Symptomatic periesophageal vagal nerve injury by different energy sources during atrial fibrillation ablation.

Background: Symptomatic gastric hypomotility (SGH) is a rare but major complication of atrial fibrillation (AF) ablation, but data on this are scarce. Objective: We compared the clinical course of SGH occurring with different energy sources. Methods: This multicenter study retrospectively collected the characteristics and clinical outcomes of patients with SGH after AF ablation. Results: The data of 93 patients (67.0 ± 11.2 years, 68 men, 52 paroxysmal AF) with SGH after AF ablation were collected from 23 cardiovascular centers. Left atrial (LA) ablation sets included pulmonary vein isolation (PVI) alone, a PVI plus a roof-line, and an LA posterior wall isolation in 42 (45.2%), 11 (11.8%), and 40 (43.0%) patients, respectively. LA ablation was performed by radiofrequency ablation, cryoballoon ablation, or both in 38 (40.8%), 38 (40.8%), and 17 (18.3%) patients, respectively. SGH diagnoses were confirmed at 2 (1-4) days post-procedure, and 28 (30.1%) patients required re-hospitalizations. Fasting was required in 81 (92.0%) patients for 4 (2.5-5) days; the total hospitalization duration was 11 [7-19.8] days. After conservative treatment, symptoms disappeared in 22.3% of patients at 1 month, 48.9% at 2 months, 57.6% at 3 months, 84.6% at 6 months, and 89.7% at 12 months, however, one patient required surgery after radiofrequency ablation. Symptoms persisted for >1-year post-procedure in 7 patients. The outcomes were similar regardless of the energy source and LA lesion set. Conclusions: The clinical course of SGH was similar regardless of the energy source. The diagnosis was often delayed, and most recovered within 6 months, yet could persist for over 1 year in 10%.

Prognostic Values of Fractional Flow Reserve Based on Clinical Outcomes in Patients on Chronic Hemodialysis.

The fractional flow reserve (FFR) cut-off values of 0.75 or 0.8 have been widely used; however, whether they apply to patients on hemodialysis remains unknown. We aimed to investigate the cut-off value of FFR associated with clinical outcomes in patients on hemodialysis. Using the Japanese multicenter registry, we analyzed data of patients on hemodialysis with measured FFR between January 2010 and December 2016. Survival classification and regression tree analysis for the composite primary outcome of cardiovascular mortality, myocardial infarction, and target vessel revascularization revealed a threshold FFR of 0.83. Multivariate Cox regression analyses were performed for the clinical outcomes. Additionally, the primary outcome was analyzed using propensity score matching by dividing the patients into complete and incomplete revascularization groups according to the presence of residual lesions with an FFR of ≤0.83 after the intervention. Of the 212 included patients, 112 (52.8%) had lesions with an FFR of ≤0.83. After adjusting for confounders, an FFR of ≤0.83 was associated with a higher risk for the primary outcome (adjusted hazard ratio 2.01, 95% confidence interval 1.11 to 3.66, p = 0.021). Propensity score matching showed that complete revascularization for lesions with an FFR of ≤0.83 was associated with a reduced risk for the primary outcome compared with incomplete revascularization (hazard ratio 0.38, 95% confidence interval 0.20 to 0.71, log-rank p = 0.0016). In conclusion, an FFR of ≤0.83 was an independent predictor of clinical events in patients on hemodialysis. Furthermore, complete revascularization was associated with better clinical outcomes. Thus, this population may require a distinct FFR cut-off value.

Comparative Study of Cryoballoon versus Radiofrequency for Pulmonary Vein Isolation when Combined with vein of Marshall Ethanol Infusion for Paroxysmal Atrial Fibrillation.

