Prognostic Value of RV Abnormalities on CMR in Patients With Known or Suspected Cardiac Sarcoidosis

BACKGROUND

Left ventricular abnormalities in cardiac sarcoidosis (CS) are associated with adverse cardiovascular events, whereas the prognostic value of right ventricular (RV) involvement found on cardiac magnetic resonance is unclear.

OBJECTIVES

This study aimed to systematically assess the prognostic value of right ventricular ejection fraction (RVEF) and RV late gadolinium enhancement (LGE) in known or suspected CS.

METHODS

This study was prospectively registered in PROSPERO (CRD42022302579). PubMed, Embase, and Web of Science were searched to identify studies that evaluated the association between RVEF or RV LGE on clinical outcomes in CS. A composite endpoint of all-cause death, cardiovascular events, or sudden cardiac death (SCD) was used. A meta-analysis was performed to determine the pooled risk ratio (RR) for these adverse events. The calculated sensitivity, specificity, and area under the curve with 95% CIs were weighted and summarized.

RESULTS

Eight studies including a total of 899 patients with a mean follow-up duration of 3.2 ± 0.7 years were included. The pooled RR of RV systolic dysfunction was 3.1 (95% CI: 1.7-5.5; P < 0.01) for composite events and 3.0 (95% CI: 1.3-7.0; P < 0.01) for SCD events. In addition, CS patients with RV LGE had a significant risk for composite events (RR: 4.8 [95% CI: 2.4-9.6]; P < 0.01) and a higher risk for SCD (RR: 9.5 [95% CI: 4.4-20.5]; P < 0.01) than patients without RV LGE. Furthermore, the pooled area under the curve, sensitivity, and specificity of RV LGE for identifying patients with CS who were at highest SCD risk were 0.8 (95% CI: 0.8-0.9), 69% (95% CI: 50%-84%), and 90% (95% CI: 70%-97%), respectively.

CONCLUSIONS

In patients with known or suspected CS, RVEF and RV LGE were both associated with adverse events. Furthermore, RV LGE shows good discrimination in identifying CS patients at high risk of SCD.

Current status of real-world big data research in the cardiovascular field in Japan

Real-world data (RWD) are observational data obtained by collecting, structuring, and accumulating patient information among the medical big data. RWD are derived from a variety of patient medical care and health information outside of conventional research data, and include electronic health records, claims data, registry data of disease, drug and device, health check-up data, and more recently, patient information data from wearable devices. They are currently being utilized in various forms for optimal medical care and real-world evidence (RWE) is constructed through a process of hypothesis generation and verification based on the RWD research. Together with classic clinical research and pragmatic trials, RWE shapes the learning healthcare system and contributes to the improvement of medical care. In the cardiovascular medical care of the current super-aged society, the need for a variety of RWE and the research is increasing, since the guidelines established over time and the medical care based on it cannot necessarily be the best in accordance with the current medical situation. In this review, we focus on the RWD and RWE studies in the cardiovascular medical field and outlines their current status in Japan. Furthermore, we discuss the potential for extending the studies and issues related to the use of medical big data and RWD.

Combination of coronary CT angiography, FFRCT , and risk factors in the prediction of major adverse cardiovascular events in patients suspected CAD

BACKGROUND

To examine the utility of fractional flow reserve by coronary computed tomography (CT) angiography (FFR_CT ) for predicting major adverse cardiovascular events (MACE) in patients with suspected coronary artery disease (CAD).

METHODS

This was a nationwide multicenter prospective cohort study including consecutive 1187 patients aged 50-74 years with suspected CAD and had available coronary CT angiography (CCTA). In patients with ≥50% coronary artery stenosis (CAS), FFR_CT was further analyzed. The Cox proportional hazards model was used to examine the association of FFR_CT and cardiovascular risk factors with incident MACE within 2 years.

RESULTS

Among 933 patients with available information on MACE within 2 years after enrollment, the incidence rate of MACE was higher in 281 patients with CAS than in those without CAS (6.11 vs. 1.16 per 100 patient-year). In 241 patients with CAS, the Cox proportional hazards analysis showed that FFR_CT as well as diabetes mellitus and low high-density lipoprotein cholesterol level were independently associated with incident MACE. Moreover, the hazard ratio was significantly higher in patients harboring all three factors compared to those harboring 0-2 of the three factors (6.01; 95% confidence interval: 2.77-13.03).

CONCLUSIONS

Combinatorial assessment using CCTA for stenosis, FFR_CT , and risk factors was useful for more accurate prediction of MACE in patients with suspected CAD. Among patients with CAS, those with lower FFR_CT , diabetes mellitus, and low high-density lipoprotein cholesterol level were at highest risk for MACE during the 2-year period following enrollment.

Abstract WMP12: Initial Severity And Functional Outcomes Of Acute Ischemic Stroke With Atrial Fibrillation On Direct Oral Anticoagulants(DOACs): Japan Stroke Data Bank

Purpose: The purpose of this study was to examine the associations between oral anticoagulants (OACs) at onset and outcomes in acute ischemic stroke (AIS) patients with atrial fibrillation.

