Prevalence of metabolic dysfunction-associated fatty liver disease and its association with physical function in patients with acute coronary syndrome

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): JSPS KAKENHI

Background

It is widely known that patients with acute coronary syndrome (ACS) are at increased risk of nonalcoholic fatty liver disease (NAFLD), which is linked to sarcopenia and physical dysfunction. However, the relationship between metabolic dysfunction-associated fatty liver disease (MAFLD) and physical dysfunction remains unclear.

Purpose

The purpose of this study was to investigate the prevalence of MAFLD in patients with ACS to assess the relationship between MAFLD and muscle strength, walking speed, and 6-minute walking distance (6 MWD).

Methods

We reviewed patients with ACS who were assessed for hepatic steatosis using the fatty liver index, and the results were further assessed to determine the presence of MAFLD. Multiple regression analysis was used to examine the association between MAFLD and physical function.

Results

Among 479 enrolled hospitalized patients, MAFLD was identified in 234 (48.9%) patients. We conducted a multiple regression analysis in which MAFLD was independently associated with lower leg strength, gait speed, and 6 MWD (leg strength, P = 0.023; gait speed, P = 0.002 and 6 MWD, P = 0.017). Furthermore, having more metabolic impairment was still associated with lower physical function decline (leg strength, P for trend = 0.002; gait speed, P for trend = 0.019 and 6 MWD, P for trend = 0.003).

Conclusions

MAFLD is common in hospitalized patients with ACS, and most patients with MAFLD have many overlapping metabolic abnormalities. MAFLD is associated with impaired physical function, and the greater the number of overlapping metabolic abnormalities, the worse the motor function.

Skeletal muscle mass metrics as factors in the prognosis of heart failure patients

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): JSPS KAKENHI Grant

Background

Sarcopenia is a chronic condition that is characterized by the loss of skeletal muscle mass with declining muscle strength and/or performance that occurs gradually with aging. It has been reported that sarcopenia is highly prevalent in patients with heart failure (HF) and is a poor prognostic factor. Therefore, it is important to accurately assess skeletal muscle mass in patients with HF. However, there are no reports that have simultaneously examined different skeletal muscle mass metrics as factors in the prognosis of HF patients.

Purpose

The purpose of this study is to examine if the different skeletal muscle mass metrics are associated with the prognosis of HF patients.

Methods

We examined a total of 869 patients with HF, aged ≥20 years (73 [63, 80] years; 537 males), who were admitted to our hospital and participated in an inpatient cardiac rehabilitation program. We used skeletal muscle mass index (SMI) as measured by bioelectrical impedance analysis (BIA), mid-upper arm circumference (MUAC), arm muscle circumference (AMC), and calf circumference (CC) as metrics of skeletal muscle mass. The primary outcome was all-cause deaths, and secondary outcome was HF readmission. To investigate the association between each skeletal muscle mass metric and prognosis, patients were divided into three groups according to the tertiles of SMI, MUAC, AMC, and CC. In addition, cumulative event rates of survival curves, Gray test, and Fine & Gray test were performed to evaluate the prognostic predictive capability.

Results

Over a median follow-up period of 0.9 years (interquartile 0.4–1.9) years, a total of 80 deaths and 195 HF readmissions occurred in the patients. Cumulative event rates of survival curves and Gray test showed that there was a significant decrease in all-cause mortality and HF readmission in the high MUAC group and high AMC group compared to their respective low groups (P < 0.05). Fine & Gray test after multivariate adjustment showed significantly better prognosis in the high MUAC group and high AMC group compared to their respective low groups (All-cause mortality: high MUAC group, subdistribution hazard ratio [sHR] = 0.42, 95% confidence interval [CI] = 0.20-0.88, P < 0.05; high AMC group, sHR = 0.34, 95%CI = 0.16-0.72 P < 0.05, HF readmission: high MUAC group, sHR = 0.69, 95%CI = 0.47-1.00, P < 0.05; high AMC group, sHR = 0.63, 95%CI = 0.43-0.93, P < 0.05).

Conclusion

Patients with HF who maintained high MUAC and high AMC had a good prognosis. CC and SMI were not associated with the prognosis of HF patients. This suggests the importance of evaluating MUAC and AMC in HF patients.

Optimal cutoff values for physical function tests in elderly patients with heart failure

Six-minute walk distance (6MWD) of 300 and 400 m are important targets of functional capacity. The present study was performed to determine cutoff values of physical function associated with 6MWD < 300 m and < 400 m in elderly patients with heart failure (HF). 6MWD, handgrip strength, quadriceps isometric strength (QIS), one-leg standing time (OLST), and 5-times sit-to-stand (5STS) before hospital discharge were evaluated in 1001 patients > 65 years (median age, 75: interquartile range, 71-80, 607 men) with HF. 6MWD < 300 and < 400 m were seen in 323 patients (32.3%) and 658 patients (65.7%), respectively. Handgrip strength, QIS, OLST, and 5STS were associated with 6MWD < 300 and < 400 m, respectively (P < 0.001). The cutoff values of handgrip strength, QIS, OLST, and 5STS were 18.9 kg, 35.0% body mass (BM), 9.1 s, and 9.5 s for 6MWD < 300 m, and 21.9 kg, 40.0% BM, 12.0 s, and 8.8 s for < 400 m, respectively. The cutoff values of physical function could be used to set cardiac rehabilitation goals and limiting determinants of reduced functional capacity in a clinical setting in elderly patients with HF.