INTRODUCTION: Ethanol infusion (EI) in the vein of Marshall (VOM) has multifactorial effects that could be synergistic to pulmonary vein isolation (PVI) in ablation of atrial fibrillation (AF). The efficacy of radiofrequency (RF) versus cryoablation when combined with a VOM-EI has never been investigated. The aim of this study is to evaluate outcome differences of AF ablation using RF versus cryoablation when combined with a VOM-EI. MATERIALS AND METHODS: Consecutive patients (n=132) underwent catheter ablation of paroxysmal AF with either RF or cryoballoon (CB) for PVI combined with VOM-EI. Bi-directional conduction block at the mitral isthmus was attempted. The end-point was the freedom from any atrial arrhythmias documented after a blanking period of 90 days after the procedure. RESULTS: Kaplan-Meier estimates of the arrhythmia-free survival after 1 year were 63.8 (RF + VOM), and 82.7 % (CB + VOM), respectively. Comparison between CB + VOM versus RF + VOM reached a significance (p=0.0292). The periprocedural complication rate was comparable in both groups (5.0 % RF, 5.8 % CB; p=0.14) with a significant difference in the incidence of phrenic nerve palsy (0 % RF, 2.0 % CB; p<0.05). CONCLUSIONS: PVI with a CB had an increased freedom from AF recurrence compared to RF combined with VOM-EI. The present results suggest a potential additive effect of a VOM-EI to CB application.

Japan ablation registry: cryoablation in atrioventricular nodal reentrant tachycardia ("JARCANRET study"): results from large multicenter retrospective investigation.

PURPOSE: Cryoenergy has been demonstrated to be a safe alternative to radiofrequency ablation for catheter ablation of atrioventricular nodal reentrant tachycardia (AVNRT). This study aimed to evaluate the safety and efficacy of cryoablation in patients with AVNRT. METHODS: A multicenter retrospective study was performed. Two hundred eighty-three consecutive patients with AVNRT underwent cryoablation. Cryomapping at - 30 °C and - 80 °C was performed to predict cryoablation outcome and ascertain antegrade conduction. Cryoenergy was delivered subsequently at the same spot (cryoablation at - 80 °C) for 240 s. RESULTS: Ablation procedure was acutely successful in 281 out of 283 patients (99.3%). Of note, 22 patients (10.1%) had transient AV block during the cryoablation, but no injurious effects on AV conduction were provoked during cryomapping. During a follow-up period of 367 ± 35 days, the recurrence rate was 3.9% (11 out of 281). There were no significant differences among the patients with a complete elimination of slow pathway conduction, AH jump without an echo beat, and AH jump with a single echo beat, in terms of the long-term recurrence of AVNRT. CONCLUSIONS: Cryoablation of AVNRT appears to be effective both acutely and during the long-term with a minimal risk of unwanted injuries to the conduction system. It seems to be important to monitor the antegrade conduction during cryoenergy applications, even when cryomapping demonstrates a safe location for cryoablation. The recurrence rate of AVNRT did not differ according to the properties of the residual slow pathway conduction.

Chemical mapping as a predictor of vein of Marshall ethanol ablative effects.

PURPOSE: The aim of this study was to test regional pharmacological effects of an antiarrhythmic agents to predict ablative effects. BACKGROUND: The vein of Marshall (VOM) providing vascular access to myocardial tissue has been used for ablative purposes using ethanol. METHODS: A total of 35 patients (male 21, 63.2 ± 7.8 years old) were included. A balloon-tipped infusion catheter was inserted into the VOM. Endocardial ultrahigh-resolution mapping was performed along the VOM region to record the change in atrial electrograms (AEs) after VOM injection of cibenzoline of 3.5 mg during sustained atrial fibrillation (AF). Subsequently, ethanol was infused into the VOM and ablative region was mapped. RESULTS: In 17 patients (49 %), cibenzoline reduced AEs amplitude by >50%, all of which had also complete elimination of AEs following ethanol (Group A). In 18 patients (Group B), cibenzoline failed to eliminate AEs; yet, in 13 of 18 AEs were eliminated by ethanol. In the remaining five patients, ethanol did not eliminate AE. CONCLUSIONS: Cibenzoline into the VOM could reliably predicts the results of subsequent ethanol infusion into the VOM using ultrahigh-resolution mapping system, which leads to avoid unnecessary permanent lesion creation by ethanol infusion.

