JCS 2017/JHFS 2017 Guideline on Diagnosis and Treatment of Acute and Chronic Heart Failure - Digest Version

Re-evaluation of intravenous steroid therapy for histologically confirmed fulminant myocarditis

BACKGROUND

The efficacy of intravenous steroids (IS) for fulminant myocarditis (FMP) remains controversial. We aimed to compare outcomes in FMP patients who received IS [IS(+)] and those who did not [IS(-)].

METHODS AND RESULTS

Data from 344 patients with histologically confirmed FMP requiring catecholamines or mechanical support were extracted from the Japanese Registry of Fulminant Myocarditis. The primary outcome was a composite of 90-day mortality and heart transplantation. Among the patients (median age 54, 40 % female), 195 received IS, 98 died within 90 days, and 16 died or underwent transplantation after 90 days. The IS(+) group had lower left ventricular ejection fraction and lower ratio of lymphocytic myocarditis, higher use of intra-aortic balloon pumping, Venoarterial extracorporeal membrane oxygenation (VA-ECMO), and intravenous immunoglobulin. Crude analysis showed worse 90-day outcomes in the IS(+) group (36.3 % vs. 19.2 %, P = 0.0021); however, after propensity score matching (PSM), outcomes were similar (26.2 % vs. 24.2 %; P = 0.95). Unadjusted Cox regression indicated worse outcomes with IS (HR 1.95, 95 % CI 1.26-3.04; P = 0.0026), but this was not significant after PSM (HR 1.02, 95 % CI 0.56-1.87; P = 0.95). Among low-risk patients, the IS(-) group showed better outcomes than the IS(+) group post-PSM (P = 0.0031). In the patients with VA-ECMO or ventricular assist devices, early IS (within 2 days of admission) showed comparable prognosis to delayed/no IS, with a trend toward better outcomes post-PSM.

CONCLUSIONS

IS effectiveness in FMP patients may vary, showing limited prognostic benefit overall. Careful consideration is warranted in its use for this population.

Palliative Care Needs Assessment Using the Surprise Question in Hospitalized Patients With Heart Failure

BACKGROUND

The surprise question "Would I be surprised if this patient dies within 1 year?" is a simple tool to identify patients who may benefit from palliative care. We aimed to investigate the usefulness of the surprise question to identify palliative care needs among patients hospitalized with heart failure (HF).

METHODS AND RESULTS

This study used a prospective observational registry that includes consecutive patients hospitalized with HF using the surprise question on admission. Patients were classified as surprised or not surprised according to the surprise question. Backgrounds, symptom burdens, and clinical outcomes were compared between groups. Of 601 patients hospitalized with HF, 181 (30%) were classified as not surprised. Patients classified as not surprised were older (86±8 versus 76±12 years, P<0.001), had a lower prevalence of men (76 [42%] versus 238 [57%], P=0.001), and had a lower left ventricular ejection fraction (41±19% versus 45±17%, P=0.015) than those classified as surprised. There were no significant differences in symptom burdens evaluated at discharge or their temporal change from admission to discharge between groups (all P>0.05). Among 489 patients followed until death or 1 year after admission, 108 (22%) all-cause deaths and 90 (18%) HF rehospitalizations occurred within 1 year. The multivariable Cox model demonstrated the independent association between the not surprised classification and higher risk of all-cause death (hazard ratio [HR], 3.34 [95% CI, 2.03-5.49]; P<0.001), whereas there was no association with HF rehospitalization (HR, 1.36 [95% CI, 0.79-2.34]; P=0.27).

CONCLUSIONS

The surprise question was significantly associated with a higher risk of all-cause death, suggesting its prognostic usefulness in identifying patients suitable for advance care planning.

Intravenous Verapamil for the Management of Atrial Fibrillation: The Gap Between the Guidelines and Clinical Practice

Objective According to the current guidelines, the use of non-dihydropyridine calcium-channel blockers for the rate control of atrial fibrillation (AF) is contraindicated in patients with heart failure (HF), especially in those with a reduced ejection fraction (EF). However, there is little data supporting this recommendation. This study aimed to investigate the use of intravenous verapamil in patients with AF. Methods We retrospectively studied 223 consecutive patients with AF treated with intravenous verapamil. We evaluated the clinical data of these patients, including any adverse events that occurred within 7 days. Results The median age of the patients was 75.9 (67.8-80.7) years. Before administration, 71 patients (31.8%) had HF, 112 patients (62.6%) had a high B-type natriuretic peptide (BNP) level, and 28 patients (13.6%) had a left ventricular (LV) EF less than 50%. The mean administered dose of verapamil was 5.4±1.6 mg. The median heart rate (HR) was significantly reduced after verapamil administration [HR:145 (130-160) bpm to 95 (82-105) bpm, p<0.001]. Twenty-eight patients (12.6%) suffered from hypotension. Two patients had bradyarrhythmias. Within 7 days, cardiovascular death occurred in three patients (1.3%). A multivariate analysis revealed that pre sBP and hemoglobin, but not LVEF or BNP, were independently associated with adverse events. Conclusion The intravenous administration of verapamil appears to be effective and safe for controlling the heart rate in most patients with AF, except in critically ill patients. However, further research is required to assess the safety of verapamil in patients for whom its use is not currently recommended by the clinical guidelines.

Preference for advance care planning in patients with pulmonary hypertension

Implementing advance care planning (ACP) is recommended in clinical guidelines. However, in pulmonary hypertension, patients' preference toward ACP remains unclear. We aimed to elucidate the preference of patients with pulmonary hypertension for ACP conversations and the association of ACP with important patient factors underlying treatment decision-making. We conducted a cross-sectional questionnaire-based study, assessing patients' preferred and actual participation in ACP conversations, as well as important patient factors underlying their treatment decision-making (including prognosis; patient values; physician recommendation; and symptom, financial, family, and social burdens). Univariate logistic regression analysis was conducted to identify patients with positive attitudes toward ACP conversations. Of 133 patients with pulmonary hypertension (median age, 60 years; mean pulmonary arterial pressure, 23 mmHg; female, 71.4%), 78.2% recognized the importance of ACP conversations. Regarding the patients' perception of appropriate ACP timing, 37.8% chose after repeated hospitalizations for worsening pulmonary hypertension and 22.4% chose during readmission for worsening pulmonary hypertension. Among these, 40.8% engaged in ACP conversations. A positive attitude toward ACP conversations was associated with marital status (married), having children, better oxygenation, and patients' preference toward physician recommendations in pulmonary hypertension treatment decision-making, but not with age, pulmonary hypertension etiology, or other patient preferences in treatment decision-making. Most patients with pulmonary hypertension preferred ACP conversations. A positive attitude toward ACP was associated with patients' preference toward physicians' recommendations in pulmonary hypertension treatment decision-making. Further research is required to establish an appropriate ACP approach that aligns with patient preference and physician recommendations for this patient population.

Calcium channel blocker use and outcomes following transcatheter aortic valve intervention for aortic stenosis

Calcium channel blockers (CCBs) are commonly used to treat coronary artery disease (CAD). The effects of the use of CCBs on the prognosis of patients with aortic stenosis (AS) after transcatheter aortic valve intervention (TAVI) has not been explored. This study elucidated the effects of the use of CCBs on clinical outcomes of patients who underwent TAVI for severe AS. This retrospective observational study included 993 consecutive patients who underwent TAVI for severe AS between January 2017 and July 2023. All patients were followed up for all-cause mortality and hospitalisation for heart failure. Composite endpoints between patients with and without CCBs at discharge were compared using propensity score matching (PSM). CCBs were administered to 590 (59.4%) patients following TAVI. Over a median follow-up period of 719 (335-1,120) days, the composite endpoint occurred in 269 patients. After PSM, there was no significant difference in the composite endpoint between the two groups (hazard ratio = 0.879; p = 0.409). Subgroup analysis revealed that the use of CCBs was associated with a better prognosis in the CAD subgroup (p for interaction = 0.002). This study does not suggest that the use of CCBs is associated with worse clinical outcomes in patients after TAVI for severe AS. Additionally, the use of CCBs may lead to a better prognosis in patients with CAD.

Factors Associated With Sacubitril/Valsartan Continuation and the Methods of Combining Heart Failure Medications in Patients With Heart Failure

BACKGROUND

Sacubitril/valsartan (SV) is recommended for patients with heart failure (HF). In addition, a combination of 4 HF medications, including SV, is recommended in patients with HF with reduced ejection fraction (HFrEF). However, evidence on the characteristics of patients who could continue SV and its initiation methods is limited.

OBJECTIVE

To investigate the factors associated with SV continuation and methods of combining HF medications.

METHODS

This retrospective cohort study included HF patients who initiated with SV at our institution. The endpoint was SV continuation for 6 months after its initiation. Multivariate analysis was used to extract factors associated with SV continuation. The relationship between the methods of combining HF medications (renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists, or sodium-glucose cotransporter 2 inhibitors), including the number of HF medications, their combination patterns, and the timing of their initiation, and SV continuation was examined in patients with HFrEF.

RESULTS

Of 186 eligible patients, 68.8% had HFrEF, and 79.0% continued SV for 6 months. Significant factors associated with SV continuation were albumin ≥ 3.5 g/dL (odds ratio, 4.81; 95% confidence interval, 2.19-10.59), body mass index (BMI) ≥ 18.5 kg/m2 (4.17; 1.10-15.85), and systolic blood pressure (SBP) ≥ 110 mmHg (2.66; 1.12-6.28). In patients with HFrEF, the proportion of HF medications not initiated simultaneously with SV was significantly higher in the continuation group than in the discontinuation group (67.3% vs 33.3%, P = 0.002). The number of HF medications and their combination patterns were not significantly associated with SV continuation.