Methods: AIS patients with comorbidity of atrial fibrillation (aged ≥18 years, pre-stroke modified Rankin Scale [mRS] 0-2) admitted within 24 hours after onset from January 2017 to December 2020 were examined from a long-lasting nationwide hospital-based multicenter prospective registry, the Japan Stroke Data Bank. Patients were classified into 3 groups according to anticoagulants at onset: no-anticoagulant group, warfarin group and DOAC group. The co-primary outcomes were the National Institutes of Stroke Scale (NIHSS) on admission and favorable outcome at discharge, corresponding to the mRS of 0-2. Mixed effects logistic regression was performed to examine the association between antithrombotic agents and these outcomes.

Results: Of a total of 6,838 patients, 4,249 (62.1 %) patients were classified into the no-anticoagulant group, 907 (13.3 %) into warfarin group and 1,682 (24.6 %) into DOACs group. Median NIHSS score on admission was 7 [interquartile range: 2-19] in the warfarin group and 5 [2-15] in the DOAC group, versus 9 [3-20] in the no-anticoagulant group. Both warfarin and DOAC groups had lower NIHSS scores as compared to no-antithrombotic group (adjusted incidence rate ratio 0.96 [95% confidence interval 0.94-0.99] and 0.81 [0.79-0.83], respectively) after adjustment by age, sex, hypertension (HT), dyslipidemia (DL), diabetes mellitus (DM) and history of stroke. The rate of favorable outcome at discharge was 41.5 % in no-anticoagulant group, 42.0% in warfarin group and 48.1 % in DOACs group. In multivariable analysis, sex, NIHSS on admission, HT, DL, DM, history of stroke and intravenous thrombolysis and mechanical thrombectomy, DOACs group more frequently had favorable outcome (odds ratio 1.20 [95% CI 1.03-1.40]) than no-anticoagulant group, but warfarin group did not (1.05 [0.86-1.27]).

Conclusion: Taking DOACs prior to onset appears associated with milder stroke severity and a more favorable outcome following acute ischemic stroke in patients with atrial fibrillation.

Impact of Low Body Mass Index on Cardiac Tamponade During Catheter Ablation for Atrial Fibrillation

BACKGROUND

Cardiac tamponade is a potentially fatal complication of catheter ablation for atrial fibrillation (AF).

OBJECTIVES

This study aimed to evaluate the impact of body mass index (BMI) on cardiac tamponade during AF ablation.

METHODS

Patients who underwent catheter ablation for AF between April 1, 2016 and March 31, 2018 were analyzed using a Japanese nationwide claims database. Mixed-effects multivariable Poisson regression analysis was performed to investigate the association between BMI and cardiac tamponade.

RESULTS

A total of 59,789 hospitalizations (age 65.6 ± 10.4 years, 29% women) with catheter ablation for AF were analyzed. Cardiac tamponade occurred in 647 patients (1.1%). Multivariable analysis revealed that being underweight (BMI <18.5 kg/m²) was associated with an increased risk of cardiac tamponade (relative risk [RR]: 1.42; 95% CI: 1.03-1.95) when compared with having a normal weight (BMI ≥18.5 and <25 kg/m²). Other characteristics that were associated with an increased risk of cardiac tamponade were age ≥75 years, female sex, and a history of heart failure, hypertension, diabetes, and dialysis treatment.

CONCLUSIONS

In this analysis of a large nationwide database of patients with AF who underwent ablation, being underweight was independently associated with an increased risk of cardiac tamponade during AF ablation. Clinicians should consider the higher risk of cardiac tamponade in the underweight population and take appropriate measures to reduce this risk.

Abstract WMP71: Changes In Severity And Outcomes Of Ischemic Stroke Associated With Atrial Fibrillation In A Long-lasting Nationwide Hospital-based Registry: Japan Stroke Data Bank

Background: To determine secular changes in severity and functional outcomes of acute atrial fibrillation (AF)-associated stroke patients using a large population.

Methods: Ischemic stroke patients with known AF or AF diagnosed after stroke onset, who were registered within 7 days after symptom onset into a hospital-based prospective registry, Japan Stroke Data Bank, from Jan 2000 to Dec 2020 were compared with those without AF. The co-primary outcomes were the initial neurological severity assessed by NIHSS and favorable outcome assessed by mRS of 0 to 2 at hospital discharge. Secondary outcomes included unfavorable outcome assessed by mRS of 5 to 6 and in-hospital death.

Results: Of 142,351 patients studied, 33,870 had AF (women 45.1%, median age 79 years, non-valvular 94.3%). Patients with AF had higher initial NIHSS score (median 9 vs. 3, adjusted coefficient 5.383, 95% CI 5.245 - 5.520) as compared to patients without AF (women 38.2%, median age 79 years). Anticoagulation prior to the index stroke showed a significant interaction with the frequency of the NIHSS score ≥10 in patients with AF relative to those without AF (aOR: 2.047 for anticoagulated patients vs. 4.189 for the others). The NIHSS score decreased over the 21-year period in AF patients (adjusted coefficient -0.104, 95% CI -0.133 - -0.074 per year). Favorable outcome was less common in patients with AF than those without AF in unadjusted analysis (48.4% vs. 70.4%) but was more common after multivariable adjustment including the initial NIHSS score (aOR 1.096, 95% CI 1.040 - 1.156). Unfavorable outcome (aOR 1.108) and in-hospital death (1.506) were also more common in AF patients. The proportion of favorable outcome showed an increase over time (aOR 1.018, 95% CI 1.009 - 1.026 per year) in AF patients but the increase was no longer significant after further adjustment by receiving reperfusion therapy (1.007, 0.998 - 1.016). The proportion of unfavorable outcome and that of in-hospital death showed a yearly decrease over time.

