Kuniya Asai

Acute decompensated heart failure syndromes (ATTEND) registry. A prospective observational multicenter cohort study: Rationale, design, and preliminary data

Acute heart failure syndromes (AHFS) are likely to increase in the future, and the high readmission rate of patients with AHFS is an important issue in Western countries. However, there are very few published epidemiological studies on AHFS in the Asia Pacific region. Because AHFS are heterogeneous, the characteristics, clinical profile, and management of AHFS should be clarified in an epidemiological study. The acute decompensated heart failure syndromes (ATTEND) registry is a prospective, observational, multicenter cohort study being performed in Japan and is the first epidemiological study of AHFS in the Asia Pacific region. This study is designed to investigate several aspects of AHFS as follows: (1) the registry allows patient-based data collection for precise evaluation of patient characteristics and short-term outcomes, including the readmission rate; (2) confirmation of clinical assessments can be performed, and new clinical assessments can be created; and (3) feedback allows the modification of guidelines for clinical management. The present report describes the clinical characteristics of patients with AHFS in Japan based on the preliminary data collected in this study, and the similarities and differences in characteristics of these patients compared with those in Western countries. Although most of the patient characteristics did not differ from those reported in Western studies, there are some unique findings in this study, including a high rate of treatment with carperitide (69.4%) and angiotensin II receptor blockers (53.9%) at discharge and a longer hospital stay (median 21 days). The ATTEND registry is designed to provide valuable information to clarify the characteristics of patients with AHFS to improve their management.

Hyponatremia and In-Hospital Mortality in Patients Admitted for Heart Failure (from the ATTEND Registry)

Hyponatremia is known to be a poor prognostic factor in patients hospitalized with heart failure (HF), however not well studied in Japan. The aims of this study were to characterize hyponatremic hospitalized patients with HF and to clarify the relations between hyponatremia and detailed in-hospital outcomes in Japan. Among 4,837 hospitalized patients with HF enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, patient characteristics and in-hospital mortality in those with hyponatremia were examined. Hyponatremia (sodium <135 mEq/L) was observed in 11.6% of patients. Patients with hyponatremia were of similar age, included fewer men, and had a higher proportion of previous hospitalizations for HF compared to those with normonatremia. On admission, lower heart rates and blood pressures and higher brain natriuretic peptide levels were observed in patients with hyponatremia. During hospitalization, inotrope levels and mechanical device use were significantly higher in patients with hyponatremia. Rates of all-cause and cardiac death were significantly higher in patients with hyponatremia, 15.0% and 11.4%, respectively, compared to 5.3% and 3.6%, respectively, in those with normonatremia. In hyponatremic hospitalized patients with HF, cardiac death accounted for 76.2% of all-cause death. In conclusion, the present study demonstrates that in Japan hyponatremia in patients hospitalized with HF is relatively common and is associated with a very high in-hospital mortality.

Impact of sleep-disordered breathing and efficacy of positive airway pressure on mortality in patients with chronic heart failure and sleep-disordered breathing: a meta-analysis.

BackgroundsTo conduct a meta-analysis to investigate whether sleep-disordered breathing (SDB) is an independent risk factor for mortality and whether positive airway pressure (PAP) decreases mortality in patients with chronic heart failure (HF). The impact of SDB and the effects of PAP on mortality in patients with chronic HF remain unclear.MethodsWe searched the MEDLINE, EMBASE, and Cochrane databases. Clinical trials that addressed mortality and the effect of PAP on mortality in chronic HF patients with SDB were included in this meta-analysis.ResultsEleven studies (1,944 participants in total) that addressed mortality in chronic HF patients with SDB were included in this study. Patients with SDB showed a significantly increased mortality risk compared to those without SDB [risk ratio (RR) 1.66 (1.19–2.31)]. In sub-analyses, a significant increase in risk of mortality was observed for central sleep apnea versus no-SDB [RR 1.48 (1.15–1.91)], whereas no significant increase in risk was observed for obstructive sleep apnea versus no-SDB. Five randomized controlled studies (395 participants) that assessed the effect of PAP in chronic HF patients with SDB were analyzed. Adaptive servo-ventilation (ASV) significantly reduced all-cause mortality in chronic HF patients with SDB [RR 0.13 (0.02–0.95)], whereas continuous PAP did not significantly reduce all-cause mortality [RR 0.71 (0.32–1.57)].ConclusionsThe prevalence of SDB in patients with chronic HF is associated with worse survival, and ASV reduces all-cause mortality in patients with chronic HF concomitant with SDB.

Impact of the efficacy of thrombolytic therapy on the mortality of patients with acute submassive pulmonary embolism: a meta-analysis

The efficacy of thrombolytic therapy in patients with submassive pulmonary embolism (PE) remains unclear. Previous meta‐analyses have not separately reported the proportion of patients with submassive PE.