CONCLUSION AND RELEVANCE

Albumin, BMI, and SBP are useful indicators for selecting patients who are likely to continue SV. In addition, initiating only SV without simultaneously initiating other HF medications in patients with HFrEF may lead to SV continuation.

Improving effect of physical exercise on heart failure: Reducing oxidative stress-induced inflammation by restoring Ca2+ homeostasis

Heart failure (HF) is associated with the occurrence of mitochondrial dysfunction. ATP produced by mitochondria through the tricarboxylic acid cycle is the main source of energy for the heart. Excessive release of Ca2+ from myocardial sarcoplasmic reticulum (SR) in HF leads to excessive Ca2+ entering mitochondria, which leads to mitochondrial dysfunction and REDOX imbalance. Excessive accumulation of ROS leads to mitochondrial structure damage, which cannot produce and provide energy. In addition, the accumulation of a large number of ROS can activate NF-κB, leading to myocardial inflammation. Energy deficit in the myocardium has long been considered to be the main mechanism connecting mitochondrial dysfunction and systolic failure. However, exercise can improve the Ca2+ imbalance in HF and restore the Ca2+ disorder in mitochondria. Similarly, exercise activates mitochondrial dynamics to improve mitochondrial function and reshape intact mitochondrial structure, rebalance mitochondrial REDOX, reduce excessive release of ROS, and rescue cardiomyocyte energy failure in HF. In this review, we summarize recent evidence that exercise can improve Ca2+ homeostasis in the SR and activate mitochondrial dynamics, improve mitochondrial function, and reduce oxidative stress levels in HF patients, thereby reducing chronic inflammation in HF patients. The improvement of mitochondrial dynamics is beneficial for ameliorating metabolic flow bottlenecks, REDOX imbalance, ROS balance, impaired mitochondrial Ca2+ homeostasis, and inflammation. Interpretation of these findings will lead to new approaches to disease mechanisms and treatment.

Association of nighttime very short-term blood pressure variability determined by pulse transit time with adverse prognosis in patients with heart failure

Long-term blood pressure (BP) variability (BPV) is associated with adverse prognosis in patients with heart failure. However, the clinical significance of very short-term (beat-to-beat) BPV is unclear. We collected data on nighttime pulse transit time-based continuous beat-to-beat BP measurement in patients with heart failure (n = 366, median age 72.0, male sex 53.3%). Coefficient of variation (CoV) of pulse transit time-based BP was considered as very short-term BPV. The primary outcome was a composite of heart failure hospitalization or cardiac death. Median values (25th and 75th percentiles) of systolic and diastolic BP CoV were 3.6% (2.8%, 4.5%) and 5.1% (3.8%, 6.5%), respectively. During a median follow-up period of 1084 days after BPV evaluation, 71 patients experienced the primary outcome. When the patients were divided into tertiles based on the systolic and diastolic BPV, the primary outcome occurred most frequently in the highest tertile of BPV. Multivariable Cox proportional hazard analysis revealed that systolic and diastolic BPV, as continuous variables, were independently associated with the primary outcome (hazard ratio 1.199 and 1.101, respectively). In conclusion, high nighttime very short-term BPV was associated with adverse prognosis in patients with heart failure.

Association between postprocedural echocardiographic and laboratory data and clinical outcomes in patients with preserved ejection fraction after catheter ablation for atrial fibrillation

BACKGROUND

The HFA-PEFF score comprising echocardiographic and laboratory data is designed to diagnose heart failure with preserved ejection fraction and holds prognostic value in patients who underwent catheter ablation for atrial fibrillation (AF). However, the incorporation of many variables into this score limits its practical use.

OBJECTIVE

We aimed to develop and to validate a simplified score (AF-HFA-PEFF score) focusing on AF-related parameters to predict cardiovascular events and AF recurrence.

METHODS

We retrospectively enrolled 354 patients with preserved ejection fraction who underwent AF ablation. Using Cox regression hazard ratios from the HFA-PEFF score variables, we generated a risk score from a random 50% of patients and validated it with the other half.

RESULTS

Univariate analysis revealed that postprocedural E/e', tricuspid regurgitation peak gradient, left atrial volume index, and brain natriuretic peptide levels were associated with 3-year cardiovascular events or AF recurrence. We developed the AF-HFA-PEFF score incorporating these factors. In the derivation group, C statistics for cardiovascular events were 0.72 for the AF-HFA-PEFF score and 0.74 for the original HFA-PEFF score and 0.71 and 0.69 for AF recurrence, respectively. Validation demonstrated that patients with an AF-HFA-PEFF score <4 had a 3-year cardiovascular event risk of 1.4% vs 9.4% for scores ≥4 (P < .001). For AF recurrence, these figures were 9.7% and 65.6%, respectively (P < .001).

CONCLUSION

The AF-HFA-PEFF score is simpler than the HFA-PEFF score and is equally associated with 3-year cardiovascular events and AF recurrence.

A Practical Scoring System for Estimating Ventricular Arrhythmia Events in Patients with Cardiac Resynchronization Therapy for Primary Prevention

The prognostic value of defibrillators in cardiac resynchronization therapy (CRT) for primary prevention remains debatable. Predicting ventricular arrhythmias (VAs) before implantation is useful for deciding whether to add a defibrillator to a CRT device. This study aimed to determine the risk factors for VA events after CRT device implantation and to construct a scoring model. A total of 153 patients who underwent CRT device implantation, with no history of sustained ventricular tachycardia or ventricular fibrillation (including 25 patients with CRT pacemakers) and with follow-up period >1 year after implantation were included. We assessed VA events requiring implantable cardioverter-defibrillator therapy and sustained VA events requiring clinical treatment. During a mean follow-up of 6.3 years, 24 patients (16%) received therapy for VA. Multivariate analysis revealed age ≤ 70 years (hazard ratio [HR] 2.936, P = 0.037), administration of tolvaptan (HR 11.259, P < 0.001), and coronary artery disease (HR 2.444, P = 0.045) were independent predictors for VA events. Risk scores were assigned based on the HR for each predictor, and the population was divided into 3 risk groups (low: 0 points; moderate: 1-3 points; high: 4-5 points). VAs occurred less frequently in the low-risk group than in the other risk groups (low: 8.1%; moderate: 18%; high: 21%) (log-rank, P < 0.001). No significant differences in mortality were observed between the groups, whereas hospitalization for heart failure occurred more frequently in the high-risk group than in the other groups. In conclusion, a scoring system using specific background information may help predict VA events in prophylactic CRT recipients.

History of Heart Failure Definition

The concept of heart failure (HF) has undergone significant transformation from ancient times to the present, evolving from rudimentary understandings to a complex clinical syndrome. Early descriptions by Egyptian, Greek and Roman physicians laid the groundwork for understanding cardiac dysfunction. The Renaissance period brought crucial insights with Harvey's discovery of blood circulation. In the 20th century, the Framingham Heart Study provided a pivotal shift, formally defining HF as a clinical syndrome with diagnostic criteria. Over the decades, definitions of HF have evolved, integrating advancements in pathophysiology, biomarkers and imaging techniques. Initially focused on symptomatic and clinical presentations, modern definitions emphasise underlying structural and functional cardiac abnormalities. This evolution reflects the growing complexity and precision of diagnosing and managing HF. A historical perspective underscores the progressive refinement in HF definitions, which enhances diagnostic precision and therapeutic strategies, ultimately improving patient outcomes. Understanding this evolution is crucial for appreciating contemporary HF management and anticipating future advances.

Histone H2A: a promising diagnostic marker in heart failure with reduced versus preserved ejection fraction

The diagnosis of heart failure with preserved left ventricle ejection fraction (HFpEF) remains a challenge, with score-based algorithms showing varying diagnostic performance and biomarkers sometimes inconclusive. This study aimed to examine whether circulating histones and histone complexes, which recently emerged as robust biomarkers of inflammation and stroke, show distinct profiles in plasma from healthy individuals, HF with reduced EF (HFrEF), and HFpEF patients. We evaluated the plasma histone profile of 30 sex/age-matched healthy individuals, 22 HFpEF and 25 HFrEF prior any therapeutic intervention. ImageStreamX-based detection approach was used to measure the levels of circulating particles positive for core histones H2A, H2B, H3, H4, histone variants macroH2A1.1 and macroH2A1.2. While we found increased levels of most of the histones and histone complexes in both HFpEF and HFrEF patients, H2A was significantly elevated only in HFpEF, compared to healthy individuals (p-value = 0.002) and to HFrEF (p-value = 0.00008). In line with these findings, H2A showed positive correlation with EF (r = 0.493). We identified a plasma histone profile able to detect HF and differentiate between HFpEF and HFrEF using a high throughput and imaging flow cytometry-adapted liquid biopsy.

2023 Update of the Japanese Heart Failure Society Scientific Statement on BNP and NT-proBNP Levels in Heart Failure Practice

This revised 2023 statement on blood brain (B-type) natriuretic peptide (BNP) and N-terminal prohormone of brain (B-type) natriuretic peptide (NT-proBNP) represents an expert consensus that aims to enhance efficient referral from general practitioners or non-cardiovascular specialists, providing a comprehensive, up-to-date perspective on BNP and NT-proBNP in the diagnosis and management of heart failure, with a focus on the following two major modifications: (1) Changes regarding cutoff values for BNP and NT-proBNP (criteria for heart failure diagnosis and referral criteria to cardiovascular specialists); and (2) Content related to heart failure management using BNP and NT-proBNP (BNP-guided therapy).

Twelve-year trends of hospitalizations and survival of acute decompensated heart failure: Data from a regional tertiary center

BACKGROUND

Recent trends in in-hospital acute decompensated heart failure (ADHF) have been reported in several registry studies demonstrating no improvement in terms of mortality rate and readmission rate due to heart failure (HF) exacerbation. Trends in management of ADHF may be different in areas where the aging rate is faster.