Efficacy and Safety of Acute Phase Intensive Electrical Muscle Stimulation in Frail Older Patients with Acute Heart Failure: Results from the ACTIVE-EMS Trial

As frailty in older patients with acute heart failure (AHF) has an adverse effect on clinical outcomes, the addition of electrical muscle stimulation (EMS) to exercise-based early rehabilitation may improve the effects of treatment. Post hoc analysis was performed on a randomized controlled study for clinical outcomes and prespecified subgroups (ACTIVE-EMS: UMIN000019551). In this trial, 31 AHF patients aged ≥ 75 years with frailty (Short Physical Performance Battery [SPPB] score 4–9) were randomized 1:1 to receive treatment with an early rehabilitation program only (n = 16) or early rehabilitation with add-on EMS therapy (n = 15) for 2 weeks. Changes in physical function and cognitive function between baseline and after two weeks of treatment were assessed. There were no adverse events during the EMS period. The EMS group showed significantly greater changes in quadriceps’ isometric strength and SPPB compared to the control group, and EMS therapy showed uniform effects in the prespecified subgroups. There were no significant differences in the changes in other indexes of physical function and cognitive function between groups. There was no significant difference in the rate of heart failure hospitalization at 90 days between groups. In conclusion, older AHF patients with frailty showed greater improvement in lower extremity function with the addition of EMS therapy to early rehabilitation without adverse events.

The Prevalence of Metabolic Dysfunction-Associated Fatty Liver Disease and Its Association with Physical Function and Prognosis in Patients with Acute Coronary Syndrome

It is believed that patients with acute coronary syndrome (ACS) are at an increased risk of nonalcoholic fatty liver disease (NAFLD), which can lead to sarcopenia and physical dysfunction. However, the relationship between metabolic dysfunction-associated fatty liver disease (MAFLD) and physical dysfunction and prognosis remains unclear. We investigated the prevalence of MAFLD in patients with ACS to assess the relationship between MAFLD and muscle strength, walking speed, and 6-min walking distance (6 MWD). We reviewed patients with ACS who were assessed for hepatic steatosis using the fatty liver index, and the results were further assessed to determine the presence of MAFLD. Among 479 enrolled hospitalized patients, MAFLD was identified in 234 (48.9%) patients. Multiple regression analysis revealed that MAFLD was independently associated with lower leg strength, gait speed, and 6 MWD (leg strength, p = 0.020; gait speed, p = 0.003 and 6 MWD, p = 0.011). Furthermore, in multivariate Poisson regression models after adjustment for clinical confounding factors, combined MAFLD and reduced physical functions were significantly associated with a higher incidence of clinical events. MAFLD is common in hospitalized patients with ACS and is associated with impaired physical function. Also, the coexistence of MAFLD and lower physical function predict the incidence of clinical events in patients with ACS.

Relationship between high-sensitivity cardiac troponin T, B-type natriuretic peptide, and physical function in patients with heart failure

AIMS

High-sensitivity cardiac troponin T (hs-cTnT) and B-type natriuretic peptide (BNP) are associated with prognosis and severity in patients with heart failure (HF); however, their association with physical function is unclear. This study aimed to investigate whether hs-cTnT and BNP levels are associated with physical function in patients with HF.

METHODS AND RESULTS

Hs-cTnT, BNP, and physical function (maximal quadriceps isometric strength [QIS], usual gait speed, and 6-min walk distance [6MWD]) were evaluated in 363 consecutive patients with HF (median age, 70 [60-78] years). Patients were divided into four groups according to their median hs-cTnT and BNP levels. After adjusting for demographic characteristics, laboratory levels, and HF severity, higher hs-cTnT and BNP levels were significantly associated with lower physical function (log hs-cTnT, β = -0.162, P = 0.001, for maximal QIS; β = -0.175, P = 0.002, for usual gait speed, and β = -0.129, P = 0.004, for 6MWD; log BNP, β = -0.090, P = 0.092, for maximal QIS, β = 0.038, P = 0.516, for usual gait speed, and β = -0.108, P = 0.023, for 6MWD). In addition, the high hs-cTnT and high BNP group had significantly lower physical function (all P < 0.05) than the low hs-cTnT and low BNP group.

CONCLUSIONS

Higher hs-cTnT and BNP levels are both associated with lower physical function in patients with HF, but hs-cTnT levels showed a more consistent association. The combination of hs-cTnT and BNP may be effective for the stratification of physical function in patients with HF.

Work status before admission relates to prognosis in older patients with heart failure partly through social frailty

BACKGROUND

No reports explicitly examined the relationship between work defined as a certain type of social participation or role and the protective effect on the prognosis of patients with heart failure (HF) by preventing frailty. Therefore, this study examined whether social participation through work before admission relates to future adverse events in HF patients aged ≥65 years, and whether each frailty domain mediates the association between work and prognosis as a second analysis of a multi-centered prospective study (FRAGILE-HF study).

METHODS

We retrospectively reviewed 1,332 older patients with HF whose work status before admission to the hospital were investigated. We assessed the physical, cognitive, and social domains of frailty and performed causal mediation analysis to examine the mediating relationship of each frail domain between work status before admission and 1-year combined events (HF-related readmission and all-cause death).

