The Cut-off Value of Physical Activity for Undergoing Total Knee Arthroplasty in Patients with Knee Osteoarthritis

BACKGROUND

We aimed to determine a cut-off value for physical activity (PA), measured using an accelerometer, between patients with knee osteoarthritis (OA) who decided to undergo total knee arthroplasty (TKA) and those who continued conservative treatment.

METHODS

Forty-two participants were assigned to either a TKA group or a non-TKA group (21 per group). They were instructed to wear an accelerometer throughout the day. Average daily steps (steps/day), average daily time of light PA (LPA) (min/day), and average daily time of moderate-to-vigorous PA (MVPA) (min/day) were measured for seven days. Variables between the two groups were compared using univariate analyses, and then a stepwise logistic regression was conducted to determine which variables best correlated with undergoing TKA. The PA cut-offs were analysed using the receiver operating characteristic curve.

RESULTS

Pain severity (p = 0.002), KL grade (p = 0.001), and MVPA (p = 0.012) differed significantly between the groups. The most useful cut-off value was 5.84 (min/day) for MVPA (AUC = 0.773), although only pain severity and KL grade were found to be significant contributors to undergoing TKA.

CONCLUSIONS

Our results revealed there was a significant decrease in PA levels (MVPA cut-off, 5-6 min/day) in the TKA group compared with the non-TKA group.

Exercise Training and Cardiac Rehabilitation in COVID-19 Patients with Cardiovascular Complications: State of Art

Recent scientific literature has investigated the cardiovascular implications of COVID-19. The mechanisms of cardiovascular damage seem to involve the protein angiotensin-converting enzyme 2 (ACE2), to which severe acute respiratory syndrome (SARS) coronavirus-2 (CoV-2) binds to penetrate cells and other mechanisms, most of which are still under study. Cardiovascular sequelae of COVID-19 include heart failure, cardiomyopathy, acute coronary syndrome, arrhythmias, and venous thromboembolism. This article aims to collect scientific evidence by exploiting PubMed, Scopus, and Pedro databases to highlight the cardiovascular complications of COVID-19 and to define the physiotherapy treatment recommended for these patients. Exercise training (ET), an important part of cardiac rehabilitation, is a powerful tool in physiotherapy, capable of inducing significant changes in the cardiovascular system and functional in the recovery of endothelial dysfunction and for the containment of thromboembolic complications. In conclusion, due to the wide variety of possible exercise programs that can be obtained by combining intensity, duration, and speed in various ways, and by adjusting the program based on continuous patient monitoring, exercise training is well suited to the treatment of post-COVID patients with an impaired cardiovascular system of various degrees.

Clinical characteristics and prognostic factors in elderly patients with chronic heart failure -A report from the CHART-2 study

Background

Since most of the randomized clinical trials for heart failure (HF) were designed to exclude elderly patients, limited data are available on their clinical characteristics, prognosis, and prognostic factors.

Methods

We compared clinical characteristics, prognosis, and prognostic factors among Stage C/D HF patients in our CHART-2 Study (N = 4876, mean 69 years, women 32%, 6.3-year follow-up) by age (G1, ≤64 years, N = 1521; G2, 65–74 years, N = 1510; and G3, ≥75 years, N = 1845).

Results

From G1 to G3, the prevalence of women, left ventricular ejection fraction (LVEF) and plasma levels of B-type natriuretic peptide (BNP) increased (all P < 0.001). Similarly, 5-year mortality increased (9.9, 17.3 to 39.9%, P < 0.001) along with a decrease in proportion of cardiovascular death and an increase in non-cardiovascular death in both sexes. While all-cause and cardiovascular mortality was comparable between the sexes, women had significantly lower incidence of non-cardiovascular death than men in G2 and G3, which was attributable to the higher incidence of cancer death and pneumonia death in men than in women. Although NYHA functional class III-IV, chronic kidney disease, cancer, LVEF, and BNP had significant impacts on all-cause death in all groups, their impacts were less evident in G3 as compared with G1.

Conclusions

The elderly HF patients, as compared with younger HF patients, were characterized by more severe clinical background, increased proportion of non-cardiovascular death and worse prognosis with different impacts of prognostic factors across the age groups.