METHODS

We retrospectively enrolled 1121 ADHF patients hospitalized between 2008 and 2019. The study patients were classified into three groups based on 4-year periods. Our primary study interests were trends over time in age, length of hospital stay, and clinical outcomes, with endpoints, including 1-year mortality and readmission for HF (reHF).

RESULTS

During the 12-year period, the length of hospital stay was not reduced, but rather prolonged in Period 3 (p < 0.001). Temporal trends in 1-year clinical outcomes showed both 1-year all-cause and cardiovascular mortality tended to increase. No improvement in 1-year reHF rates was observed over time. All-cause mortality was associated with Period 2 (95%CI 1.02-4.97), Period 3 (95%CI 1.30-6.05), older age (≥79 years, 95%CI 1.01-3.20), decreased left ventricular ejection fraction (95%CI 1.08-3.62), higher loop diuretics dose (95%CI 1.07-1.25), higher B-type natriuretic peptide (BNP) levels (95%CI 1.00, 1.01), and decreased hemoglobin levels (95%CI 0.74-0.97). Factors associated with cardiovascular mortality included Period 3 (95%CI 1.02-7.31), higher loop diuretics dose (HR 1.17, 95%CI 1.07-1.27), higher BNP levels (95%CI1.00-1.01), and lower estimated glomerular filtration rate (eGFR) levels on admission (95%CI 0.70-0.95). Predictors of reHF were number of previous HF hospitalizations (95%CI 1.13-1.94), lower eGFR levels (95%CI 0.79-0.94) on admission and suboptimal guideline-directed medical therapy (95%CI 0.50-0.79).

CONCLUSIONS

Despite the recent advances in medical therapy, readmission rate in patients with ADHF did not improve during the 12-year observation period. The mortality rate worsened over time. These findings warrant prompt establishment of more effective approaches to prevent and treat ADHF.

A randomized trial of early cardiotoxicity in breast cancer patients receiving postoperative IMRT with or without serial cardiac dose constraints

Optimal cardiac dose constraints in breast cancer (BC) patients undergoing postoperative intensity-modulated radiation therapy (IMRT) are unclear, although as low as possible is recommended. This trial proposes serial cardiac dose constraint to optimize cardiac safety. Postoperative BC patients eligible for anthracycline/taxanes-based chemotherapy or HER2-targeted therapy were randomized to cardiac safety arm with prespecified mean heart dose (MHD) (≤6 Gy), V30 (≤20%), and V10 (≤50%) constraints, or to a control arm with in-house protocol (mainly MHD ≤8 Gy). The primary endpoint was cumulative incidence of newly onset cardiac events within 1-year post-RT. An exploratory analysis examined the relationship between whole heart dose metrics and those of substructures. Of 199 participants, 93 were in the cardiac safety and 106 in the control arm. The cardiac safety group showed lower MHD, V10, and V30. The 1-year cardiac event incidence was slightly lower in the cardiac safety group (19.4%) compared to controls (24.9%). The LVEF and diastolic dysfunction rates were 0% and 5.4% in the study arm, and 1.9% and 8.8% in the control arm, respectively. The LAD, LV, and RV received the highest doses for left-sided patients. For right-sided patients, RA, RCA, and RV were most irradiated. The MHD, V10, and Dmax of heart significantly correlated with all substructure doses in either laterality. Our study supports the early cardiac safety profile using IMRT in BC patients receiving cardiac-toxic systemic therapy, with serial cardiac dose constraints. Combined constraints on MHD and dose-volume parameters are representative of the cardiac substructure dose.

Role of a Bioelectrical Impedance Analysis in Predicting Anemia among Cardiovascular Disease Patients

Objective Anemia frequently complicates cardiovascular disease (CVD) and is associated with high mortality rates. A bioelectrical impedance analysis (BIA) is a noninvasive method for measuring human body composition. A direct association between serum hemoglobin (Hb) levels and the extracellular water-to-total body water (ECW/TBW) ratio, as measured by a BIA in patients with diabetes, has been reported. However, the predictive value of the ECW/TBW ratio for detecting anemia in patients with CVD has not been fully elucidated. Methods We conducted a study involving consecutive patients admitted to our cardiology department from January 1, 2021, to December 31, 2022. A BIA was performed once during hospitalization for all patients, whenever possible. The correlation between the Hb level and ECW/TBW ratio was assessed. The predictive accuracy for anemia was evaluated using a receiver operating characteristic (ROC) curve analysis. Results The ECW/TBW ratio was significantly higher in the anemia group than in the non-anemia group (0.41 [0.40, 0.41] vs. 0.39 [0.38, 0.40], p<0.001). The ECW/TBW ratio exhibited a significant negative correlation with Hb, with an R value of 0.57 and a p-value of <0.01. However, this correlation coefficient decreased to 0.45 among subjects with BNP levels ≥200 pg/mL. The area under the ROC curve (AUC) for the ECW/TBW ratio for detecting anemia was 0.83. However, its predictive performance decreased in patients with BNP levels exceeding 200 pg/mL, with an AUC of 0.71. Conclusion The BIA-derived ECW/TBW ratio is a valuable predictor of anemia in patients with CVD, provided BNP levels are not elevated.

Clinical advantages of reduced expiratory positive airway pressure setting in adaptive servo-ventilation therapy

The clinical ramifications of adaptive servo-ventilation (ASV) therapy have stirred debate within the medical community. Given the potential detrimental effect of elevated expiratory positive airway pressure (EPAP) on cardiac output, we hypothesized that relatively lower EPAP may be recommended for successful ASV therapy. In-hospital patients with congestive heart failure refractory to medical therapy were included in the prospective cohort study of ASV therapy on prognosis in repeatedly hospitalized patients with chronic heart failure: longitudinal observational study of effects on readmission and mortality (SAVIOR-L) study. Assignment to either the ASV treatment group or the medical management group was at the discretion of the attending physicians. For the purposes of this retrospective study, our focus remained solely on the ASV cohort. We conducted an extensive analysis to elucidate the influence of lower EPAP settings on midterm mortality. A total of 108 patients were included. The median age was 74 years, and 83 (77%) patients were male. The median EPAP setting employed was 4 cmH2O, with 60 patients subjected to EPAP levels below 5 cmH2O. There were no significant differences in the baseline characteristics between the lower and higher EPAP groups, which were divided at the EPAP cutoff of 4.5 cmH2O (p > 0.05 for all). A trend toward reduced mortality emerged among patients with EPAP settings below 5 cmH2O, exhibiting a hazard ratio of 0.48 (95% confidence interval 0.22-1.07, p = 0.072) after adjusting for potential confounding factors: 2-year mortality 26% vs. 38%; p = 0.095. Heart failure readmission rates were not significantly different between the two groups (p = 0.61). The adoption of relatively lower EPAP settings during ASV therapy may be advisable. Such an approach has the potential to ameliorate mortality rates while concurrently maintaining heart failure recurrence rates at levels commensurate with those with default EPAP settings.

Association between complementary use of Goreisan (a Japanese herbal Kampo medicine) and heart failure readmission: A nationwide propensity score-matched study

BACKGROUND

Goreisan, a Japanese herbal medicine, possesses aquaretic properties to regulate body fluid homeostasis and may therefore be effective as a complement to standard therapy in improving outcomes in patients with heart failure (HF).

METHODS

We retrospectively identified 431,393 patients (mean age 79.2 ± 12.6 years; male 52.3 %) who were admitted for HF for the first time and were discharged alive with standard HF medications between April 2016 and March 2022, using the Japanese Diagnosis Procedure Combination database. We divided patients into two groups according to the prescription of Goreisan at discharge: patients who received standard HF medications plus Goreisan and those who received standard medications alone. We compared the incidence of HF readmission within 1 year after discharge between the groups using propensity score matching.

RESULTS

Overall, Goreisan was prescribed in 1957 (0.45 %) patients at discharge. Patients who received Goreisan were older and received diuretics more frequently than those who did not. One-to-four propensity score matching created a cohort of 1957 and 7828 patients treated with and without Goreisan, respectively. No significant difference was found in the incidence of 1-year HF readmission between the groups [22.1 % vs. 21.7 %; hazard ratio (HR) = 1.02, 95 % confidence interval (CI) = 0.92-1.13]. This result was consistent with that from competing risk analysis (subdistribution HR = 1.02, 95 % CI = 0.92-1.13) and across clinically relevant subgroups except for renal disease. Goreisan use was associated with a lower incidence of HF readmission among patients with renal disease (HR = 0.77, 95 % CI = 0.60-0.97), but not among those without (HR = 1.09, 95 % CI = 0.97-1.23; p for interaction = 0.009).

CONCLUSIONS

This nationwide propensity score-matched analysis did not demonstrate that complementary Goreisan use at discharge was associated with a lower incidence of 1-year HF readmission in patients with HF receiving standard medications. An ongoing randomized trial is awaited to establish the effectiveness of Goreisan use in patients with HF.

Epidemiological characteristics and risk factors for heart failure in Japanese patients with type 2 diabetes: A retrospective analysis of the J-DREAMS database

AIM

To determine the epidemiological characteristics and risk factors for heart failure (HF) among Japanese patients with type 2 diabetes.

METHODS

A retrospective cohort analysis, using J-DREAMS database, was conducted from December 2015 to January 2020 with type 2 diabetes. The primary objectives were to describe patient characteristics stratified by HF history at baseline and new HF events during follow-up. The secondary objectives were to clarify the association between HF history or new HF events and clinical characteristics. The association between renal disease stage and HF was also studied.