Chemical ablation of ventricular tachycardia arising from the left ventricular summit.

Ventricular tachycardia (VT) arising from the left ventricular summit is very tough to treat endocardially and epicardially due to the distance from the VT origin and close proximity to the coronary arteries, respectively. Ethanol infusions into coronary veins feeding VT origins were able to safely abolish this type of VT.

The clinical impact of the left atrial posterior wall lesion formation by the cryoballoon application for persistent atrial fibrillation: Feasibility and clinical implications.

INTRODUCTION: The left atrial (LA) posterior wall (LAPW) has been targeted to improve the clinical outcomes in patients with persistent atrial fibrillation (PersAF). This study aimed to investigate the feasibility, safety, and clinical implications of cryoballoon (CB) applications on the LAPW to accomplish electrical isolation (EI) of the LAPW with CB. METHODS: A total of 100 patients (males, 84; mean age, 64 ± 10 years) with PersAF were enrolled. The first 50 patients underwent only pulmonary vein isolation (PVI) (PVI-only group) and the remaining 50 patients underwent PVI and EI of the LAPW with CB (EI-LAPW group). RESULTS: One-year sinus rhythm maintenance probability was significantly higher in the EI-LAPW group than in PVI-only group (80.0% vs 55.1%, P = 0.01). The success rate of constructing an LA roof block line (LA-RB), bottom block line, and EI of the LAPW was 92%, 60%, and 58%, respectively. The nadir CB temperature (-45°C ± 4°C vs -39°C ± 5°C, P = 0.005) and anatomical angle of the left atrial roof (106°C ± 30°C vs 144°C ± 17°C, P < 0.001) significantly predicted the successful LA-RB construction. The left ventricular ejection fraction was significantly higher in unsuccessful cases than in successful cases of an EI of the LAPW (64% ± 8% vs 58% ± 11%, P = 0.041). Even though the EI of the LAPW was unsuccessful, CB freezing in LAPW significantly debulked the nonscar area (≥0.1 mV) in LAPW (18.1 ± 5.6 vs 2.2 ± 3.1 cm 2 , P < 0.001) and provided the equivalent 1-year outcome of successful cases (79.3% vs 81.0%, P = 0.90). CONCLUSION: The combination of PVI and EI of the LAPW with CB provided better clinical outcomes than conventional PVI procedure for patients with PersAF.

Clinical impact of ethanol infusion into the vein of Marshall on the mitral isthmus area evaluated by atrial electrograms recorded inside the coronary sinus.

BACKGROUND: The left atrial myocardium (LAM) and coronary sinus (CS) musculature (CSM) generate atrial electrograms recorded inside the CS (AECSs). The vein of Marshall (VOM) courses the mitral isthmus (MI), and ethanol infusion into the VOM (EI-VOM) is useful to ablate it. However, its detailed effect on the MI, which contains the LAM, CSM, and those connections, is unknown. OBJECTIVE: The purpose of this study was to investigate the impact of EI-VOM on the MI by assessing the AECS. METHODS: Eighty-four consecutive patients with atrial fibrillation undergoing MI ablation with successful EI-VOM were included. After EI-VOM, radiofrequency (RF) catheter touchup ablation was performed at MI gap sites or inside the CS (RFCS), as needed, to achieve bidirectional conduction block. Ablation effects on AECSs were evaluated during the MI ablation procedure. RESULTS: AECSs demonstrated double potentials consisting of low-amplitude LAM components and high-amplitude CSM components in 31 patients (37%). Of those patients, 21 had a distal-to-proximal activation sequence of the LAM along with a proximal-to-distal activation sequence of the CSM during left atrial appendage pacing, suggesting CSM isolation from the LAM due to electrical LAM-CSM disconnection. Only 2 of the 21 patients required RFCS. The remaining 10 patients with distal-to-proximal activation in both CSM and LAM, suggesting incomplete CSM isolation and persistent LAM-CSM conduction, required RFCS. Overall, combined EI-VOM with RF created bidirectional conduction block at the MI in 78 patients (93%). CONCLUSION: EI-VOM can ablate the LAM and myocardial connections between the LAM and CSM. Careful assessment of AECSs can predict a requirement for RFCS.

