Changes in walking speed 6 months after discharge may be more sensitive to subsequent prognosis than handgrip strength in patients hospitalized for heart failure.

BACKGROUND: Despite the prognostic importance of walking speed (WS) and handgrip strength (HGS) in patients with heart failure (HF), no study has reported the prognostic impact of changes in these parameters. This study aimed to examine the association between changes after discharge and the subsequent prognosis. METHODS: This study included 881 elderly patients hospitalized for HF. WS and HGS were measured at discharge and 6 months after discharge. Based on the presence of slowness (WS <0.98 m/s) or weakness (HGS <30.0 kg for men and < 17.5 kg for women) at both points, patients were divided into four groups (WS: A = -/-, B = -/+, C = +/-, D = +/+; HGS: E = -/-, F = -/+, G = +/-, H = +/+). The study endpoint was a composite of all-cause mortality and HF rehospitalization during the 18 months after 6 months of discharge. The Cox proportional hazards model was used to assess the association between the groups and study outcomes. RESULTS: Stratified by the WS change patterns, groups B and D showed higher risk of the study outcomes than group A [B: hazard ratio 2.34, 95% confidence interval (CI) 1.29-4.28; D: 2.38, 1.67-3.39], whereas group C was not. When stratified by the HGS change in patterns, only group H was associated with a worse prognosis (HR; 1.85, 95%CI; 1.31-2.60). CONCLUSION: Changes in WS were related to HF prognosis, suggesting that changes in WS may be more sensitive to further risk stratification than changes in HGS.

Prognostic impact of nutrition measures in patients with heart failure varies with coexisting physical frailty.

AIMS: Malnutrition is prevalent among patients with heart failure (HF); however, the effects of coexisting malnutrition and frailty on prognosis are unknown. This study examines the impact of malnutrition and frailty on the prognosis of patients with HF. METHODS AND RESULTS: We examined 1617 patients with HF aged 65 years or older (age: 78.6 ± 7.4; 44% female) from a Japanese multicentre prospective cohort study. The nutritional status was evaluated using the Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status (CONUT), and Mini Nutritional Assessment Short Form on discharge. Frailty was assessed using the criteria determined in a previous study on patients with HF. The prognostic impact of each nutrition measure on the risk of composite all-cause mortality and cardiac readmissions within 2 years of hospital discharge was assessed using Kaplan-Meier survival curves and Cox proportional hazards model analysis for non-frail and frail groups. Over 2324.2 person-years of follow-up, 88 patients died and 448 patients experienced readmission due to HF. In the non-frail group, poor nutritional status assessed using the GNRI and CONUT was associated with an increased hazard ratio (HR) of composite outcomes in the crude model; however, adjustment for potential confounders diminished the association. In the frail group, all three nutritional indicators were associated with the cumulative incidence of the study outcome (log-rank test, P < 0.05). In multivariate analysis, only the CONUT score was associated with an increased HR even after adjustment for confounders. CONCLUSIONS: The CONUT score predicted a poor prognosis in HF patients with coexisting physical frailty, highlighting the potential clinical benefit of nutritional assessment based on biochemical data for further risk stratification.

Prognostic effects of cardiac rehabilitation in heart failure patients classified according to physical frailty: A propensity score-matched analysis of a nationwide prospective cohort study.