Conclusions: AF patients showed favorable clinical outcome after ischemic stroke relative to patients without AF by adjustment using the NIHSS score and others. Initial stroke severity became milder and functional outcomes tended to improve in AF patients during the past 21 years.

Abstract WP88: Discrepant Nationwide Trends In Outcomes Of Acute Ischemic Stroke Depending On Severity: The Japan Stroke Data Bank

Background and Purpose: Whether specific patient groups have benefited from advances of treatment technologies including acute reperfusion therapy is uncertain. We aimed to investigate long-term trends of acute reperfusion therapy and functional outcomes according to the stroke severity using a large clinical registry.

Methods: In the nationwide, hospital-based, multicenter, prospective registry cohort from the Japan Stroke Data Bank between January 2000 and December 2020, patients with ischemic stroke were studied. The baseline National Institutes of Health Stroke Scale (NIHSS) score of 10 or more was considered as possible large vessel occlusions (LVOs). Secular changes were assessed per 5-year categories (2000-2005, 2006-2010, 2011-2015, 2016-2020). Outcomes included favorable outcome (mRS score was 0 to 2 at discharge), and in-hospital mortality.

Results: Of 235,695 patients, 127,741 ischemic stroke patients (76,850 men [60.2 %]; median age 75, [interquartile range, 66-82] years) with available data on NIHSS score were analyzed. NIHSS score was ≥10 in 31,747 patients (24.9%). In both patients with NIHSS ≥10 and those with NIHSS <10, the frequencies of intravenous thrombolysis (1.6% to 26.5%, and 0.3% to 6.9%, respectively) and endovascular therapy (2.0% to 29.8%, and 0.8% to 3.8%, respectively) increased from the 2000-2005 period to the 2015-2020 period. In patients with NIHSS ≥10, favorable outcome was more frequent in the 2015-2020 cohort than that in the 2000-2005 cohort (adjusted odds ratio, 1.63; [95% CI, 1.44-1.85]). In contrast, patients with NIHSS <10 had a decreased favorable outcome in the 2015-2020 cohort than that in the 2000-2005 cohort (adjusted odds ratio, 0.80; 95% CI, [0.75-0.85]). In-hospital mortality decreased in both patients with NIHSS ≥10 and NIHSS <10 per step on the 5-year categories.

Conclusions: Over the 20-year period, acute reperfusion therapy has increasingly been provided to patients with NIHSS ≥10. Favorable outcomes significantly increased in patients with NIHSS ≥10 but decreased in those with NIHSS <10 over time. In-hospital mortality decreased across all NIHSS scores.

Abstract WP201: Outcomes Of Ischemic And Hemorrhagic Stroke Patients With Cancer: Japan Stroke Data Bank

Purpose: We aim to clarify the association between history of cancer with clinical outcomes after ischemic stroke (IS) or hemorrhagic stroke (HS).

Methods: Study participants were adult patients within seven days after onset of IS or HS from the register of the Japan Stroke Data Bank, a hospital-based multicenter stroke registration database, between 2000 and 2021, whose modified Rankin Scale score at discharge was available. Participants were divided into three groups [active cancer (AC) group, inactive cancer (iAC) group, and without cancer group]. Outcomes including good functional outcome, representing modified Rankin Scale score 0-2 at discharge, and in-hospital death was compared between the groups using multivariate analysis by forward-backward stepwise selection method for stroke subtype. AC was defined as cancer diagnosed within six months, requiring chemotherapy or surgical treatment, metastatic, or inoperable.

Results: Of 171292 stroke patients, including 128145 with IS and 43147 with HS, 1074 patients had AC (women 42.5%; median age, 77 years; median (interquartile range) baseline National Institutes of Health Stroke Scale 5 [2–15]; IS 84.3%), 6337 patients had iAC (37.9%; 73 years; 4 [2–13]; 79.5%), and 163881 patients did not have cancer (42.4%; 73years; 4 [2–12]; 74.6%). Good functional outcome after IS was less common in cancer patients [AC; 39.4%, adjusted odds ratio (OR) 0.78, 95% confidence interval (CI) 0.71-0.86: iAC; 49.1%, adjusted OR 0.92, 95% CI 0.85-0.99] than those without cancer (56.3%), and mortality in cancer patients was higher (AC; 10.6%, adjusted OR 1.77, 95% CI 1.56-2.01: iAC; 5.6%, adjusted OR 1.26, 95% CI 1.09-1.47) than those without cancer (4.4%). Good functional outcome after HS was less common in cancer patients [AC; 22.0%, adjusted OR 0.81, 95% CI 0.61-1.07: iAC; 24.6%, adjusted OR 0.78, 95% CI 0.64-0.94] than those without cancer (35.3%), and mortality after HS was higher in AC patients (29.8%) than those without cancer (15.9%, adjusted OR 1.61, 95% CI 1.26-2.07)

Conclusions: IS patients with AC and those with iAC significantly had less achievement of good functional outcomes and more in-hospital death, and HS patients with AC led to more in-hospital death than patients without cancer.