RESULTS

The subjects' median age was 81 years, and 56.9% (758/1,332) were male. Among the three domains of frailty, work before admission reduced only social frailty after adjusting for confounding factors (odds ratio: 0.505, 95% confidence interval: 0.364-0.701). Patients with work before admission had a significantly better prognosis (hazard ratio: 0.720, 95% confidence interval: 0.523-0.989). Only social frailty partly mediated the relationship between work status and combined events (p <0.05).

CONCLUSIONS

Work status before admission is associated with 1-year combined events, in part through social frailty.

Effect of atrial fibrillation on response to exercise-based cardiac rehabilitation in older individuals with heart failure

BACKGROUND

Although the coexistence of heart failure (HF) with atrial fibrillation (AF) exhibits poor outcomes, the correlation between AF status and outcomes after exercise-based cardiac rehabilitation (CR) remains unclear in older individuals with HF.

OBJECTIVE

This retrospective study aimed to investigate the impact of AF on changes in physical function and prognosis after CR in older individuals with HF.

METHODS

We enrolled consecutive individuals with HF who were ≥ 60 years old who received 5-month CR. Exercise-based CR involved moderate-intensity aerobic exercises tailored to each participant. Isometric quadriceps strength (QS) and 6-min walk distance (6MWD) were measured as physical function, at baseline and 5 months thereafter. We compared QS and 6MWD changes from baseline to the 5-month observation period (QS and 6MWD) between sinus rhythm and AF. We examined composite incidence of all-cause death or unplanned readmission after 5-month CR and analysed the association of QS and 6MWD with clinical events, estimating adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

Of the 764 participants, 476 (62%) had sinus rhythm, and 288 (38%) had AF. AF was associated with lower QS and 6MWD at baseline. The 2 groups did not differ in QS and 6MWD after adjusting for clinical confounders. With sinus rhythm, greater change in QS and 6MWD was significantly associated with reduced incidence of clinical events (QS tertile: aHR 0.75 [95% CI 0.60-0.92]; 6MWD tertile: aHR 0.59 [95% CI 0.46-0.76]); however, with AF, this association was observed for only 6MWD and not QS (QS: aHR 0.92 [95% CI 0.72-1.17]; 6MWD: aHR 0.73 [95% CI 0.54-0.98]).

CONCLUSION

AF in older individuals with HF is associated with reduced physical function at baseline but not response to exercise-based CR. Furthermore, positive response of physical function after CR is associated with better prognosis regardless of AF, which suggests that exercise-based CR is potentially effective in older individuals with HF and AF.

Associations between kidney function and outcomes following cardiac rehabilitation in patients with heart failure

Background

Kidney dysfunction is considered one of the most prevalent comorbidities in patients with heart failure (HF). A combination of HF and kidney dysfunction is associated with peripheral muscle impairment, exercise intolerance, and poor prognosis. Conversely, cardiac rehabilitation (CR) for HF patients has been recognized to improve their clinical outcomes. However, the impact of kidney function on responses to CR in patients with HF is still unclear.

Purpose

This study aimed to investigate the associations between baseline kidney function and outcomes following CR including changes in physical function and prognosis in HF patients.

Methods

We reviewed a total of 3,727 patients who were admitted for HF treatment and underwent comprehensive CR during hospitalization. In addition to clinical characteristics, we assessed the kidney function using estimated glomerular filtration rate (eGFR) based on serum creatinine level at hospital discharge as baseline. The quadriceps strength (QS) and 6-minute walk distance (6MWD) were measured as muscle strength and functional capacity, respectively, at baseline. We also remeasured these parameter 5 months after hospital discharge in patients who participated in outpatient CR. The association between participation in outpatient CR and composite outcome of all-cause death and/or unplanned readmission were assessed using the multivariate Cox proportional hazard models in a subgroup of baseline eGFR. We also compared the changes in QS and 6MWD (ΔQS and Δ6MWD) between the eGFR stages.

Results

During the median follow-up period of 1.9 years, all-cause death/readmission occurred in 1604 (43.0%) patients, and their rate of incidence was 20.9/100 person-years. Out of studied patients, 1,585 (42.5%) patients participated in outpatient CR that was significantly associated with lower incidences of all-cause clinical events in patients with both eGFR ≥60 (adjusted hazard ratio [HR]: 0.73, 95% confidence interval [CI]: 0.60–0.89, P=0.002) and eGFR &lt;60 (adjusted HR: 0.88, 95% CI: 0.78–0.99, P=0.045), but those with an eGFR &lt;60 showed significant interaction between CR participation and adverse clinical events (interaction P&lt;0.035, Figure 1). Among the outpatient CR participants, QS and 6MWD were significantly higher after 5-month CR than those at baseline (P&lt;0.001, respectively), but the low baseline eGFR correlated with low ΔQS and Δ6MWD (trend P&lt;0.001, respectively) even after adjustment for clinical confounding factors (Figure 2).

Conclusions

Although the outcomes following CR is affected by baseline kidney function, outpatient CR is significantly associated with the positive change in physical function and better prognosis in HF patients with low kidney function.

Funding Acknowledgement

Type of funding sources: None.

Usefulness of physical function sub-item of SF-36 survey to predict exercise intolerance in patients with heart failure

Background

Exercise intolerance is widely known to be a major cardinal symptom in patients with heart failure (HF), but due to the recent coronavirus disease 2019 epidemic, it is still difficult to directly measure exercise tolerance in many hospitals and facilities. The 36-Item Short-Form Health Survey physical functioning (SF-36PF) pertain to lower extremity functioning and walking. The purpose of this study was to investigate whether SF-36PF is a useful predictor of exercise intolerance and to provide its optimal cut-off value for patients with HF.