Clinical investigation of esophageal injury from cryoballoon ablation of persistent atrial fibrillation.

BACKGROUND: The cryoballoon (CB) can be utilized for extra pulmonary vein (PV) ablation such as for a left atrial (LA) posterior wall (LAPW) isolation. However, scrutiny of the esophageal injuries during the LAPW isolation has never been performed. We sought to thoroughly investigate the esophageal lesions (ELs) and gastric hypomotility (GH) caused by an LAPW isolation using a CB. METHODS: A total of 101 persistent atrial fibrillation patients who underwent an LAPW isolation using a CB were enrolled. The CB was applied on the roof and bottom area of the LAPW after a PV isolation. The luminal esophageal temperature (LET) was monitored by a thermistor probe during the CB applications. When the LET reached 15°C, the freezing application was prematurely interrupted. Esophagogastroscopy was performed on the next day following the ablation. RESULTS: All PVs were successfully isolated in all patients. A successful LAPW isolation solely with CB ablation was performed in 72 (71.3%) patients. Cryofreezing applications were prematurely interrupted due to low LETs in 49 (48.5%) patients predominantly during the LA bottom line ablation. ELs and GH were observed in 11 (10.9%) and 16 patients (15.8%), respectively. The nadir LET tended to be lower in patients with ELs and GH than in those without (ELs: 14.8 ± 4.5°C vs 17.4 ± 6.0°C, P = 0.17; GH: 15.5 ± 4.5°C vs 17.5 ± 6.1°C, P = 0.23, respectively). CONCLUSIONS: Esophageal complications such as ELs and GH occur during the LAPW isolation with a CB. There was no reliable predictor of those adverse events.

"Clinical Impact of the Cryoballoon Temperature and Occlusion Status on the Success of Pulmonary Vein Isolation".

BACKGROUND: Complete occlusion of the pulmonary veins (PVs) with the cryoballoon (CB) is considered to be the crucial factor for a successful PV isolation (PVI). We investigated whether a complete occlusion was indispensable for a successful CB based PVI of every PV. METHODS AND RESULTS: Atrial fibrillation patients (n=123, 97; paroxysmal) undergoing a de novo PVI were enrolled. A total of 477 PVs were analyzed. The occlusion grade (OG) was scored as follows: OG3 (complete occlusion), OG2 (incomplete occlusion with slight leakage), OG1 (poor occlusion with massive leakage). There was no significant difference in the CB temperature (CBT) at all measured time points (from 30 to 120sec after freezing) and nadir CBT between OG2 and OG3 in all PVs except for the right inferior PV (RIPV). The RIPV isolation success rate was significantly lower for the OG2 status than OG3 (97.5 vs. 57.6%; p<0.0001). In contrast, there was not significant difference in the isolation success rate of the other three PVs between OG2 and OG3. In particular, the success rate of the right superior PV (RSPV) isolation was >95% for both OG2 and OG3. Phrenic nerve paralysis (PNP) was provoked during the RSPV isolation in two patients in whom the RSPVs were frozen during OG3. CONCLUSION: An OG3 may not always be required for a successful PVI of all PVs except the RIPV. OG2 could have comparable effects as OG3 in terms of a successful RSPV isolation. Not aiming for OG3 for the RSPV may reduce the risk of PNP.