Background: Research regarding cardiac rehabilitation (CR) in the prognosis of heart failure (HF) patients and frailty remains lacking. Here, the effects of CR on the 2-year prognosis of HF patients were examined according to their frailty status. Methods: This multicenter prospective cohort study enrolled patients hospitalized for HF. Patients who underwent ≥1 session per 2 weeks of CR within 3 months after discharge were categorized in the CR group. Patients were divided in a non-frailty (≤8 points) and physical frailty group (≥9 points) based on their FLAGSHIP frailty score. The score is based on HF prognosis, with a higher score indicating worsened physical frailty. A propensity score-matched analysis was performed to compare survival rates between the two groups according to their physical frailty status. Endpoints included HF re-hospitalization and all-cause mortality during a 2-year follow-up period. Results: Of 2697 patients included in the analysis, 285 and 95 matched pairs were distributed in the non-frailty and physical frailty groups, respectively, after propensity-score matching. CR was associated with lower incidence of HF rehospitalization in both non-frailty (hazard ratio 0.65; 95% confidence interval 0.44-0.96; p = 0.032) and physical frailty (0.54; 0.32-0.90; p = 0.019) groups. CR was not associated with all-cause mortality in either group (log-rank test, p > 0.05). Conclusion: These findings suggest the effects of CR on reduced HF rehospitalization, regardless of physical frailty status.

Physical Frailty May Predict 2-Year Prognosis in Elderly Patients With Acute Myocardial Infarction　- A Report From the FLAGSHIP Study.

BACKGROUND: Elderly patients with acute myocardial infarction (AMI) are a high-risk population for heart failure (HF), but the association between physical frailty and worsening prognosis, including HF development, has not been documented extensively.Methods and Results: As part of the FLAGSHIP study, we enrolled 524 patients aged ≥70 years hospitalized for AMI and capable of walking at discharge. Physical frailty was assessed using the FLAGSHIP frailty score. The primary outcome was a composite outcome of all-cause death and HF rehospitalization within 2 years after discharge. The secondary outcome was all-cause death and HF rehospitalization. After adjusting for confounders, physical frailty showed a significant association with an increased risk of the composite outcome (hazard ratio [HR]=2.09, 95% confidence interval [CI]: 1.03-4.22, P=0.040). The risk of HF rehospitalization increased with physical frailty, but the association was not statistically significant (HR=2.14, 95% CI: 0.84-5.44, P=0.110). Physical frailty was not associated with an increased risk of all-cause death (HR=1.45, 95% CI: 0.49-4.26, P=0.501). CONCLUSIONS: The findings suggest that physical frailty assessment serves as a stratifying tool to identify high-risk populations for post-discharge clinical events among ambulant elderly patients with AMI.

Clinical benefit of combined assessment of physical and psychological frailty in patients with heart failure.

OBJECTIVES: Physical frailty becomes a robust risk factor in patients with heart failure (HF) and coexistence of physical and psychological frailty is likely to be a prognostic indicator. This study aimed to analyze the prognosis of coexistence of these two factors in patients with HF. METHODS: This study was a secondary analysis of a multicenter prospective cohort study (FLAGSHIP). We analyzed data from 2502 patients with HF from the FLAGSHIP study in Japan. We divided the patients into four physical frailty categories using a frailty score ranging from 0 to 14 (<4: I, 4-8: II, 9-12: III, and 14: IV, the score 13 does not exist in calculation). The higher category indicates more severe physical frailty. Psychological frailty was defined as the presence of cognitive decline and/or depressive symptoms. The study outcome was a 2-year composite outcome of rehospitalization for HF or all-cause mortality after hospital discharge. RESULTS: During the 3734.7 person-year follow-up, 774 patients experienced the composite outcome. After adjusting for confounders, physical and psychological frailty were independently associated with adverse outcomes. Using physical frailty category I, without psychological frailty as the reference, adjusted hazard ratios for adverse outcomes were 1.29 [95% confidence interval (CI) 0.86-1.92] for category I with psychological frailty, 0.99 (95% CI 0.71-1.37) for category II without psychological frailty, 1.61 (95% CI 1.16-2.23) for category II with psychological frailty, 1.56 (95% CI 1.14-2.15) for category III without psychological frailty, 1.62 (95% CI 1.20-2.20) for category III with psychological frailty, 1.50 (95% CI 1.05-2.14) for category IV without psychological frailty, and 2.16 (95% CI 1.59-2.94) for category IV with psychological frailty, respectively. CONCLUSIONS: Combined assessment of physical and psychological frailty leads to more detailed risk stratification of patients with HF.