Methods and results

SF-36PF and 6-min walking distance (6MWD) were evaluated in 372 consecutive patients with HF. Exercise intolerance was defined at 6MWD cut-offs of 200, 300, and 400 m. The addition of SF-36PF to the pre-existing determinants of exercise tolerance significantly improved the area under the curve scores (0.85 vs. 0.89, P = 0.011 for 6MWD <200 m; 0.90 vs. 0.93, P = 0.001 for 6MWD <300 m; 0.88 vs. 0.90, P = 0.021 for 6MWD <400 m) for the predictive effect on exercise intolerance. The cut-off values of SF-36PF for predicting exercise intolerance defined by 6MWD <200, 300, and 400 m were 45, 50, and 70, respectively.

Conclusions

SF-36PF is a useful tool as an alternative index to predict exercise intolerance in patients with HF.

Standardized gait speed ratio in elderly patients with heart failure

Aims

Although aging is strongly associated with both heart failure and a decline in gait speed, a definition of slowness incorporating an age‐related decline has yet to be developed. We aimed to define an event‐driven cut‐off for the relative decline in gait speed against age‐adjusted reference values derived from the general population and evaluate its prognostic implications.

Methods and results

Standardized gait speed (SGS) was defined as the median gait speed stratified by age, sex, and height in 3777 elderly (age ≥ 65 years) individuals without a history of cardiovascular diseases (Tokyo Metropolitan Institute of Gerontology‐Longitudinal Interdisciplinary Study on Aging: general population cohort). The mortality event‐driven optimal cut‐off of the SGS ratio (actual gait speed divided by the respective SGS) was defined using FRAGILE‐HF cohort data and externally validated using Kitasato cohort data, comprising 1301 and 1247 hospitalized elderly patients with heart failure, respectively. Using FRAGILE‐HF data, the optimal SGS ratio cut‐off was determined as 0.527. In the Kitasato cohort, SGS ratio < 0.527 was associated with a higher 1 year [hazard ratio (HR): 1.70, 95% confidence interval (CI): 1.07–2.72, P = 0.024] and long‐term (HR: 1.46, 95% CI: 1.05–2.02, P = 0.024) mortality rate, independent of pre‐existing covariates.

Conclusions

Gait speed was significantly declined in patients with heart failure, even after taking age and sex‐related decline into account. A SGS ratio of 0.527 is a validated cut‐off for slowness independently associated with mortality in patients with heart failure age ≥65.

Low skeletal muscle density combined with muscle dysfunction predicts adverse events after adult cardiovascular surgery

BACKGROUND AND AIMS

Although muscle dysfunctions are widely known as a poor prognostic factor in patients with cardiovascular disease, no study has examined whether the addition of low skeletal muscle density (SMD) assessed by computed tomography (CT) to muscle dysfunctions is useful. This study examined whether SMDs can strengthen the predictive ability of muscle dysfunctions for adverse events in patients who underwent cardiovascular surgery.

METHODS AND RESULTS

We retrospectively reviewed 853 patients aged ≥40 years who had preoperative CT for risk management purposes and who measured muscle dysfunctions (weakness: low grip strength and slowness: slow gait speed). Low SMD based on transverse abdominal CT images was defined as a mean Hounsfield unit of the psoas muscle <45. All definitions of muscle dysfunction (weakness only, slowness only, weakness or slowness, weakness and slowness), the addition of SMDs was shown to significantly improve the continuous net reclassification improvement and integrated discrimination improvement for adverse events in all analyses (p < 0.05). Low SMDs combined with each definition of muscle dysfunction had the highest risk of all-cause death (hazard ratio: lowest 3.666 to highest 6.002), and patients with neither low SMDs nor muscle dysfunction had the lowest risk of all-cause and cardiovascular-related events.

CONCLUSION

The addition of SMDs consistently increased the predictive ability of muscle dysfunctions for adverse events. Our results suggest that when CT is performed for any clinical investigation, the addition of the organic assessment of skeletal muscle can strengthen the diagnostic accuracy of muscle wasting.

Associations between kidney function and outcomes of comprehensive cardiac rehabilitation in patients with heart failure

AIMS

To investigate the impact of baseline kidney function on outcomes following comprehensive cardiac rehabilitation (CR) in patients with heart failure (HF).

METHODS

We reviewed a total of 3,727 patients who were admitted for HF treatment. Estimated glomerular filtration rate (eGFR), quadriceps strength (QS), and 6-min walk distance (6MWD) were measured at hospital discharge as a baseline and 5 months thereafter in participants of outpatient comprehensive CR. The association between outpatient CR participation and all-cause events was evaluated using propensity score-matched analysis in subgroups across eGFR stages. The changes in QS and 6MWD following 5-month CR were compared between eGFR stages.

RESULTS

Out of the studied patients, 1585 (42.5%) participated in outpatient CR. After propensity matching for clinical confounders, 2680 patients were included for analysis (pairs of n = 1340 outpatient CR participants and nonparticipants). The participation in outpatient CR was significantly associated with low clinical events in subgroups of eGFR ≥ 60 [hazard ratio (HR): 0.65, 95% confidence interval (CI): 0.51-0.84] and eGFR 45-60 (HR: 0.71, 95% CI: 0.55-0.92), but not in eGFR 30-45 (HR: 0.83, 95% CI: 0.64-1.08) and eGFR < 30 (HR: 0.88, 95% CI: 0.69-1.12). QS and 6MWD were significantly higher after 5-month CR than those at baseline (P < 0.001, respectively), but lower baseline eGFR correlated with lower changes in QS and 6MWD (trend P < 0.001, respectively).