Self-reported and objectively measured physical activity in people with and without chronic heart failure: UK Biobank analysis

Objective

The impact of heart failure (HF) on perceived and objectively measured levels of physical activity (PA) can inform risk stratification and treatment recommendation. We aimed to compare self-reported and objectively measured PA levels in a large sample of participants with and without HF.

Methods

A validated PA questionnaire was used to estimate self-reported weekly PA among 1600 participants with HF and 387 580 participants without HF. Accelerometer data were studied in 596 participants with HF and 96 105 participants without HF for a period of 7 days. Using multivariable linear regression models, we compared the PA levels between participants with HF and without HF, focusing on both the average daily PA levels and the intensity of PAs throughout the day.

Results

PA levels were significantly lower in participants with HF using both self-report (excess metabolic equivalent of task hours per week of 26.5 (95% CI 24.7 to 28.4) vs 34.7 (95% CI 34.5 to 34.9), respectively (p<0.001)) and accelerometer measures (mean accelerations of 23.7 milligravity (95% CI 23.1 to 24.4) vs 28.1 milligravity (95% CI 28.0 to 28.1), respectively (p<0.001)). Findings were consistent across different PA intensities. Hour-by-hour comparisons showed that accelerometer-derived PA levels of patients with HF were reduced throughout the day.

Conclusion

Perceived and objectively recorded PA levels of patients with chronic HF are significantly lower than those of individuals without HF. This difference is continuous throughout the different hours of the day, with individuals with HF being on average 16% less active than individuals without HF. In patients with HF, increases in everyday activity may be a potential alternative to structured exercise programmes.

Soluble urokinase-type plasminogen activator receptor represents exercise tolerance and predicts adverse cardiac events in patients with heart failure

Soluble urokinase-type plasminogen activator receptor (suPAR) is a membrane-binding protein that is released into the blood stream by immune activation. Recent reports suggest that circulating suPAR levels are associated with adverse cardiovascular outcomes. Exercise tolerance is an independent predictor of prognosis in patients with heart failure (HF); however, the relationship between serum suPAR level and exercise tolerance is unclear. We prospectively enrolled 94 patients who were hospitalized for worsening of HF. All patients underwent a symptom-limited cardiopulmonary exercise test to evaluate exercise tolerance. The median value of serum suPAR was 4848 pg/ml. During follow up, 44 patients (47%) were admitted for all-cause mortality and re-hospitalization for HF. Median serum suPAR was significantly higher in the patients with cardiac events than in the patients with non-event group. Patients were divided into two groups according to circulating suPAR levels. Kaplan-Meier analysis demonstrated that adverse cardiac events were significantly higher in the high suPAR group (log-rank p = 0.023). Multivariate analysis revealed that suPAR was independently correlated with the parameters of exercise tolerance such as anaerobic threshold (p = 0.007) and peak oxygen uptake (p = 0.005). suPAR levels predicted adverse cardiac events and independently correlated with the parameters of exercise tolerance. suPAR could be a useful surrogate biomarker of exercise tolerance in patients with HF.

Increased Physical Activity Post-Myocardial Infarction Is Related to Reduced Mortality: Results From the SWEDEHEART Registry

Background

With increasing survival rates among patients with myocardial infarction (MI), more demands are placed on secondary prevention. While physical activity (PA) efforts to obtain a sufficient PA level are part of secondary preventive recommendations, it is still underutilized. Importantly, the effect of changes in PA after MI is largely unknown. Therefore, we sought to investigate the effect on survival from changes in PA level, post‐MI.

Methods and Results

Data from Swedish national registries were combined, totaling 22 227 patients with MI. PA level was self‐reported at 6 to 10 weeks post‐MI and 10 to 12 months post‐MI. Patients were classified as constantly inactive, increased activity, reduced activity, and constantly active. Proportional hazard ratios were calculated. During 100 502 person‐years of follow‐up (mean follow‐up time 4.2 years), a total of 1087 deaths were recorded. Controlling for important confounders (including left ventricular function, type of MI, medication, smoking, participation in cardiac rehabilitation program, quality of life, and estimated kidney function), we found lower mortality rates among constantly active (hazard ratio: 0.29, 95% confidence interval: 0.21–0.41), those with increased activity (0.41, 95% confidence interval: 0.31–0.55), and those with reduced activity (hazard ratio: 0.56, 95% confidence interval: 0.45–0.69) during the first year post‐MI, compared with those being constantly inactive. Stratified analyses indicated strong effect of PA level among both sexes, across age, MI type, kidney function, medication, and smoking status.

