Clinical Background and Coronary Artery Lesions Characteristics in Japanese Patients With Acute Coronary Syndrome Suffering Major Bleeding

Background: Although the clinical factors that predict major bleeding in Western patients with acute coronary syndrome (ACS) are becoming elucidated, they have not been fully investigated, especially coronary lesion characteristics, in a Japanese population. Methods and Results: ACS patients (n=1,840) were divided into a "bleeding group" and a "no-bleeding group," according to whether they had major bleeding during the 2-year follow-up period, to investigate the prognostic effect of bleeding and the predictive factors of bleeding. Among them, patients who underwent primary percutaneous coronary intervention with optical coherence tomography (OCT) guidance (n=958) were examined to identify the effect of coronary lesion characteristics on bleeding. Of the 1,840 enrolled patients, 124 (6.7%) experienced major bleeding during the 2-year follow-up period. Incidence of cardiovascular death during the 2-year follow-up period was significantly higher among patients with major bleeding (26.4% vs. 8.5%, P=0.001). OCT examination showed that disrupted fibrous cap (DFC: 68% vs. 48%, P=0.014) and calcified plaque (63% vs. 42%, P=0.011) were more prevalent in the bleeding group. DFC was a predictor of major bleeding in the multivariate Cox proportional hazards analyses (hazard ratio 2.135 [95% confidence interval 1.070-4.263], P<0.001). Conclusions: ACS patients with major bleeding had poorer cardiac outcomes. Advanced atherosclerosis at the culprit lesion influences the higher incidence of major bleeding in ACS patients.

Clinical Significance of the Triglyceride-Glucose Index in Patients Requiring Nonsurgical Intensive Care

The evaluation of triglyceride-glucose (TyG) index has not been sufficient in patients requiring nonsurgical intensive care.A total of 3,906 patients who required intensive care were enrolled. We computed the TyG index using the value on admission by the following formula: ln [triglyceride (mg/dL) × glucose (mg/dL) /2]. Patients were divided into three groups according to the TyG index quartiles: low (quartile 1 [Q1]; TyG index ≤ 8.493, n = 977), middle (Q2/Q3; 8.494 ≤ TyG index ≤ 9.536, n = 1,953), and high (Q4; TyG index > 9.537, n = 976). The median (interquartile range) TyG index was 9.00 (8.50-9.54); acute coronary syndrome (ACS) had the highest TyG index among all etiologies at 9.12 (8.60-9.68). A multivariate logistic regression model showed that ACS (odds ratio [OR], 2.133; 95% confidence interval [CI], 1.783-2.552) were independently correlated with high TyG index. A Cox proportional hazards regression model revealed that, in ACS, the Q2/Q3 and Q4 groups were independent predictors of 30-day all-cause mortality (hazard ratio [HR], 1.778; 95% CI, 1.014-3.118; HR, 2.986; 95% CI, 1.680-5.308; respectively) and that in acute heart failure [AHF], the Q4 group was a converse independent predictor of 30-day all-cause mortality (HR, 0.488; 95% CI, 0.241-0.988).High TyG index was linked to ACS and negative outcomes in the ACS group; in contrast, low TyG index was associated with adverse outcomes in the AHF group.

Timing and Degree of Acute Kidney Injury in Patients Requiring Non-Surgical Intensive Care

BACKGROUND

The degree and timing of acute kidney injury (AKI) on admission and during hospitalization in patients requiring non-surgical intensive care remain unclear.Methods and Results: In this study, 3,758 patients requiring intensive care were analyzed retrospectively. AKI was defined based on the ratio of serum creatinine concentrations recorded at each time point (i.e., on admission and during the first 5 days in the intensive care unit and during hospitalization) to those measured at baseline. Patients were grouped by combining AKI severity (RIFLE class) and timing (i.e., from admission to 5 days [A-5D]; from 5 days to hospital discharge [5D-HD]) as follows: No-AKI; New-AKI (no AKI to Class R [risk; ≥1.5-fold increase in serum creatinine], I [injury; ≥2.0-fold increase in serum creatinine], and F [failure; ≥3.0-fold increase in serum creatinine or receiving dialysis during hospitalization]); Stable-AKI (Class R to R; Class I to I); and Worsening-AKI (Class R to I or F; Class I to F). Multivariate logistic regression analysis indicated that 730-day mortality was independently associated with Class R, I, and F on admission; Class I and F during the 5D-H period; and New-AKI and Worsening-AKI during A-5D and 5D-HD.

CONCLUSIONS

AKI on admission, even Class R, was associated with a poor prognosis. An increase in RIFLE class during hospitalization was identified as an important factor for poor prognosis in patients requiring intensive care.

Comparisons of Patients Living Alone versus Living with Others in Acute Coronary Syndrome

We aimed to examine the relationship of living arrangements (i.e., living alone or living with others) with background, clinical severity, preintervention culprit lesion plaque morphology, and clinical outcomes in patients with acute coronary syndrome (ACS). Among 1,683 consecutive patients with ACS, we retrospectively compared patients living alone ( n  = 318) versus living with others ( n  = 1,362). Optical coherence tomography (OCT) findings, which are high-resolution intracoronary imaging devices, were analyzed in patients with preintervention OCT and compared between patients living alone ( n  = 174) versus those living with others ( n  = 665). Older (median; 69 vs. 67 y, p  = 0.046) and female (31 vs. 17%, p  < 0.001) patients more frequently lived alone. Frequency of achieving a time interval of 6 hours or less from ACS onset to admission was lower in patients living alone (56 vs. 63%, p  = 0.022). Clinical presentation was more severe in patients living alone (Killip II/III/IV; 27 vs. 22%, p  = 0.029). Plaque morphology evaluated by OCT was similar between groups (plaque rapture; 48 vs. 48%, p  = 0.171). Kaplan-Meier analyses revealed higher rates of cardiac mortality during 2-year follow-up period in patients living alone [13.9 vs. 8.5%, hazard ratio (HR) 1.604, 95% confidence interval (CI) 1.112-2.313, p  = 0.010]. After traditional cardiovascular risk factors and clinical severity upon admission had been adjusted, living alone was an independent predictor of cardiac mortality in ACS patients (HR 1.582, 95% CI 1.056-2.371, p  = 0.026). Living alone was independently associated with 2-year cardiacmortality in ACS patients after adjusting for background and presentation and might be unrelated to the development of atherosclerosis.

Organ dysfunction, injury, and failure in cardiogenic shock

BACKGROUND

Cardiogenic shock (CS) is caused by primary cardiac dysfunction and induced by various and heterogeneous diseases (e.g., acute impairment of cardiac performance, or acute or chronic impairment of cardiac performance).

MAIN BODY

Although a low cardiac index is a common finding in patients with CS, the ventricular preload, pulmonary capillary wedge pressure, central venous pressure, and systemic vascular resistance might vary between patients. Organ dysfunction has traditionally been attributed to the hypoperfusion of the organ due to either progressive impairment of the cardiac output or intravascular volume depletion secondary to CS. However, research attention has recently shifted from this cardiac output ("forward failure") to venous congestion ("backward failure") as the most important hemodynamic determinant. Both hypoperfusion and/or venous congestion by CS could lead to injury, impairment, and failure of target organs (i.e., heart, lungs, kidney, liver, intestines, brain); these effects are associated with an increased mortality rate. Treatment strategies for the prevention, reduction, and reversal of organ injury are warranted to improve morbidity in these patients. The present review summarizes recent data regarding organ dysfunction, injury, and failure.

CONCLUSIONS

Early identification and treatment of organ dysfunction, along with hemodynamic stabilization, are key components of the management of patients with CS.

Effect of sacubitril/valsartan on natriuretic peptide in patients with compensated heart failure

The time-dependent changes in the natriuretic peptide families during sacubitril/valsartan (S/V) treatment remain obscure in the Asian heart failure (HF) cohort. Eighty-one outpatients with compensated HF were analyzed. The patients were divided into two groups based on the administration of S/V (n = 42) or angiotensin converting enzyme inhibitor (ACE-I; n = 39). Changes to the natriuretic peptide families and the daily dose of loop diuretics were evaluated 3 and 6 months after the intervention. The atrial natriuretic peptide (ANP) level was significantly increased (102 [63-160] pg/mL to 283 [171-614] pg/mL [3 months]; 409 [210-726] pg/mL [6 months]) in the S/V group but not in the ACE-I group. The dose of furosemide was significantly decreased during the six-month follow-up period in the S/V group (40 [20-40] mg to 20 [10-20] mg) but not in the ACE-I group. A multivariate logistic regression model showed that the presence of persistent atrial fibrillation (AF) and HF with a preserved left ventricular ejection fraction (HFpEF) was independently associated with a high delta-ANP ratio (≥ 4.5 ANP value on the start date/ANP value at 6 months; the mean value was used as the cutoff value) (odds ratio [OR]: 4.649, 95% CI 1.032-20.952 and OR: 7.558, 95% CI 1.427-40.042). The plasma level of ANP was increased, and the loop diuretic dose was decreased by the addition of neprilysin inhibitor therapy in patients with compensated HF. In patients with HFpEF and complicated persistent AF, neprilysin inhibitor therapy was associated with an increase in ANP.