CONCLUSIONS

Although low baseline kidney function attenuates the outcomes of CR, outpatient CR seems to be associated with a better prognosis and positive change in physical function in HF patients with low kidney function.

MO554THE EFFECT OF HEMOGLOBIN CHANGES AND THE SEVERITY OF CHRONIC KIDNEY DISEASE IN PHYSICAL FUNCTION IN ELDERLY PATIENTS WITH HEART FAILURE

Background and Aims

Anemia is frequently observed in patients with heart failure (HF) and causes increased hospitalization and mortality rates. Anemia is also associated with and is a major risk factor of impaired physical function and frailty. On the other hand, a high percentage of elderly patients with HF have chronic kidney disease (CKD), which is an aggravating factor for anemia, and the combination of anemia and CKD has been reported to increase physical dysfunction and mortality. However, the relationship between hemoglobin (Hb) changes and physical function during hospitalization in elderly patients with HF is unclear, and the impact of CKD severity on these relationships is also unclear. This study aimed to examine the relationship between Hb changes and physical function during hospitalization in elderly patients with HF. We further examined the relationship when stratified by CKD severity.

Method

Seven hundred and thirty-seven elderly patients with HF, who underwent changes in Hb and physical function test (leg strength, gait speed, and 6-min walking distance [6MWD]), were included in this study. Using a multiple linear regression model, associations between Hb changes and physical function were assessed. In addition, using a generalized linear mixed model, we divided the HF patients into three groups with eGFR ≥60, 30–60, and &lt;30, and examined whether the severity of CKD was related to the Hb change and physical function.

Results

The median age of the subjects in this study was 77 years (interquartile range 72–82). Changes in Hb during hospitalization were independent determinants of physical function (leg strength, β: 0.158, P &lt; 0.001; gait speed, β: 0.023, P &lt; 0.001; 6MWD, β: 13.039, P &lt; 0.001), even after accounting for factors related to severity of HF. Moreover, the group with more severe CKD showed significantly lower physical function, although Hb improved (P &lt; 0.001) with respect to leg strength and 6MWD compared with the group with lower CKD stage.

Conclusion

Hb change during hospitalization was an independent determinant of physical function in patients with HF. Patients with a more severe CKD showed lower leg strength values and 6MWD even if Hb improved.

Hemodynamic Changes During Neuromuscular Electrical Stimulation and Mobility Therapy for an Advanced Heart Failure Patient with Impella 5.0 Device

The Impella 5.0 is a catheter-mounted left ventricular assist device that is inserted through the patient's subclavian artery. This device allows patient mobilization. Early mobility improves outcomes, including physical function and exercise tolerance, in critically ill patients and those with heart failure (HF). However, there have been no studies regarding the safety of early mobilization during the period of Impella 5.0 insertion based on hemodynamic assessment.A 39-year-old man with idiopathic dilated cardiomyopathy and cardiogenic shock was transferred to our hospital for Impella 5.0 insertion. We started neuromuscular electrical stimulation (NMES) and mobilization eight days after Impella 5.0 insertion. The safety of NMES and mobilization was assessed based on mean blood pressure, heart rate (HR), and mean pulmonary artery pressure measurements as hemodynamic indicators. Muscle strength was also assessed using the Medical Research Council (MRC) scale. Throughout the interventions, only the HR increased slightly during mobilization, and there were no hemodynamic abnormalities. Also, the MRC scale score improved as mobilization progressed. The results presented here suggest that NMES and mobilization are safe and feasible in patients with Impella 5.0 insertion, and therefore should be widely adopted.

Associations of severity of liver damages with physical function and prognosis in patients with heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

Heart failure (HF) and liver dysfunction often coexist because of complex cardiohepatic interactions, which adversely affects prognosis. However, the association between liver dysfunction and physical dysfunction, and between coexistence of both and prognosis in HF patients remains unclear.

Purpose

We evaluated the associations of severity of liver damage and physical function and prognosis in patients with HF.

Methods

The study population consisted of 895 patients with HF (mean age, 69.4 ± 14.2 years) who underwent liver function test using model for end-stage liver disease excluding international normalized ratio (MELD-XI) score and physical function test (grip strength, leg strength, gait speed, and 6-minute walking distance [6MWD]). The associations between MELD-XI score and physical function were assessed by multivariate linear regression model analysis. Moreover, we investigated the prognostic value of coexistence of liver dysfunction and physical dysfunction. The endpoint was all-cause mortality.