Conclusions

The present article shows that increasing the PA level, compared with staying inactive the first year post‐MI, was related to reduced mortality.

Factors limiting habitual exercise in patients with chronic heart failure: a multicenter prospective cohort study

Physical activity (PA) in the daily life is strongly related to prognosis in patients with or at high risk of heart failure (HF). However, factors limiting habitual exercise and their prognostic impacts remain unknown in HF patients. We sent questionnaires asking factors limiting habitual exercise in the daily life to 8370 patients with Stage A/B/C/D HF in our nationwide registry and received valid responses from 4935 patients (mean age 71.8 years, 71.0% male). Among the 5 components consisting of "busyness", "weak will", "dislike, "socioeconomic reasons" and "diseases" in the questionnaires, "busyness" (34.5%) and "diseases" (34.7%) were the most frequently reported factors limiting habitual exercise, while "socioeconomic reasons" were the least (15.3%). Multiple Cox proportional hazard models indicated that "busyness"and "diseases" were associated with better (hazard ratio (HR) 0.53, 95% confidence interval (CI) 0.39-0.72, P < 0.001) and worse prognosis (HR 1.57, 95% CI 1.21-1.98, P < 0.001), respectively, while other components were not. Furthermore, it was noted that, while prognostic relevance of "busyness" limiting exercise did not differ by age or sex, negative impact of "diseases" was particularly evident in patients with age < 75 years (P for interaction < 0.01). Factors limiting habitual exercise were associated with "busyness" and "diseases", but not with "weak will", "dislike, or "socioeconomic reasons". While "busyness" was associated with better prognosis regardless of age and sex, "diseases" was associated with worse prognosis in younger populations. Thus, physicians may pay more attentions to the reasons that limit exercise in the daily lives of HF patients rather than the low amount of exercise itself.

Increased Activity in Patients with Cardiovascular Risk Factors Increases Heart Rate Variability

This study evaluated the effect of increased physical activity on high-frequency (HF) heart rate variability (HRV) during the first hour after sleep onset in patients with hypertension and/or stable angina pectoris. Physical activity and HF were measured using activity monitors and 24-hour Holter monitors at baseline and 6 months later. The physical activity increased in 28 patients (increase group) and decreased in 20 patients (decrease group) after 6 months. In this study, after 6 months, compared to the decreased physical activity group, the increased physical activity group showed a significant increase in the HF index during the first hour after sleep onset. Therefore, the increase in the HF index may have been due to the increase in physical activity. An increase in physical activity suggests that the quality of sleep early in the sleep cycle may be improved, which may affect the patient's prognosis.

Influence of Baseline Physical Activity Level on Exercise Training Response and Clinical Outcomes in Heart Failure: The HF-ACTION Trial

OBJECTIVES

This study sought to evaluate the influence of baseline physical activity (PA) on responses to aerobic exercise training and clinical events in outpatients with chronic systolic heart failure (HF) from the multicenter HF-ACTION (Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure) trial.

BACKGROUND

The influence of baseline PA on exercise capacity, responses to exercise training and clinical outcomes in patients with chronic HF is unclear.

METHODS

Of 2,130 participants who provided consent for this analysis, 1,494 patients (64%) had complete baseline PA data, using a modified version of the International Physical Activity Questionnaire-Short Form questionnaire and were included in the analysis; 742 received usual care and 752 were allocated to the exercise training group. Changes in exercise capacity, all-cause mortality and hospitalization, cardiovascular (CV) mortality and hospitalization, and CV mortality and HF hospitalization were evaluated as a function of baseline PA tertile.

RESULTS

At baseline, the highest PA tertile showed greater peak oxygen uptake, cardiopulmonary exercise test duration, and 6-min walk test distance than the other 2 PA tertiles, as well as lower New York Heart Association functional class, lower Beck depression score, and lower atrial fibrillation prevalence than the lowest PA tertile. Compared to the lowest PA tertile, the middle tertile had 18% lower risk of CV death/CV hospitalizations, and the upper tertile showed 23% lower risk of CV death/HF hospitalizations. Exercise capacity and clinical outcome responses to training were similar and largely nonsignificant across baseline PA tertiles with significant benefit of training on exercise test duration for all tertiles.

