Miyuki Tsuchihashi-Makaya

Hyperuricemia predicts adverse outcomes in patients with heart failure.

BACKGROUND Hyperuricemia is associated with worse outcomes of patients with chronic heart failure (HF). However, it is unknown in an unselected HF patients encountered in routine clinical practice. We thus assessed the impact of hyperuricemia on long-term outcomes including mortality and rehospitalization among patients hospitalized with worsening HF. METHODS The Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD) studied prospectively the characteristics and treatments in a broad sample of hospitalized HF patients and the outcomes were followed for 2.1 years after discharge. Study cohorts (n=1869) were divided into 2 groups according to serum uric acid (UA) at discharge; ≥ 7.4 mg/dL (n=908) and <7.4 mg/dL (n=961). RESULTS Of the total cohort of HF patients, 56% had hyperuricemia defined as UA ≥ 7.0mg/dl. Patients with UA ≥ 7.4 mg/dL had higher rates of all-cause death, cardiac death, rehospitalization, and all-cause death or rehospitalization due to worsening HF. After multivariable adjustment, higher UA levels were a significant and independent predictor for all-cause death (adjusted hazard ratio [HR] 1.413, 95% confidence interval [CI] 1.094-1.824, P=0.008) and cardiac death (adjusted HR 1.399, 95% CI 1.020-1.920, P=0.037). CONCLUSIONS Hyperuricemia was common in patients with HF encountered in clinical practice and higher UA was independently associated with long-term adverse outcomes in these patients.

Clinical characteristics and outcomes of heart failure with preserved ejection fraction: Lessons from epidemiological studies

Recent epidemiological studies have demonstrated that nearly half of all patients with heart failure (HF) have preserved left ventricular ejection fraction (HFPEF). Compared to those with reduced EF, patients with HFPEF are older, more likely to be women, less likely to have coronary artery disease, and more likely to have hypertension and atrial fibrillation. Patients with HFPEF receive different pharmacological as well as nonpharmacological treatments from those with reduced EF. Morbidity and mortality in patients with HFPEF are largely similar to those with reduced EF. Although much information has recently been obtained about the clinical characteristics, medications, and outcomes of HFPEF by large-scale clinical and epidemiological studies, effective management strategies need to be established for this type of HF.

Spironolactone use at discharge was associated with improved survival in hospitalized patients with systolic heart failure

BACKGROUND The RALES trial demonstrated that spironolactone improved the prognosis of patients with heart failure (HF). However, it is unknown whether the discharge use of spironolactone is associated with better long-term outcomes among hospitalized systolic HF patients in routine clinical practice. We examined the effects of spironolactone use at discharge on mortality and rehospitalization by comparing with outcomes in patients who did not receive spironolactone. METHODS The JCARE-CARD studied prospectively the characteristics and treatments in a broad sample of patients hospitalized with worsening HF and the outcomes were followed with an average of 2.2 years of follow-up. RESULTS A total of 946 patients had HF with reduced left ventricular ejection fraction (LVEF) (<40%), among whom spironolactone was prescribed at discharge in 435 patients (46%), but not in 511 patients (54%). The mean age was 66.3 years and 72.2% were male. Etiology was ischemic in 39.7% and mean LVEF was 27.1%. After adjustment for covariates, discharge use of spironolactone was associated with a significant reduction in all-cause death (adjusted hazard ratio 0.612, P=.020) and cardiac death (adjusted hazard ratio 0.524, P=.013). CONCLUSIONS Among patients with HF hospitalized for systolic dysfunction, spironolactone use at the time of discharge was associated with long-term survival benefit. These findings provide further support for the idea that spironolactone may be useful in patients hospitalized with HF and reduced LVEF.

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

BACKGROUND The characteristics, in-hospital management, and outcomes of patients hospitalized with worsening heart failure (HF) have been described by large-scale registries performed mainly in the USA and Europe. However, little information is available in Japan. We thus clarified the characteristics and clinical status as well as in-hospital management and outcomes among patients hospitalized with worsening HF in Japan and compared them with those reported in previous studies. METHODS The Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD) studied prospectively the characteristics and treatments in patients hospitalized with worsening HF. From the total cohort of JCARE-CARD, 1677 patients were randomly selected and their detailed data during acute phase were collected as another registry database in the present study. The characteristics, in-hospital management, and outcomes were analyzed. RESULTS The mean age was 70.7 years and 59.4% were male. Etiology was ischemic in 34.0% and mean left ventricular ejection fraction was 42.5%. Carperitide was highly used as in-hospital management in Japan (33.5%) compared to the use of nesiritide in the USA (8-11%). The use of angiotensin-converting enzyme inhibitors was lower and angiotensin II receptor blockers (ARB) were more commonly used in this study compared to other studies in the USA and Europe. In-hospital crude mortality rate was comparable among studies (4-8%), however, length of stay was longer in Japan (15-20 versus 4-9 days). CONCLUSIONS The characteristics, clinical status, and laboratory data on admission in patients hospitalized with worsening HF were similar between the present study and previous Japanese and western studies. Management was also similar except for higher use of carperitide and ARB. The most striking difference between Japanese registries and those from the USA and Europe was the longer length of stay.