Abstract TP182: Relationship Between Cardiovascular Calcification And Stroke Incidence

Purpose: To assess the relationship between cardiovascular calcifications including coronary artery (CAC), aortic valve (AVC), and aortic root (ARC) and stroke incidence in patients with suspected coronary artery disease (CAD).

Methods: In the multicenter prospective cohort study, 1187 patients with suspicious of CAD who underwent coronary computed tomography were registered. Cardiovascular events were recorded with prospective follow-up. Cox proportional hazard model with adjustment for total points of Framingham risk score composed with age, sex, total-cholesterol, high-density lipoprotein cholesterol, diabetes mellitus and smoking were conducted. Hazard ratio (HR) and 95% confidence interval (CI) were calculated.

Results: A total of 980 patients (mean age, 65 ± 7 years; female, 45.8%) with assessment of CAC, AVC and ARC Agatston scores were analyzed. During a median follow-up of 4.0 years), 19 patients developed stroke and 67 developed cardiac events. Cox proportional hazard analyses showed CAC or AVC Agatston scores were significantly associated with incidence of stroke (Agatston score [/+100 points], HR 1.09 [95% CI: 1.06-1.13], and HR 1.09 [95%CI: 1.05-1.13], respectively). In contrast, CAC or ARC Agatston scores were associated with incidence of cardiac events (Agatston score [/+100 points], HR 1.07 [95%CI: 1.05-1.10], and HR 1.04 [95%CI: 1.02-1.07], respectively).

Conclusion: Although higher CAC Agatston scores were significantly associated with incidence of both stroke and cardiac events, higher AVC and ARC were associated with incidence of stroke and cardiac events, respectively.

Abstract WP124: Stroke Severity And In-hospital Death In Intracerebral Hemorrhage Patients Taking Antithrombotic Agents: Japan Stroke Data Bank

Purpose: The purpose of this study was to determine the associations between antithrombotic agents at onset and outcomes in intracerebral hemorrhage (ICH) patients.

Methods: ICH patients admitted within 24 hours after onset from January 2017 to December 2020 were examined from a long-lasting nationwide hospital-based multicenter prospective registry, the Japan Stroke Data Bank. Patients were classified into 4 groups according to types of antithrombotic agents at onset: no-antithrombotic, antiplatelet, warfarin, and DOAC groups. Patients with combination of antiplatelet and anticoagulant agents were classified into respective anticoagulant groups. The outcomes were NIHSS on admission, in-hospital death and unfavorable outcome corresponding to mRS of 5-6 at discharge.

Results: Of a total of 9,948 ICH patients (female: 4,329, age 70±15 years old), 77.4% of patients were classified into the no-antithrombotic group, 13.0% into the antiplatelet group, 3.9% into the warfarin group and 5.7% into the DOAC group. Median NIHSS on admission was 12 (interquartile range: 5-22), 13 (5-26), 15 (5-30) and 13 (6-24), respectively. In multivariable analysis, the warfarin group was significantly associated with higher NIHSS on admission (adjusted incidence rate ratio, 1.08 [95% CI, 1.05-1.12], setting the no-antithrombotic group as reference), but the antiplatelet group (1.01 [0.99-1.03]) or the DOAC group (0.97 [0.94-1.00]) was not. The rate of in-hospital death was 13.0% in the no-antithrombotic group, 17.8% in the antiplatelet group, 27.3% in the warfarin group and 18.9% in the DOAC group and that of unfavorable outcome was 30,8%, 41.9%, 48.6% and 41.5%, respectively. In multivariable analysis, the warfarin group was significantly associated with in-hospital death and unfavorable outcome (adjusted odds ratio: 1.62 [95% CI, 1.07-2.46] and 1.79 [1.23-2.6], respectively, setting the no-antithrombotic group as reference), but the antiplatelet group (1.14 [0.87-1.36], 1.11 [0.90-1.36]) or the DOAC group (1.07 [0.72-1.60], 1.27 [0.90-1.78]) was not.

Conclusion: ICH patients taking warfarin at onset had higher NIHSS on admission, in-hospital death and unfavorable outcome compared to those without antithrombotic agents, but those taking DOAC did not.

Temporal Trends and Regional Variations in Cardiovascular Care in Japan, 2010-2019

Cardiovascular diseases are a major cause of mortality worldwide. Nonetheless, the current trend in cardiology hospitals in Japan has not been comprehensively explored.This descriptive study used the Japanese Registry of All Cardiac and Vascular Diseases database during 2010-2019. The nationwide 10-year trend in cardiovascular medical care systems was described in detail corresponding to the regions in Japan.Cardiovascular facilities and the number of cardiology beds, hospitalized patients, and cardiologists increased during 2010-2019. There were regional differences in the number of patients and cardiologists per bed, but the differences in the number of hospitalized patients per cardiologist decreased among the regions. Of the three major acute cardiovascular diseases, patients hospitalized with heart failure per cardiologist have been increasing. However, the in-hospital mortality rates have not changed over the last decade (8.6% for acute myocardial infarction, 7.7% for heart failure, and 12.7% for acute aortic dissection in 2019).There was an increasing trend in the availability of cardiovascular care resources in Japan during 2010-2019. This study provides a comprehensive summary of the current cardiovascular care and the follow-up required in the future.