Evaluation of Plasma Xanthine Oxidoreductase (XOR) Activity in Patients with Cardiopulmonary Arrest

Plasma xanthine oxidoreductase (XOR) activity in patients with cardiopulmonary arrest (CPA) has not yet been studied.A total of 1,158 patients who required intensive care and 231 control patients who attended a cardiovascular outpatient clinic were prospectively analyzed. Blood samples were collected within 15 minutes of admission from patients in intensive care patients, which were divided into a CPA group (n = 1,053) and a no-CPA group (n = 105). Plasma XOR activity was compared between the 3 groups and factors independently associated with extremely elevated XOR activity were identified using a multivariate logistic regression model. Plasma XOR activity in the CPA group (median, 1,030.0 pmol/hour/mL; range, 233.0-4,240.0 pmol/hour/mL) was significantly higher than in the no-CPA group (median, 60.2 pmol/hour/mL; range, 22.5-205.0 pmol/hour/mL) and control group (median, 45.2 pmol/hour/mL; range, 19.3-98.8 pmol/hour/mL). The regression model showed that out-of-hospital cardiac arrest (OHCA) (yes, odds ratio [OR]: 2.548; 95% confidence interval [CI]: 1.098-5.914; P = 0.029) and lactate levels (per 1.0 mmol/L increase, OR: 1.127; 95% CI: 1.031-1.232; P = 0.009) were independently associated with high plasma XOR activity (≥ 1,000 pmol/hour/mL). Kaplan-Meier curve analysis indicated that the prognosis, including all-cause death within 30 days, was significantly poorer in high-XOR patients (XOR ≥ 6,670 pmol/hour/mL) than in the other patients.Plasma XOR activity was extremely high in patients with CPA, especially in OHCA. This would be associated with a high lactate value and expected to eventually lead to adverse outcome in patients with CPA.

Time-Dependent Changes in N-Terminal Pro-Brain Natriuretic Peptide and B-Type Natriuretic Peptide Ratio During Hospitalization for Acute Heart Failure

The time-dependent changes in the simultaneous evaluation of B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) levels during hospitalization for acute heart failure (AHF) remain obscure.A total of 356 AHF patients were analyzed. Blood samples were collected within 15 minutes of admission (Day 1), 48-120 hours (Day 2-5) and between days 7 and 21 (Before-discharge). Plasma BNP and serum NT-proBNP were significantly decreased on Days 2-5 and Before-discharge in comparison to Day 1, but the NT-proBNP/BNP ratio was not changed. Patients were divided into 2 groups according to the median NT-proBNP/BNP (N/B) ratio on Day 2-5 (Low-N/B versus High-N/B). A multivariate logistic regression model showed that age (per 1-year increase), serum creatinine (per 1.0-mg/dL increase), and serum albumin (per 1.0-mg/dL decrease) were independently associated with High-N/B (odds ratio [OR]: 1.071, 95%confidence interval [CI]: 1.036-1.108, OR: 1.190, 95%CI: 1.121-1.264 and OR: 2.410, 95%CI: 1.121-5.155, respectively). Kaplan-Meier curve analysis showed that the High-N/B group had a significantly poorer prognosis than the Low-N/B group, and a multivariate Cox regression model revealed that High-N/B was an independent predictor of 365-day mortality (hazard ratio [HR]: 1.796, 95%CI: 1.041-3.100) and HF events (HR: 1.509, 95%CI: 1.007-2.263). The same trend in prognostic impact was significantly observed in both low and high delta-BNP cohorts (< 55% and ≥ 55% BNP value on the start date/BNP value at 2-5-days).A high NT-proBNP/BNP ratio on Day 2-5 was associated with non-cardiac conditions and was associated with adverse outcomes even if BNP was adequately decreased by the treatment of AHF.

Ulk1-dependent alternative mitophagy plays a protective role during pressure overload in the heart

AIMS

Well-controlled mitochondrial homeostasis, including a mitochondria-specific form of autophagy (hereafter referred to as mitophagy), is essential for maintaining cardiac function. The molecular mechanism mediating mitophagy during pressure overload (PO) is poorly understood. We have shown previously that mitophagy in the heart is mediated primarily by Atg5/Atg7-independent mechanisms, including Unc-51-like kinase 1 (Ulk1)-dependent alternative mitophagy, during myocardial ischaemia. Here, we investigated the role of alternative mitophagy in the heart during PO-induced hypertrophy.

METHODS AND RESULTS

Mitophagy was observed in the heart in response to transverse aortic constriction (TAC), peaking at 3-5 days. Whereas mitophagy is transiently up-regulated by TAC through an Atg7-dependent mechanism in the heart, peaking at 1 day, it is also activated more strongly and with a delayed time course through an Ulk1-dependent mechanism. TAC induced more severe cardiac dysfunction, hypertrophy, and fibrosis in ulk1 cardiac-specific knock-out (cKO) mice than in wild-type mice. Delayed activation of mitophagy was characterized by the co-localization of Rab9 dots and mitochondria and phosphorylation of Rab9 at Ser179, major features of alternative mitophagy. Furthermore, TAC-induced decreases in the mitochondrial aspect ratio were abolished and the irregularity of mitochondrial cristae was exacerbated, suggesting that mitochondrial quality control mechanisms are impaired in ulk1 cKO mice in response to TAC. TAT-Beclin 1 activates mitophagy even in Ulk1-deficient conditions. TAT-Beclin 1 treatment rescued mitochondrial dysfunction and cardiac dysfunction in ulk1 cKO mice during PO.

CONCLUSION

Ulk1-mediated alternative mitophagy is a major mechanism mediating mitophagy in response to PO and plays an important role in mediating mitochondrial quality control mechanisms and protecting the heart against cardiac dysfunction.

Successful treatment of a patient with type-A acute aortic dissection with emergent percutaneous coronary intervention and thoracic endovascular aortic repair under percutaneous cardiopulmonary support: a case report

Background

Type-A acute aortic dissection (AAD) with acute coronary involvement can be instantly fatal. The patient’s haemodynamics can easily collapse, so rapid decisions regarding treatment strategy are essential.

Case summary

A 76-year-old man requested an ambulance because of sudden back pain and paraplegia. He was admitted to the emergency room with cardiogenic shock due to acute myocardial infarction with ST-segment elevation. Computed tomography angiography revealed a thrombosed AAD from the ascending to the distal aorta after the renal artery bifurcation, suggesting a retrograde DeBakey type IIIb (DeBakey IIIb + r, Stanford type-A) dissection. He suddenly developed ventricular fibrillation with cardiac arrest and haemodynamic collapse. We thus performed percutaneous coronary intervention (PCI) and thoracic endovascular aortic repair under percutaneous cardiopulmonary support (PCPS). Percutaneous cardiopulmonary support and respiratory support were withdrawn 5 and 12 days after admission, respectively. The patient was transferred to the general ward on Day 28; he was eventually discharged to a rehabilitation hospital on Day 60, having recovered completely.

Conclusion

Immediate decisions regarding treatment strategy are essential. Non-invasive emergent treatment strategies (such as PCI and TEVAR under PCPS) may be options for critically ill patients with type-A AAD.

Type III procollagen peptide level can indicate liver dysfunction associated with volume overload in acute heart failure

Aim

The role of serum type III procollagen peptide (P3P) level in the acute phase of acute heart failure (AHF) requires clarification. We hypothesized that serum P3P level is temporarily higher during the acute phase, reflecting liver dysfunction due to congestion.

Methods and results

A total of 800 AHF patients were screened, and data from 643 patients were analysed. Heart failure was diagnosed by the treating physician according to the European Society of Cardiology (ESC) guidelines, and included patients being treated with high‐concentration oxygen inhalation (including mechanical support) for orthopnea, inotrope administration, or mechanical support for low blood pressure, and various types of diuretics for peripheral or pulmonary oedema. In all cases, diuretics or vasodilators were administered to treat AHF. The patients were divided into three groups according to their quartile (Q) serum P3P level: low‐P3P (Q1, P3P ≤ 0.6 U/mL), mid‐P3P (Q2/Q3, 0.6 < P3P <1.2 U/mL), and high‐P3P (Q4, P3P ≥ 1.2 U/mL). The plasma volume status (PVS) was calculated using the following formula: ([actual PV − ideal PV]/ideal PV) × 100 (%). The primary endpoint was 365 day mortality. A Kaplan–Meier curve analysis showed that prognoses, including all‐cause mortality and heart failure events within 365 days, were significantly (P < 0.001) worse in the high‐P3P group when compared with the mid‐P3P and low‐P3P groups. A multivariate logistic regression analysis showed that high PVS (Q4, odds ratio [OR]: 4.702, 95% CI: 2.012–20.989, P < 0.001), high fibrosis‐4 index (Q4, OR: 2.627, 95% CI: 1.311–5.261, P = 0.006), and low estimated glomerular filtration rate per 10 mL/min/1.73 m² decrease (OR: 1.996, 95% CI: 1.718–2.326, P < 0.001) were associated with high P3P values. The Kaplan–Meier curve analysis demonstrated a significantly lower survival rate, as well as a higher rate of heart failure events, in the high‐P3P and high‐PVS groups when compared with the other groups. A multivariate Cox regression model identified high P3P level and high PVS as an independent predictor of 365 day all‐cause mortality (hazard ratio [HR]: 2.249; 95% CI: 1.081–3.356; P = 0.026) and heart failure events (HR: 1.586, 95% CI: 1.005–2.503, P = 0.048).

Conclusion

A high P3P level during the acute phase of AHF served as a comprehensive biomarker of liver dysfunction with volume overload (i.e. liver congestion) and renal dysfunction. A high P3P level at admission may be able to predict adverse outcomes in AHF patients.

Successful Treatment of Thrombocytopenia, Anasarca, Fever, Reticulin Myelofibrosis/Renal Insufficiency, and Organomegaly Syndrome Using Plasma Exchange Followed by Rituximab in the Intensive Care Unit

Thrombocytopenia, anasarca, fever, reticulin myelofibrosis/renal insufficiency, and organomegaly (TAFRO) syndrome is treated using corticosteroids and/or immunosuppressive agents as first-line therapy. We report the case of a 69-year-old female with TAFRO syndrome in which the patient presented multiple organ failure and steroid resistance, which was successfully treated using plasma exchange (PE) followed by rituximab. Decisions regarding the next treatment, including PE, are urgent for patients with steroid-resistant TAFRO syndrome. Since it is considered that immunosuppressive agents may be removed by PE, the performance of PE before treatment with immunosuppressive agents might be an option for steroid-resistant TAFRO syndrome.