Results

After adjusting for covariates, MELD-XI score was independently associated with lower grip strength, leg strength, gait speed, and 6MWD (P &lt; 0.001). In addition, hierarchical multivariate linear regression analysis revealed that adding MELD-XI scores or BNP explained additional variance in the physical function measures. The MELD-XI score added to the clinical model was significantly more predictive of physical function (grip strength, change in F: 27.105, P &lt; 0.001; leg strength, change in F: 33.980, P &lt; 0.001; gait speed, change in F: 22.826, P &lt; 0.001; 6MWD, change in F: 59.193, P &lt; 0.001) than BNP added to the clinical model. Eighty-six deaths occurred over a median follow-up period of 1.67 years (interquartile range: 0.62 – 3.04). Patients with high MELD-XI score and reduced physical function were found to have significantly higher mortality risk even after adjusting for several covariates (grip strength, hazard ratio [HR] = 3.80 [95% confidence interval (CI) = 2.04 – 7.08], P &lt; 0.001; leg strength, HR = 4.65 [95% CI = 2.47 - 8.75], P &lt; 0.001 and gait speed, HR = 2.49 [95% CI = 1.43 - 4.33], P = 0.001; 6MWD, HR = 5.48 [95% CI = 2.88 - 10.41], P &lt; 0.001).

Conclusions

Liver dysfunction was correlated with reduced physical function. Moreover, the coexistence of lower physical function and liver dysfunction considerably affected prognosis in patients with HF.

Abstract Figure. Kaplan–Meier survival curves

Low skeletal muscle density combined with muscle dysfunction predicts adverse events after adult cardiovascular surgery

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): This study was supported by the Grant for Japan Society for the Promotion of Science (JSPS) KAKENHI.

Introduction

Although muscle dysfunction is widely known as a poor prognostic factor in patients with cardiovascular disease, no study has examined whether the addition of low skeletal muscle density (SMD) assessed by computed tomography (CT) to muscle dysfunction is useful.

Purpose

The present study aimed to examine whether SMDs can strengthen the predictive ability of muscle dysfunction for adverse events in patients who underwent cardiovascular surgery.

Methods

We retrospectively reviewed 853 patients (median age: 69 years, 65.1% male) aged ≥40 years who had preoperative CT for risk management purposes and muscle dysfunctions measured during postoperative cardiac rehabilitation. Muscle dysfunctions were determined from weakness (low grip strength) and slowness (slow gait speed) based on the Asia Working Group for Sarcopenia. Low SMD based on transverse abdominal CT images was defined as a mean Hounsfield unit of the psoas muscle &lt;45. To examine the complementary prognostic value for all-cause deaths, all-cause events, and cardiovascular-related events when low SMDs were added to four patterns of muscle dysfunction (weakness only, slowness only, weakness or slowness, and weakness and slowness), the continuous net reclassification improvement (cNRI) and integrated discrimination improvement (IDI) index were calculated.

Results

For all definitions of muscle dysfunction, the addition of SMDs was shown to significantly improve the cNRI (estimates: 0.377 to 0.468 for all-cause death, 0.220 to 0.248 for all-cause events, 0.308 to 0.322 for cardiovascular-related events) and IDI (estimates: 0.005 to 0.011 for all-cause death, 0.005 to 0.010 for all-cause events, 0.009 to 0.012 for cardiovascular-related events) in all analyses. Low SMDs combined with muscle dysfunctions were associated with the highest risk of all-cause death (Figure 1: A-D). Patients with neither low SMDs nor muscle dysfunction had the lowest risk of all-cause events and cardiovascular-related events (Figure1: E-L).

Conclusion

The predictive ability of muscle dysfunction for adverse events was consistently increased by addition of SMDs in patients who underwent cardiovascular surgery. Our results suggest that when CT is performed for any clinical investigation, the addition of the organic assessment of skeletal muscle can strengthen the diagnostic accuracy of muscle wasting.

Abstract Figure 1

Clinical usefulness of oxygen uptake during usual gait in patients with cardiovascular disease

BACKGROUND

Although oxygen uptake (VO₂) during exercise stress is a surrogate marker for prognosis in patients with cardiovascular disease (CVD), the stress test is sometimes difficult to perform owing to patient conditions, such as ageing or comorbidities. We investigated the relationships between VO₂ during usual gait with physical function and prognosis in patients with CVD.

METHODS

This single-centre observational study enrolled consecutive patients who were hospitalized for CVD treatment. Isometric quadriceps strength (QS) and 6-min walk distance (6MWD) as physical functions, and VO₂ during usual gait speed were measured at hospital discharge. We assessed the changes in VO₂ per body weight between at rest and during gait divided by gait speed (VO₂/kg/gait) and analysed the relationships of VO₂/kg/gait with physical functions and composite incidences of all-cause death or unplanned readmission after discharge.

RESULTS

In 367 patients (age, 65 ± 13 years; females, 34%), 112 clinical events occurred. VO₂/kg/gait showed significant negative correlations to QS (β = -0.114, p = 0.024) and 6MWD (β = -0.163, p < 0.001) after adjusting for confounding factors. High VO₂/kg/gait was significantly associated with a high rate of clinical events (hazard ratio for 1 standard deviation of VO₂/kg/gait, 1.36; 95% confidence interval, 1.11-1.66). This association was also observed in subgroups of older age and frailty.

CONCLUSIONS

High VO₂ during usual gait was a relevant factor for low physical function and poor prognosis in patients with CVD and even in older age and frailty, meaning that VO₂ during usual gait might be a novel and useful marker in clinical practice.

Validity and Utility of the Questionnaire-based FRAIL Scale in Older Patients with Heart Failure: Findings from the FRAGILE-HF

OBJECTIVES

We investigated whether the FRAIL scale questionnaire is consistent with the Fried criteria, predicts all-cause mortality, and reflects physical dysfunction in patients with heart failure (HF).

DESIGN

Secondary analysis of FRAGILE-HF, a cohort study that enrolled participants from 2016 to 2018 and followed-up for 1-year of discharge.