RESULTS

Among 18,250 adult patients with type 2 diabetes, 3,613 (19.8%) patients had HF history and the mean age was 68.46 years, predominantly male (66.4%) with 13.32 years of mean duration of type 2 diabetes. Patients with HF history had a higher proportion of patients with nephropathy (51.2%) and coronary heart disease (55.6%) than those without HF history. Coronary heart disease (CHD) and deteriorating renal function were strongly associated with both HF history (CHD adjusted odds ratio [OR]: 7.41, 95% confidence interval [CI]: 6.05-9.08; eGFR G5 stage adjusted OR: 6.56, 95% CI: 2.97-14.49) and new HF events (CHD adjusted OR: 1.63, 95% CI: 1.17-2.29; eGFR G4 stage adjusted OR: 3.42, 95% CI: 1.81-6.47).

CONCLUSIONS

Comorbidities, especially CHD and deteriorating renal function, were strongly associated with HF history and new HF events among Japanese patients with type 2 diabetes. The study results suggested the importance of early intervention to treat comorbidities and maintain renal function.

Hospital Variability in the Use of Vasoactive Agents in Patients Hospitalized for Acute Decompensated Heart Failure for Clinical Phenotypes

BACKGROUND

The absence of practice standards in vasoactive agent usage for acute decompensated heart failure has resulted in significant treatment variability across hospitals, potentially affecting patient outcomes. This study aimed to assess temporal trends and institutional differences in vasodilator and inotrope/vasopressor utilization among patients with acute decompensated heart failure, considering their clinical phenotypes.

METHODS

Data were extracted from a government-funded multicenter registry covering the Tokyo metropolitan area, comprising consecutive patients hospitalized in intensive/cardiovascular care units with a primary diagnosis of acute decompensated heart failure between January 2013 and December 2021. Clinical phenotypes, that is, pulmonary congestion or tissue hypoperfusion, were defined through a comprehensive assessment of clinical signs and symptoms, vital signs, and laboratory findings. We assessed the frequency and temporal trends in phenotype-based drug utilization of vasoactive agents and investigated institutional characteristics associated with adopting the phenotype-based approach using generalized linear mixed-effects models, with random intercepts to account for hospital-level variability.

RESULTS

Among 37 293 patients (median age, 80 years; 43.7% female), 88.6% and 21.2% had pulmonary congestion and tissue hypoperfusion status, respectively. Throughout the study period, both overall and phenotype-based vasodilator utilizations showed significant declines, with overall usage dropping from 61.4% in 2013 to 48.6% in 2021 (Ptrend<0.001). Conversely, no temporal changes were observed in overall inotrope/vasopressor utilization from 24.6% in 2013 to 25.8% in 2021 or the proportion of phenotype-based utilization. Notably, there was considerable variability in phenotype-based drug utilization among hospitals, with a median ranging from 48.3% to 77.8%. In multivariable-adjusted models, a higher number of board-certified cardiologists were significantly associated with lower rates of phenotype-based vasodilator utilization and reduced inappropriate inotrope/vasopressor utilization, while tertiary care hospitals were linked to more appropriate inotrope/vasopressor utilization.

CONCLUSIONS

Substantial variability existed among hospitals in phenotype-based drug utilization of vasoactive agents for patients with acute decompensated heart failure, highlighting the need for standardized treatment protocols.

REGISTRATION

URL: https://www.umin.ac.jp/ctr/index.htm; Unique identifier: UMIN000013128.

Effect of low-dose administration of carperitide for acute heart failure: the LASCAR-AHF trial

AIMS

The effects of low-dose carperitide on long-term clinical outcomes of patients with acute heart failure (AHF) have not yet been fully elucidated. This study aimed to evaluate the effects of low-dose intravenous carperitide on the long-term clinical outcomes of patients with AHF.

METHODS AND RESULTS

In this multicentre, open-label, randomized controlled trial, 247 patients with AHF received low-dose carperitide intravenously with standard treatment or matching standard treatment for 72 h from November 2014 to March 2021 across nine sites in Japan. The primary endpoint was a composite of all-cause death and heart failure hospitalization within 2 years. The primary endpoint was observed in 36 of 122 patients (29.5%) and 35 of 125 patients (28.0%) in the carperitide group and standard treatment groups, respectively [hazard ratio 1.26; 95% confidence interval (CI) 0.78-2.06, P = 0.827]. No significant differences were observed in the secondary endpoints, including cumulative urine volume at 72 h; change in the degree of dyspnoea over 72 h; and changes in brain natriuretic peptide, cystatin C, renin, aldosterone, and catecholamine levels at 72 h post-randomization between the groups. A greater decrease in the estimated glomerular filtration rate was observed in the carperitide group compared with the standard treatment group (inter-group difference -3.9 mL/min/1.73 m2; 95% CI -7.0 to -0.8).

CONCLUSION

In patients with AHF, low-dose carperitide did not reduce long-term mortality or hospitalization events when combined with standard treatment. Because patient enrolment was terminated prematurely, the study was underpowered and inconclusive.

Influence of inspiratory muscle strength on 6-minute walk distance in patients with acute heart failure

Inspiratory muscle weakness may affect exercise tolerance; however, the relationship between inspiratory muscle strength and the 6-minute walk distance (6MWD) in patients with acute heart failure (AHF) is unknown. This study aimed to quantitatively investigate the association between inspiratory muscle strength at the start of cardiac rehabilitation (CR) and 6MWD at discharge in patients with AHF. This single-center, retrospective, observational study enrolled 275 patients with AHF who underwent CR. Patients unable to walk before admission, with isometric knee extensor strength/weight (%IKES) < 0.3 kgf/kg at the start of CR, or unable to undergo examination were excluded. Maximum inspiratory mouth pressure (PI-max) was used as an indicator of inspiratory muscle strength and was measured at the start of CR. The measured PI-max was divided by the predicted value and used for analysis (%PI-max). The primary outcome was 6MWD, an indicator of exercise tolerance, and was measured at discharge. Statistical analysis was performed using multiple regression analysis, with 6MWD at discharge as the dependent variable and %PI-max at the start of CR as the independent variable. Covariates were age, New York Heart Association class, physical frailty, and %IKES at the start of CR. The final analysis included 94 patients (median age 83.0 years, 57.5% male). Multiple regression analysis showed that %PI-max at the start of CR was significantly associated with 6MWD at discharge even after adjustment for covariates (β =  0.223, 95% confidence interval: 0.063-0.382, p =  0.007). PI-max was a factor associated with 6MWD at discharge in patients with AHF. In conclusion, increased inspiratory muscle strength may contribute to improved 6MWD in patients with AHF.

Predictors of the diuretic response in acute decompensated heart failure patients with severe aortic stenosis: sub-analysis of the LOHAS registry

For severe aortic stenosis (AS) patients awaiting valve replacement, managing acute decompensated heart failure (ADHF) is crucial due to poor prognosis. The LOHAS registry evaluated the effect of tolvaptan in patients (mean age: 85 years) with severe AS and ADHF, demonstrating stable hemodynamics and sufficient diuresis. We investigated predictors of rapid successful decongestion. In the LOHAS study, eligible patients received tolvaptan (7.5 mg) on day 1 plus standard ADHF treatments. Patients were divided based on decongestion achievement on day 4. Of 59 enrolled, 35 (59%) achieved decongestion (decongestion group), and 24 (41%) remained congested (congestion group). Changes in body weight, renal function, and hemodynamics were comparable between groups over the first 4 days. However, the maximum inferior vena cava (IVC) diameter at admission was significantly larger in the decongestion group than the congestion group (12.6 ± 6.3 vs. 7.6 ± 4.8 mm, p = 0.007). ROC analysis revealed a cut-off of 11 mm for maximum IVC diameter to predict decongestion on day 4 (AUC: 0.73, 95% CI 0.58-0.88). In-hospital mortality was lower in the decongestion group (0% vs. 13%, p = 0.06). In conclusion, in this high-risk severe AS and ADHF population, adding tolvaptan to standard therapy may rapidly improve decompensation if patients have a sufficiently expanded IVC at admission. Maximum IVC diameter could predict successful decongestion with tolvaptan.

Anticoagulation with Nafamostat Mesilate During Impella Support: A Case Report

Achieving an optimal balance between thrombosis prevention and bleeding risk during temporary mechanical circulatory support remains a significant clinical challenge. Effective anticoagulation management that ensures device functionality while minimizing major bleeding events should have the potential to improve short-term outcomes. Here, we report the successful use of nafamostat mesilate (NM) as an anticoagulant during Impella support in two male patients with advanced heart failure and cardiogenic shock. NM therapy resulted in improved thrombocytopenia without the occurrence of major bleeding or thrombotic events. However, NM-related hyponatremia was observed, highlighting the need for careful monitoring during its administration and further cumulative evidence to validate optimal NM therapy during temporary mechanical circulatory supports.

Association Between Complementary Use of Daikenchuto (a Japanese Herbal Medicine) and Readmission in Older Patients With Heart Failure and Constipation

Background

Constipation commonly coexists with heart failure (HF) and can increase blood pressure because of straining during defecation and accompanying mental stress. Daikenchuto, a Japanese herbal medicine to ameliorate gastrointestinal motility, may be effective as a complement to laxatives in improving outcomes in patients with HF and constipation.

Methods and Results

We used the Diagnosis Procedure Combination database to identify patients aged ≥65 years who were admitted for HF, had constipation, and were discharged alive between April 2016 and March 2022. We divided the 115,544 eligible patients into 2 groups according to the prescription of Daikenchuto in addition to laxatives at discharge and compared the incidence of 1-year HF readmission using 1 : 4 propensity score matching. Daikenchuto was prescribed at discharge in 3,315 (2.9%) patients. In the unmatched cohort, patients treated with Daikenchuto were more often male and had a higher prevalence of malignancy than those treated without Daikenchuto. In the 1 : 4 propensity score-matched cohort (3,311 and 13,243 patients with and without Daikenchuto, respectively), no significant difference was noted in 1-year HF readmission between the groups (22.2% vs. 21.9%; hazard ratio=1.02, 95% confidence interval=0.94-1.11). This result was consistent across clinically relevant subgroups except for renal disease.