Clinical significance of the N-terminal pro-brain natriuretic peptide and B-type natriuretic peptide ratio in the acute phase of acute heart failure

AIMS

Serum N-terminal pro-brain natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP) levels are rarely evaluated simultaneously in the acute phase of acute heart failure (AHF).

METHOD AND RESULTS

A total of 1207 AHF patients were enrolled, and 1002 patients were analysed. Blood samples were collected within 15 min of admission. Patients were divided into two groups according to the median value of the NT-proBNP/BNP ratio [low-NT-proBNP/BNP group (Group L) vs. high-NT-proBNP/BNP group (Group H)]. A multivariate logistic regression model showed that the C-reactive protein level (per 1-mg/dL increase), Controlling Nutrition Status score (per 1-point increase), and estimated glomerular filtration rate (eGFR, per 10-mL/min/1.73 m2 increase) were independently associated with Group H [odds ratio (OR) 1.049, 95% confidence interval (CI) 1.009-1.090, OR 1.219, 95% CI 1.140-1.304, and OR 1.543, 95% CI 1.401-1.698, respectively]. A Kaplan-Meier curve analysis showed that the prognosis was significantly poorer in Group H than in Group L, and a multivariate Cox regression model revealed Group H to be an independent predictor of 180-day mortality [hazard ratio (HR) 3.084, 95% CI 1.838-5.175] and HF events (HR 1.963, 95% CI 1.340-2.876). The same trend in the prognostic impact was significantly observed in the low-BNP (<810 pg/mL, n = 501), high-BNP (≥810 pg/mL, n = 501), and low-eGFR (<60 mL/min/1.73 m2, n = 765) cohorts, and tended to be observed in normal-eGFR (≥60 mL/min/1.73 m2, n = 237) cohort.

CONCLUSION

A high NT-proBNP/BNP ratio was associated with a non-cardiac condition (e.g. inflammatory reaction, nutritional status, and renal dysfunction) and is independently associated with adverse outcomes in AHF.

Alternative Mitophagy Protects the Heart Against Obesity-Associated Cardiomyopathy

RATIONALE

Obesity-associated cardiomyopathy characterized by hypertrophy and mitochondrial dysfunction. Mitochondrial quality control mechanisms, including mitophagy, are essential for the maintenance of cardiac function in obesity-associated cardiomyopathy. However, autophagic flux peaks at around 6 weeks of high-fat diet (HFD) consumption and declines thereafter.

OBJECTIVE

We investigated whether mitophagy is activated during the chronic phase of cardiomyopathy associated with obesity (obesity cardiomyopathy) after general autophagy is downregulated and, if so, what the underlying mechanism and the functional significance are.

METHODS AND RESULTS

Mice were fed either a normal diet or a HFD (60 kcal% fat). Mitophagy, evaluated using Mito-Keima, was increased after 3 weeks of HFD consumption and continued to increase after conventional mechanisms of autophagy were inactivated, at least until 24 weeks. HFD consumption time-dependently upregulated both Ser555-phosphorylated Ulk1 (unc-51 like kinase 1) and Rab9 (Ras-related protein Rab-9) in the mitochondrial fraction. Mitochondria were sequestrated by Rab9-positive ring-like structures in cardiomyocytes isolated from mice after 20 weeks of HFD consumption, consistent with the activation of alternative mitophagy. Increases in mitophagy induced by HFD consumption for 20 weeks were abolished in cardiac-specific ulk1 knockout mouse hearts, in which both diastolic and systolic dysfunction were exacerbated. Rab9 S179A knock-in mice, in which alternative mitophagy is selectively suppressed, exhibited impaired mitophagy and more severe cardiac dysfunction than control mice following HFD consumption for 20 weeks. Overexpression of Rab9 in the heart increased mitophagy and protected against cardiac dysfunction during HFD consumption. HFD-induced activation of Rab9-dependent mitophagy was accompanied by upregulation of TFE3 (transcription factor binding to IGHM enhancer 3), which plays an essential role in transcriptional activation of mitophagy.

CONCLUSIONS

Ulk1-Rab9-dependent alternative mitophagy is activated during the chronic phase of HFD consumption and serves as an essential mitochondrial quality control mechanism, thereby protecting the heart against obesity cardiomyopathy.

The Prognostic Impact of Hospital Transfer after Admission due to Acute Heart Failure

The prognostic impact of transfer to another hospital among acute heart failure (AHF) patients has not been well elucidated.Of the 800 AHF patients analyzed, 682 patients were enrolled in this study for analysis. The subjects were divided into two groups according to their discharge location: discharge home (Group-H, n = 589) or transfer to another hospital for rehabilitation (Group-T, n = 93). The Kaplan-Meier curves revealed a poorer prognosis, including all-cause death and heart failure (HF) events (death, readmission-HF), in Group-T than that in Group-H (P < 0.001, respectively). A multivariate Cox regression model showed that Group-T was an independent predictor of 365-day all-cause death (hazard ratio: 2.618, 95% confidence interval [CI]: 1.510-4.538, P = 0.001). The multivariate logistic regression analysis showed that aging (per 1-year-old increase, odds ratio [OR]: 1.056, 95% CI: 1.028-1.085, P < 0.001), female gender (OR: 2.128, 95% CI: 1.287-3.521, P = 0.003), endotracheal intubation during hospitalization (OR: 2.074, 95% CI: 1.093-3.936, P = 0.026), and increased Controlling Nutritional Status score on admission (per 1.0-point increase, OR: 1.247, 95% CI: 1.131-1.475, P < 0.001) were associated with transfer to another hospital after AHF admission. The prognosis, including all-cause death, was determined to be significantly poorer in patients who were transferred to another hospital, as their activities of daily living were noted to lessen before discharge (n = 11) compared to others (n = 82).Elderly AHF patients suffering from malnutrition were difficult to discharge home after AHF admission, and transfer to another hospital only led to adverse outcomes. Appropriate rehabilitation during definitive hospitalization appears necessary for managing elderly patients in the HF pandemic era.

Impact of Low Body Mass Index on Features of Coronary Culprit Plaques and Outcomes in Patients With Acute Coronary Syndrome

The mechanisms behind poorer cardiac outcomes in underweight patients with acute coronary syndrome (ACS) are not understood and features of coronary culprit lesions in underweight ACS patients have not been fully examined. A total of 1,683 patients with ACS were divided into 4 groups according to body mass index (BMI): <18.5 (n = 73), 18.5 to 24.9 (n = 995), 25 to 29.9 (n = 488), and ≥30 (n = 117). Angiography and optical coherence tomography (OCT) images were analyzed for 1,428 of these patients who had primary percutaneous coronary intervention (PCI) and 838 who had primary PCI with OCT guidance, respectively. Diabetes (p <0.001), hypertension (p <0.001), and dyslipidemia (p <0.001) were less prevalent in BMI <18.5. Statin prescription at discharge was less frequent in the BMI <18.5 group (p <0.001). Quantitative coronary angiography analyses revealed smaller reference vessel (p = 0.001) and minimum lumen diameters after PCI (p = 0.019) and OCT revealed longer lipidic plaque length (p = 0.029) in the BMI <18.5 group. Kaplan-Meier analyses revealed higher rates of cardiac mortality (p <0.001) and major bleeding (p = 0.034) during the 2-year follow-up in the BMI <18.5 group. After adjusting for traditional cardiovascular risk factors, BMI <18.5 independently predicted 2-year cardiac mortality (hazard ratio 1.917 [95% confidence interval [1.082 to 3.397], p = 0.026). In conclusion, being underweight contributed to poorer cardiac outcomes in established ACS population. Smaller minimum lumen diameter after PCI and further progressed atherosclerosis at the culprit lesions despite their lower prevalence of comorbid metabolic risk factors may be related partly to poorer cardiac outcomes.

Clinical Significance of Low-Triiodothyronine Syndrome in Patients Requiring Non-Surgical Intensive Care - Triiodothyronine Is a Comprehensive Prognostic Marker for Critical Patients With Cardiovascular Disease

Background: Low-triiodothyronine (T₃) syndrome is a known complication in intensive care unit (ICU) patients, but the underlying mechanisms and prognostic impact are unclear.

Methods and Results: This study retrospectively enrolled 2,976 patients who required care in the ICU. Of these patients, 2,425 were euthyroid and were divided into normal (n=1,666; free T₃ [FT₃] ≥1.88 µIU/L) and low-FT₃ (n=759; FT₃ <1.88 µIU/L) groups. Multivariate logistic regression analysis revealed that prognostic nutritional index >46.03 (odds ratio [OR] 2.392; 95% confidence interval [CI] 1.904–3.005), age (per 1-year increase; OR 1.022; 95% CI 1.013–1.031), creatinine (per 0.1-mg/dL increase; OR 1.019; 95% CI 1.014–1.024), and C-reactive protein (per 1-mg/dL increase; OR 1.123; 95% CI 1.095–1.151) were independently associated with low FT₃. Survival rates (within 365 days) were significantly lower in the low-FT₃ group. A multivariate Cox regression model showed that low FT₃ was an independent predictor of 365-day mortality (hazard ratio 1.785; 95% CI 1.387–2.297). Low-T₃ syndrome was significantly more frequent in patients with non-cardiovascular than cardiovascular diseases (73.5% vs. 25.8%). Prognosis was significantly poorer in the low-FT₃ than normal group for patients with cardiovascular disease, particularly those with acute coronary syndrome and acute heart failure.