Prognostic Effects of Cardiac Rehabilitation in Patients With Heart Failure (from a Multicenter Prospective Cohort Study).

The prognostic effects of cardiac rehabilitation (CR) are inconsistent in recent reports on heart failure (HF). Generally, participants in previous trials were relatively young and had HF with reduced ejection fraction. Herein, we examined the effects of CR on HF prognosis using a nationwide cohort study. This multicenter prospective cohort study included hospitalized patients with acute HF or worsening chronic HF. Patients who underwent CR once or more times weekly for 6 months after discharge were included in the CR group. The main study end point was a composite of all-cause mortality and HF rehospitalization during a 2-year follow-up period. We performed propensity score matching to compare the survival rates between the CR and non-CR groups. Of the 2,876 enrolled patients, 313 underwent CR for 6 months. After propensity score matching using confounding factors, 626 patients (313 pairs) were included in the survival analysis (median age: 74 years). CR was associated with a reduced risk of composite outcomes (hazard ratio [HR] 0.66; 95% confidence interval [CI] 0.48 to 0.91; p = 0.011), all-cause mortality (HR 0.53; 95% CI 0.30 to 0.95; p = 0.032), and HF rehospitalization (HR 0.66; 95% CI 47 to 0.92; p = 0.012). Subgroup analysis showed similar CR effects in patients with HF with preserved ejection fraction (≥50%) and HF with reduced ejection fraction (<40%). In the landmark analysis, CR did not reduce the aforementioned end points beyond 6 months after discharge (log-rank test: composite outcomes, p = 0.943; all-cause mortality, p = 0.258; HF rehospitalization, p = 0.831). CR is a standard treatment for HF regardless of HF type; however, further challenges may affect the long-term prognostic effects of CR.

Impact of weight loss in patients with heart failure with preserved ejection fraction: results from the FLAGSHIP study.

AIMS: Weight loss (WL) is a poor prognostic factor for patients with heart failure (HF) with reduced ejection fraction. However, its prognostic impact on patients with HF with preserved ejection fraction (HFpEF) remains unestablished. The evidence regarding the effects of obesity on the prognosis of WL is also unclear. We aimed to identify the risk factors for WL and examine the association between WL and prognosis of HFpEF in obese and non-obese patients. METHODS AND RESULTS: In this multicentre cohort study, the data of 573 patients hospitalized with HFpEF [median age: 78 years (interquartile range, 71-84 years); 49.2% female] were identified from hospital databases. WL was defined as ≥5% weight reduction within 6 months after discharge. Obesity was defined according to Japanese criteria as body mass index ≥25 kg/m2 . The main study outcomes were all-cause mortality and HF rehospitalization between 6 and 24 months after hospital discharge. Logistic regression analysis and Cox proportional hazards regression analysis were performed to identify independent the risk factors associated with WL and to calculate the hazard ratios (HRs) associated with adverse outcomes. The prevalence of obesity at discharge was 21.1%. At 6 month follow-up, WL occurred in 17.4% and 10.8% of the obese and non-obese patients, respectively. Onset of WL in non-obese patients was associated with prior hospitalization for HF [odds ratio (OR) 2.39, 95% confidence interval (CI) 1.22-4.68, P = 0.011] and high levels of brain natriuretic peptide (OR 2.32, CI 1.17-4.60, P = 0.015). In obese patients, WL was associated with the use of mineralocorticoid receptor antagonists (OR 3.26, CI 1.08-9.76, P = 0.03) and vasopressin receptor antagonists (OR 6.61, CI 2.03-21.2, P = 0.001). During 1021.3 person-years of follow-up, 31 patients died, and upon 1081.0 person-years follow-up, 84 patients required rehospitalization for HF. In proportional hazards analysis, WL was associated with all-cause mortality (HR 5.12, CI 2.08-12.5, P < 0.001) and HF rehospitalization (HR 2.63, CI 1.38-5.01, P = 0.003) after adjustment for confounders in non-obese patients, but not in obese patients. CONCLUSIONS: Weight loss should be considered as an indicator for monitoring worsening of HF condition in non-obese patients with HFpEF. WL was not associated with adverse events in obese patients with HFpEF, possibly due to appropriate fluid management during follow-up.