Validity of Diagnostic Algorithms for Cardiovascular Diseases in Japanese Health Insurance Claims

BACKGROUND

We aimed to validate a claims-based diagnostic algorithm to identify hospitalized patients with acute major cardiovascular diseases (CVDs) from health insurance claims in Japan.Methods and Results: This retrospective multicenter validation study was conducted at 4 institutes, including Japanese Circulation Society-certified and uncertified hospitals in Japan. Data on patients with CVDs in departmental lists or with International Classification of Diseases, 10th Revision (ICD-10) codes for CVDs hospitalized between April 2018 and March 2019 were extracted. We examined the sensitivity and positive predictive value of a diagnostic algorithm using ICD-10 codes, medical examinations, and treatments for acute coronary syndrome (ACS), acute heart failure (HF), and acute aortic disease (AAD). We identified 409 patients with ACS (mean age 70.6 years; 24.7% female), 615 patients with acute HF (mean age 77.3 years; 46.2% female), and 122 patients with AAD (mean age 73.4 years; 36.1% female). The respective sensitivity and positive predictive value for the algorithm were 0.86 (95% confidence interval [CI] 0.82-0.89) and 0.95 (95% CI 0.92-0.97) for ACS; 0.74 (95% CI 0.70-0.77) and 0.79 (95% CI 0.76-0.83) for acute HF; and 0.86 (95% CI 0.79-0.92) and 0.83 (95% CI 0.76-0.89) for AAD.

CONCLUSIONS

The validity of the diagnostic algorithm for Japanese claims data was acceptable. Our results serve as a foundation for future studies on CVDs using nationwide administrative data.

Differences in patient characteristics, clinical practice and outcomes of cardiac implantable electric device therapy between Japan and the USA: a cross-sectional study using data from nationally representative administrative databases

OBJECTIVES

To identify differences in patient characteristics, clinical practice and outcomes of cardiac implantable electronic device (CIED) therapy between Japan and the USA.

DESIGN

A cross-sectional study.

SETTING

Nationally representative administrative databases from Japan and the USA containing hospitalisations with first-time implantations of pacemakers, implantable cardioverter-defibrillators (ICD) and cardiac-resynchronisation therapy with or without defibrillators (CRTP/CRTD).

PARTICIPANTS

Patients hospitalised with first-time implantations of CIEDs.

OUTCOME MEASURES

In-hospital mortality, in-hospital complication and 30-day readmission rates.

RESULTS

Overall, 107 339 (median age 78 (71-84), 48 415 women) and 295 584 (age 76 (67-83), 127 349 women) records with CIED implantations were included from Japan and the USA, respectively. Proportion of women in defibrillator recipients was lower in Japan than in the USA (ICD, 21% vs 28%, p<0.001; CRTD, 24% vs 29%, p<0.001). Length of stay after CIED implantation was longer in Japan than in the USA for all device types (conventional pacemaker, 8(7-11) vs 1 (1-3) days, p<0.001; leadless pacemaker, 5 (3-9) vs 2 (1-5) days, p<0.001; ICD, 8 (7-11) vs 1 (1-3) days, p<0.001, CRTP, 9 (7-13) vs 2 (1-4) days, p<0.001; CRTD, 9 (8-14) vs 2 (1-4) days, p<0.001). In-hospital mortality after CIED implantation was similar between Japan and the USA ((OR) (95% CI), conventional pacemaker 0.58 (0.83 to 1.004); ICD 0.77 (0.57 to 1.03); CRTP 0.85 (0.51 to 1.44); CRTD 1.11 (0.81 to 1.51)), except that after leadless pacemaker implantation in Japan was lower than that in the USA (0.32 (0.23 to 0.43)). 30-day readmission rates were lower in Japan than in the USA for all device types (conventional pacemaker 0.55 (0.53 to 0.57); leadless pacemaker 0.50 (0.43 to 0.58); ICD 0.54 (0.49 to 0.58); CRTP 0.51 (0.42 to 0.62); CRTD 0.57 (0.51 to 0.64)).

CONCLUSIONS

International variations in patient characteristics, practice and outcomes were observed. In-hospital mortality after CIED implantation was similar between Japan and the USA, except in cases of leadless pacemaker recipients.

Hyperuricemia predicts increased cardiovascular events in patients with chronic coronary syndrome after percutaneous coronary intervention: A nationwide cohort study from Japan

Background

The causal relationship between hyperuricemia and cardiovascular diseases is still unknown. We hypothesized that hyperuricemic patients after percutaneous coronary intervention (PCI) had a higher risk of major adverse cardiovascular events (MACE).

Methods

This was a large-scale multicenter cohort study. We enrolled patients with chronic coronary syndrome (CCS) after PCI between April 2013 and March 2019 using the database from the Clinical Deep Data Accumulation System (CLIDAS), and compared the incidence of MACE, defined as a composite of cardiovascular death, myocardial infarction, and hospitalization for heart failure, between hyperuricemia and non-hyperuricemia groups.