Conclusions

Complementary use of Daikenchuto in combination with laxatives was not associated with a lower incidence of HF readmission in patients with HF and constipation.

Recent Trends in Achievement Rates and Time Required for Left Ventricular Reverse Remodeling in Dilated Cardiomyopathy

Background

Left ventricular reverse remodeling (LVRR) is associated with a good prognosis in patients with dilated cardiomyopathy (DCM), so in this study we examined the achievement rates of LVRR, the time taken to LVRR and the factors associated with LVRR in recent cases of DCM.

Methods and Results

We enrolled 121 patients with DCM. LVRR was defined as a left ventricular ejection fraction ≥40% at follow-up with a ≥10% improvement. LVRR was observed in 82 patients (68%). The median time to LVRR was 208 days. Multivariate analysis revealed that B-type natriuretic peptide (BNP) levels at discharge (per 1-SD increase, odds ratio: 0.483, 95% confidence interval (CI): 0.224-0.963; P=0.0385) and β-blocker dose (per 1-SD increase, odds ratio: 3.379, 95% CI: 1.644-7.702; P=0.0007) were independently associated with LVRR. When the patients were divided into 2 groups according to the first (2007-2017; n=64) and second (2018-2022; n=57) time periods, there was a significantly higher LVRR achievement rate (48.4% vs. 89.5%) and shorter time to LVRR in the second period than in the first.

Conclusions

The LVRR achievement rate in DCM has been increasing, and the time to LVRR has been shortened in recent years. Beta-blocker dose and BNP levels at discharge may be strongly associated with LVRR.

Heart Rate Reduction and the Prognosis of Heart Failure Focused on Ivabradine

Cardioprotective medications referred to as the fantastic four are used to treat heart failure (HF). Additionally, ivabradine can also be used if the heart rate (HR) is elevated. An elevated HR is a prognostic factor in HF patients, as well as in the general population. In both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF), an elevated HR is associated with all-cause mortality, whereas cardiovascular death is only associated with the former. In addition, previous clinical trials revealed that ivabradine was useful only in HFrEF but not in HFpEF. Therefore, ivabradine is indicated for patients only with HFrEF. Moreover, ivabradine increases the stroke volume by ensuring an effective diastolic time as a result of the decreased HR. Including this effect, the introduction of ivabradine allowed for the discontinuation of dobutamine infusion used in HF patients and the uptitration of β-blockers in other reports. Additionally, ivabradine improves exercise tolerance and the subjective symptoms of HF. However, the effects of ivabradine on exercise tolerance remain poorly understood, and prospective clinical trials are underway. While these beneficial effects have been reported, side effects such as photopsia and atrial fibrillation have also been reported. It is important to use ivabradine appropriately in conjunction with standard HF treatment, including quadruple therapy.

Molecular imaging of cardiovascular disease: Current status and future perspective

Advancements in knowledge of cardiovascular disease, pharmacology, and chemistry have led to the development of newer radiopharmaceuticals and targets for new and more suitable molecules. Molecular imaging encompasses multiple imaging techniques for identifying the characteristics of key components involved in disease. Despite its limitations in spatial resolution, the affinity for key molecules compensates for disadvantages in diagnosing diseases and elucidating their pathophysiology. This review introduce established molecular tracers involved in clinical practice and emerging tracers already applied in clinical studies, classifying the key component in A: artery, specifically those vulnerable plaque (A-I) inflammatory cells [18F-FDG]; A-II) lipid/fatty acid; A-III) hypoxia; A-IV) angiogenesis; A-V) protease [18F/68Ga-FAPI]; A-VI) thrombus/hemorrhage; A-VII) apoptosis and A-VIII) microcalcification [18F-NaF]) and B: myocardium, including myocardial ischemia, infarction and myocardiopathy (B-I) myocardial ischemia; B-II) myocardial infarction (myocardial damage and fibrosis); B-III) myocarditis and endocarditis; B-IV) sarcoidosis; B-V) amyloidosis; B-VI) metabolism; B-VII) innervation imaging). In addition to cardiovascular-specific tracers tested in animal models, many radiotracers may have been developed in other areas, such as oncology imaging or neuroimaging. While this review does not cover all available tracers, some of them hold potential for future use assessing cardiovascular disease. Advances in molecular biology, pharmaceuticals, and imaging sciences will facilitate the identification of precise disease mechanisms, enabling precise diagnoses, better assessment of disease status, and enhanced therapeutic evaluation in this multi-modality era.

Age-Specific Changes in Physical Function in Patients with Acute Decompensated Heart Failure

Cardiac rehabilitation (CR) improves physical function in patients with acute decompensated heart failure (ADHF) and frailty. However, few studies have assessed physical function through multiple measures during hospitalization; moreover, the effect of age remains unclear. This study aimed to evaluate age-specific changes in physical function during the acute-phase treatment period in patients with ADHF. Patients with ADHF hospitalized between June 2018 and June 2023, who were aged ≥ 60 years and underwent CR, were included in the study. Physical function assessments at admission and discharge included grip strength, quadriceps isometric strength, short physical performance battery (SPPB), gait speed, and frailty. Changes in physical function from admission to discharge were assessed. The mean age of the 531 patients was 79.8 ± 9.0 years and 58% were male. Physical function at admission and discharge significantly decreased with age according to all measures. In patients aged ≥ 90 years, quadriceps isometric strength (0.27 ± 0.11 kgf/BW kg) and the SPPB score (4.5 ± 3.6 points) were severely impaired at admission. However, no significant differences were observed in changes in physical function according to age; the improvement in the SPPB score tended to increase with age (+1.7 ± 1.9, +2.3 ± 2.1, +2.2 ± 2.4, and +2.3 ± 1.8, in the 60-69-, 70-79-, 80-89-, and ≥ 90-year age groups, respectively). The improvement in frailty was similar in all groups. Although physical function declined with age, the changes in physical function were similar in patients with ADHF at any age above 60 years who underwent CR.

Interrelationships Between Plasma Levels of Brain Natriuretic Peptide and Prolonged Symptoms Due to Long COVID

Objectives: Evidence for the usefulness of biomarkers that aid in diagnosis, assessment of severity, and prediction of prognosis in patients with long COVID is limited. The aim of this study was to clarify the characteristics of brain natriuretic peptide (BNP) in long COVID. Methods: We conducted a retrospective observational study of patients who visited the COVID-19 aftercare outpatient clinic at Okayama University Hospital from February 2021 to April 2024. Results: A total of 428 patients were enrolled in this study, and the patients were divided into a group with normal BNP (n = 314, ≤18.4 pg/mL) and a group with increased BNP (n = 114, >18.4 pg/mL). The long COVID group with increased BNP had a higher proportion of females (44.3% vs. 73.7%, p < 0.01) and an older median age (38 vs. 51 years, p < 0.01). Fatigue and brain fog were commonly manifested in both groups, while dyspnea was a more frequent complaint in the group with increased BNP. Various symptoms including fatigue, palpitations, and taste and/or olfactory disorders were associated with elevated BNP (23 to 24 pg/mL). Memory impairment was also linked to higher BNP (OR: 2.36, p = 0.05). In long COVID patients, plasma BNP elevation appears to be more pronounced in females and is often related to cardiogenic factors, in which inflammatory responses are also involved. Conclusions: Plasma BNP measurement may be useful for evaluating the severity of long COVID, especially in female patients and those with respiratory symptoms and/or memory impairment.

Safety and efficacy of catheter ablation in atrial fibrillation patients with heart failure with preserved ejection fraction

PURPOSE

Catheter ablation (CA) for atrial fibrillation (AF) in heart failure patients with preserved ejection fraction (HFPEF) has shown promising results in reducing mortality and improving heart function. However, previous studies have been limited by a lack of control groups and significant heterogeneity in their methodologies.

HYPOTHESIS

CA for AF in HFPEF patients may not increase the complications and had similarly the rate of freedom from AF vs. patients without HFPEF, and it may reduce hospitalizations and mortality and improve heart function VS medical treatment.

METHODS

Three groups of AF patients were included in the study: 187 patients with HFPEF for their first CA (AFPHF-CA), 187 patients with HFPEF who were undergoing medical therapy (AFPHF-Med), and 196 patients without HFPEF for their first CA (AF-CA).

RESULTS

After a mean (± SD) follow-up of 36 ± 3 months, 50.8% of patients in the AFPHF-CA group and 52.0% in the AF-CA group remained in sinus rhythm (P = 0.94), compared to only 12.5% in the AFPHF-Med group (P < 0.001). Age (OR: 1.09, 95% CI: 1.02-1.08, P = 0.016), duration of AF history (OR: 1.01, 95% CI: 1.00-1.02, P = 0.017), left atrial diameter (OR: 1.52, 95% CI: 1.06-2.19, P = 0.024), and the type of atrial fibrillation (OR: 4.02, 95% CI: 1.28-12.62, P = 0.017) were consistent multivariable predictors for sinus rhythm maintenance in AFPHF. HF hospitalization was significantly lower in the AFPHF-CA group (0.38 (0,2)) than in the AFPHF-Med group (1.28(0,3), P < 0.001) during the follow-up. Stroke occurred in 18 of 187 (9.63%) patients in the AFPHF-CA group, significantly lower than the AFPHF-Med group, with approximately 31 of 187 (16.58%) (P < 0.01), but not statistically different from AF-CA, where approximately 17 of 196 (8.67%) experienced stroke (P = 0.65). Regarding mortality, death occurred in 12.8% of patients in the AFPHF-Med group, higher than 7.5% in the AFPHF-CA group and 6.6% in the AF-CA group (P = 0.49). Significant improvements in heart function were observed in the AFPHF-CA group compared to the AFPHF-Med group, including reductions in left ventricular end-diastolic diameter (P < 0.001), New York Heart Association classification (P < 0.001), left ventricular mass index (P < 0.001), and left atrial volume index (P < 0.001). HF hospitalization was significantly lower in the AFPHF-CA group compared to AFPHF-Med (P < 0.001).