Association between length of stay, frequency of in-hospital death, and causes of death in Japanese patients with acute heart failure syndromes.

in Japanese patients with acute heart failure syndromes☆ Katsuya Kajimoto ⁎, Naoki Sato , Takehiko Keida , Masayuki Mizuno , Yasushi Sakata , Kuniya Asai , Teruo Takano f and on behalf of the investigators of the Acute Decompensated Heart Failure Syndromes (ATTEND) registry a Division of Cardiology, Sensoji Hospital, Tokyo, Japan b Internal Medicine, Cardiology, and Intensive Care Unit, Nippon Medical School Musashi-Kosugi Hospital, Kanagawa, Japan c Department of Cardiovascular Medicine, Edogawa Hospital, Tokyo, Japan d Department of Cardiology, Tokyo Womens Medical University, Tokyo, Japan e Department of Cardiology, Osaka University Graduate School of Medicine, Osaka, Japan f Department of Internal Medicine, Nippon Medical School, Tokyo, Japan

The prognostic impact of uric acid in patients with severely decompensated acute heart failure

BACKGROUNDnThe serum level of uric acid (UA) is a well-known prognostic factor for heart failure (HF) patients. However, the prognostic impact of hyperuricemia and the factors that induce hyperuricemia in acute HF (AHF) patients are not well understood.nnnMETHODS AND RESULTSnEight hundred eighty-nine AHF patients were enrolled in this study. The patients were assigned into a low UA group (UA≤7.0mg/dl, n=495) or a high UA group (UA>7.0mg/dl, n=394) according to their UA level on admission. A Kaplan-Meier curve showed that the survival rate of the low UA group was significantly higher than that of the high UA group. A multivariate Cox regression model identified that a high UA level (HR: 1.192, 95%CI 1.112-1.277) was an independent predictor of 180-day mortality. A multivariate logistic regression model for a high serum UA level on admission indicated that chronic kidney disease (CKD) (OR: 2.030, 95%CI: 1.298-3.176, p=0.002) and the administration of loop diuretics before admission (OR: 1.556, 95%CI: 1.010-2.397, p=0.045) were independent factors. The prognosis, including all-cause death and HF events, was significantly poorer among patients who had a high UA level who had previously used loop diuretics and among CKD patients with a high UA level than among other patients.nnnCONCLUSIONSnThe serum UA level was an independent predictor in patients who were hospitalized during an emergent situation for AHF. An elevated serum UA level on admission was associated with the presence of CKD and the use of loop diuretics. These factors were also associated with adverse outcomes in hyperuricemic patients with AHF.

Elevated peripheral blood mononuclear cell count is an independent predictor of left ventricular remodeling in patients with acute myocardial infarction

OBJECTIVESnPeripheral blood mononuclear cells (PBMCs) increase after acute myocardial infarction (AMI) and infiltrate to the infarct region. However, its impact on left ventricular (LV) remodeling remains unclear. The purpose of the present study was to clarify whether elevated PBMC count contributed to LV remodeling in patients with AMI.nnnSUBJECTS AND METHODSnA total of 131 patients with AMI were recruited. White blood cell (WBC), monocyte, and lymphocyte counts were measured at presentation and every 24h for five days after presentation. The correlation between PBMC count and LV remodeling was evaluated. LV remodeling was defined as an increase of LV end-diastolic volume index ≥ 10% at the 6-month follow-up left ventriculography.nnnRESULTSnForty-eight patients had LV remodeling. Peak WBC (p=0.008), peak monocyte (p=0.001), and peak PBMC (p<0.001) counts were significantly greater in patients with LV remodeling than those without remodeling. Multivariate analysis revealed the peak PBMC count ≥ 3600/mm(3) was an independent predictor of LV remodeling [relative risk (RR) 3.243, p=0.011].nnnCONCLUSIONnIncreased PBMC count is significantly correlated with LV remodeling, thus suggesting that PBMCs play a pivotal role for the development of LV remodeling after AMI.

Autophagic vacuoles in cardiomyocytes of dilated cardiomyopathy with initially decompensated heart failure predict improved prognosis