Results

In total, 9,936 patients underwent PCI during the study period. Of these, 5,138 patients with CCS after PCI were divided into two group (1,724 and 3,414 in the hyperuricemia and non-hyperuricemia groups, respectively). The hyperuricemia group had a higher prevalence of hypertension, atrial fibrillation, history of previous hospitalization for heart failure, and baseline creatinine, and a lower prevalence of diabetes than the non-hyperuricemia group, but the proportion of men and age were similar between the two groups. The incidence of MACE in the hyperuricemia group was significantly higher than that in the non-hyperuricemia group (13.1 vs. 6.4%, log-rank P < 0.001). Multivariable Cox regression analyses revealed that hyperuricemia was significantly associated with increased MACE [hazard ratio (HR), 1.52; 95% confidential interval (CI), 1.23-1.86] after multiple adjustments for age, sex, body mass index, estimated glomerular filtration rate, left main disease or three-vessel disease, hypertension, diabetes mellitus, dyslipidemia, history of myocardial infarction, and history of hospitalization for heart failure. Moreover, hyperuricemia was independently associated with increased hospitalization for heart failure (HR, 2.19; 95% CI, 1.69-2.83), but not cardiovascular death or myocardial infarction after multiple adjustments. Sensitive analyses by sex and diuretic use, B-type natriuretic peptide level, and left ventricular ejection fraction showed similar results.

Conclusion

CLIDAS revealed that hyperuricemia was associated with increased MACE in patients with CCS after PCI. Further clinical trials are needed whether treating hyperuricemia could reduce cardiovascular events or not.

Current status and future aspects in the Japan Stroke Data Bank

The Japanese National Plan for the Promotion of Measures Against Cerebrovascular and Cardiovascular Diseases was formulated on October 27, 2020. One purpose of this plan was to promote research on cerebrovascular and cardiovascular diseases. Therefore, it is necessary to clarify the actual status of stroke treatment in Japan and operate a national stroke database with high public interest completely and accurately. The Japan Stroke Data Bank (JSDB; https://strokedatabank.ncvc.go.jp/en/) was established by the Ministry of Health, Labor and Welfare Scientific Research in Shimane University (Shimane, Japan) in 1999 and was transferred to the National Cerebral and Cardiovascular Center (Osaka, Japan) as a part of the Cardiovascular Disease Registry in 2015. More than 200,000 of stroke cases have been registered using individual forms from more than 100 nationwide stroke centers over ~20 years. Since there are few large-scale stroke registries with nationwide coverage in Asia, including Japan, compared with those in Europe and North America, the role of the JSDB in the plan will be important in the future. To construct a high-quality stroke registry, we aimed to (1) collect detailed data through individual questionnaires for each participating stroke center, (2) link to external databases (e.g., insurance claims and public death registries), (3) improve the quality of treatment at participating hospitals through benchmarking, and (4) obtain stable funding through sustained support from government and academic societies. We also describe the history of the JSDB and changes in the trend of real-world stroke treatment in Japan based on the results of analysis of data in the JSDB.

Outpatient cardiac rehabilitation dose after acute coronary syndrome in a nationwide cohort

OBJECTIVE

Cardiac rehabilitation (CR) is effective in patients with acute coronary syndrome (ACS); however, CR programmes have not been fully implemented. This study aimed to reveal the current practice of outpatient CR and the dose-effect relationship of CR in real-world settings.

METHODS

We performed a nationwide retrospective cohort study using the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients with ACS who underwent percutaneous coronary intervention between April 2014 and March 2018 were included. We analysed the implementation rate and dose of outpatient CR and the association between dose and outcomes.

RESULTS

Out of 202 320 patients who underwent percutaneous coronary intervention for ACS, a total of 20 444 (10%) underwent outpatient CR. The median (IQR) number of total CR sessions was 9 (3-17), and the median (IQR) duration for each session was 60 (42-60) min. Patients were divided into four groups according to the total number of sessions (≤9 times or ≥10 times) and the duration per session (<50 min or ≥50 min). Compared with the low-number/short-duration group, the adjusted HR for all-cause mortality was 1.00 (95% CI 0.80 to 1.24, p=0.97) in the low-number/long-duration group, 0.63 (95% CI 0.46 to 0.87, p=0.005) in the high-number/short-duration group and 0.74 (95% CI 0.60 to 0.92, p=0.008) in the high-number/long-duration group, respectively.

CONCLUSION

We found that the participation rate for outpatient CR after ACS was low and the doses of sessions vary in real-world settings. A higher number of total sessions of outpatient CR is associated with a better prognosis irrespective of the session's duration.

Hospital- and Patient-Level Analysis of Quality Indicators in Acute Coronary Syndrome Care: A Nationwide Database Study

BACKGROUND

This study aimed to clarify the variations in the quality of care provided to patients with acute coronary syndrome (ACS) and to investigate the association between quality of care and mortality at both hospital and patient levels with the use of a nationwide database.

METHODS

Patients with ACS who underwent percutaneous coronary intervention (PCI) from April 2014 to March 2018 were included from the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Twelve quality indicators (QIs) available from administrative data and the association of the QIs with all-cause mortality were investigated.

RESULTS

From the analysis of 216,436 patients from 1215 hospitals, adherence to PCI on admission day, aspirin use on arrival, P2Y12 inhibitor use, and left ventricular function assessment were high (median proportion > 90%), and adherence to outpatient cardiac rehabilitation was low (median proportion < 10%). At the hospital level, acute-phase composite QI score was associated with reduced risk-adjusted 30-day mortality (β = -0.92 [95% confidence interval -1.19 to -0.65]; P < 0.001). At the patient level, all acute-phase and subacute-phase QIs were inversely associated with 30-day and 2-year mortalities, respectively (all P < 0.001).