CONCLUSION

CA for AF has showed significant benefits in patients with HFPEF compared to medical treatment alone. These benefits include improvements in heart function, reduced mortality, incidence of stroke, and hospitalizations. Importantly, CA in HFPEF patients showed comparable maintenance of sinus rhythm (SR) and safety outcomes when compared to CA in individuals with normal heart function.

Effects of Acute Phase Intensive Exercise Training in Patients With Acute Decompensated Heart Failure

BACKGROUND

Acute decompensated heart failure (ADHF) leads to hospitalizations and functional decline in older adults. Although cardiac rehabilitation (CR) is effective for stable heart failure, its impact on ADHF patients, particularly those without frailty, is unclear.

OBJECTIVES

The goal of this study was to evaluate the efficacy and safety of early in-hospital CR for patients hospitalized with ADHF who are not frail.

METHODS

In this multicenter trial (ACTIVE-ADHF [Effects of Acute Phase Intensive Exercise Training in Patients with Acute Decompensated Heart Failure]), ADHF patients without physical frailty were randomized 2:1 to undergo either exercise-based CR or standard care. The intervention included early mobilization and structured exercise training. The primary outcome was the change in 6-minute walk distance (6MWD) from baseline to discharge. Secondary outcomes assessed physical and cognitive function, quality of life, and safety.

RESULTS

A total of 91 patients were randomized to treatment, with 59 allocated to the intervention group and 32 to the control group. The primary outcome, 6MWD, improved significantly more in the intervention group, with a mean increase of 75.0 ± 7.8 m vs 44.1 ± 10.2 m in the control group, with an effect size of 30.9 ± 13.1 m (95% CI: 4.8-57.0; P = 0.021). The intervention group showed favorable results in secondary efficacy outcomes, including physical and cognitive function, physical activity, and quality of life. Safety outcomes were similar between groups, except for a greater reduction in B-type natriuretic peptide levels at 90 days' postdischarge in the intervention group.

CONCLUSIONS

In patients with ADHF without physical frailty, in-hospital exercise-based CR led to significant improvements in 6MWD at 2 weeks after randomization without compromising safety. (ACTIVE-ADHF [Effects of Acute Phase Intensive Exercise Training in Patients with Acute Decompensated Heart Failure]; UMIN000020919).

Clinical Outcomes of Catheter Ablation for Atrial Fibrillation in Patients with Acute Decompensated Heart Failure

Background: The prognosis of acute decompensated heart failure (ADHF) and heart failure (HF) with atrial fibrillation (AF) has been dismal. This study was performed to investigate the clinical outcomes of catheter ablation (CA) performed in patients with concurrent ADHF and AF. Methods: We retrospectively analyzed ADHF patients with AF who were admitted to our institution from 2007 to 2017. Results: In total, 472 patients were included in this study, with a mean follow-up duration of 32.8 ± 32.9 months. The 5-year event-free rate (cardiovascular death and HF hospitalization) was 61.4%, and the 10-year event-free rate was 42.7%. A comparative analysis of the event group and control group revealed that patients in the event group were older (event group vs. control group: 72.1 ± 11.0 vs. 68.8 ± 13.4 years, p = 0.008) and had a higher proportion of Clinical Scenario 3 classifications (event group vs. control group: 24% vs. 12%, p = 0.001). Notably, patients in the event group had a lower sinus rhythm maintenance rate (event group vs. control group: 17% vs. 31%, p < 0.001) and CA rate (event group vs. control group: 9% vs. 21%, p = 0.003). The CA group had a higher event-free rate than the non-CA group, and this trend persisted even after matching the patients' backgrounds (log-rank test: p < 0.001). Conclusions: Patients presenting with AF at the onset of ADHF showed a poor prognosis, whereas CA demonstrated potential for improving the prognosis for some of these patients.

Association between Gardening Activity and Frailty in Patients with Heart Failure

Objective Frailty is common in patients with heart failure (HF). Given that gardening demands regular physical activity and offers therapeutic relaxation benefits, this activity may reduce frailty. We investigated the association between gardening activities and frailty in patients with HF. Methods Between August 2022 and March 2023, we surveyed patients at risk of HF and those with HF who regularly attended a cardiology outpatient clinic. Gardening activities were defined as the ongoing cultivation of flowers, vegetables, or fruits for more than a year. The questionnaire assessed the presence or absence of gardening activities as well as the frequency, duration per session, years of experience, and scale of such activities. We calculated the frailty index. Frailty was defined as a frailty index of 0.25 or greater. Results Of the 1,277 respondents, 69% engaged in gardening and 35% were frail. After adjusting for multiple confounding factors, gardening activities showed an inverse association with frailty [odds ratio=0.723, 95% confidence interval (0.533-0.981)]. Moreover, frailty and the frailty index showed an inverse association with more extended and large-scale gardening activities. Conclusion Gardening activities were thus found to be associated with a low prevalence of frailty in patients with HF.

Importance of early use of tolvaptan in hyponatremic acutely decompensated heart failure patients, a retrospective study

BACKGROUND

Hyponatremia is one of the complicating findings in acute decompensated heart failure. Decrease in cardiac output and systemic blood pressure triggers activation of renin-angiotensin-aldosterone system, antidiuretic hormone, and norepinephrine due to the perceived hypovolemia. Fluid-overloaded heart failure patients are commonly treated with loop diuretics, acutely decompensated heart failure patients tend to be less responsive to conventional oral doses of a loop diuretic, while other different diuretics could work in different part of nephron circulation system. In this study, we aim to further examine the role of tolvaptan, a vasopressin receptor antagonist, in the treatment of hyponatremia secondary to acutely decompensated heart failure.

RESULTS

A total of 71 patients with hyponatremia secondary to ADHF were included, and all patients were given tolvaptan. 37 patients were administered tolvaptan early (up until 5 th day of admission). 34 patients received tolvaptan after 5 th day of admission mean administration as 6.86 th day, and median administration was 5 th day. Analysis showed lower length of stay in patients receiving early administration of tolvaptan compared to late administration (8.86 ± 5.06 vs 18.5 ± 9.05 p0.001, respectively). Patients with early initiation of tolvaptan also achieved a larger net increase in sodium levels at discharge compared to admission (6.46 ± 6.69 vs 3.68 ± 4.70 p0.048, respectively).

CONCLUSIONS

Early administration of tolvaptan in treating hyponatremia in acutely decompensated heart failure patients is associated with a lower length of hospitalization and a higher increase in serum sodium of patients in hyponatremic ADHF patients.

Prognostic implication of sarcopenia diagnosed by updated Asian Working Group for Sarcopenia criteria in older patients with heart failure: Utility and limitation

OBJECTIVES

The utility of the updated Asian Working Group for Sarcopenia (AWGS) criteria in diagnosing sarcopenia in older patients with heart failure (HF) remains unclear.

OBJECTIVE

To analyze the prevalence and prognostic impact of sarcopenia diagnosed by the updated AWGS criteria in older patients with HF.

DESIGN

Ambispective cohort study.

SETTING & SUBJECTS

534 older patients with HF from a university hospital in Japan.

MEASUREMENTS

Sarcopenia was assessed using different versions of the AWGS criteria: AWGS 2014, AWGS 2019H (muscle mass relative to height squared), and AWGS 2019B (muscle mass relative to BMI). The primary endpoint was all-cause mortality at three years post-discharge.

RESULTS

Of 534 patients, 42%, 57%, and 44% were diagnosed with sarcopenia according to AWGS 2014, AWGS 2019H, AWGS 2019B, respectively. Among patients without AWGS 2014-defined sarcopenia, 23% were reclassified as having sarcopenia by AWGS 2019H criteria. Forty-four percent of sarcopenic patients diagnosed by AWGS 2019H were re-classified as non-sarcopenic by AWGS 2019B, with lower fat mass and poorer nutritional status. After the multivariate Cox proportional hazard analyses, an association between all-cause death and sarcopenia remained significant for AWGS 2014 (hazard ratio [HR], 1.55; 95% confidence interval [CI], 1.01-2.37) and AWGS 2019H (HR, 1.65; 95% CI, 1.05-2.59), but not for AWGS 2019B (HR, 0.99; 95% CI, 0.64-1.51).

CONCLUSION

The updated AWGS 2019H criteria detected more sarcopenic patients with HF while maintaining favorable predictive ability. The use of BMI-adjusted muscle mass reclassified underweight and malnourished patients as non-sarcopenic, limiting its impact on the mortality prediction in older patients with HF.

Emergency department clinical performance of ADVIA Centaur n-terminal prohormone of B-type natriuretic peptide assay

BACKGROUND

Natriuretic peptide testing is guideline recommended as an aid to the diagnosis of heart failure (HF). We sought to evaluate the performance of the ADVIA Centaur (Siemens Healthcare Diagnostics, Tarrytown, NY) NT-proBNPII assay (PBNPII) in emergency department (ED) dyspneic patients.

METHODS

Eligible patients presented to the ED with dyspnea, with their gold standard diagnosis determined by up to 3 cardiologists blinded to the PBNPII results. Patients were stratified into 3 groups based on PBNPII resultsa rule out group of NT-proBNP<300  pg/mL, an age-specific rule in group using cutoffs of 450, 900, and 1800 pg/mL, for <50, 50-75, and > 75 years respectively, and an intermediate cohort for results between the rule out and rule in groups.