Conclusions: Low-T₃ syndrome was associated with aging, inflammatory reaction, malnutrition, and renal insufficiency and could lead to adverse outcomes in patients admitted to a non-surgical ICU.

Clinical Significance of the Fibrosis-4 Index in Patients with Acute Heart Failure Requiring Intensive Care

The Fibrosis-4 (FIB4) index could indicate the liver fibrosis in patients with chronic hepatic diseases. It was calculated using the following formula: (age × aspartate aminotransferase [U/L]) / (platelet count [10³/μL] × √alanine aminotransferase [U/L]). However, the clinical impact of the FIB4 index in the acute phase of acute heart failure (AHF) has not been sufficiently investigated.A total 1,468 AHF patients were analyzed. The median FIB4 index was 2.71 [1.85-4.22]. The patients were divided into three groups according to the quartiles of their FIB4 index (low-FIB4 [Q1, ≤ 1.847], middle-FIB4 [Q2/Q3, 1.848-4.216], and high-FIB4 [Q4, ≥ 4.216] groups). A Kaplan-Meier curve analysis showed that the prognosis, such as all-cause mortality and HF events within 365 days, was significantly poorer in the high-FIB4 group than in the middle-FIB4 and low-FIB4 groups. A multivariate Cox regression model identified high FIB4 index as an independent predictor of 365-day all-cause death (hazard ratio (HR): 1.660, 95% CI: 1.136-2.427) and HF events (HR: 1.505, 95% CI: 1.145-1.978). The multivariate logistic regression analysis showed that the high plasma volume status (PVS) (Q4, odds ratio [OR]: 2.099, 95% CI: 1.429-3.082), low systolic blood pressure (SBP) (< 100 mmHg, OR: 3.825, 95% CI: 2.504-5.840), and low left ventricular ejection fraction (< 40%, OR: 1.321, 95% CI: 1.002-1.741) were associated with a high FIB4 index.A high FIB4 index can predict adverse outcomes in AHF patients, which indicate that congestive liver and liver hypoperfusion occur due to low cardiac output in the acute phase of AHF.

The prognostic impact of the serum heart-type fatty acid-binding protein level in patients with sepsis who were admitted to the non-surgical intensive-care unit

Ongoing myocardial damage at the acme of the sepsis status has not been sufficiently evaluated. The clinical data of 160 sepsis patients who require intensive care and 127 outpatients with chronic heart failure (HF) were compared as a retrospective cohort study. Thereafter, the sepsis patients were divided into 3 groups according to the serum heart-type fatty acid-binding protein (H-FABP) quartiles [low H-FABP = Q1 (n = 39), middle H-FABP = Q2/Q3 (n = 81), and high H-FABP = Q4 group (n = 40)]. The H-FABP level was measured within 15 min of admission. The serum H-FABP levels in the sepsis patients [26.6 (9.3-79.0) ng/ml] were significantly higher than in the choric HF patients [6.6 (4.6-9.7) ng/ml]. A Kaplan-Meier curve showed that the survival rate of the high-H-FABP group was significantly lower than that of the middle- and low-H-FABP groups. The multivariate Cox regression analysis for the 365-day mortality showed that the high-H-FABP group (hazard ratio: 6.544, 95% confidence interval [CI] 2.026-21.140; p = 0.002) was an independent predictor of the 365-day mortality. The same trend in the prognostic impact was significantly (p = 0.015) observed in the cohort that had not been suffering from the cardiac disease before admission. The serum H-FABP level was an independent predictor of the 365-day mortality in the patients who were emergently hospitalized in the intensive-care unit due to sepsis. Ongoing myocardial damage was detected in the majority of patients with sepsis, suggesting that ongoing myocardial damage might be a candidate predictor of adverse outcomes in sepsis patients.

Effect of Gonadectomy and Angiotensin II Receptor Blockade in a Mouse Model of Isoproterenol-induced Cardiac Diastolic Dysfunction

BACKGROUND

Although heart failure (HF) with preserved ejection fraction (HFpEF) is more common in postmenopausal women than in men, the effect of sex hormones on cardiac diastolic function remains unclear. We examined the effect of gonadectomy with or without the angiotensin receptor blocker olmesartan (Olm) in an isoproterenol (ISO) -induced mouse model of left ventricular hypertrophy (LVH) and cardiac diastolic dysfunction.

METHODS

ISO or ISO with Olm were administered for 28 days in sham-operated male and female, castrated (CAS), and ovariectomized (OVX) mice. LV ejection fraction (EF) and E/A ratio were analyzed by echocardiography, and the LV and lung weight corrected by tibial length were used as indices of LVH and lung congestion, respectively.

RESULTS

On echocardiography, systolic function did not differ between the four groups. LV/tibial length (TL) and Lung/TL significantly increased in all groups. The LV/TL ratio was lower in castrated-ISO vs. Male-Sham-ISO but did not differ between Female-Sham-ISO and OVX-ISO. However, the Lung/TL ratio of OVX-ISO was greater than that of Female-Sham-ISO. Olm prevented LV hypertrophy in all groups. The decrease in E/A and increase in lung weight were improved by Olm in Male-Sham and OVX-ISO but not in the other groups.

CONCLUSION

These sex differences suggest that sex hormones play a pivotal role in modulating cardiac hypertrophy and diastolic dysfunction induced by chronic β-adrenoceptor stimulation, and thus affect the therapeutic potential of angiotensin receptor blockade.

YAP plays a crucial role in the development of cardiomyopathy in lysosomal storage diseases

Lysosomal dysfunction caused by mutations in lysosomal genes results in lysosomal storage disorder (LSD), characterized by accumulation of damaged proteins and organelles in cells and functional abnormalities in major organs, including the heart, skeletal muscle, and liver. In LSD, autophagy is inhibited at the lysosomal degradation step and accumulation of autophagosomes is observed. Enlargement of the left ventricle (LV) and contractile dysfunction were observed in RagA/B cardiac-specific KO (cKO) mice, a mouse model of LSD in which lysosomal acidification is impaired irreversibly. YAP, a downstream effector of the Hippo pathway, was accumulated in RagA/B cKO mouse hearts. Inhibition of YAP ameliorated cardiac hypertrophy and contractile dysfunction and attenuated accumulation of autophagosomes without affecting lysosomal function, suggesting that YAP plays an important role in mediating cardiomyopathy in RagA/B cKO mice. Cardiomyopathy was also alleviated by downregulation of Atg7, an intervention to inhibit autophagy, whereas it was exacerbated by stimulation of autophagy. YAP physically interacted with transcription factor EB (TFEB), a master transcription factor that controls autophagic and lysosomal gene expression, thereby facilitating accumulation of autophagosomes without degradation. These results indicate that accumulation of YAP in the presence of LSD promotes cardiomyopathy by stimulating accumulation of autophagosomes through activation of TFEB.

Importance of the Corrected Calcium Level in Patients With Acute Heart Failure Requiring Intensive Care

Background: Serum calcium (Ca) concentrations in the acute phase of acute heart failure (AHF) have not been not sufficiently investigated.

Methods and Results: This study enrolled 1,291 AHF patients and divided them into 3 groups based on original and corrected Ca concentrations: (1) hypocalcemia (both original and corrected Ca ≤8.7 mg/dL; n=651); (2) pseudo-hypocalcemia (original and corrected Ca ≤8.7 and >8.7 mg/dL, respectively; n=300); and (3) normal/hypercalcemia (both original and corrected Ca >8.7 mg/dL; n=340). AHF patients were also divided into 2 groups based on corrected Ca concentrations: (1) corrected hypocalcemia (corrected Ca ≤8.7 mg/dL; n=651); and (2) corrected normal/hypercalcemia (corrected Ca >8.7 mg/dL; n=640). Of the 951 patients with original hypocalcemia (≤8.7 mg/dL), 300 (31.5%) were classified as corrected normal/hypercalcemia after correction of Ca concentrations by serum albumin. The prognoses in the pseudo-hypocalcemia, low albumin, and corrected normal/hypercalcemia groups, including all-cause death within 730 days, were significantly poorer than in the other groups. Multivariate Cox regression analysis showed that classification into the pseudo-hypocalcemia, hypoalbumin, and corrected normal/hypercalcemia groups independently predicted 730-day all-cause death (hazard ratios [95% confidence intervals] of 1.497 [1.153–1.943], 2.392 [1.664–3.437], and 1.294 [1.009–1.659], respectively).

Conclusions: Corrected normal/hypercalcemia was an independent predictor of prognosis because this group included patients with pseudo-hypocalcemia, which was affected by the serum albumin concentration.

Ser9 phosphorylation of GSK-3β promotes aging in the heart through suppression of autophagy

INTRODUCTION

Glycogen synthase kinase-3β (GSK-3β) is a serine/threonine kinase and a negative regulator of cardiac hypertrophy. Phosphorylation of GSK-3β at Ser9 negatively regulates its kinase activity. The role of GSK-3β in cardiac aging remains poorly understood.

AIM

The study aimed to elucidate the role of GSK-3β Ser9 phosphorylation in mediating cardiac aging and the underlying mechanism.

METHODS AND RESULTS

Phosphorylation of GSK-3β at Ser9 and the levels of β-catenin and Mcl-1 were increased in the mouse heart during aging, suggesting that GSK-3β is inactivated during aging in the heart. Age-induced cardiac hypertrophy, fibrosis, left ventricular dysfunction, and increases in cardiomyocyte apoptosis and senescence were all attenuated in constitutively active GSK-3β^S9A knock-in (KI) mice compared to littermate wild type mice. Although autophagy is inhibited in the heart during aging, KI of GSK-3β^S9A reversed the age-associated decline in autophagy in the mouse heart. GSK-3β directly phosphorylates Ulk1, a regulator of autophagy, at Ser913, thereby stimulating autophagy in cardiomyocytes. Ulk1Ser913A KI mice exhibited decreased autophagic flux and increased senescence in cardiomyocytes.

