Toshiyuki Nagai

Elevated Plasma D-Dimer Level Is Associated With Short-Term Risk of Ischemic Stroke in Patients With Acute Heart Failure

Background and Purpose— The incidence of heart failure increases the subsequent risk of ischemic stroke, and its risk could be higher in the short-term period after an acute heart failure (AHF) event. However, its determinants remain to be clarified. Plasma D-dimer level reflects fibrin turnover and exhibits unique properties as a biomarker of thrombosis. The aim of this study is to investigate whether D-dimer level is a determinant of short-term incidence of ischemic stroke in patients with AHF. Methods— We examined 721 consecutive hospitalized AHF patients with plasma D-dimer level on admission from our prospective registry between January 2013 and May 2016. The study end points were incidence of ischemic stroke during hospitalization and at 30 days after admission. Results— Of the total participants (mean age, 76 years; male, 60%; atrial fibrillation, 54%; mean left ventricular ejection fraction, 38%), in-hospital ischemic stroke occurred in 18 patients (2.5%) during a median hospitalization period of 21 days, and 30-day ischemic stroke occurred in 16 patients (2.2%). Higher D-dimer level on admission was an independent determinant of subsequent risk of in-hospital ischemic stroke even after adjustment by CHA2DS2-VASc score (odds ratio, 2.29; 95% confidence interval, 1.46–3.60; P<0.001) or major confounders, including age, atrial fibrillation, and antithrombotic therapy (odds ratio, 2.31; 95% confidence interval, 1.43–3.74; P<0.001). Subgroup analyses showed consistent findings in patients without atrial fibrillation (odds ratio, 2.46; 95% confidence interval, 1.39–4.54; P=0.002) and those without antithrombotic therapy (odds ratio, 2.79; 95% confidence interval, 1.53–5.57; P<0.001). Similar results were obtained for 30-day ischemic stroke as an alternative outcome. Conclusions— Elevated plasma D-dimer level on admission was significantly associated with increased incidence of ischemic stroke shortly after admission for AHF, suggesting a predictive role of D-dimer for short-term ischemic stroke events in patients with AHF. Clinical Trial Registration— URL: https://www.umin.ac.jp/ctr/index.htm. Unique identifier: UMIN000017024.

Mortality after admission for heart failure in the UK compared with Japan

Objective Mortality amongst patients hospitalised for heart failure (HHF) in Western and Asian countries may differ, but this has not been investigated using individual patient-level data (IPLD). We sought to remedy this through rigorous statistical analysis of HHF registries and variable selection from a systematic literature review. Methods and results IPLD from registries of HHF in Japan (n=3781) and the UK (n=894) were obtained. A systematic literature review identified 23 models for predicting outcome of HHF. Five variables appearing in 10 or more reports were strongly related to prognosis (systolic blood pressure, serum sodium concentration, age, blood urea nitrogen and creatinine). To compare mortality in the UK and Japan, variables were imputed in a propensity model using inverse probability of treatment weighting (IPTW) and IPTW with logistic regression (doubly robust IPTW). Overall, patients in the UK were sicker and in-patient and post-discharge mortalities were greater, suggesting that the threshold for hospital admission was higher. Covariate-adjusted in-hospital mortality was similar in the UK and Japan (IPTW OR: 1.14, 95%u2009CI 0.70 to 1.86), but 180-day postdischarge mortality was substantially higher in the UK (doubly robust IPTW OR: 2.33, 95%u2009CI 1.58 to 3.43). Conclusions Despite robust methods to adjust for differences in patient characteristics and disease severity, HHF patients in the UK have roughly twice the mortality at 180 days compared with those in Japan. Similar analyses should be done using other data sets and in other countries to determine the consistency of these findings and identify factors that might inform healthcare policy and improve outcomes.

A case of medical management of tricuspid regurgitation related to atrial fibrillation with constrictive pericarditis-like hemodynamics

Severe tricuspid regurgitation (TR) is reported to represent a hemodynamic pattern similar to that of constrictive pericarditis (CP), which should be clearly differentiated for appropriate management. We report the case of a patient with severe TR due to atrial fibrillation (AF) in whom hemodynamic monitoring played a role in the selection of the management strategy. An 81-year-old Japanese man with chronic AF was admitted due to worsening heart failure. Echocardiography showed the dilation of bilateral atria and a right ventricle with severe TR. The right heart catheterization demonstrated the elevation and equalization of diastolic pressures of four cardiac chambers with impaired diastolic filling pattern, which are hallmarks of pericardial constriction due to CP. Of note, the CP-like hemodynamics were completely normalized by 10xa0days of medical therapies including diuretics and carperitide. After his discharge and over a 1-year follow-up, he has never experienced worsening heart failure and remained NYHA class II with moderate TR. Medical management targeted at volume reduction and vasodilation can be a therapeutic option for CP-like hemodynamics in isolated severe TR related to AF. Repeated hemodynamic assessment is an appropriate tool to help our understanding of the CP-like physiology caused by severe TR based on chronic AF. <Learning objective: Atrial fibrillation (AF)-related severe tricuspid regurgitation (TR) is sometimes reported to hemodynamically mimic constrictive pericarditis. However, it has never been described whether such a hemodynamics could be reversed by medical treatment alone. Repeated pressure monitoring may be helpful to obtain important clues for the diagnosis and the therapeutic strategy in pericardial constraint due to AF-related TR.>.