Health literacy is independently associated with self-care behavior in patients with heart failure

OBJECTIVE Health literacy (HL) has been recognized as an important concept in patient education and disease management for heart failure (HF). However, previous studies on HL have focused predominantly on the relationships between functional HL (the ability to read and write), comprehensive HL including the ability to access information (communicative HL), and the ability to critically evaluate information (critical HL). Self-care behavior has not been evaluated. This study determined the relationship between functional, communicative, and critical HL and self-care behavior in HF patients. METHODS Cross-sectional analysis of the data was completed for HL, HF-related knowledge, and HF-related self-care behaviors. Sociodemographic and clinical characteristics were also assessed. Multivariate linear regression analysis was used to estimate the associations between literacy and self-care behavior. RESULTS 249 patients with HF were assessed (mean age, 67.7±13.9years). Patients with low HL had poorer knowledge and self-care behavior than those with high HL. Critical HL was an independent determinant of self-care behavior (sβ=-0.154, P=0.027). CONCLUSIONS Critical HL was independently associated with self-care behavior in HF patients. PRACTICE IMPLICATIONS Effective intervention should be developed to improve patient skills for critically analyzing information and making decisions.

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

BACKGROUND AND PURPOSE Hyponatremia is common and is associated with poor in-hospital outcomes in patients hospitalized with heart failure (HF). However, it is unknown whether hyponatremia is associated with long-term adverse outcomes. The purpose of this study was to clarify the characteristics, clinical status on admission, and management during hospitalization according to the serum sodium concentration on admission, and determine whether hyponatremia was associated with in-hospital as well as long-term outcomes in 1677 patients hospitalized with worsening HF on index hospitalization registered in the database of the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD). METHODS AND SUBJECTS We studied the characteristics and in-hospital treatment in 1659 patients hospitalized with worsening HF by using the JCARE-CARD database. Patients were divided into 2 groups according to serum sodium concentration on admission <135mEq/mL (n=176; 10.6%) or ≥135mEq/mL (n=1483; 89.4%). RESULTS The mean age was 70.7 years and 59.2% were male. Etiology was ischemic in 33.9% and mean left ventricular ejection fraction was 42.4%. After adjustment for covariates, hyponatremia was independently associated with in-hospital death [adjusted odds ratio (OR) 2.453, 95% confidence interval (CI) 1.265-4.755, p=0.008]. It was significantly associated also with adverse long-term (mean 2.1±0.8 years) outcomes including all-cause death (OR 1.952, 95% CI 1.433-2.657), cardiac death (OR 2.053, 95% CI 1.413-2.983), and rehospitalization due to worsening HF (OR 1.488, 95% CI 1.134-1.953). CONCLUSIONS Hyponatremia was independently associated with not only in-hospital but also long-term adverse outcomes in patients hospitalized with worsening HF.

Discharge use of angiotensin receptor blockers provides comparable effects with angiotensin-converting enzyme inhibitors on outcomes in patients hospitalized for heart failure

Large-scale, placebo-controlled, randomized clinical trials have shown that angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) reduce mortality and hospitalization in patients with heart failure (HF) caused by left ventricular systolic dysfunction (LVSD). However, it is unknown whether ACE inhibitors and ARBs have similar effects on the long-term outcomes in HF patients encountered in routine clinical practice. The Japanese Cardiac Registry of Heart Failure in Cardiology enrolled HF patients hospitalized with worsening symptoms and they were followed during an average of 2.2 years. The outcome data were compared in patients with LVSD by echocardiography (ejection fraction, EF <40%) according to the predischarge use of ACE inhibitors (n=356) or ARBs (n=372). The clinical characteristics were similar between patients with ACE inhibitor and ARB use, except for higher prevalence of hypertensive etiology and diabetes mellitus. There was no significant difference between ACE inhibitor and ARB use in all-cause death (adjusted hazard ratio 0.958, 95% confidence interval 0.601–1.527, P=0.858) and rehospitalization (adjusted hazard ratio 0.964, 95% confidence interval 0.683–1.362, P=0.836). The effects of ACE inhibitor and ARB use on the outcomes were generally consistent across all clinically relevant subgroups examined, including age, sex, etiology, EF, hypertension, diabetes mellitus, and β-blocker use. Discharge use of ARBs provided comparable effects with ACE inhibitors on outcomes in patients hospitalized for HF. These findings provide further support for guideline recommendations that ARBs can be used in patients with HF and LVSD as an alternative of ACE inhibitors.