CONCLUSIONS

Substantial variations in ACS care were observed in the current nationwide database. High adherence to the QI sets was associated with significant survival gains at both hospital and patient levels. Multilevel approach in QI assessment may be effective for improvement of survival in this population.

Clinical Predictors of Pacing Device Implantation in Implantable Cardiac Monitor Recipients for Unexplained Syncope

Background

Implantable cardiac monitors (ICMs) help investigate the cause of unexplained syncope, but the probability and predictors of needing a pacing device thereafter remain unclear.

Methods

We retrospectively analyzed the data of patients who received ICM insertion for unexplained syncope with suspected arrhythmic etiology. The data were obtained from a nationwide database obtained between April 1, 2012 and March 31, 2020. Multivariable mixed-effects survival analysis was performed to identify predictors of pacing device implantation (PDI), and a risk score model was developed accordingly.

Results

In total, 2905 patients (age: 72 years [range: 60-78]) implanted with ICMs to investigate the cause of syncope were analyzed. During the median follow-up period of 128 days (range: 68-209) days, 473 patients (16%) underwent PDI. Older age, history of atrial fibrillation, bundle branch block (BBB), and diabetes were independent predictors of PDI in multivariable analysis. A risk score model was developed with scores ranging from 0 to 32 points. When patients with the lowest quartile score (0-13 points) were used as a reference, those with higher quartiles had a higher risk of PDI (second quartile: 14-15 points, hazard ratio [HR]: 3.86, 95% confidence interval [CI]: 2.62-5.68; third quartile: 16-18 points, HR: 4.67, 95% CI: 3.14-6.94; fourth quartile: 19-32 points, HR: 6.59, 95% CI: 4.47-9.71).

Conclusions

The 4 identified predictors are easily assessed during the initial evaluation of patients with syncope. They may help identify patients with a higher risk of requiring permanent PDI.

Multifactorial Effects of Outpatient Cardiac Rehabilitation in Patients with Heart Failure: A Nationwide Retrospective Cohort Study

AIM

Although cardiac rehabilitation (CR) is a strongly recommended therapy, no large study has assessed the effects of outpatient CR in patients with heart failure (HF) in real-world settings. Therefore, this study aimed to investigate the multifactorial effects of outpatient CR in patients with HF using a nationwide database.

METHODS AND RESULTS

This nationwide retrospective cohort study was performed using the National Database of Health Insurance Claims and Specific Health Checkups of Japan. Patients with acute HF who underwent inpatient CR between April 2014 and March 2020 were included. The association between outpatient CR participation and all-cause mortality, rehospitalisation for HF, use of medical resources, and medical costs was analysed using propensity score matching analysis. Of 250,528 patients, 17,884 (7.1%) underwent outpatient CR. After propensity score matching, the CR (+) group was associated with a reduction in the risk of all-cause mortality (hazard ratio [HR]: 0.64, 95% confidence interval [CI]: 0.60-0.68, p < 0.001) and rehospitalisation for HF compared to the CR (-) group (HR: 0.87, 95% CI: 0.82-0.92, p < 0.001). The proportion of guideline-based medication use for HF at 1 year was higher in the CR (+) group than in the CR (-) group. The total medical costs from the index hospitalisation to 1.5 years after admission were similar between the groups.

CONCLUSION

Outpatient CR participation after discharge from HF was associated with reduced mortality and rehospitalisation for HF without increasing medical costs.

Efficacy of Early Cardiac Rehabilitation After Cardiac Surgery - Verification Using Japanese Diagnosis Procedure Combination Data

Background: The current status of cardiac rehabilitation (CR) after cardiac surgery and the introduction of early CR (E-CR) in Japan are not fully understood. In this study, the current status of E-CR and its efficacy were investigated by the Academic Committee of the Japanese Association of Cardiac Rehabilitation. Methods and Results: We examined the rate of introduction of E-CR and its effects among 220,122 patients who underwent major cardiac and thoracic vascular surgery, as registered in the Diagnosis Procedure Combination (DPC) classification system, between April 2012 and March 2018. In this study, E-CR was defined as CR starting within 1 day after surgery. Patients with and without E-CR were propensity score matched and analyzed for clinical outcomes. Of all patients participating in CR after surgery, E-CR was initiated in 52.1%, 56.9%, 47.4%, and 54.1% of patients undergoing coronary artery bypass grafting, valve surgery, aortic surgery, and other cardiovascular surgery, respectively. After propensity score matching, outcomes for E-CR were significantly superior to non-E-CR in terms of in-hospital deaths, Barthel Index score at discharge, length of hospital stay, and hospitalization costs. Conclusions: E-CR after cardiac surgery was effective in terms of prognosis, hospital stay, and medical costs. This study is the first report using big data in Japan. The results indicate that further introduction of E-CR needs to be recommended in the future.

Mortality and 30-Day Readmission Rates After Inpatient Leadless Pacemaker Implantation: Insights From a Nationwide Readmissions Database

BACKGROUND

This study aimed to provide real-world data on the rates, trends, and predictors of in-hospital complications and 30-day readmission following leadless pacemaker (LP) implantation.

