Yuya Matsue

Pharmacist-led intervention in the multidisciplinary team approach optimizes heart failure medication

We evaluated the impact of pharmacist-led heart failure (HF) drug recommendations during hospitalization for hospitalized patients with HF. Hospitalized patients with HF were retrospectively reviewed. Patients were hospitalized before (nxa0=xa0208, non-intervention group) or after (nxa0=xa0170, intervention group) the launch of the HF multidisciplinary team (HFMDT) approach with pharmacist-led HF medication optimization. There were no significant group differences in patient background characteristics at admission. Patients with HF with reduced ejection fraction who were not on beta blockers or angiotensin-converting enzyme inhibitor/angiotensin receptor blockers (ACE-I/ARB) at admission were significantly more likely to be on beta blockers at the time of discharge in the intervention group (73.3 vs 96.3%, Pxa0=xa00.027) compared to those in non-intervention group; however, the change in ACE-I/ARB prescriptions was not significant (53.3 vs 63.3%, Pxa0=xa00.601). The proportion of patients on any drug with recommendations against its use in patients with HF did not change from admission to discharge in the non-intervention group (21.2 vs. 20.2%, Pxa0=xa00.855), but was significantly reduced in the intervention group (22.9 vs. 12.9%, Pxa0=xa00.005). There were no group differences in the in-hospital all-cause mortality (non-intervention, 3.4%; intervention, 2.4%; Pxa0=xa00.761) or length of hospital stay (median: non-intervention, 13xa0days; intervention, 14xa0days; Pxa0=xa00.508). Pharmacist-led HF drug recommendations during hospitalization as part of a HFMDT approach for hospitalized patients with HF can increase beta blocker prescriptions and decrease non-preferred drug prescriptions.

Relationship between blood urea nitrogen-to-creatinine ratio at hospital admission and long-term mortality in patients with acute decompensated heart failure

Although elevated blood urea nitrogen (BUN)-to-creatinine (BUN/Cr) ratio at hospital admission has been reported to be associated with poor short-term prognosis, its association to long-term mortality in patients with acute decompensated heart failure (ADHF) remains to be elucidated. Moreover, an additive prognostic value to preexisting renal markers including creatinine and BUN has not been well described. A cohort of 557 consecutive ADHF patients admitted to the cardiac intensive care unit was studied. All cohorts were divided into high and low BUN/Cr ratios according to the median value of BUN/Cr ratio at admission. Association between admission BUN/Cr ratio and long-term all-cause mortality was assessed. There were 145 deaths (27%) observed during the follow-up period of 1.9xa0years in median. Patients with high BUN/Cr ratio showed with higher mortality compared to low BUN/Cr ratio (log-rank: Pxa0=xa00.006). In the multivariable analysis, patients with high BUN/Cr ratio at admission were associated with high mortality independently from other covariates including BUN and creatinine (HR 1.81, 95% CI 1.16–2.80, Pxa0=xa00.009). In patients with ADHF, there is a relationship between admission BUN-to-creatinine ratio and long-term mortality.

Arterial inflammation measured by 18 F-FDG-PET-CT to predict coronary events in older subjects

BACKGROUND AND AIMSnAlthough 18F-fluorodeoxyglucose (FDG) uptake has emerged as a sensitive and reliable marker of atherosclerotic inflammation, its additive predictive value for future coronary disease in older subjects is unknown. The aim of this study was to test the prognostic value of aortic inflammation detected via FDG-positron emission tomography (PET)-computed tomography (CT) in older subjects.nnnMETHODSnWe retrospectively utilized the records of 309 subjects aged over 65 years, without a history of coronary artery disease, who underwent 18F-FDG-PET-CT mostly due to the clinical suspicion of cancer, but eventually turned out to be cancer-free. Target-to-background ratio (TBR) was calculated at the ascending aorta. The endpoint was occurrence of coronary heart disease (CHD) events.nnnRESULTSnDuring a median follow-up of 3.9 years, 28 subjects experienced CHD events and 12 patients died due to non-CHD causes. The highest TBR tertile was associated with a high CHD event rate, accounting for death due to non-CHD causes as a competing risk (Gray test, pxa0=xa00.005). In a Fine and Gray competing risk proportional hazard regression model, TBR was associated with significantly high CHD events independently of FRS, with a hazard ratio (HR) of 1.19 per 0.1 TBR increase (pxa0<xa00.001). Likewise, a significant increase in the area under the curve (from 0.57 to 0.73, pxa0=xa00.028) and a significant improvement in net reclassification (0.42, pxa0=xa00.038) were observed when TBR was added to the model with FRS alone.nnnCONCLUSIONSnIn older subjects with no history of malignant disease or overt coronary artery disease, arterial inflammation evaluated by FDG uptake provides information on future occurrence of coronary artery events.