CONCLUSIONS

In patients with chronic systolic HF, aerobic exercise training significantly improves exercise test duration to a similar extent across baseline PA tertiles. Although higher baseline PA was associated with lower risk of clinical events, no significant differences in event rates within each PA tertile were seen between subgroups randomized to exercise training versus usual care. (Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure [HF-ACTION]; NCT00047437).

Combined Exercise and Inspiratory Muscle Training in Patients With Heart Failure: A SYSTEMATIC REVIEW AND META-ANALYSIS

PURPOSE

Studies have reported the benefits of exercise and inspiratory muscle training (IMT) in patients with heart failure (HF); however, there is no meta-analysis on the effects of the combination of exercise and IMT in patients with HF. The objective of this study was to determine whether combined exercise/IMT was more effective than conventional exercise on exercise capacity, respiratory muscle strength, and quality of life in patients with HF.

METHODS

This is a systematic review and meta-analysis. We searched MEDLINE, LILACS, CINAHL, EMBASE, PEDro, and the Cochrane Central Register of Controlled Trials (from the earliest date available to April 2015) for randomized controlled trials, examining effects of combined exercise/IMT versus conventional exercise on exercise capacity, respiratory muscle strength, and quality of life measurements in patients with HF. Two reviewers selected studies independently. Weighted mean differences and 95% CIs were calculated.

RESULTS

Three studies met the study criteria. Combined exercise/IMT resulted in improvement in maximal inspiratory pressure weighted mean differences (20.89 cm H2O; 95% CI, 14.0-27.78) and Minnesota Living with Heart Failure Questionnaire weighted mean differences (4.43; 95% CI, 0.72-8.14). Nonsignificant difference was observed in peak (Equation is included in full-text article.)O2 for participants in the combined exercise/IMT group compared with the conventional exercise group. No serious adverse events were reported.

CONCLUSIONS

Combined exercise/IMT may improve maximal inspiratory pressure and quality of life in patients with HF and should be considered for inclusion in cardiac rehabilitation programs.

Lifestyle Medicine and the Management of Cardiovascular Disease

PURPOSE OF REVIEW

Evidence has clearly demonstrated the importance of lifestyle factors (e.g., diet, physical activity, smoking) in the development of cardiovascular disease (CVD). Interventions targeting these behaviors may improve outcomes for CVD patients. The aim of this review is to summarize the effects of lifestyle interventions in individuals with established CVD.

RECENT FINDINGS

Most recent trials focused on diet, physical activity, stress reduction, or a combination of these. Findings were mixed, but most interventions improved at least some markers of cardiovascular risk. Few studies measured long-term clinical outcomes, but some suggested a possible benefit of stress reduction and multifaceted interventions on cardiovascular events. The benefits of lifestyle change for CVD patients have been established by decades of evidence. However, further research is needed to determine the optimal intensity, duration, and mode of delivery for interventions. Additional studies with long-term follow-up and measurement of clinical outcomes are also needed.

Changes in physical activity and risk of all-cause mortality in patients on maintence hemodialysis: a retrospective cohort study

Background

A previous cohort study indicated a significant association of lower baseline level of physical activity in hemodialysis patients with elevated risks of mortality. However, there have been no reports regarding the association between changes in physical activity over time and mortality in hemodialysis patients. This study was performed to examine the prognostic significance of physical activity changes in hemodialysis patients.

Methods

This retrospective cohort study was performed in 192 hemodialysis patients with a 7-year follow-up. The average number of steps taken per non-dialysis day was used as a measure of physical activity. Forty (20.8%) patients had died during the follow-up period. The percentage change in physical activity between baseline and 12 months was determined, and patients were divided into three categories according to changes in physical activity. A decrease or increase in physical activity > 30% was defined as becoming less or more active, respectively, while decrease or increase in physical activity < 30% were classified as stable.

Results

Forty seven (24.5%), 51 (26.6%), and 94 (49.0%) patients were classified as becoming less active, becoming more active, and stable, respectively. The hazard ratio on multivariate analysis in patients with decreased physical activity was 3.68 (95% confidence interval, 1.55–8.78; P < 0.01) compared to those with increased physical activity.

Conclusions

Reductions in physical activity were significantly associated with poor prognosis independent of not only patient characteristics but also baseline physical activity. Therefore, improved prognosis in hemodialysis patients requires means of preventing a decline in physical activity over time.