METHODS

We analysed leadless and conventional pacemaker implantations with the use of the all-payer, nationally representative Nationwide Readmissions Database from 2017 to 2019. The national trends of in-hospital mortality, in-hospital complications, and 30-day readmission rates after pacemaker implantation were analysed. Mixed-effects multivariable logistic regression analysis was performed to identify factors associated with in-hospital death and 30-day readmission in LP patients.

RESULTS

A total of 137,732 admissions (age 78 years, IQR 70-85 years, 5986 LP implantations) were analysed. The in-hospital mortality, overall in-hospital complication, and 30-day readmission rates after LP implantations were 5.0%, 16%, and 16%, respectively. In LP recipients, the national estimate of in-hospital mortality declined from 10.9% in the second quarter of 2017 to 4.3% in the fourth quarter of 2019 (P < 0.001). Furthermore, the national estimate of overall complications declined from 20.6% in the second quarter of 2017 to 13.0% in the fourth quarter of 2019 (P < 0.001). In LP recipients, female sex, history of chronic kidney disease, heart failure, and malnutrition were factors associated with in-hospital death.

CONCLUSIONS

Analysis of the nationally representative claims database from the United States showed in-hospital mortality and complication rates (for LP implantation performed during hospitalisation) of 5.0% and 16%, respectively. Although these rates showed a decreasing trend over time, ongoing surveillance is needed for the safety of LP implantation.

Mortality and 30-day readmission rate following leadless pacemaker implantation: insights from the Nationwide Readmissions Database

Background

Clinical trials and registry data showed encouraging outcomes for leadless pacemaker (LP) implantation. However, reports of patient characteristics, trends, and clinical outcomes in a real-world population are limited.

Purpose

To provide real-world evidence of the rates, trends, and patient characteristics associated with in-hospital complications and 30-days readmission after LP implantations.

Methods

Using the all-payer, nationally representative Nationwide Readmissions Database between 2017 and 2019, we analyzed leadless or conventional pacemaker implantations. The national trends of in-hospital mortality, in-hospital complication rates and 30-day readmission rates after pacemaker implantation and their national trends were analyzed. Mixed-effects multivariable logistic regression analysis was performed to identify factors associated with in-hospital death and 30-days readmission in LP patients.

Results

A total of 137,732 admissions (age: 78 [70–85], 5,986 LP implantations) were analyzed (Figure 1). The in-hospital mortality, overall in-hospital complication rate, and 30-days readmission rates after LP implantations were 5.0%, 16%, and 16%, respectively. In LP recipients, the national estimate of in-hospital mortality declined from 10.9% in the second quarter of 2017 to 4.3% in the fourth quarter of 2019 (P&lt;0.001) (Figure 2a). Furthermore, the national estimate of overall complication rate declined from 20.6% in the second quarter of 2017 to 13.0% in the fourth quarter of 2019 (P&lt;0.001) (Figure 2b). Conversely, non-elective 30-day readmission rate did not show any increasing or decreasing trends in LP recipients (P=0.74) (Figure 2c). In LP recipients, female sex (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.04–1.93), history of heart failure (OR 2.02, 95% CI 1.46–2.79), and first quartile annual pacemaker implantation hospital volume (OR 2.49, 95% CI 1.56–3.97, fourth quartile annual pacemaker implantation hospital volume used as a reference standard) were factors associated with in-hospital death.

Conclusions

Analysis of the nationally representative claims database in the US showed in-hospital mortality, complication rates, and non-elective 30-day readmission rate of 5.0%, 16%, and 16% respectively, for LP implantation performed during hospitalization. Although in-hospital mortality and complication rates showed a decreasing trend over time, ongoing surveillance is needed for the safety of LP implantation.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Intramural research fund (21-6-9)for cardiovascular diseases of national cerebral and cardiovascular center.

Hospital-associated disability and hospitalization costs for acute heart failure stratified by body mass index- insight from the JROAD/JROAD-DPC database

BACKGROUND

The impact of body mass index (BMI) on hospital mortality in patients with acute heart failure has been well documented in Asian populations. However, the relationship between BMI, hospital-associated disability (HAD), and hospitalization costs in patients with heart failure is poorly understood. This study aimed to explore the impact of BMI on HAD and hospitalization costs for acute heart failure in Japan.

METHODS

From April 2012 to March 2020, the Japanese Registry of All Cardiac and Vascular Disease Diagnosis Procedure Combination (JROAD-DPC) database was used to identify patients with acute heart failure. All patients were categorized into five groups according to the World Health Organization Asian BMI criteria. The hospitalization costs and HAD were evaluated.

RESULTS

Among the 238,160 eligible patients, 15.7% were underweight, 42.2% were normal, 16.7% were overweight, 19.3% were obese I, and 6.0% were obese II, according to BMI. The prevalence of HAD was 7.43% in the total cohort, and the risk of HAD increased with a lower BMI. Restricted cubic spline analysis showed a U-shaped relationship between BMI and hospitalization costs for all ages. Furthermore, developing HAD was associated with greater costs compared with non-HAD, regardless of BMI category.

CONCLUSIONS

We found that the lower the BMI, the higher the incidence of HAD. A U-shaped association was confirmed between BMI and hospitalization costs, indicating that hospitalization costs increased for both lower and higher BMI regardless of age. BMI could be an important and informative risk stratification tool for functional outcomes and economic burdens.