence interval 61.8-78.6%) patients using the laryngeal handshake method compared to 78 (63.4%, 95% confidence interval 54.3-71.9%) patients using simple palpation (P = .188). The time required to identify the cricothyroid membrane was longer when using the laryngeal handshake method (15 [3-48] seconds vs 10.9 [3-55] seconds, P = .003).

CONCLUSION

The success rate of identifying the cricothyroid membrane was similar among the anesthesiologists who performed the laryngeal handshake method and also among otorhinolaryngologists who used simple palpation.

A high-resolution anorectal manometry parameter based on integrated pressurized volume: A study based on 204 male patients with constipation and 26 controls

BACKGROUND

Conventional anorectal manometric parameters based on linear waves cannot properly predict balloon expulsion (BE) time. We aimed to determine the correlation between integrated pressurized volume (IPV) parameters during simulated evacuation (SE) and BE time in healthy individuals and constipated patients and to assess the correlation between each parameter and symptoms.

METHODS

A total of 230 male participants (including 26 healthy volunteers and 204 chronically constipated patients) underwent high-resolution anorectal manometry (HRAM) and BE tests. The IPV was calculated by multiplying the amplitude, distance, and time from the HRAM profile. Receiver operating characteristic curve (ROC) analysis and partial least square regression (PLSR) were performed.

KEY RESULTS

ROC analysis indicated that the IPV ratio between the upper 1 cm and lower 4 cm of the anal canal was more effective for predicting BE time (area under the curve [AUC]: 0.74, 95% confidence interval [CI]: 0.67-0.80, P < .01) than the conventional anorectal parameters, including defecation index and rectoanal gradient (AUC: 0.60, 95% CI: 0.52-0.67, P = .01). PLSR analysis of a linear combination of IPV parameters yielded an AUC of 0.79. Moreover, the IPV ratio showed a greater clinical correlation with patient symptoms than conventional parameters.

CONCLUSIONS AND INFERENCES

The IPV parameters and the combination of IPV parameters via PLSR were more significantly correlated with BE time than the conventional parameters. Thus, this study presents a useful diagnostic tool for the evaluation of pathophysiologic abnormalities in dyssynergic defecation using IPV and BE time.