Effect of Optimizing Guideline-Directed Medical Therapy Before Discharge on Mortality and Heart Failure Readmission in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction

Guideline-directed medical therapy (GDMT) is recommended for patients with heart failure with reduced ejection fraction (HFrEF). However, the prognostic impact of medication optimization at the time of discharge in patients hospitalized with heart failure (HF) is unclear. We analyzed 534 patients (73u2009±u200913 years old) with HFrEF. The status of GDMT at the time of discharge (prescription of angiotensin converting enzyme inhibitor [ACE-I]/angiotensin receptor blocker [ARB] and β blocker [BB]) and its association with 1-year all-cause mortality and HF readmission were investigated. Patients were divided into 3 groups: those treated with both ACE-I/ARB and BB (Both group: nu2009=u2009332, 62%), either ACE-I/ARB or BB (Either group: nu2009=u2009169, 32%), and neither ACE-I/ARB nor BB (None group: nu2009=u200933, 6%), respectively. One-year mortality, but not 1-year HF readmission rate, was significantly different in the 3 groups, in favor of the Either and Both groups. A favorable impact of being on GDMT at the time of discharge on 1-year mortality was retained even after adjustment for covariates (Either group: hazard ratio [HR] 0.44, 95% confidence interval [CI] 0.21 to 0.90, pu2009=u20090.025 and Both group: HR 0.29, 95% CI 0.13-0.65, pu2009=u20090.002, vs None group). For 1-year HF readmission, no such association was found. In conclusion, optimization of GDMT before the time of discharge was associated with a lower 1-year mortality, but not with HF readmission rate, in patients hospitalized with HFrEF.

Impact of early treatment with intravenous vasodilators and blood pressure reduction in acute heart failure

Objective Although vasodilators are used in acute heart failure (AHF) management, there have been no clear supportive evidence regarding their routine use. Recent European guidelines recommend systolic blood pressure (SBP) reduction in the range of 25% during the first few hours after diagnosis. This study aimed to examine clinical and prognostic significance of early treatment with intravenous vasodilators in relation to their subsequent SBP reduction in hospitalised AHF. Methods We performed post hoc analysis of 1670 consecutive patients enrolled in the Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure. Intravenous vasodilator use within 6u2009hours of hospital arrival and subsequent SBP changes were analysed. Outcomes were gauged by 1-year mortality and diuretic response (DR), defined as total urine output 6u2009hours posthospital arrival per 40u2009mg furosemide-equivalent diuretic use. Results Over half of the patients (56.0%) were treated with intravenous vasodilators within the first 6u2009hours. In this vasodilator-treated cohort, 554 (59.3%) experienced SBP reduction ≤25%, while 381 (40.7%) experienced SBP reduction >25%. In patients experiencing ≤25%u2009drop in SBP, use of vasodilator was associated with greater DR compared with no vasodilators (p<0.001). Moreover, vasodilator treatment with ≤25%u2009drop in SBP was independently associated with lower all-cause mortality compared with those treated without vasodilators (adjusted HR 0.74, 95% CI 0.57 to 0.96, p=0.028). Conclusions Intravenous vasodilator therapy was associated with greater DR and lower mortality, provided SBP reduction was less than 25%. Our results highlight the importance in early administration of intravenous vasodilators without causing excess SBP reduction in AHF management. Clinical trial registration URL: http://www.umin.ac.jp/ctr/ Unique identifier: UMIN000014105.