CONCLUSION

Our results suggest that GSK-3β is inactivated during aging through Ser9 phosphorylation, which in turn plays an important role in mediating cardiac aging. GSK-3β promotes autophagy through phosphorylation of Ulk1 at Ser913, which in turn prevents aging in the heart.

β 3-Adrenergic Receptor Agonist Prevents Diastolic Dysfunction in an Angiotensin II-Induced Cardiomyopathy Mouse Model

β3-Adrenergic receptor expression is enhanced in the failing heart, but its functional effects are unclear. We tested the hypothesis that a β3-agonist improves left ventricular (LV) performance in heart failure. We examined the chronic effects of a β3-agonist in the angiotensin II (Ang II)-induced cardiomyopathy mouse model. C57BL/6J mice were treated with Ang II alone or Ang II + BRL 37344 (β3-agonist, BRL) for 4 weeks. Systolic blood pressure in conscious mice was significantly elevated in Ang II and Ang II + BRL mice compared with control mice. Heart rate was not different among the three groups. Systolic performance parameters that were measured by echocardiography and an LV catheter were similar among the groups. LV end-diastolic pressure and end-diastolic pressure-volume relationships were higher in Ang II mice compared with control mice. However, the increase in these parameters was prevented in Ang II + BRL mice, which suggested improvement in myocardial stiffness by BRL. Pathologic analysis showed that LV hypertrophy was induced in Ang II mice and failed to be prevented by BRL. However, increased collagen I/III synthesis, cardiac fibrosis, and lung congestion observed in Ang II mice were inhibited by BRL treatment. The cardioprotective benefits of BRL were associated with downregulation of transforming growth factor-β1 expression and phosphorylated-Smad2/3. Chronic infusion of a β3-agonist has a beneficial effect on LV diastolic function independent of blood pressure in the Ang II-induced cardiomyopathy mouse model. SIGNIFICANCE STATEMENT: Chronic infusion of a β3-adrenergic receptor agonist attenuates cardiac fibrosis and improves diastolic dysfunction independently of blood pressure in an angiotensin II-induced hypertensive mouse model. This drug might be an effective treatment of heart failure with preserved ejection fraction.

Time-dependent changes in plasma xanthine oxidoreductase during hospitalization of acute heart failure

Aims

The aim of present study is to evaluate the clinical significance of the time‐dependent changes in xanthine oxidoreductase (XOR) activity during hospitalization for acute heart failure (AHF).

Methods and results

A total of 229 AHF patients who visited to emergency room were prospectively enrolled, and 187 patients were analysed. Blood samples were collected within 15 min of admission (Day 1), after 48–72 h (Day 3), and between Days 7 and 21 (Day 14). The AHF patients were divided into two groups according to the XOR activity on Day 1: the high‐XOR group (≥100 pmol/h/mL, n = 85) and the low‐XOR group (<100 pmol/h/mL, n = 102). The high‐XOR patients were assigned to two groups according to the rate of change in XOR from Day 1 to Day 14: the decreased group (≥50% decrease; n = 70) and the non‐decreased group (<50% decrease; n = 15). The plasma XOR activity significantly decreased on Days 3 and 14 [23.6 (9.1 to 63.1) pmol/h/mL and 32.5 (10.2 to 87.8) pmol/h/mL, respectively] in comparison with Day 1 [78.5 (16.9 to 340.5) pmol/h/mL]. A Kaplan–Meier curve indicated that the prognosis, including heart failure (HF) events (all‐cause death and readmission by HF) within 365 days, was significantly poorer in the low‐XOR patients than in the high‐XOR patients and was also significantly poorer in the non‐decreased group than in the decreased group.

Conclusions

The plasma XOR activity was rapidly decreased by the appropriate treatment of AHF. Although high‐XOR activity on admission was not associated with increased HF events in AHF, high‐XOR activity that was not sufficiently reduced during appropriate treatment was associated with increased HF events.

Empagliflozin Administration Can Decrease the Dose of Loop Diuretics and Prevent the Exacerbation of Renal Tubular Injury in Patients With Compensated Heart Failure Complicated by Diabetes

Background: Whether the dose of loop diuretics can be decreased by administration of a sodium-glucose cotransporter 2 (SGLT2) inhibitor in diabetic outpatients with compensated heart failure (HF) is unclear.

Methods and Results: This study prospectively enrolled 60 diabetic outpatients with compensated HF. Patients were randomly divided into 2 groups: those administered the SGLT2 inhibitor empagliflozin (n=28) and those not (n=30). Changes in the daily dose of loop diuretics, blood sampling data, and urinary renal tubular biomarkers were evaluated 6 months after the intervention. The median (interquartile range) furosemide dose decreased significantly over the 6-month follow-up period in the empagliflozin group (from 40 [20–40] to 20 [10–20] mg), but not in the non-empagliflozin group (from 23 [20–40] to 40 [20–40] mg). Hemoglobin levels increased significantly in the empagliflozin group (from 13.2 [11.9–14.6] to 14.0 [12.7–15.0] g/dL). In addition, excretion of acetyl-β-D-glucosaminidase decreased significantly over the 6-month follow-up in the empagliflozin group (from 4.8 [2.6–11.7] to 3.3 [2.1–5.4] IU/L), especially in the group in which the dose of loop diuretics decreased (from 4.7 [2.5–14.8] to 3.3 [2.1–4.5] IU/L).

Conclusions: Empagliflozin administration decreased the dose of loop diuretics and increased the production of erythropoietin, which may help prevent renal tubular injury in diabetic outpatients with HF.

Characteristics of Patients with an Abnormally Decreased Plasma Xanthine Oxidoreductase Activity in Acute Heart Failure Who Visited the Emergency Department

Background: The factors associated with a low plasma xanthine oxidoreductase (XOR) activity were not elucidated in patients with acute heart failure (AHF). Methods: Two-hundred and twenty-nine AHF patients who visited the emergency department were prospectively analyzed. AHF patients were divided into 3 groups according to the plasma XOR quartiles (Q1 = low-XOR group [n = 57], Q2/Q3 = middle-XOR group [n = 115], and Q4 = high-XOR group [n = 57]). The prognostic nutritional index (PNI) and the controlling nutritional status (CONUT) score were evaluated. Results: The multivariate logistic regression model showed that the nutritional status (PNI: OR 1.044, 95% CI 1.000–1.088; CONUT: OR 3.805, 95% CI 1.158–12.498), age, and serum creatinine level were independently associated with a low plasma XOR activity. The Kaplan-Meier curve showed a significantly lower incidence of heart failure events in the low-XOR group than in the middle + high-XOR group (hazard ratio, HR 1.648, 95% CI 1.061–2.559). In particular, a low XOR activity with an increased serum creatinine level (>1.21 mg/dL) was independently associated with heart failure events (HR 1.937, 95% CI 1.199–3.130). Conclusion: A low plasma XOR activity was associated with malnutrition, renal dysfunction, and aging in AHF. A low XOR activity complicated with renal dysfunction leads to adverse long-term outcomes.

Plasma xanthine oxidoreductase (XOR) activity in patients who require cardiovascular intensive care

Hyperuricemia is known to be associated with adverse outcomes in cardiovascular intensive care patients, but its mechanisms are unknown. A total of 569 emergency department patients were prospectively analyzed and assigned to intensive care (ICU group, n = 431) or other departments (n = 138). Uric acid (UA) levels were significantly higher in the intensive care patients (6.3 [5.1-7.6] mg/dl vs. 5.8 [4.6-6.8] mg/dL). The plasma xanthine oxidoreductase (XOR) activity in the ICU group (68.3 [21.2-359.5] pmol/h/mL) was also significantly higher than that in other departments (37.2 [15.1-93.6] pmol/h/mL). Intensive care patients were divided into three groups according to plasma XOR quartiles (Q1, low-XOR, Q2/Q3, normal-XOR, and Q4, high-XOR group). A multivariate logistic regression model showed that lactate (per 1.0 mmol/L increase, OR 1.326; 95%, CI 1.166-1.508, p < 0.001) and the Acute Physiology and Chronic Health Evaluation II score (per 1.0 point increase, OR 1.095, 95% CI 1.034-1.160, p = 0.002) were independently associated with the high-XOR group. In-hospital mortality was significantly higher in the high-XOR group (n = 28, 26.2%) than in the normal- (n = 11, 5.1%) and low- (n = 9, 8.3%) XOR groups. The high-XOR group (vs. normal-XOR group) was independently associated with the in-hospital mortality (OR 2.934; 95% CI 1.170-7.358; p = 0.022). Serum UA levels and plasma XOR activity were high in patients admitted to intensive care. The enhanced XOR activity may be one of the mechanisms under which hyperuricemia was associated with adverse outcomes in patients requiring cardiovascular intensive care.