Association between a pre-admission limitation in walking ability and post-discharge adverse outcomes among hospitalized patients with heart failure: Report from a multicenter prospective cohort study.

BACKGROUND: Although limited walking ability at discharge is a known risk factor for adverse outcomes in older patients with heart failure (HF), the association between pre-admission limitations and adverse outcomes is unknown. Therefore, we evaluated the prevalence of a pre-admission limitation in walking ability and its relationship with post-discharge outcomes among patients with HF with reduced, mid-range, and preserved left-ventricular ejection fraction (HFrEF, HFmrEF, and HFpEF). METHODS: We followed 2042 patients aged ≥65 years (HFrEF, n = 668; HFmrEF, n = 360; HFpEF, n = 1014) from a multicenter cohort study in Japan. A limitation in walking ability was defined as the necessity of any assistance or a walking aid. Adverse outcomes were defined as the composite of HF rehospitalization and all-cause death within 2 years after discharge. RESULTS: During 2978.0 person-years of follow-up, 563 patients were rehospitalized due to HF exacerbation and 103 patients died. In HFrEF, HFmrEF, and HFpEF groups, the prevalence of a pre-admission limitation in walking ability was 12.1%, 18.6%, and 21.1%, respectively, the crude hazard ratios [95% confidence interval] of a pre-admission limitation in walking ability were 2.46 [1.79-3.39], 1.34 [0.87-2.06], and 1.94 [1.53-2.47], and the adjusted hazard ratios were 2.21 [1.58-3.16], 1.19 [0.75-1.89], and 1.39 [1.06-1.82], respectively. CONCLUSIONS: A pre-admission limitation in walking ability is a predictor of post-discharge HF rehospitalization or all-cause death among patients with HFrEF and HFpEF, but not among patients with HFmrEF. Shortly after admission, information regarding pre-admission functional limitations should be obtained to better understand the risk of post-discharge adverse outcomes.

Effect of obesity and underweight status on the hospital-acquired functional decline in patients with cardiovascular surgery: an analysis of data from a prospective observational multicenter cohort study.

OBJECTS: The aim of this study was to determine the association between underweight or obese status and hospital- acquired functional decline (HAFD) following cardiovascular surgery. METHODS: We performed a retrospective, observational, multicenter cohort study of cardiovascular surgery patients between April, 2010, and June, 2017. Body mass index (BMI) was categorized into four classes: underweight group (< 18.5 kg/m2), normal weight group (18.5 to < 25 kg/m2), overweight group (25 to < 30 kg/m2), and obese group (≥ 30 kg/m2). HAFD was defined as a decrease of at least one point on the short physical performance battery score at discharge, compared with the preoperative score. RESULTS: A total of 3,850 adult patients were included in the analysis data set (median age 72 years, 35% female). A total of 811 (21.0%) patients demonstrated HAFD: 27.2% in the underweight group, 21.3% in the normal weight group, 18.8% in the overweight group, and 19.3% in the obese group. The relative risk for HAFD was 1.381 (95% CI 1.052-1.814) for the underweight group versus the normal weight group, although that is comparable to the obese group after adjustment by confounding factors. Analyses of subgroup interactions showed that the relative risk of HAFD in the obese group compared with the normal group was higher in patients with muscle wasting (p < 0.05). CONCLUSION: HAFD was significantly worse for underweight patients following cardiovascular surgery. In contrast, obese status was not associated with HAFD, exclusive of the obese patients with muscle wasting.

Postoperative atrial fibrillation is associated with delayed early rehabilitation after heart valve surgery: a multicenter study.