Validation and Recalibration of Seattle Heart Failure Model in Japanese Acute Heart Failure Patients

BACKGROUNDnPrecise risk stratification in heart failure (HF) patients enables clinicians to tailor the intensity of their management. The Seattle Heart Failure Model (SHFM), which uses conventional clinical variables for its prediction, is widely used. We aimed to externally validate SHFM in Japanese HF patients with a recent episode of acute decompensation requiring hospital admission.nnnMETHODS AND RESULTSnSHFM was applied to 2470 HF patients registered in the West Tokyo Heart Failure and National Cerebral And Cardiovascular Center Acute Decompensated Heart Failure databases from 2006 to 2016. Discrimination and calibration were assessed with the use of the c-statistic and calibration plots, respectively, in HF patients with reduced ejection fraction (HFrEF; <40%) and preserved ejection fraction (HFpEF; ≥40%). In a perfectly calibrated model, the slope and intercept would be 1.0 and 0.0, respectively. The method of intercept recalibration was used to update the model. The registered patients (mean age 74 ± 13 y) were predominantly men (62%). Overall, 572 patients (23.2%) died during a mean follow-up of 2.1years. Among HFrEF patients, SHFM showed good discrimination (c-statisticu202f=u202f0.75) but miscalibration, tending to overestimate 1-year survival (slopeu202f=u202f0.78; interceptu202f=u202f-0.22). Among HFpEF patients, SHFM showed modest discrimination (c-statisticu202f=u202f0.69) and calibration, tending to underestimate 1-year survival (slopeu202f=u202f1.18; interceptu202f=u202f0.16). Intercept recalibration (replacing the baseline survival function) successfully updated the model for HFrEF (slopeu202f=u202f1.03; interceptu202f=u202f-0.04) but not for HFpEF patients.nnnCONCLUSIONSnIn Japanese acute HF patients, SHFM showed adequate performance after recalibration among HFrEF patients. Using prediction models to tailor the care for HF patients may improve the allocation of medical resources.

Validation of U.S. mortality prediction models for hospitalized heart failure in the United Kingdom and Japan

Prognostic models for hospitalized heart failure (HHF) were developed predominantly for patients of European origin in the United States of America; it is unclear whether they perform similarly in other health care systems or for different ethnicities. We sought to validate published prediction models for HHF in the United Kingdom (UK) and Japan.

Impact of left ventricular systolic diameter on the in-hospital improvement of systolic function in acute decompensated heart failure with high blood pressure presentation

Purpose: In-hospital improvement of left ventricular (LV) systolic function is frequently observed in acute decompensated heart failure (ADHF) patients presented with high systolic blood pressure (SBP) on admission. However, determinants of improved LV systolic function in patients with ADHF remain unclear.nnMethods: We examined 214 consecutive patients admitted by ADHF with SBP > 140 mmHg, impaired LV systolic function, defined as LV ejection fraction (EF) < 50% or fractional shortning < 26%, but no acute coronary syndrome. Patients were divided into 2 groups according to the presence or absence of improved LV systolic function, defined as normalized predischarge LV systolic function.nnResults: Improved LV systolic function was observed in 54 patients and length of hospital stay was comparable between two groups. Patients with improved LV systolic function had lower BNP level, smaller LV systolic and diastolic diameters at admission, higher baseline and % increase of LV systolic function than those without. ROC curves showed that smaller LV systolic diameter (LVSD) at admission was superior to other variables for predicting improved LV systolic function (AUC: 0.80) (Figure). Multivariate logistic regression analysis showed that smaller LVSD (<46mm) was the strongest independent determinant for improvement of LV systolic function (OR: 6.51, 95% CI: 1.60-26.34, p=0.0086) among variables including lower BNP level (OR: 2.09, 95% CI: 1.01-4.30), no history of coronary artery disease (OR: 2.37, 95% CI: 1.12-5.01), and LV diastolic diameter at admission (p = 0.98).nn![Figure][1] nnFigure 1nnnnnnConclusions: Smaller LVSD at admission was the strongest determinant for in-hospital improvement of LV systolic function in patients with ADHF with high blood pressure and impaired LV systolic function.nn [1]: pending:yes