RESULTS

Of 3128 eligible patients, 1148 (36.7 %) were adjudicated as acute heart failure (AHF). The gold standard AHF diagnosis rate was 3.7, 24.3, and 67.2 % for patients with NTproBNPII in the negative, indeterminate, and positive groups, respectively. Overall likelihood ratios (LR) were 0.07 (95 % CI: 0.05,0.09), 0.55 (0.45,0.67), and 3.53 (3.26,3.83) for the same groups, respectively. Individual LR+for age dependent cutoffs were 5.01 (4.25,5.91), 3.71 (3.25,4.24), and 2.38 (2.10,2.69), respectively. NTproBNPII increased with increasing severity of HF when stratified by NYHA classification.

CONCLUSIONS

The ADVIA Centaur PBNPII assay demonstrates acceptable clinical performance using the recommended single rule out and age dependent rule in cutoffs for an AHF diagnosis in dyspneic ED patients.

Uptitration of Sacubitril/Valsartan and Outcomes in Patients With Heart Failure - Insight From the REVIEW-HF Registry

BACKGROUND

Guideline-directed medical therapy has become an important component of heart failure (HF) therapy, with sacubitril/valsartan as one of the recommended drugs; however, the real-world prognostic implications of sacubitril/valsartan uptitration are unclear.

METHODS AND RESULTS

Patients with HF newly initiated on sacubitril/valsartan were registered in a retrospective multicenter study (REVIEW-HF). In all, 995 patients were divided into 3 groups according to the maximum dose achieved: high dose, sacubitril/valsartan 400 mg; intermediate dose, sacubitril/valsartan 200-<400 mg; and low dose, sacubitril/valsartan <200 mg. A total of 397 (39.9%) patients received high-dose sacubitril/valsartan; they had a significantly lower risk of mortality or HF hospitalization than patients in the low-dose (hazard ratio [HR] 0.39; 95% confidence interval [CI] 0.29-0.53; P<0.001) and intermediate-dose (HR 0.64; 95% CI 0.45-0.94; P=0.03) groups. In the multivariable Cox regression model, higher systolic blood pressure and maintained geriatric nutritional risk index were significantly associated with a higher incidence of achieving a high dose of sacubitril/valsartan. Patients who did not receive high-dose sacubitril/valsartan experienced more hypotension during the follow-up period, whereas hyperkalemia, severe renal events, and angioedema did not differ across the achieved dose classifications.

CONCLUSIONS

Patients who achieved sacubitril/valsartan uptitration had a better prognosis than those who did not. Before sacubitril/valsartan uptitration, patients need to monitor blood pressure closely to prevent worsening events.

Characteristics, Treatment, and Prognosis in Octogenarian and Older Patients With Acute Heart Failure in Japan - Prospective Observational Study on Acute Pharmacotherapy and Prognosis in Management of Acute Heart Failure (POPEYE-AHF Registry)

BACKGROUND

The number of older people in Japan is increasing more quickly than in other countries; with this aging of society, the number of elderly patients hospitalized for acute heart failure (HF) is also increasing. The treatment and prognosis of acute HF may be changing, but there are insufficient recent data, especially for octogenarian and older patients.

METHODS AND RESULTS

This study investigated the characteristics and treatment of acute HF patients in Japan. From 2018 to 2020, 1,146 patients from 7 Tokai area hospitals were followed for at least 1 year. The mean age was 78 years. Compared with patients aged <80 years, those aged ≥80 years were more likely to be female (57.4% vs. 34.2%), have a lower body mass index (22.2 vs. 24.9 kg/m2), and have HF with preserved ejection fraction (43.1% vs. 21.4%), and less likely to have HF with reduced ejection fraction (38.9% vs. 61.7%). During hospitalization, 6.5% died. After discharge, patients faced high risks of rehospitalization for HF and death (27.6 and 14.2 per 100 patient-years, respectively). Notably, prescription rates of HF medications have declined over time for all patients, but especially for those aged ≥80 years.

CONCLUSIONS

Guideline-directed medical therapy should be provided based on a thorough understanding of an individual's background rather than withheld simply because of clinical inertia due to a patient's advanced age.

Associated Factors for Quality of Life, Anxiety, and Depression in Patients with Chronic Heart Failure and Their Family Caregivers: A Cross-Sectional Study in Japan

Background

Family caregivers (FCs) need to provide regular assistance and good quality care to patients to prevent the deterioration of chronic heart failure (CHF); therefore, they may have physical and mental distress. However, physical and mental distress in FCs of patients with CHF in Japan is unclear.

Objective

This study aimed to clarify the quality of life (QoL), anxiety/depression, and associated factors in patients with CHF and their FCs.

Design

We conducted a multicenter cross-sectional survey using a questionnaire between 2016 and 2017 among patients with CHF and their FCs. Demographic data were extracted from medical records. Health-related QoL and anxiety/depression were assessed using the Short Form-12 and the Hospital Anxiety and Depression Scales, respectively.

Results

Of 286 patients and FCs (response rate 57.2%), the physical component summary and mental component summary (MCS) scores of FC were higher than those of patients (p < 0.001 and p = 0.047, respectively). The incidence of anxiety and depression in patients with CHF was 7.0% and 10.8%, respectively, whereas that in FC was 10.1% and 12.6%. In multivariable analysis, the MCS score of FC was associated with the MCS score of patients (β = 0.22, p < 0.001). Anxiety in FC was associated with anxiety (β = 0.30, p < 0.001) in patients, respectively.

Conclusions

It is necessary to carefully monitor the physical and mental condition of patients with CHF and provide palliative care in collaboration with the palliative care team as needed. Stabilizing the patient's physical and mental condition through palliative care may also help alleviate the suffering of FC.

Knowledge of Illness Trajectory and Symptoms of Heart Failure in Patients with Acute Coronary Syndrome

BACKGROUND

Preventive management of heart failure (HF) should involve strategies to increase awareness of HF in patients with pre-HF and those at risk of HF. However, the perception of HF in patients with acute coronary syndrome (ACS) remains unclear. This study aimed to assess patient understanding of the definition of HF for the public-that is, its illness trajectory (intermittent decline), impact on life expectancy (HF would limit life expectancy), and symptoms (shortness of breath, swelling)-that was introduced by the Japanese Circulation Society.

METHODS

This cross-sectional, questionnaire-based study enrolled 209 emergently admitted patients with ACS who underwent a cardiac rehabilitation program at a single university-based hospital. We identified the clinical characteristics of patients who understood HF definition.

RESULTS

Among the enrolled patients (median age, 69 years; males, 81.3%; 59.8% with ST-elevation myocardial infarction), 64.0% and 53.1% chose the correct answers regarding HF illness trajectory and impact on life expectancy, respectively. While 92.3% of the patients correctly chose shortness of breath as an HF symptom, 56.7% correctly chose swelling. Patient understanding of the definition of HF was associated with younger age, but not with HF risk (i.e., hypertension, diabetes, higher natriuretic peptide levels, lower left ventricular ejection fraction) and history of symptomatic HF.

CONCLUSIONS

Among patients with ACS who participated in the cardiac rehabilitation program in this cohort, patient understanding of HF definition was suboptimal. Effective measures to improve their understanding should be considered to enhance the prevention of HF.

Clinical Implication of HIF-PH Inhibitor in Patients with Heart Failure, Chronic Kidney Disease, and Renal Anemia

Background: Hypoxia-inducible factor-prolyl hydroxylase (HIF-PH) inhibitors have been developed as a treatment for renal anemia. However, their therapeutic impact on patients with concomitant heart failure remains uncertain. We investigated the impact of HIF-PH inhibitors on improving renal anemia and associated clinical outcomes in patients with heart failure. Methods: Patients with both heart failure and renal anemia who received HIF-PH inhibitors were retrospectively analyzed over a six-month follow-up period. Hemoglobin levels and other clinical parameters were compared between the six-month pre-treatment period without HIF-PH inhibitors and the six-month treatment period with HIF-PH inhibitors. Results: A total of 69 patients (median age 82 years, 27 male) were included. Baseline hemoglobin was 9.2 (8.8, 10.3) g/dL, baseline plasma B-type natriuretic peptide level was 264 (156, 372) pg/mL, and baseline estimated glomerular filtration rate was 29.1 (19.0, 35.1) mL/min/1.73 m2. Hemoglobin levels declined during the pre-treatment period from 10.5 (9.4, 11.5) g/dL to 9.2 (8.8, 10.3) g/dL (p < 0.001) but subsequently increased to 10.9 (10.1, 12.0) g/dL following six months of HIF-PH inhibitor treatment (p < 0.001). This increase in hemoglobin was accompanied by a reduction in plasma BNP levels, improved renal function, and reduced systemic inflammation (p < 0.05 for all). Conclusions: HIF-PH inhibitors demonstrated efficacy in this cohort of patients with heart failure, with associated improvements in heart failure severity, renal function, and systemic inflammation.

J-shaped association between serum glucose potassium ratio and prognosis in heart failure with preserved ejection fraction with stronger predictive value in non-diabetic patients

BACKGROUND

The relationship between serum glucose/potassium ratio (GPR) and the adverse outcomes in patients with heart failure with preserved ejection fraction (HFpEF) has not been completely clarified.

METHODS

Patients were included from the American cohort of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. The primary endpoint was the composite of cardiovascular mortality, aborted cardiac arrest, and hospitalization for HF. The Cox regression models were applied to calculate the hazard ratio (HR) and 95% confidence interval (CI) to examine the relationship between GPR and prognosis. Restricted cubic spline (RCS) curves were performed to explore the nonlinear relationship between GPR and the primary endpoint. Receiver Operating Characteristic (ROC) curves were constructed, and the areas under the curves (AUCs) for GPR and its components were compared using the DeLong test. Subgroup analysis and interaction effect were also explored.