Mechanisms of Urgently Presenting Acute Heart Failure

The mechanisms of urgently presenting acute heart failure (AHF) are not clear. We evaluated the serum catecholamine values of AHF patients immediately after admission. A total of 1,475 AHF patients were screened, and 484 who were admitted from their homes and in whom serum catecholamine could be evaluated immediately after admission were analyzed. The patients were divided into three groups according to the time interval from the onset of symptoms to admission (OA): < 3 hours (early-OA group; n = 283), 3-24 hours (middle-OA group; n = 142), and ≥24 hours (late-OA group; n = 59). In the early-OA group, the systolic blood pressure (SBP) was significantly higher, orthopnea was more frequent, the pH value was significantly decreased, and the use of noninvasive positive-pressure ventilation was required significantly more often than in the other groups. The serum noradrenaline level was significantly increased in the early-OA group (1.96 [1.02-3.60] ng/mL) than in the middle-OA (1.49 [0.73-3.41] ng/mL) and late-OA (1.40 [0.91-2.42] ng/mL) groups, and the adrenaline level was significantly increased in the early-OA group (0.36 [0.13-1.17] ng/mL) than in the late-OA (0.22 [0.09-0.52] ng/mL) group. A multivariate logistic regression model indicated the early-OA group was independently associated with the SBP > 140 mmHg (odds ratio [OR]: 2.219, 95% CI: 1.375-3.581), midnight/early morning admission (OR: 3.158, 95% CI: 2.048-4.868), and high serum catecholamine value (adrenaline > 0.96 ng/mL, noradrenaline > 3.39 ng/mL, and dopamine > 0.21 ng/mL) (OR 2.091, 95% CI: 1.161-3.767). In conclusion, urgently presented AHF might be induced by an endogenous catecholamine surge, which causes an excessive rise in blood pressure leading to increased after-overload and volume-shift lung congestion.

Mitophagy Is Essential for Maintaining Cardiac Function During High Fat Diet-Induced Diabetic Cardiomyopathy

RATIONALE

Diabetic patients develop cardiomyopathy characterized by hypertrophy, diastolic dysfunction, and intracellular lipid accumulation, termed lipotoxicity. Diabetic hearts utilize fatty acids as a major energy source, which produces high levels of oxidative stress, thereby inducing mitochondrial dysfunction.

OBJECTIVE

To elucidate how mitochondrial function is regulated in diabetic cardiomyopathy.

METHODS AND RESULTS

Mice were fed either a normal diet or high-fat diet (HFD, 60 kcal % fat). Although autophagic flux was activated by HFD consumption, peaking at 6 weeks ( P<0.05), it was attenuated thereafter. Mitophagy, evaluated with Mito-Keima, was increased after 3 weeks of HFD feeding (mitophagy area: 8.3% per cell with normal diet and 12.4% with HFD) and continued to increase even after 2 months ( P<0.05). By isolating adult cardiomyocytes from GFP-LC3 mice fed HFD, we confirmed that mitochondria were sequestrated by LC3-positive autophagosomes during mitophagy. In wild-type mice, cardiac hypertrophy, diastolic dysfunction (end diastolic pressure-volume relationship =0.051±0.009 in normal diet and 0.11±0.004 in HFD) and lipid accumulation occurred within 2 months of HFD feeding ( P<0.05). Deletion of atg7 impaired mitophagy, increased lipid accumulation, exacerbated diastolic dysfunction (end diastolic pressure-volume relationship =0.11±0.004 in wild type and 0.152±0.019 in atg7 cKO; P<0.05) and induced systolic dysfunction (end systolic pressure-volume relationship =24.86±2.46 in wild type and 15.93±1.76 in atg7 cKO; P<0.05) during HFD feeding. Deletion of Parkin partially inhibited mitophagy, increased lipid accumulation and exacerbated diastolic dysfunction (end diastolic pressure-volume relationship =0.124±0.005 in wild type and 0.176±0.018 in Parkin KO, P<0.05) in response to HFD feeding. Injection of TB1 (Tat-Beclin1) activated mitophagy, attenuated mitochondrial dysfunction, decreased lipid accumulation, and protected against cardiac diastolic dysfunction (end diastolic pressure-volume relationship =0.110±0.009 in Control peptide and 0.078±0.015 in TB1, P<0.05) during HFD feeding.

CONCLUSIONS

Mitophagy serves as an essential quality control mechanism for mitochondria in the heart during HFD consumption. Impairment of mitophagy induces mitochondrial dysfunction and lipid accumulation, thereby exacerbating diabetic cardiomyopathy. Conversely, activation of mitophagy protects against HFD-induced diabetic cardiomyopathy.

Relation of Low Triiodothyronine Syndrome Associated With Aging and Malnutrition to Adverse Outcome in Patients With Acute Heart Failure

Low triiodothyronine (T3) syndrome has recently been evaluated as a prognostic marker of acute heart failure (AHF). However, in which cases low T3 syndrome typically leads to adverse outcomes remain unclear. Of 1,432 AHF patients screened, 1,190 were enrolled. Euthyroidism was present in 956 patients (80.3%), who were divided into 2 groups: the normal group (n = 445, FT3 ≥1.88 µIU/L) and low-FT3 group (n = 511, FT3 <1.88 µIU/L). The survival rates and event-free rates within 365 days were significantly lower in the low-FT3 group than in the normal group. A multivariate Cox regression model showed that the low-FT3 group was an independent predictor of 365-day mortality (hazard ratio [HR] 1.429, 95% confidence interval [CI] 1.013 to 2.015) and HF events (HR 1.349, 95% CI 1.047 to 1.739). The multivariate logistic regression analysis revealed that age (per 10-year old increase, odds ratio [OR]: 1.186, 95% CI: 1.046 to 1.345) and prognostic nutritional index (PNI; per 1-point increase, OR: 1.067, 95% CI: 1.046 to 1.089) were independently associated with the low-FT3 group. The prognosis in patients with a low PNI and over 75 years old, including all-cause death within 365 days, was significantly poorer in the low-FT3 group than in the normal group. In conclusion, adverse outcomes were predicted by the presence of low T3. AHF patients with low T3 syndrome are strongly associated with aging and malnutrition. Low T3 syndrome complicated with older age and malnutrition is likely to lead to adverse outcomes in patients with AHF.

Clinical Approach to Shortening Length of Hospital Stay in Elderly Patients With Acute Heart Failure Requiring Intensive Care

Background: The length of hospital stay (LOHS) after acute heart failure (AHF) is too long in Japan. The clinical approach to shortening LOHS is an urgent issue in the aging Japanese society.

Methods and Results: Of 1,473 AHF patients screened, 596 patients >75 years old were enrolled. They were divided by LOHS: <28 days (<28-day group, n=316) and ≥28 days (≥28-day group, n=280). Systolic blood pressure and serum hemoglobin were significantly higher and serum blood urea nitrogen and creatinine significantly lower in the <28-day group than in the ≥28-day group. Non-invasive positive pressure ventilation (NPPV) use was significantly more frequent in the <28-day group than in the ≥28-day group. Furthermore, newly initiated tolvaptan in <12 h was significantly more frequent in the <28-day group than in the ≥28-day group (P=0.004). On multivariate logistic regression analysis, newly initiated tolvaptan in <12 h (OR, 2.574; 95% CI: 1.146–5.780, P=0.022) and NPPV use (OR, 1.817; 95% CI: 1.254–2.634, P=0.002) were independently associated with the <28-day group. The same result was found after propensity score matching for LOHS.

Conclusions: LOHS was prolonged in patients with severe HF but could be shortened by early tolvaptan treatment.

Plasma Xanthine Oxidoreductase (XOR) Activity in Cardiovascular Disease Outpatients

Background: The mechanisms of the increased plasma xanthine oxidoreductase (XOR) activity in outpatients with cardiovascular disease were unclear.

Methods and Results: A total of 372 outpatients were screened, and 301 outpatients with cardiovascular disease were prospectively analyzed. Blood samples were collected from patients who visited a daily cardiovascular outpatient clinic. Patients with diabetes mellitus (DM) were significantly more likely to be classified into the high-XOR group (≥100 pg/h/mL; 50%) than the low-XOR group (<100 pmol/h/mL; 28.7%). On multivariate logistic regression analysis, DM (OR, 2.683; 95% CI: 1.441–4.996) was independently associated with high plasma XOR activity in all cohorts. In the diabetic cardiovascular disease patients (n=100), median body mass index (BMI) in the high-XOR group (28.0 kg/m²; IQR, 25.2–29.4 kg/m², n=32) was significantly higher than in the low-XOR group (23.6 kg/m²; IQR, 21.2–25.7 kg/m², n=68), and BMI was independently associated with high plasma XOR activity (OR, 1.340; 95% CI: 1.149–1.540). Plasma hydrogen peroxide was significantly higher in DM patients with high plasma XOR activity and obesity (>22 kg/m²) than in other patients.

Conclusions: DM with obesity is one of the mechanisms of XOR enhancement in cardiovascular disease. The increase of XOR is a possible pathway for the production of reactive oxygen species in obese cardiovascular disease patients with DM.

Prognostic Value of Both Plasma Volume Status and Nutritional Status in Patients With Severely Decompensated Acute Heart Failure

BACKGROUND

Plasma volume status (PVS) has been evaluated recently as a prognostic marker of acute heart failure (AHF). However, whether evaluating PVS alone is sufficient remains unclear.

METHODS

Of 675 patients with AHF screened, 601 were enrolled. The PVS, prognostic nutritional index (PNI) (lower = worse), and Controlling Nutritional Status (CONUT) score (higher = worse) were evaluated. Patients were divided into 2 groups according to PVS value (low- or high-PVS group) and were further subdivided into 4 groups (low- or high-PVS/CONUT group and low- or high-PVS/PNI group).

RESULTS

A Kaplan-Meier curve showed a significantly lower survival rate in the high-PVS group than in the low-PVS group, the high-PVS/high-CONUT group than in the high-PVS/low-CONUT group, and the high-PVS/low-PNI group than in the high-PVS/high-PNI group. A multivariate Cox regression model showed that high PVS (hazard ratio [HR], 1.642; 95% confidence interval [CI], 1.049-2.570) and high PVS/high CONUT (HR, 2.076; 95% CI, 1.147-3.757) and high PVS/low PNI (HR, 2.094; 95% CI, 1.166-3.761) were independent predictors of 365-day mortality.

CONCLUSIONS

An adverse outcome was predicted by the evaluation of PVS; furthermore, a malnutrition status with a high PVS leads to an adverse outcome. The simultaneous evaluation of nutrition status and PVS is essential to predict an AHF outcome.