OBJECTIVE: Postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery. The aim of this multicenter study was to determine the relationship between POAF and patients' progress in early rehabilitation after heart valve surgery. METHODS: We enrolled 302 patients (mean age, 69±10 years) who had undergone heart valve surgery. POAF was monitored using continuous electrocardiogram telemetry, and the Short Physical Performance Battery (SPPB) was used to assess lower-extremity function before surgery and at the time of discharge. Progress in early rehabilitation was evaluated by the duration from the surgery to independent walking. We determined factors associated delayed early rehabilitation and evaluated the interplay of POAF and delayed early rehabilitation in increasing the risk of decline in lower-extremity function from preoperatively to hospital discharge. RESULTS: Multivariate analysis determined POAF to be independent predictors of delayed early rehabilitation after heart valve surgery (OR: 3.906, P = .01). The association between delayed early rehabilitation and decline in lower extremity function was stronger in patients with POAF (OR: 2.73, P = .041) than in those without (OR: 2.22, P = .052). CONCLUSIONS: POAF was clinical predictors of delayed early rehabilitation in patients undergoing heart valve surgery. The combination of POAF with delayed early rehabilitation conferred a high risk of decline in lower-extremity function during hospitalization.

Factors related to physical functioning decline after cardiac surgery in older patients: A multicenter retrospective study.

BACKGROUND: As few studies have examined physical functioning changes after cardiac surgery, the factors related to the decline in physical functioning remain unclear. This study aimed to investigate the factors related to physical functioning decline after cardiac surgery in older patients. METHODS: The final study sample consisted of 523 older (≥65 years) patients (age 74.2±6.1 years, 66% male) who underwent cardiac surgery at 8 Japanese institutions. We excluded patients who were unable to walk independently or had a slow gait speed (<0.8m/s) before surgery, and those who were unable to regain independent walking after surgery. We divided the patients into two groups, a decline-in-gait-speed group and a non-decline-in-gait-speed group, according to whether their gait speed was less than 0.8m/s at discharge. We analyzed patients' clinical characteristics to identify the factors that predicted the postoperative decline in gait speed. RESULTS: Eighty-nine patients (17.0%) showed a postoperative decline in gait speed. Multivariate logistic regression analysis showed that the following factors predicted a postoperative decline in gait speed: age [odds ratio (OR) 1.06, 95% confidence interval (CI) 1.02-1.11]; estimated glomerular filtration rate (OR 0.98, CI 0.96-0.99); preoperative gait speed (OR 0.01, CI 0.00-0.08); and the postoperative day on which the patient could walk independently (OR 1.08, CI 1.02-1.14). CONCLUSIONS: Physical functioning declined in 17% of patients after surgery. The decline could be predicted by several clinical factors, including some that are modifiable. These results suggest that further interventional research on rehabilitation before and after cardiac surgery for older patients might help overcome the decline in physical functioning.

Impact of preoperative frailty on regaining walking ability in patients after cardiac surgery: Multicenter cohort study in Japan.

BACKGROUND: This study aimed to examine the relationship between preoperative frailty and the reacquisition of walking ability in patients after cardiac surgery. METHODS: 450 patients who underwent cardiac surgery were included as subjects. We implemented the Short Physical Performance Battery (SPPB) before surgery and classified subjects into three groups according to the SPPB score: SPPB 10-12, SPPB 7-9, and SPPB 0-6. We examined the postoperative day and the rate of the reacquisition of walking ability after surgery, and compared them among three groups. In addition, we calculated the cutoff value for the SPPB score to regain walking ability by performing a receiver operating characteristic curve analysis. RESULTS: The postoperative day of the reacquisition of walking ability in SPPB 10-12 was earlier than other groups (SPPB 10-12: 4.0 days, SPPB 7-9: 4.5 days, SPPB 0-6: 6.0 days, p < 0.01), and SPPB 0-6 was lower than other groups in the rate of the reacquisition of walking ability (SPPB 10-12: 98.8%, SPPB 7-9: 96.4%, SPPB 0-6: 76.2%, p < 0.01). The cutoff value for SPPB was ≧9(Area under the curve: 0.85, sensitivity: 0.82, specificity: 0.71, p < 0.001). CONCLUSION: Preoperative frailty affected the day of the reacquisition of walking ability in patients after cardiac surgery. The preoperative SPPB cutoff value which indicates the feasibility of reacquisition walking ability after surgery was ≧ 9.