ABSTRACT Autophagy is a process of bulk protein degradation and organelle turnover, and is a current therapeutic target in several diseases. The present study aimed to clarify the significance of myocardial autophagy of patients with dilated cardiomyopathy (DCM). Left ventricular endomyocardial biopsy was performed in 250 consecutive patients with DCM (54.9±13.9 years; male, 79%), initially presenting with decompensated heart failure (HF). The association of these findings with HF mortality or recurrence was examined. Myofilament changes, which are apparent in the degenerated cardiomyocytes of DCM, were recognized in 164 patients (66%), and autophagic vacuoles in cardiomyocytes were identified in or near the area of myofilament changes in 86 patients (34%). Morphometrically, fibrosis (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.93 to 0.99) and mitochondrial abnormality (OR, 2.24; 95% CI, 1.23 to 4.08) were independently related with autophagic vacuoles. During the follow-up period of 4.9±3.9 y, 24 patients (10%) died, including 10 (4%) who died of HF, and 67 (27%) were readmitted for HF recurrence. Multivariate analysis identified a family history of DCM (hazard ratio [HR], 2.117; 95% CI, 1.199 to 3.738), hemoglobin level (HR, 0.845; 95% CI, 0.749 to 0.953), myofilament changes (HR, 13.525; 95% CI, 5.340 to 34.255), and autophagic vacuoles (HR, 0.214; 95% CI, 0.114 to 0.400) as independent predictors of death or readmission due to HF recurrence. In conclusion, autophagic vacuoles in cardiomyocytes are associated with a better HF prognosis in patients with DCM, suggesting autophagy may play a role in the prevention of myocardial degeneration.

Ultrastructural features of cardiomyocytes in dilated cardiomyopathy with initially decompensated heart failure as a predictor of prognosis

AIMSnThe aim of the present study was to clarify the significance of myocardial ultrastructural changes in patients with dilated cardiomyopathy (DCM).nnnMETHODS AND RESULTSnEndomyocardial biopsy of the left ventricle was performed in 250 consecutive DCM patients (54.9 ± 13.9 years, 79% men), presenting initially as decompensated heart failure (HF). Myofilament changes of cardiomyocytes were evaluated by electron microscopy and compared with clinical and morphometric data. Mortality and HF recurrence were evaluated during the follow-up period. During the follow-up period (4.9 ± 3.9 years), 24 patients (10%) died and 67 (27%) were readmitted because of HF recurrence, including those who had died because of HF. Myofilament changes, classified as either focal derangement of myofilaments (sarcomere damage) or diffuse myofilament lysis (disappearance of most sarcomeres in cardiomyocytes), were identified in 164 patients (66%). Multivariate analysis identified a family history of DCM [hazard ratio (HR) 4.763; 95% confidence interval (CI) 1.012-12.518], atrial fibrillation (HR 6.132; 95% CI 2.188-17.180), haemoglobin level (HR 0.685; 95% CI 0.528-0.889), and diffuse myofilament lysis (HR 4.048; 95% CI 1.427-11.481) as independent predictors of mortality. A family history of DCM (HR 2.268; 95% CI 1.276-4.030), haemoglobin level (HR 0.876; 95% CI 0.785-0.979), focal derangement of myofilaments (HR 7.431; 95% CI 2.916-18.934), and diffuse myofilament lysis (HR 6.480; 95% CI 2.403-17.473) were predictors of readmission due to HF recurrence.nnnCONCLUSIONSnIn DCM patients with first-decompensated HF, myofilament changes are strongly associated with mortality and HF recurrence.

New scoring system (APACHE-HF) for predicting adverse outcomes in patients with acute heart failure: Evaluation of the APACHE II and Modified APACHE II scoring systems

BACKGROUNDnNo scoring system for assessing acute heart failure (AHF) has been reported.nnnMETHODS AND RESULTSnData for 824 AHF patients were analyzed. The subjects were divided into an alive (n=750) and a dead group (n=74). We constructed a predictive scoring system based on eight significant APACHE II factors in the alive group [mean arterial pressure (MAP), pulse, sodium, potassium, hematocrit, creatinine, age, and Glasgow Coma Scale (GCS); giving each one point], defined as the APACHE-HF score. The patients were assigned to five groups by the APACHE-HF score [Group 1: point 0 (n=70), Group 2: points 1 and 2 (n=343), Group 3: points 3 and 4 (n=294), Group 4: points 5 and 6 (n=106), and Group 5: points 7 and 8 (n=11)]. A higher optimal balance was observed in the APACHE-HF between sensitivity and specificity [87.8%, 63.9%; area under the curve (AUC)=0.779] at 2.5 points than in the APACHE II (47.3%, 67.3%; AUC=0.558) at 17.5 points. The multivariate Cox regression model identified belonging to Group 5 [hazard ratio (HR): 7.764, 95% confidence interval (CI) 1.586-38.009], Group 4 (HR: 6.903, 95%CI 1.940-24.568) or Group 3 (HR: 5.335, 95%CI 1.582-17.994) to be an independent predictor of 3-year mortality. The Kaplan-Meier curves revealed a poorer prognosis, including all-cause death and HF events (death, readmission-HF), in Group 5 and Group 4 than in the other groups, in Group 3 than in Group 2 or Group 1, and in Group 2 than in Group 1.nnnCONCLUSIONSnThe new scoring system including MAP, pulse, sodium, potassium, hematocrit, creatinine, age, and GCS (APACHE-HF) can be used to predict adverse outcomes of AHF.