Gender Differences in the Social Determinants of the Long-term Prognosis for Severely Decompensated Acute Heart Failure in Patients over 75 Years of Age

Objective The aim of present study was to elucidate the gender differences in social determinants among patients with acute heart failure (AHF). Methods A total of 1,048 AHF patients were enrolled, and the 508 AHF patients who were ≥75 years old and the 540 patients who were <75 years old were evaluated as the elderly and non-elderly cohorts, respectively. Participants who met one of the three marital status-, offspring-, and living status-related criteria were considered socially vulnerable, and subjects were thus classified into socially vulnerable and non-socially vulnerable groups by gender in both the non-elderly and elderly cohorts. Social vulnerability was significantly more common in the elderly cohort (n=246, 48.4%) than in the non-elderly cohort (n=197, 36.5%) and significantly more common in the elderly women (n=157, 69.4%) than in the elderly men (n=89, 31.5%). Kaplan-Meier curves showed that the survival rate of the socially vulnerable group was significantly poorer than that of the non-socially vulnerable group in the elderly male cohort (p=0.010). Social vulnerability was an independent predictor of the 1,000-day mortality in the elderly male cohort (hazard ratio: 1.942, 95% confidence interval: 1.102-3.422) but not in the elderly female cohort according to a multivariate analysis. Conclusion Social vulnerability was shown to be more common in elderly female AHF patients than in elderly men, although it was associated with a poor prognosis in elderly men. Reinforcing the social structure of elderly male AHF patients might help improve their prognosis.

Trends in the Management of Acute Heart Failure Requiring Intensive Care

The aim of the present study was to elucidate trends in managing acute heart failure (AHF) patients who require intensive care over a 19-year period. We evaluated a total of 1,475 AHF patients, comparing patient backgrounds, in-hospital management, and prognosis according to the year of admission (2000s group, n = 608 and 2010s group, n = 867). A multivariate logistic regression analysis revealed that age (≥75 years; odds ratio [OR] 1.334, 95% confidence interval [CI] 1.048 to 1.700), systolic blood pressure (<100 mm Hg; OR 1.934, 95% CI 1.170 to 3.198), left ventricular ejection fraction (>40%; OR 1.441, 95% CI 1.125 to 1.847), and prognostic nutritional index (severe; OR 1.865, 95% CI 1.224 to 2.841) were independently associated with admission in the 2010s group. The use of intra-aortic balloon pumping and noninvasive positive pressure ventilation increased significantly, whereas the need for endotracheal intubation and administration of furosemide and carperitide in the 2010s group decreased significantly compared with the 2000s group. Tolvaptan therapy was introduced from 2010. The duration of intensive care unit admission and total hospitalization in the 2010s group (4 [3 to 6] and 23 [15 to 40] days, respectively) were significantly shorter than in the 2000s group (5 [4 to 8] and 30 [20 to 54] days, respectively). A Kaplan-Meier survival curve analysis showed the survival rate of the 2010s group was significantly poorer compared with the 2000s group (hazards ratio 1.435, 95% CI 1.113 to 1.851). After propensity score matching, the 365-day mortality rates of the 2 groups did not significantly differ. In conclusion, the condition of AHF patients became more critical year by year, leading to poorer long-term prognosis despite improved treatment strategy. These findings will be useful for managing AHF in the next pandemic era.

Comparison of Coronary Culprit Lesion Morphology Determined by Optical Coherence Tomography and Relation to Outcomes in Patients Diagnosed with Acute Coronary Syndrome During Winter -vs- Other Seasons

Patients diagnosed with acute coronary syndrome (ACS) during winter have worse outcomes; however, mechanisms driving this trend are unclear. We examined coronary culprit lesion morphologies using optical coherence tomography (OCT). Features and outcomes were retrospectively compared between patients admitted with ACS in winter (W-ACS; n = 390) and in other seasons (O-ACS; n = 1,027). Angiography and OCT results were analyzed in patients who underwent OCT examination (173 patients in W-ACS and 450 in O-ACS). On initial angiography, minimum lumen diameter was smaller (median; 0.12 mm vs 0.25 mm, p = 0.021) and Thrombolysis in myocardial infarction flow grade was worse (Thrombolysis in myocardial infarction 0/1; 57% vs 44%, p = 0.005) in W-ACS. OCT performed before coronary interventions or just after intracoronary thrombectomy showed that plaque rupture (56% vs 46%) and calcified nodules (8% vs 5%) were more prevalent, and plaque erosion (37% vs 49%) was less prevalent in W-ACS (p = 0.039 for all 3 variables). At 2-year follow-up for all admitted ACS patients, Kaplan-Meier estimates showed higher cardiac mortality in W-ACS (11.8% vs 8.3%, p = 0.043). Multivariate Cox proportional hazard analysis showed that patients in W-ACS group had a 1.5-fold increased risk of cardiac death within 2 years after adjusting for traditional cardiovascular risk factors (hazard ratio, 1.54 [95% confidence interval, 1.06 to 2.23]; p = 0.024). In conclusion, patients diagnosed with ACS during winter had worse angiographic results and OCT revealed less plaque erosion (more plaque rupture or calcified nodules) at the culprit lesions, which may be partly associated with worse cardiac mortality within 2 years.

Hyperuricemia complicated with acute kidney injury is associated with adverse outcomes in patients with severely decompensated acute heart failure

Background

The relationship between the serum level of uric acid (UA) and the acute kidney injury on admission in patients with acute heart failure (AHF) remain unclear.

Methods and results

A total of 1326 AHF patients were screened, and data for 1047 patients who were admitted to the intensive-care unit were analyzed. The patients were assigned to a low-UA group (UA ≤ 7.0 mg/dl, n = 569) or a high-UA group (UA > 7.0 mg/dl, n = 478) according to their UA level at admission. Acute kidney injury (AKI) at admission was defined based on the ratio of the serum creatinine value recorded on admission to the baseline creatinine value: no-AKI (n = 736) or AKI (n = 311). The patients were therefore assigned to four groups: low-UA/no-AKI (n = 428), high-UA/no-AKI (n = 308), low-UA/AKI (n = 141) and high-UA/AKI (n = 170). The high-UA patients were significantly more frequent in the AKI group than in the non-AKI group among all patients and the non-chronic kidney injury (CKD) cohort. A Kaplan-Meier curve showed a significantly lower 365-day survival rate in the high-UA/AKI group than in the other groups. The multivariate Cox regression model identified only high-UA/AKI as an independent predictor of 365-day mortality (hazard ratio [HR]: 2.511, 95% confidence interval [CI] 1.671–3.772 in all AHF patients, HR: 1.884, 95% CI 1.022–3.473 in non-CKD patients and HR: 3.546, 95% CI 2.136–5.884 in CKD patients).

Conclusion

An elevated serum UA level complicated with AKI was an independent predictor of mortality in patients with severely decompensated AHF.

Recruitment of RNA Polymerase II to Metabolic Gene Promoters Is Inhibited in the Failing Heart Possibly Through PGC-1α (Peroxisome Proliferator-Activated Receptor-γ Coactivator-1α) Dysregulation

BACKGROUND

Proper dynamics of RNA polymerase II, such as promoter recruitment and elongation, are essential for transcription. PGC-1α (peroxisome proliferator-activated receptor [PPAR]-γ coactivator-1α), also termed PPARGC1a, is a transcriptional coactivator that stimulates energy metabolism, and PGC-1α target genes are downregulated in the failing heart. However, whether the dysregulation of polymerase II dynamics occurs in PGC-1α target genes in heart failure has not been defined.

METHODS AND RESULTS

Chromatin immunoprecipitation-sequencing revealed that reduced promoter occupancy was a major form of polymerase II dysregulation on PGC-1α target metabolic gene promoters in the pressure-overload-induced heart failure model. PGC-1α-cKO (cardiac-specific PGC-1α knockout) mice showed phenotypic similarity to the pressure-overload-induced heart failure model in wild-type mice, such as contractile dysfunction and downregulation of PGC-1α target genes, even under basal conditions. However, the protein levels of PGC-1α were neither changed in the pressure-overload model nor in human failing hearts. Chromatin immunoprecipitation assays revealed that the promoter occupancy of polymerase II and PGC-1α was consistently reduced both in the pressure-overload model and PGC-1α-cKO mice. In vitro DNA binding assays using an endogenous PGC-1α target gene promoter sequence confirmed that PGC-1α recruits polymerase II to the promoter.

CONCLUSIONS

These results suggest that PGC-1α promotes the recruitment of polymerase II to the PGC-1α target gene promoters. Downregulation of PGC-1α target genes in the failing heart is attributed, in part, to a reduction of the PGC-1α occupancy and the polymerase II recruitment to the promoters, which might be a novel mechanism of metabolic perturbations in the failing heart.

Worsening renal failure in patients with acute heart failure: the importance of cardiac biomarkers

Aims

The importance of true worsening renal failure (WRF), which is associated with a poor prognosis, had been suggested in patients with acute heart failure (AHF). The aim of the present study was to establish the biomarker strategy for the prediction of true WRF in AHF.