Addition of non-invasive ventilatory support to combined aerobic and resistance training improves dyspnea and quality of life in heart failure patients: a randomized controlled trial

Objective:

To test the hypothesis that combined aerobic and resistance training and non-invasive ventilatory support result in additional benefits compared with combined aerobic and resistance training alone in heart failure patients.

Design:

A randomized, single-blind, controlled study.

Setting:

Cardiac rehabilitation center.

Participants:

A total of 46 patients with New York Heart Association class II/III heart failure were randomly assigned to a 10-week program of combined aerobic and resistance training, plus non-invasive ventilatory support ( n = 23) or combined aerobic and resistance training alone ( n = 23).

Methods:

Before and after intervention, results for the following were obtained: 6-minute walk test, forced vital capacity, forced expiratory volume at one second, maximal inspiratory muscle pressure, and maximal expiratory muscle pressure, with evaluation of dyspnea by the London Chest Activity of Daily Living scale, and quality of life with the Minnesota Living With Heart Failure questionnaire.

Results:

Of the 46 included patients, 40 completed the protocol. The combined aerobic and resistance training plus non-invasive ventilatory support, as compared with combined aerobic and resistance training alone, resulted in significantly greater benefit for dyspnea (mean change: 4.8 vs. 1.3, p = 0.004), and quality of life (mean change: 19.3 vs. 6.8, p = 0.017 ). In both groups, the 6-minute walk test improved significantly (mean change: 45.7 vs. 44.1, p = 0.924), but without a statistically significant difference.

Conclusion:

Non-invasive ventilatory support combined with combined aerobic and resistance training provides additional benefits for dyspnea and quality of life in moderate heart failure patients. Trial registration: ClinicalTrials.gov identifier: NCT02384798. Registered 03 April 2015.

Trends in coronary risk factors and electrocardiogram findings from 1977 to 2009 with 10-year mortality in Japanese elderly males - The Tanushimaru Study

BACKGROUND

An understanding of the trends in regard to coronary risk factors and electrocardiogram (ECG) findings has an important role in public health. We investigated the trends in coronary risk factors and main ECG findings in 1977, 1989, 1999, and 2009 in the Japanese cohort of the Seven Countries Study, in Tanushimaru, a typical farming town on Kyushu Island.

METHODS AND RESULTS

A total of 1397 subjects (231 in 1977, 332 in 1989, 389 in 1999, and 445 in 2009) were enrolled in this study, and all of them were males aged over 65 years. In coronary risk factors, total cholesterol levels, diastolic blood pressure, body mass index, and uric acid significantly increased during these 3 decades. The prevalence of smokers markedly decreased from 56.7% in 1977 to 16.8% in 2009. ECG changes during 3 decades were wider QRS interval, increased prevalence of major abnormality, reduced heart rate, shortened PR interval and corrected QT, and decreased prevalence of left ventricular hypertrophy. Age, smoking habits, major and minor abnormalities in ECG were associated with mortality in 1977-1987. Age, total cholesterol levels (inversely) and corrected QT were associated with mortality in 1989-1999. Age, smoking habits, heart rate, and systolic blood pressure were associated with mortality in 1999-2009.

CONCLUSIONS

Predictors of mortality have changed with the times. Coronary risk factors such as smoking, increased heart rate, and elevated blood pressure have been recently associated with mortalities in elderly male Japanese general population.

Do heart failure status and psychosocial variables moderate the relationship between leisure time physical activity and mortality risk among patients with a history of myocardial infarction?

BACKGROUND

Leisure time physical activity (LTPA) is inversely related to mortality risk among patients with a history of myocardial infarction (MI). The aims were to explore if heart failure (HF) status and psychosocial variables moderate the association.

METHODS

Participants (n = 1169) were from a multi-center prospective cohort study. Information on LTPA (none, irregular,1-150, 151-300 and >300 weekly minutes), depression, social support and other prognostic indicators were collected 10-13 years after index MI. Cox regressions were conducted, adjusting for potential confounders. In case of significant moderation by HF-status or psychosocial variables, stratified analyses were performed.