Weekend versus weekday hospital admission and outcomes during hospitalization for patients due to worsening heart failure: a report from Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD)

The day of the week of admission may influence the length of stay and in-hospital death. However, the association between the admission day of the week and in-hospital outcomes has been inconsistent in heart failure (HF) patients among studies reported from Western countries. We thus analyzed this association in HF patients encountered in routine clinical practice in Japan. We studied the characteristics and in-hospital treatment in 1620 patients hospitalized with worsening HF by using the database of the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD). Patients were divided into two groups according to weekday (n = 1355; 83.6 %) or weekend admission (n = 265; 16.4 %). The mean age was 70.7 years and 59.4 % were male. Etiology was ischemic in 34.0 %, and mean left ventricular ejection fraction was 42.5 %. Patients admitted on the weekend were significantly older and had more comorbidities, and more severe symptoms and signs of HF on admission. Length of stay was comparable between weekend and weekday admission (35.2 ± 47.0 days vs 33.6 ± 32.0 days, P = 0.591). Crude in-hospital mortality did not differ between patients admitted on the weekend and weekdays (7.5 % vs 5.2 %, P = 0.136). Even after adjustment for covariates in multivariable modeling with patients admitted on weekday as the reference, in-hospital death was comparable between patients admitted on the weekend and weekdays (adjusted odds ratio 1.125, 95 % confidence interval 0.631–2.004, P = 0.691). Among patients hospitalized for worsening HF, admission day of the week did not affect in-hospital death and length of stay.

Sex differences with respect to clinical characteristics, treatment, and long-term outcomes in patients with heart failure

The effect of sex on the etiology, risk factors, comorbidities, treatment and prognosis in patients with heart failure (HF) encountered in routine clinical practice in Asian populations has not been well described. The objective of the present study was to elucidate sex differences with respect to the clinical characteristics, treatment, and prognosis of HF patients treated in routine clinical practice settings using the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD) database, which is a nationwide registry for hospitalized patients with HF in Japan. JCARE-CARD enrolled 2675 patients hospitalized for HF at 164 participating hospitals from January 2005 to June 2006. HF was diagnosed by the simultaneous presence of at least two major criteria or onemajor criterion in conjunctionwith twominor criteria by use of the criteria from the Framingham Heart Study [1]. For each patient, baseline data recorded on the form were: demography; HF causes; comorbidities; complications; clinical status; echocardiographic findings; plasma B-type natriuretic peptide (BNP); and treatments. Longterm follow-up data could be obtained from 2305 patients after hospital discharged. Mean post-discharge follow-up was 2.3±0.7 years.

Development and Validation of a Heart Failure-Specific Health Literacy Scale.

Background:Health literacy (HL) is an important concept for patient education and disease management with heart failure (HF). However, research on HL has predominantly focused on functional HL (ability to read and write). The World Health Organization advocates evaluating comprehensive HL, including the ability to access information (communicative HL) and critically evaluate that information (critical HL). Objective:We developed an instrument for measuring functional, communicative, and critical levels of HL in patients with HF. Methods:We evaluated the reliability and validity of those 3 HL scales in a sample of 191 outpatients with HF (mean [SD] age, 66.9 [13.9] years; 64.9% males). Sociodemographic and clinical characteristics, knowledge of HF, a well as motivation to obtain health information were assessed for each patient through a self-administered questionnaire and review of electronic medical records. Results:We constructed scale items to reflect directly the comprehensive World Health Organization definition of HL. We identified 3 interpretable factors by exploratory factor analysis. Internal consistency was marginally acceptable for total HL (Cronbach &agr; = 0.71), functional HL (&agr; = 0.73), communicative HL (&agr; = 0.68), and critical HL (&agr; = 0.69); the interclass correlation coefficients of the functional, communicative, and critical HL subscales were 0.882, 0.898, and 0.882, respectively. Low functional, communicative, and critical HL was characteristic of older patients, those with lower socioeconomic status, patients living alone, those without a high school education, and patients lacking HF knowledge. Conclusions:Our new HL scale was demonstrated to be a reliable, valid instrument for measuring functional, communicative, and critical HL in patients with HF. Exploring a patient’s HL level, including the ability to access, understand, and use health information as well as the ability to read and write, may provide better understanding of patients’ potential barriers to self-care.