Pupillary light reflex as a new prognostic marker in patients with heart failure

BACKGROUNDnAutonomic function can be evaluated based on the pupillary light reflex (PLR). However, the relationship between PLR and prognosis in patients with heart failure (HF) remains unclear. This study was performed to examine whether PLR could be used as a prognostic indicator in patients with HF.nnnMETHODS AND RESULTSnA retrospective review was performed in 535 consecutive Japanese patients hospitalized for acute HF (mean age 66.1 ± 13.7 y). PLR was recorded at least 7 days after hospitalization for HF with the use of a pupilometer. Fifty-three patients died over a median follow-up period of 1.3 years (interquartile range 0.6-2.3 y). After adjustment for several preexisting prognostic factors, including Seattle Heart Failure Score (SHFS), PLR as assessed by recovery time (time to 63% redilation) was independently associated with all-cause mortality (hazard ratio 0.50, 95% confidence interval 0.35-0.73; P < .001). The addition of recovery time to SHFS resulted in a significant increase in the area under the curve on receiver-operating characteristic curve analysis (0.69 vs 0.77; P < .001).nnnCONCLUSIONSnPLR assessed by recovery time was an independent predictor of mortality and added prognostic information to the SHFS in patients with HF. Our results suggest that PLR may be useful as a new prognostic marker in HF patients.

Social isolation is associated with 90-day rehospitalization due to heart failure

Background: Social isolation has been reported to be associated with decreased quality of life and the onset of organic diseases. The objective of this study was to investigate the prevalence of social isolation in patients with heart failure and whether it is associated with rehospitalization. Methods and results: The study included consecutive patients aged ⩾55 years who were hospitalized due to heart failure. Social isolation was assessed using total scores less than 12 on an abbreviated version of the Lubben Social Network Scale. The endpoint was heart failure rehospitalization within 90 days after discharge. Among 148 patients with heart failure (80±8 years old, 51% male), 73 (49%) were socially isolated. The patients with social isolation had similar comorbidities compared with those without social isolation. Heart failure rehospitalization occurred within 90 days for 25 patients and the heart failure rehospitalization rate was significantly higher in the social isolation group (p=0.036). LASSO (least absolute shrinkage and selection operator) regression confirmed that social isolation was one of the strongest predictors of heart failure rehospitalization, showing larger effects than living alone, being unemployed, and other established risk factors. Conclusion: Half of the patients with heart failure reported social isolation, which had a strong association with heart failure rehospitalization.

Discordance between subjective and objective evaluations of cognitive function in old Japanese patients with heart failure

Although cognitive impairment is common among patients with chronic heart failure (HF), the accuracy with which caregivers can recognize it is unknown. This study aimed to examine the degree to which subjective and objective evaluations coincide.

Effects of Acute Phase Intensive Electrical Muscle Stimulation in Frail Elderly Patients With Acute Heart Failure (ACTIVE-EMS): Rationale and protocol for a multicenter randomized controlled trial

In elderly patients with acute heart failure (AHF), clinical outcome is adversely affected by frailty. Although a number of potentially effective interventions for frailty have been reported, little is known about the effects of rehabilitation programs in frail elderly AHF patients. We postulated that addition of electrical muscle stimulation (EMS), which induces muscle contraction without requiring patient volition, to early rehabilitation would be efficacious in frail elderly AHF patients. The ACTIVE‐EMS (Effects of Acute Phase Intensive Electrical Muscle Stimulation in Frail Elderly Patients With AHF; UMIN000019551) trial is a multicenter, randomized controlled trial that will enroll 80 patients from 3 hospitals in Japan. AHF patients age ≥ 75 years positive for frailty, defined as Short Physical Performance Battery score 4 to 9, will be randomly assigned to receive early rehabilitation program only or EMS add‐on therapy for 2 weeks. The primary endpoint of the trial is the change in quadriceps isometric strength between baseline and 2 weeks, with changes in physical function and cognitive function, and clinical safety and feasibility of EMS therapy as secondary outcomes. ACTIVE‐EMS is the first randomized trial to evaluate the clinical effectiveness of adding EMS therapy to early rehabilitation in frail elderly AHF patients. The results of this study will provide insight for the development of appropriate rehabilitation programs for this high‐risk population.