SETTING AND PARTICIPANTS

A prospective multicenter cohort study in which 15 hospitals in Japan (8 university hospitals and 7 nonuniversity teaching hospitals) participated. We prospectively enrolled 1332 consecutive hospitalized patients ≥65 years old with HF and analyzed 1028 patients after excluding 304 patients with missing data on the FRAIL scale.

METHODS

The FRAIL scale, the Fried model, and physical function were measured before discharge. The endpoint was all-cause mortality.

RESULTS

According to the FRAIL scale, 459 (44.6%) and 491 (47.8%) were classified as frail and prefrail, respectively. The Kappa coefficient between the FRAIL scale and the Fried criteria were 0.39 [95% confidence interval (CI) 0.34-0.44; P < .001]. The area under the receiver-operating characteristic curves for frailty diagnosed by the Fried criteria of the FRAIL scale was 0.74 (95% CI 0.71-0.76; P < .001). A total of 118 deaths occurred during 1 year of follow-up. After adjusting for the MAGGIC risk score and log-BNP, The FRAIL scale predicted all-cause mortality (hazard ratio 1.17; 95% CI 1.01-1.36; P = .035). The FRAIL scale was also associated with various physical dysfunctions that correlated with poor prognosis.

CONCLUSIONS AND IMPLICATIONS

The FRAIL scale had moderate consistency with the Fried criteria, predicted all-cause mortality, and reflected clinically important physical dysfunctions.

Post-intensive care syndrome as a predictor of mortality in patients with critical illness: A cohort study

Introduction

The post-intensive care syndrome (PICS) encompasses multiple, diverse conditions, such as physical disability, cognitive impairment, and depression. We sought to evaluate whether conditions within PICS have similar associations with mortality among survivors of critical illness.

Materials and methods

In this retrospective cohort study, we identified 248 critically ill patients with intensive care unit stay ≥72 hours, who underwent PICS evaluation. Patients with disability in activities of daily living, cognitive impairment, or depression before hospitalization were excluded. We defined PICS using established measures of physical disability (usual gait speed), cognitive impairment (Mini-Cog test), and depression (Patient Health Questionnaire-2) at hospital discharge. The endpoint was all-cause mortality.

Results

Patients had a median age of 69 years and Acute Physiology and Chronic Health Evaluation (APACHE) II score of 16. One hundred thirty-two patients were classified as having PICS, and 19 patients died. 81/248 (34%) patients had physical disability, 42/248 (19%) had cognitive impairment, and 44/248 (23%) had depression. After adjusting for covariates on multivariable Cox regression analyses, PICS was significantly associated with all-cause mortality (hazard ratio [HR] 3.78, 95% confidence interval [CI] 1.02 – 13.95; P = 0.046). However, the association between PICS and all-cause mortality was related to physical disability and cognitive impairment (P = 0.001 and P = 0.027, respectively), while depression was not (P = 0.623).

Conclusion

While PICS as a syndrome has been useful in gaining attention to the sequelae of critical illness, its relationship with long-term mortality is driven largely by physical disability and cognitive impairment and not depression.

Prognostic value of cardio-hepatic-skeletal muscle syndrome in patients with heart failure

Although heart failure (HF) and liver dysfunction often coexist because of complex cardiohepatic interactions, the association between liver dysfunction and physical dysfunction, and between coexistence of both and prognosis in HF patients remains unclear. We reviewed 895 patients with HF (mean age, 69.4 ± 14.2 years) who underwent liver function test using model for end-stage liver disease excluding international normalized ratio (MELD-XI) score and physical function test (grip strength, leg strength, gait speed, and 6-min walking distance [6MWD]). In the multiple regression analysis, MELD-XI score was independently associated with lower grip strength, leg strength, gait speed, and 6MWD (all P < 0.001). One hundred thirty deaths occurred over a median follow-up period of 1.67 years (interquartile range: 0.62–3.04). For all-cause mortality, patients with high MELD-XI scores and reduced physical functions were found to have a significantly higher mortality risk even after adjusting for several covariates (grip strength, hazard ratio [HR]: 3.80, P < 0.001; leg strength, HR: 4.65, P < 0.001; gait speed, HR: 2.49, P = 0.001, and 6MWD, HR: 5.48, P < 0.001). Liver dysfunction was correlated with reduced physical function. Moreover, the coexistence of lower physical function and liver dysfunction considerably affected prognosis in patients with HF.

Quantification of Oscillatory Shear Stress from Reciprocating CSF Motion on 4D Flow Imaging

BACKGROUND AND PURPOSE

Oscillatory shear stress could not be directly measured in consideration of direction, although cerebrospinal fluid has repetitive movements synchronized with heartbeat. Our aim was to evaluate the important of oscillatory shear stress in the cerebral aqueduct and foramen magnum in idiopathic normal pressure hydrocephalus by comparing it with wall shear stress and the oscillatory shear index in patients with idiopathic normal pressure hydrocephalus.

MATERIALS AND METHODS

By means of the 4D flow application, oscillatory shear stress, wall shear stress, and the oscillatory shear index were measured in 41 patients with idiopathic normal pressure hydrocephalus, 23 with co-occurrence of idiopathic normal pressure hydrocephalus and Alzheimer-type dementia, and 9 age-matched controls. These shear stress parameters at the cerebral aqueduct were compared with apertures and stroke volumes at the foramen of Magendie and cerebral aqueduct.