Methods and results

Two hundred eighty‐one patients with AHF were analysed. Their biomarkers were measured within 30 min of admission. Patients were assigned to the non‐WRF (n = 168), pseudo‐WRF (n = 56), or true‐WRF (n = 57) groups using the criteria of both acute kidney injury on admission and increasing serum creatinine value during the first 7 days. A Kaplan–Meier curve showed that the survival and heart failure event rate of the true‐WRF group within 1000 days was significantly lower than that of the non‐WRF and pseudo‐WRF groups (P ≤ 0.001). The multivariate Cox regression model also indicated that true WRF was an independent predictor of 1000 day mortality and heart failure events [hazard ratio: 4.315, 95% confidence interval (CI): 2.466–7.550, P ≤ 0.001, and hazard ratio: 2.834, 95% CI: 1.893–4.243, P ≤ 0.001, respectively]. The serum heart‐type fatty acid‐binding protein (s‐HFABP) levels were significantly higher in the true‐WRF group than in the non‐WRF and pseudo‐WRF groups (P ≤ 0.001). The multivariate logistic regression model indicated that the predictive biomarker for the true‐WRF group was the s‐HFABP level (odds ratio: 5.472, 95% CI: 2.729–10.972, P ≤ 0.001). The sensitivity and specificity for indicating the presence of true WRF were 73.7% and 76.8% (area under the curve = 0.831) for s‐HFABP in whole patients, respectively, and 94.7% and 72.7% (area under the curve = 0.904) in non‐chronic kidney disease (CKD) patients, respectively.

Conclusions

Cardiac biomarkers, especially the s‐HFABP, might predict the development of true WRF in AHF patients. Furthermore, the predictive value was higher in AHF patients without CKD than in those with CKD.

Impact of Accumulated Serum Uric Acid on Coronary Culprit Lesion Morphology Determined by Optical Coherence Tomography and Cardiac Outcomes in Patients with Acute Coronary Syndrome

Objectives: We aimed to examine the relations of very high levels of serum uric acid (sUA) with features of culprit lesion plaque morphology determined by optical coherence tomography (OCT) and adverse clinical outcomes in patients with acute coronary syndrome (ACS). Methods: We retrospectively compared ACS patients according to sUA levels of > 8.0 mg/dL (n = 169), 7.1–8.0 mg/dL (n = 163), 6.1–7.0 mg/dL (n = 259), and ≤6.0 mg/dL (n = 717). Angiography and OCT findings were analyzed in patients with preintervention OCT and the 4 sUA groups (> 8.0 mg/dL, n = 61; 7.1–8.0 mg/dL, n = 72; 6.1–7.0 mg/dL, n = 131; and ≤6.0 mg/dL, n = 348) were compared. Results: Cardiogenic shock was more prevalent in ACS patients with sUA > 8.0 mg/dL (22% vs. 19% vs. 10% vs. 6%, p < 0.001). Plaque rupture was observed more prevalently by OCT in patients with sUA > 8.0 mg/dL (67% vs. 47% vs. 56% vs. 45%, p = 0.027). At the 2-year follow-up, Kaplan-Meier estimates showed higher cardiac mortality in patients with sUA > 8.0 mg/dL (25% vs. 12% vs. 5% vs. 5%, p < 0.001). After adjusting for traditional cardiovascular risk factors and creatinine levels, patients with sUA > 8.0 mg/dL showed a 4.5-fold increased risk in 2-year cardiac death by multivariate Cox proportional hazard analysis (hazard ratio 4.54, 95% confidence interval 2.98–6.91; p < 0.001). Conclusions: Very high sUA levels like > 8.0 mg/dL are the primary predictor of 2-year cardiac mortality and could partly be caused by adverse effects of accumulated sUA on plaque morphology in patients with ACS.

Clinical Features of Acute Heart Failure During Sleep - Prognostic Impact of a Prodrome in Patients With Severely Decompensated Acute Heart Failure Admitted at Midnight or Early Morning

Background: The features of sleep-associated acute heart failure (AHF) patients admitted at midnight or early morning (M/E) are unclear. Methods and Results: Of 1,268 AHF patients screened, 932 were analyzed, and divided into 2 groups by admission time (M/E group, 23:00-06:59, n=399; daytime group, 07:00-22:59, n=533). Those in the M/E group were further divided by the presence of a prodrome: with (n=176; prodrome group) or without (n=223; sudden onset group). The median time from symptom onset to hospitalization was significantly shorter in the M/E group (98 min; range, 65-170 min) than in the daytime group (123 min; range, 68-246 min). The 365-day HF event rate in the M/E group was significantly lower than that of the daytime group. On multivariate logistic regression modeling the M/E group was independently associated with a better outcome than the daytime group (OR, 0.673; 95% CI: 0.500-0.905). In the M/E group, the 365-day HF event rate was significantly lower in the prodrome group than in the sudden onset group. On multivariate logistic regression modeling, inclusion in the prodrome group was independently associated with a better outcome (OR, 0.544; 95% CI: 0.338-0.877). Conclusions: AHF patients admitted during sleeping hours were not sicker than those admitted during the daytime. The absence of a prodrome, however, might be associated with future repeated HF events.

The prognostic impact of the uric acid level in patients who require cardiovascular intensive care - is serum uric acid a surrogate biomarker for critical patients in the non-surgical intensive care unit?

BACKGROUND

The prognostic impact of hyperuricemia and the factors that induce hyperuricemia in cardiovascular intensive care patients remain unclear.

METHODS AND RESULTS

A total of 3257 emergency department patients were screened, and data for 2435 patients who were admitted to an intensive care unit were analyzed. The serum uric acid level was measured within 15 min of admission. The patients were assigned to a low-uric acid group (uric acid ⩽7.0 mg/dl, n=1595) or a high-uric acid group (uric acid >7.0 mg/dl, n=840) according to their uric acid level on admission. Thereafter, the patients were divided into four groups according to the quartiles of their serum uric acid level (Q1, Q2, Q3 and Q4), and uric acid levels and Acute Physiology and Chronic Health Evaluation II (APACHE II) score. A Kaplan-Meier curve showed a significantly lower 365-day survival rate in a high-uric acid group than in a low-uric acid group, and in Q3 than in Q1 or Q2 and in Q4 than in the other groups. The multivariate logistic regression model for 30-day mortality identified Q4 (odds ratio: 1.856, 95% confidence interval (CI) 1.140-3.022; p=0.013) as an independent predictor of 30-day mortality. The area under the receiver-operating characteristic curve values of the serum uric acid level and APACHE II score for the prediction of 30-day mortality were 0.648 and 0.800, respectively. The category-free net reclassification improvement and integrated discrimination improvement showed that the calculated risk shifted to the correct direction by adding the serum uric acid level to the APACHE II score (0.204, 95% CI 0.065-0.344; p=0.004, and 0.015, 95% CI 0.005-0.025; p=0.004, respectively). The prognosis, including the 365-day mortality, among patients with a high uric acid level and a high APACHE II score was significantly poorer in comparison with other patients.

CONCLUSION

The serum uric acid level, which might be elevated by the various critical stimuli on admission, was an independent predictor in patients who were emergently hospitalized in the intensive care unit. The serum uric acid level is therefore useful as a surrogate biomarker for critical patients in the intensive care unit.

Yes-associated protein (YAP) mediates adaptive cardiac hypertrophy in response to pressure overload

Cardiovascular disease (CVD) remains the leading cause of death globally, and heart failure is a major component of CVD-related morbidity and mortality. The development of cardiac hypertrophy in response to hemodynamic overload is initially considered to be beneficial; however, this adaptive response is limited and, in the presence of prolonged stress, will transition to heart failure. Yes-associated protein (YAP), the central downstream effector of the Hippo signaling pathway, regulates proliferation and survival in mammalian cells. Our previous work demonstrated that cardiac-specific loss of YAP leads to increased cardiomyocyte (CM) apoptosis and impaired CM hypertrophy during chronic myocardial infarction (MI) in the mouse heart. Because of its documented cardioprotective effects, we sought to determine the importance of YAP in response to acute pressure overload (PO). Our results indicate that endogenous YAP is activated in the heart during acute PO. YAP activation that depended upon RhoA was also observed in CMs subjected to cyclic stretch. To examine the function of endogenous YAP during acute PO, Yap ^{+/ flox};Cre ^α-MHC (YAP-CHKO) and Yap ^{+/ flox} mice were subjected to transverse aortic constriction (TAC). We found that YAP-CHKO mice had attenuated cardiac hypertrophy and significant increases in CM apoptosis and fibrosis that correlated with worsened cardiac function after 1 week of TAC. Loss of CM YAP also impaired activation of the cardioprotective kinase Akt, which may underlie the YAP-CHKO phenotype. Together, these data indicate a prohypertrophic, prosurvival function of endogenous YAP and suggest a critical role for CM YAP in the adaptive response to acute PO.

Plasma xanthine oxidoreductase activity in patients with decompensated acute heart failure requiring intensive care

Aims

Plasma xanthine oxidoreductase (XOR) activity during the acute phase of acute heart failure (AHF) requires further elucidation.

Methods and results

One hundred eighteen AHF patients and 231 control patients who attended a cardiovascular outpatient clinic were prospectively analysed. Blood samples were collected within 15 min of admission from AHF patients (AHF group) and control patients who visited a daily cardiovascular outpatient clinic (control group). Plasma XOR activity was compared between the two groups, and factors independently associated with extremely elevated XOR activity were identified using a multivariate logistic regression model. Plasma XOR activity in the AHF group (median, 104.0 pmol/h/mL; range, 25.9–423.5 pmol/h/mL) was significantly higher than that in the control group (median, 45.2 pmol/h/mL; range, 19.3–98.8 pmol/h/mL). The multivariate logistic regression model showed that serum uric acid (per 1.0 mg/dL increase, odds ratio: 1.280; 95% confidence interval: 1.066–1.536; P = 0.008) and lactate levels (per 1.0 mmol/L increase, odds ratio: 1.239; 95% confidence interval: 1.040–1.475; P = 0.016) were independently associated with high plasma XOR activity (>300 pg/h/mL) during the acute phase of AHF.

Conclusions

Plasma XOR activity was extremely high in patients with severely decompensated AHF. This would be associated with a high lactate value and would eventually lead to hyperuricaemia in patients with AHF.