Clinical characteristics of functional recovery after coronary artery bypass graft surgery in Japanese octogenarians.

[Purpose] This study aimed to elucidate characteristics of postoperative physical functional recovery in octogenarians undergoing coronary artery bypass graft surgery. [Subjects and Methods] This was a multi-center, retrospective study. Nine hundred and twenty-seven elective isolated coronary artery bypass graft surgeries were evaluated (746 males and 181 females, mean age: 68.6 years, range: 31-86 years). Participants were stratified according to age < 80 years (n = 840; mean age, 67.1; range, 31-79) or > 80 years (n = 87; mean age, 82.2; range, 80-86). Patient characteristics and postoperative physical functional recovery outcomes were compared between groups. [Results] There was no significant difference between groups when considering the postoperative day at which patients could sit on the edge of the bed, stand at bedside, or walk around the bed. The postoperative day at which patients could walk 100 m independently was later in octogenarians, when compared with non-octogenarians (6.1 ± 3.2 days vs. 4.9 ± 3.9 days). In octogenarians, the percentage of patients who could walk 100 m independently within 8 days after surgery was 79.5%. [Conclusion] A postoperative target time in octogenarians for independent walking, following coronary artery bypass grafting, can be set at approximately 6 days.

Mechanical ventilatory assistance may reduce dyspnea during walking especially in patients with impaired cardiopulmonary function early after cardiovascular surgery.

BACKGROUND: To determine which patients effectively respond to ventilatory assistance (VA) and to examine the factors influencing patient response in patients who underwent cardiovascular (CV) surgery. METHODS: We conducted the first walking session after surgery either with or without VA in a randomized order. The patients walked with 3cmH2O of inspiratory pressure support. We measured dyspnea and leg fatigue during initial walking either with or without VA by using a modified Borg scale. Ventilatory parameters were measured by mechanical ventilation before and immediately after walking. Lung function and maximal inspiratory pressure (MIP) were measured and chest radiographs were analyzed by the same cardiac surgeon on the same day as walking. RESULTS: From the total of 74 patients who underwent CV surgery, 56 patients were successively enrolled in the study. Thirty-five out of 56 patients had dyspnea and 18 patients (30% of the total patients) effectively responded to VA (responders). Minute ventilation/estimated maximum voluntary ventilation immediately after walking significantly decreased with VA, and MIP was lower in responders than in non-responders after surgery. The responders revealed greater pulmonary edema scores than non-responders. CONCLUSIONS: The findings of the present study suggest that VA may possibly facilitate successful mobilization early after CV surgery, especially in patients with impaired cardiopulmonary function.

Predictive impact of daily physical activity on new vascular events in patients with mild ischemic stroke.