RESULTS

A total of 1749 HFpEF patients were included. During the follow-up, 514 (29.4%) patients reached the primary outcome. An increase in GPR was independently associated with a higher risk in the primary endpoint [Tertile 3 vs. Tertile 1: HR (95% CI), 1.35 (1.07-1.70), P = 0.012] and HF hospitalization [Tertile 3 vs. Tertile 1: HR (95% CI), 1.57 (1.20-2.05), P = 0.001]. RCS curve showed a J-shape trend between GPR and primary endpoint (non-linear P = 0.002). The AUC for GPR was superior to that of the glucose and potassium (De long test P < 0.05). Additionally, the prognostic value of GPR was stronger in patients without diabetes and with less severe heart failure symptoms (P interaction < 0.05).

CONCLUSION

A J-shaped relationship was existed between GPR levels and the primary outcome in HFpEF patients. An increased GPR was an independent predictor of poor prognosis in HFpEF patients, especially in non-diabetic patients and those with less severe heart failure symptoms.

Clinical outcomes during and after wearable cardioverter defibrillator use in Japanese patients with heart failure: A single-center experience

Background

A wearable cardioverter defibrillator (WCD) is indicated for a limited period in patients at high risk of sudden cardiac death (SCD). Nonischemic heart failure (HF) is common among Japanese patients with HF. The aim of this study was to evaluate the incidence of fatal arrhythmias during WCD use and the clinical outcomes after WCD withdrawal in Japanese patients with HF.

Methods

We retrospectively studied 105 hospitalized HF patients who were discharged with a WCD. The main outcome was SCD/ventricular arrhythmias during WCD use and the other outcomes were implantation of an implantable cardioverter-defibrillator (ICD), SCD/ventricular arrhythmias after WCD withdrawal, and changes in left ventricular ejection fraction (LVEF).

Results

Eighty-seven (83%) patients received a WCD for primary prevention of SCD, of whom 60 (69%) were new-onset HF patients with an LVEF ≤35%. The median daily wear time was 22.1 h. Two patients experienced sustained ventricular tachycardia and one patient experienced atrioventricular block with asystole while on WCD. After WCD withdrawal, 81 (77%) patients decided not to receive ICD implantation. The percentage of patients with an LVEF ≥35% increased from 20% at baseline to 70% at 1 year after discharge. During the median follow-up of 50 months, 78 (96%) of the 81 patients who did not have an ICD were free of SCD/ventricular arrhythmias.

Conclusions

The use of a WCD is useful for determining the appropriate indication for ICD implantation in Japanese patients with new-onset HF, a low LVEF, and a risk of SCD.

Efficacy and safety of patiromer for non-dialysis and dialysis patients with hyperkalemia: the randomized, placebo-controlled and long-term study

BACKGROUND

The objectives of this phase two study are to investigate the efficacy of two starting doses of 8.4 g and 16.8 g and evaluate the long-term safety of patiromer in Japanese patients with hyperkalemia.

METHODS

This study comprised three cohorts; non-dialysis patients with baseline serum potassium (sK) level of 5.1 to < 6.0 mmol/L (NDC1); 6.0 to < 6.5 mmol/L (NDC2); dialysis patients with baseline sK level of 5.5 to < 6.5 mmol/L (DC). The study design was one-week, randomized, double-blind, placebo-controlled, and open label extension for one year in NDC1, open label during the study in NDC2 and DC. Patients were randomly assigned to patiromer 8.4 g, 16.8 g or placebo in NDC1, 8.4 g or 16.8 g in NDC2 and DC. Dose was adjusted up to 25.2 g according to the titration algorism in open label period.

RESULTS

A total of 185 patients were randomized (NDC1:153, NDC2:10, and DC:22). The primary endpoint of the change in least squares mean sK levels at Week 1 in NDC1 was  - 0.55,  - 0.77 and  - 0.10 mmol/L for the 8.4 g, 16.8 g and placebo group (P < 0.001 for the patiromer group vs the placebo group). In all cohorts for each patiromer group, more than 80% of patients achieved normal sK at Week 5. There was no severe treatment-related adverse event.

CONCLUSION

Treatment with patiromer was effective in lowering and maintaining target sK levels, also well tolerated for one year in Japanese patients with hyperkalemia.

Post-Discharge Self-Care Confidence and Performance Levels in Patients Hospitalized due to Heart Failure

BACKGROUND

Multidisciplinary self-care education plays a critical role in ensuring the high-quality transitional care of patients hospitalized due to heart failure (HF). However, whether confidence concerning self-care during their index hospitalizations would influence their post-discharge self-care performances and long-term outcomes remains uncertain.

METHODS

We conducted an assessment of 100 consecutive patients with HF who completed self-care questionnaires both during their hospitalizations and 1 year after discharge. Among these patients hospitalized due to HF, self-care confidence was assessed immediately after they completed their pre-discharge education program. One year after the index hospitalization, we evaluated self-care performance by using the European Heart Failure Self-care Behavior Scale. Logistic regression analysis was employed to identify determinants of poor self-care behavior 1 year after the hospitalization. Additionally, the Cox proportional hazards model with adjustment for the Seattle Heart Failure Model was applied to assess their association with 2-year mortality and readmission risk.

RESULTS

The enrolled patients predominantly had HF with reduced ejection fraction (43.0%), and approximately half of the patients had experienced a previous hospitalization due to HF (47.0%). The 3 worst-performing aspects of post-discharge self-care behavior (among the 12 items) were appropriate consultation for fatigue (40.0%), weight gain (52.0%) and application of regular exercise (57.0%). After adjustment, low self-care confidence during the index hospitalization was associated with poor post-discharge self-care performance (OR: 1.11, CI: 1.00-1.21). Poor post-discharge self-care behavior was not associated with worse prognoses over a 2-year follow-up (hazard ratio [HR]: 1.82, CI: 0.85-3.86); however, the association was significant in patients with reduced ejection fraction (HR: 4.04, CI: 1.17-13.89) and previous HF hospitalization (HR: 3.66, CI: 1.46-9.13).

CONCLUSIONS

Post-discharge self-care performance was associated with self-care confidence during the index HF hospitalization. Effective measures that improve pre-discharge confidence levels in self-care should be considered to enhance the quality of transitional care.

In-hospital initiation of angiotensin receptor-neprilysin inhibition in acute heart failure: the PREMIER trial

BACKGROUND AND AIMS

The efficacy and safety of early sacubitril/valsartan (Sac/Val) initiation after acute heart failure (AHF) has not been demonstrated outside North America. The present study aimed to evaluate the effect of in-hospital Sac/Val therapy initiation after an AHF episode on N-terminal pro-B-type natriuretic peptide (NT-proBNP) level in Japanese patients.

METHODS

This was an investigator-initiated, multicentre, prospective, randomized, open-label, blinded-endpoint pragmatic trial. After haemodynamic stabilization within 7 days after hospitalization, eligible inpatients were allocated to switch from angiotensin-converting enzyme inhibitor or angiotensin receptor blocker to Sac/Val (Sac/Val group) or to continue angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (control group). The primary efficacy endpoint was the 8-week proportional change in geometric means of NT-proBNP levels.

RESULTS

A total of 400 patients were equally randomized, and 376 (median age 75 years, 31.9% women, de novo heart failure rate 55.6%, and median left ventricular ejection fraction 37%) were analysed. The per cent changes in NT-proBNP level geometric means at Weeks 4/8 were -35%/-45% (Sac/Val group) and -18%/-32% (control group), and their group ratio (Sac/Val vs. control) was 0.80 (95% confidence interval 0.68-0.94; P = .008) at Week 4 and 0.81 (95% confidence interval 0.68-0.95; P = .012) at Week 8, respectively. In the pre-specified subgroup analyses, the effects of Sac/Val were confined to patients with a left ventricular ejection fraction < 40% and were more evident in those in sinus rhythm and taking mineralocorticoid receptor antagonists. No adverse safety signal was evident.

CONCLUSIONS

In-hospital Sac/Val therapy initiation in addition to contemporary recommended therapy triggered a greater NT-proBNP level reduction in Japanese patients hospitalized for AHF. These findings may expand the evidence on Sac/Val therapy in this clinical situation outside North America.

CLINICAL TRIAL REGISTRATION

ClinicalTrial.gov (NCT05164653) and Japan Registry of Clinical Trials (jRCTs021210046).

Heart failure with preserved ejection fraction management: a systematic review of clinical practice guidelines and recommendations

Multiple guidelines exist for the diagnosis and management of heart failure with preserved ejection fraction (HFpEF). We systematically reviewed current guidelines and recommendations, developed by national and international medical organizations, on the management of HFpEF in adults to aid clinical decision-making. We searched MEDLINE and EMBASE on 28 February 2024 for publications over the last 10 years as well as websites of organizations relevant to guideline development. Of the 10 guidelines and recommendations retrieved, 7 showed considerable rigour of development and were subsequently retained for analysis. There was consensus on the definition of HFpEF and the diagnostic role of serum natriuretic peptides and resting transthoracic echocardiography. Discrepancies were identified in the thresholds of serum natriuretic peptides and transthoracic echocardiography parameters used to diagnose HFpEF. There was agreement on the general pharmacological and supportive management of acute and chronic HFpEF. However, differences exist in strategies to identify and address specific phenotypes. Contemporary guidelines for HFpEF management agree on measures to avoid its development and the consideration of cardiac transplantation in advanced diseases. There were discrepancies in recommended frequency of surveillance for patients with HFpEF and sparse recommendations on screening for HFpEF in the general population, use of diagnostic scoring systems, and the role of newly emerging therapies.