RESULTS

During follow-up (M = 8.4 years), 25.6 % of the sample had died. LTPA was inversely associated with mortality (p for trend < 0.01 in all models). HF did not, but psychosocial variables did, moderate the association. In the LTPA category 1-150 weekly minutes, patients with a high level of depression had a lower mortality risk in comparison to those with a low level (hazard ratios (95 % confidence intervals) were 0.43 (0.25, 0.75) versus 0.69 (0.36, 1.32)), and patients with a low level of social support had a lower mortality risk in comparison to those with a high level (0.40 (0.21, 0.77) versus 0.71 (0.39, 1.27)). In the category >300 min, patients with a high level of social support had a lower mortality risk than those with a low level (0.38 (0.19, 0.79) versus 0.51 (0.30, 0.87)).

CONCLUSIONS

LTPA was inversely related to mortality risk of post-MI patients. HF did not moderate the relationship; depression and social support partially did.

Prevalence and Prognostic Impact of Metabolic Syndrome in Asymptomatic (Stage A and B Heart Failure) Patients

BACKGROUND

Metabolic syndrome (MS) has an increased risk of cardiovascular events. Its relationship with asymptomatic left ventricular dysfunction (LVD) and prognosis has not been completely clarified.

OBJECTIVES

To determine, in asymptomatic patients (Stage A, B heart failure, HF), whether MS is associated with left ventricular systolic dysfunction (LVSD) and left ventricular diastolic dysfunction and its predictive role for cardiovascular events.

MATERIALS AND METHODS

We included 1920 nonconsecutive patients without symptoms of HF, with at least one cardiovascular risk factor, undergoing echocardiographic evaluation as preventive screening. We subdivided the study population according to the presence (Group 1) or absence (Group 2) of MS. The primary endpoint was a composite of cardiac death, myocardial infarction, coronary artery revascularization, stroke, and acute pulmonary edema. Secondary endpoints were hospitalization for HF and HF progression.

RESULTS

Overall prevalence of MS was 13.4% (n = 262, Group 1). In Group 2 (n = 1658), the prevalence of LVSD was 12.2%, while the prevalence of LVSD was 21.8% in Group 1 (relative risk [RR] 2.01; 95% confidence interval 1.4-2.8; P < 0.001). Adjusting for age and gender, MS resulted an independent predictor of LVSD (P < 0.001). After a median follow-up of 22 months, Group 1 patients had a significantly higher incidence of primary events (P < 0.001), including cardiac death (P = 0.04), and secondary events (P < 0.001). Both primary and secondary endpoints were more frequent in patients with LVSD (P < 0.001). In multivariate survival analysis, MS (but not its specific components) and LVSD were independently associated both with primary and secondary events (P ≤ 0.003). Incremental chi-square analysis showed the presence of combined LVD added to MS, and age raised significantly the predictive value of the model for the primary endpoint (Incremental chi-square = 8.6).

CONCLUSIONS

In stage A and B HF subjects, the coexistence of MS with functional or structural cardiac abnormalities, detected by echocardiography, showed a significant incremental value in predicting clinical cardiovascular events.

Prognostic Impacts of Metabolic Syndrome in Patients With Chronic Heart Failure - A Multicenter Prospective Cohort Study

BACKGROUND

Metabolic syndrome (MetS) is involved in the increased risk of atherosclerotic cardiovascular diseases. We have previously reported that the prevalence of MetS is more than 2-fold greater in patients with chronic heart failure (CHF) than in the general population in Japan. However, the prognostic impact of MetS in CHF patients remains to be elucidated.

METHODS AND RESULTS

In the present nationwide, large-scale clinical study in Japan, we enrolled 4,762 patients with Stage C/D CHF. The prevalence of MetS by the definition of the Japanese Committee for the Diagnostic Criteria in 2005 was 41.3% (50.6% in males, 21.5% in females). MetS was characterized by higher prevalence of males, obesity and lifestyle-related comorbidities, including glucose intolerance, dyslipidemia and hypertension. Multivariate Cox hazard analysis showed that MetS was associated with increased incidence of the composite of all-cause death and atherosclerotic events in males (hazard ratio [HR] 1.28; 95% confidence interval [CI] 1.06-1.54, P=0.011) but not in females (HR 1.23, 95% CI 0.87-1.75, P=0.241). Among the components of MetS, over waist circumference and glucose intolerance were significantly associated with increased incidence of the composite endpoint (HR 1.23, P=0.038, and HR 1.29, P<0.001, respectively) in males but not in females.

CONCLUSIONS

The results indicate that MetS only has a negative prognostic impact in male CHF patients. (Circ J 2016; 80: 677-688).