BACKGROUND: Daily physical inactivity is associated with a substantially increased risk of cardiovascular events. However, the target level of daily physical activity remains unclear. AIM: We aimed to evaluate the impact of physical activity on long-term vascular events in patients with mild ischemic stroke. METHODS: We designed a single hospital-based prospective observational study and studied 166 ischemic stroke patients (mean age: 63.9 ± 9.2) who had a modified Rankin Scale 0-1. We measured the daily step count as a variable of the daily physical activity after three-months from the stroke onset. Other clinical characteristics including age, body mass index, blood pressure, blood laboratory tests, vascular function and medications were also assessed. The primary outcomes were hospitalization due to stroke recurrence, myocardial infarction, angina pectoris and peripheral artery disease. Survival curves were calculated by a Kaplan-Meier survival analysis, and the hazard ratios for recurrences were determined by univariate and multivariate Cox proportional hazards regression models. RESULTS: After a median follow-up periods of 1332 days, 34 vascular events (23 stroke recurrences, 11 coronary artery disease) and 7 drop-outs occurred, and the remaining patients were divided into two groups: the without recurrence group (n = 125) and the with recurrence group (n = 34). The daily step count was lower in the nonsurvivor group than in the survivor group. Univariate and multivariate Cox proportional hazards analyses revealed that the daily step counts was independent predictors of new vascular events. A daily step count cutoff value of 6025 steps per day was determined by analyzing the receiver-operating characteristics that showed a sensitivity of 69.4% and a specificity of 79.4%. The Kaplan-Meier survival curves after a log-rank test showed a significantly lower event rate in the more than 6025 steps per day group compared with the less than 6025 steps per day group (P = 0.0002). The positive and negative predictive values of less than 6025 steps were 38.0% and 91.6%, respectively. CONCLUSION: Our data indicate that daily physical activity evaluated by step counts may be useful for forecasting the prognosis in patients with mild ischemic stroke. Daily step counts of approximately 6000 steps per day may be an initial target level for reducing new vascular events.

[Determinants of prolonged mechanical ventilation after cardiac surgery].

PURPOSE: This study aimed to examine factors that delay weaning from ventilation after cardiac surgery. METHODS: A retrospective examination was made on 1,033 patients who had undergone cardiac surgery through a midsternal incision between January 2009 and July 2011. The items examined were duration of postoperative ventilation, patient's background, and other surgical information. If patients were weaned within 24 hours from intensive care unit (ICU) admission, they were included in the timely weaning group. If patients required 24 hours or more to be weaned, they were included in the delayed weaning group. RESULTS: There was a relationship between prolonged ventilation and the following factors: emergency surgery, history of arrhythmia, history of motor system disorder, preoperative estimated glomerular filtration rate (eGFR), preoperative New York Heart Association (NYHA) classification, preoperative left ventricular ejection fraction (LVEF), operative method, operative time, blood loss, intraoperative fluid management, and number of days from surgery until achievement of independent gait. The independent factors delaying extubation were emergency surgery, preoperative NYHA classification, preoperative LVEF, operative method, operative time, blood loss, and intraoperative fluid management(p<0.05). CONCLUSION: Surgical invasiveness and preoperative heart failure were involved in the prolonged ventilation after cardiac surgery.

Recurrence risk after noncardioembolic mild ischemic stroke in a Japanese population.

BACKGROUND AND PURPOSE: This study aimed to identify the recurrence rate and risk factors or clinical variables predictive of vascular events after mild ischemic stroke (IS). METHODS: From December 2006 to September 2007, patients with acute IS with a modified Rankin Scale of 0∼1 were consecutively enrolled in this study. Variables including sex, family history of vascular disease, age, height, weight, stroke subtype, blood pressure, lipid profile, fasting glucose, HbA1c, smoking, alcohol consumption, exercise habits, waist circumference, ankle-brachial pressure index, salt intake and physical activity were assessed. The primary outcome was stroke recurrence or other vascular events such as myocardial infarction, angina pectoris, and peripheral artery disease. Survival curves were calculated by Kaplan-Meier survival analysis, and hazard ratios for recurrence were determined by univariate and multivariate Cox proportional hazards regression models. RESULTS: A total of 102 mild IS patients (78 men and 24 women, mean age 64 years) were successfully followed for 3 years. Of those 102 patients, 25 (24.5%) had stroke recurrence, and 4 (3.9%) had a coronary event. Among the variables studied, abnormal ankle-brachial pressure index, metabolic syndrome, stroke subtypes, salt intake and poor lifestyle management were significant independent predictors of stroke recurrence or cardiovascular events. CONCLUSIONS: In mild IS patients within 3 years after onset, not only pathophysiological factors but also lifestyle factors can aid in the identification of patients at high risk for recurrence.