RESULTS

Two wall shear stress magnitude peaks during a heartbeat were changed to periodic oscillation by converting oscillatory shear stress. The mean oscillatory shear stress amplitude and time-averaged wall shear stress values at the dorsal and ventral regions of the cerebral aqueduct in the idiopathic normal pressure hydrocephalus groups were significantly higher than those in controls. Furthermore, those at the ventral region of the cerebral aqueduct in the idiopathic normal pressure hydrocephalus group were also significantly higher than those in the co-occurrence of idiopathic normal pressure hydrocephalus with Alzheimer-type dementia group. The oscillatory shear stress amplitude at the dorsal region of the cerebral aqueduct was significantly associated with foramen of Magendie diameters, whereas it was strongly associated with the stroke volume at the upper end of the cerebral aqueduct rather than that at the foramen of Magendie.

CONCLUSIONS

Oscillatory shear stress, which reflects wall shear stress vector changes better than the conventional wall shear stress magnitude and the oscillatory shear index, can be directly measured on 4D flow MR imaging. Oscillatory shear stress at the cerebral aqueduct was considerably higher in patients with idiopathic normal pressure hydrocephalus.

Prevalence and prognostic value of the coexistence of anaemia and frailty in older patients with heart failure

Aims

There have been no investigations of the prevalence and clinical implications of coexistence of anaemia and frailty in older patients hospitalized with heart failure (HF) despite their association with adverse health outcomes. The present study was performed to determine the prevalence and prognostic value of the coexistence of anaemia and frailty in hospitalized older patients with HF.

Methods and results

We performed post hoc analysis of consecutive hospitalized HF patients ≥65 years old enrolled in the FRAGILE‐HF, which was the prospective, multicentre, observational study. Anaemia was defined as haemoglobin < 13 g/dL in men and <12 g/dL in women, and frailty was evaluated according to the Fried phenotype model. The study endpoint was all‐cause mortality. Of the total of 1332 patients, 1217 (median age, 81 years; 57.4% male) were included in the present study. The rates of anaemia and frailty in the study population were 65.7% and 57.0%, respectively. The patients were classified into the non‐anaemia/non‐frail group (16.6%), anaemia/non‐frail group (26.4%), non‐anaemia/frail group (17.7%), and anaemia/frail group (39.3%). A total of 144 patients died during 1 year of follow‐up. In multivariate analyses, only the anaemia/frail group showed a significant association with elevated mortality rate (adjusted hazard ratio, 1.94; 95% confidence interval, 1.02–3.70; P = 0.043), compared with the non‐anaemia/non‐frail group after adjusting for other covariates.

Conclusions

Coexistence of anaemia and frailty are prevalent in hospitalized older patients with HF, and it has a negative impact on mortality.

Correlation between respiratory muscle weakness and frailty status as risk markers for prognosis in patients with cardiovascular disease

Background

Respiratory muscle weakness (RMW), frequently observed in patients with cardiovascular disease (CVD), is documented as a predictor for exercise intolerance and poor prognosis. On the other hand, frailty is commonly associated with disease condition, leading to increased risk of morbidity and mortality. Although the developmental mechanism of RMW and frailty is partly similar, the relationship between these statuses remains unclear.

Purpose

We aimed to investigate the correlation between RMW and frailty and its impact on prognosis in patients with CVD.

Methods

We studied 771 consecutive patients (68.5±13.1 years, 256 females) who were hospitalized for CVD treatment and underwent cardiac rehabilitation during hospitalization. Patients who received thoracic surgery within the last 3 months or could not perform respiratory function test were excluded from this study. As patient characteristics, we obtained body mass index, comorbidity conditions, smoking history, blood examinations, echocardiographical variables, and lung function from medical database. The frailty status on admission was assessed using frailty score consisting of 5 items including gait speed, nutrition/shrinking, physical activity, forgetfulness, and emotions/exhaustion, and patients who had 3 items were defined as frailty. We also measured maximal inspiratory pressure (PImax) as respiratory muscle strength at hospital discharge, and RMW was defined with PImax &lt;70% of predicted value. Primary end-point was all-cause clinical events including all-cause death and/or unplanned readmission after hospital discharge. We examined the prevalence of RMW and frailty and the correlation between these statuses. The relationships of RMW with the clinical events for each presence or absence of frailty were also investigated using multivariate Cox proportional hazard models.

Results

RMW and frailty were defined in 163 (33.5%) and 126 (28.7%) patients, respectively, and 95 patients (12.4%) among them showed an overlap of both statuses (Figure 1). Frailty was detected as a significant indicator of RMW after adjusting for confounding factors (adjusted odds ratio: 1.57, 95% CI: 1.12–2.19, P=0.009). Over the median follow-up periods of 1.2 years, all-cause clinical events occurred in 154 patients (20.0%). RMW was significantly and independently associated with increased incidence of all-cause clinical events in patients with both non-frailty (adjusted hazard ratio [HR]: 1.64, 95% CI: 1.09–2.46, P=0.017) and frailty (adjusted HR: 1.97, 95% CI: 1.14–3.42, P=0.015) even after adjusting for clinical confounding factors (Figure 2).

Conclusions

This study is the first to demonstrate that RMW correlated to frailty in patients with CVD, and 12.4% of patients had overlap status. Moreover, RMW was significantly associated with an increased risk of all-cause clinical events in patients with CVD and frailty.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science Grant-in-Aid