Heart failure as a general pandemic in Asia

Heart failure (HF) is an epidemic in healthcare worldwide, including Asia. It appears that HF will become more serious in the near future, with the epidemiological transition and ageing of the population. However, in contrast to Western countries, information on HF epidemiology is still limited in Asia, particularly in South Asia. In this review, we will briefly summarize available information regarding the current and future burden of HF in Asia, which indicates the importance of both primary prevention of underlying diseases of HF and secondary prevention, including management of ischaemic HF, HF with preserved EF, and HF in the elderly.

Clinical impacts of additive use of olmesartan in hypertensive patients with chronic heart failure: the supplemental benefit of an angiotensin receptor blocker in hypertensive patients with stable heart failure using olmesartan (SUPPORT) trial

We examined whether an additive treatment with an angiotensin receptor blocker, olmesartan, reduces the mortality and morbidity in hypertensive patients with chronic heart failure (CHF) treated with angiotensin-converting enzyme (ACE) inhibitors, β-blockers, or both. In this prospective, randomized, open-label, blinded endpoint study, a total of 1147 hypertensive patients with symptomatic CHF (mean age 66 years, 75% male) were randomized to the addition of olmesartan (n = 578) to baseline therapy vs. control (n = 569). The primary endpoint was a composite of all-cause death, non-fatal acute myocardial infarction, non-fatal stroke, and hospitalization for worsening heart failure. During a median follow-up of 4.4 years, the primary endpoint occurred in 192 patients (33.2%) in the olmesartan group and in 166 patients (29.2%) in the control group [hazard ratio (HR) 1.18; 95% confidence interval (CI), 0.96–1.46, P = 0.112], while renal dysfunction developed more frequently in the olmesartan group (16.8 vs. 10.7%, HR 1.64; 95% CI 1.19–2.26, P = 0.003). Subgroup analysis revealed that addition of olmesartan to combination of ACE inhibitors and β-blockers was associated with increased incidence of the primary endpoint (38.1 vs. 28.2%, HR 1.47; 95% CI 1.11–1.95, P = 0.006), all-cause death (19.4 vs. 13.5%, HR 1.50; 95% CI 1.01–2.23, P = 0.046), and renal dysfunction (21.1 vs. 12.5%, HR 1.85; 95% CI 1.24–2.76, P = 0.003). Additive use of olmesartan did not improve clinical outcomes but worsened renal function in hypertensive CHF patients treated with evidence-based medications. Particularly, the triple combination therapy with olmesartan, ACE inhibitors and β-blockers was associated with increased adverse cardiac events. This study is registered at clinicaltrials.gov-NCT00417222.

Circulating thrombospondin-2 reflects disease severity and predicts outcome of heart failure with reduced ejection fraction

BACKGROUND

 Thrombospondin-2 (TSP-2) is a matricellular protein found in human serum. Deletion of TSP-2 causes age-dependent dilated cardiomyopathy. We hypothesized that TSP-2 is a useful biomarker in patients with heart failure with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

 Serum TSP-2 was measured in 101 patients with HFrEF, and mortality and cardiovascular events were followed. Serum TSP-2 in the HFrEF group was significantly higher than in the non-HF group (n=17). Mean NYHA functional class was significantly higher in the high TSP-2 group (>median) than the low TSP-2 group (2.26 vs. 1.76, P=0.004). Circulating TSP-2 level was significantly associated with that of B-type natriuretic peptide (BNP; r=0.40, P<0.0001) on multivariate linear regression analysis. On Kaplan-Meier curve analysis the high TSP-2 group had a lower event-free rate than the low TSP-2 group (log-rank test, P=0.03). Multivariate Cox hazard analysis identified hemoglobin (hazard ratio [HR], 0.66; 95% confidence interval [CI]: 0.53-0.82, P<0.0001), and TSP-2 (ln[TSP-2]; HR, 3.34; 95% CI: 1.03-10.85, P=0.045) as independent predictors of adverse outcome. The area under the curve for 1-year events increased when TSP-2 was added to Framingham risk score (FRS; alone, 0.60) or BNP (alone, 0.69; FRS+TSP-2, 0.75; BNP+TSP-2, 0.76).

CONCLUSIONS

 TSP-2 is a potentially useful biomarker for assessment of disease severity and prognosis in HFrEF.