Quick, safe, and effective maneuver to prevent phrenic nerve injury during cryoballoon ablation of atrial fibrillation.

PURPOSE: Phrenic nerve (PN) injury is a typical complication of cryoballoon ablation (CBA) of pulmonary veins. The PN function is monitored by palpating the abdomen during PN pacing, and freezing is prematurely terminated when a reduction in the diaphragm movement is recognized. This study aimed to investigate the efficacy and safety of a "pull-back" maneuver to prevent PN injury. METHODS: A total of 284 patients were included, and the PN function was monitored by recording the diaphragmatic compound motor action potentials (CMAP) during the cryoballoon applications for pulmonary vein (PV) isolation. When the CMAP amplitude was reduced by more than 30% compared to the control, the "pull-back" maneuver (PBM) was undertaken to prevent PN injury. RESULTS: The average CMAP amplitude significantly decreased from 0.81 ± 0.04 to 0.31 ± 0.21 (p < 0.01) mV during the cryoballoon applications of PVs in 92 PVs. The PBM was employed in all cases, and the average CMAP amplitude recovered to 0.87 ± 0.31 mV (p < 0.01) in 79 out of 92 PVs (85.9%), accomplishing the CBA. Cryofreezing had to be prematurely terminated due to failure of the PBM in 13 out of 92 cases (14.1%). CONCLUSIONS: The PBM was an effective maneuver to prevent PN injury by creating a distance between the PN and location of the cryoballoon. No adverse events were provoked by this procedure.

Characteristics of dormant pulmonary vein conduction induced by adenosine triphosphate in patients with atrial fibrillation undergoing cryoballoon ablation.

BACKGROUND: Adenosine triphosphate (ATP) can provoke acute reconnections after pulmonary vein isolation (PVI). This study aimed to investigate dormant conduction (DC) after ablation with second-generation cryoballoon (CB). METHODS: Two hundred sixteen patients (148 male; age 64±9 years) with atrial fibrillation (AF) were included. After a successful PVI with the CB, 20mg of ATP was administered. All patients were followed up for 425±56 days. RESULTS: Seven hundred ninety-five out of 864 (92%) PVs were successfully isolated solely by the CB. DCs were revealed in 8 (3.7%) after ATP injections. AF recurrences occurred in 2 out of 8 patients, while no AF recurrences could be documented in 6 out of 8 patients with DCs after a blanking period of 3 months (25% vs. 75%). In contrast, 29 (13.9%) patients without DCs had AF recurrences, and there was no significant difference between those with and without DCs regarding the recurrence rate of AF (p=0.38). There were no reliable predictors of DCs after the PVI with the CB. CONCLUSION: The present study demonstrated a low rate of transient PV reconnection after adenosine infusion following successful PVI with the CB. There was no reliable predictor of DCs. Further studies will be needed in order to appreciate the prognostic value of adenosine testing after successful PVI with the CB.

Trends and predictors of non-cardiovascular death in patients hospitalized for acute heart failure.

BACKGROUND: Little information is available on non-cardiovascular (CV) death in acute heart failure (AHF) patients. The present study determined the incidence, time course, and factors associated with long-term non-CV death in AHF patients in a real-world setting. METHODS: The ATTEND registry, a nationwide, prospective observational multicenter cohort study, included 4842 consecutive patients hospitalized for AHF. The primary endpoint of the present study was non-CV death. RESULTS: Median follow-up duration from admission was 513 (range, 385-778) days. Over the study period, 1183 patients died; 356 deaths (30.1%) were non-CV related. The proportion of non-CV deaths increased in the later follow-up phase (0-180days, 26.7%; 181-360days, 38.4%; >360days, 36.6%, p<0.001). After adjustment for all variables at baseline, age (hazard ratio [HR] 1.6 per decade, p<0.001) and non-cardiac comorbidities including chronic obstructive pulmonary disease (HR 1.58, p=0.003), history of stroke (HR 1.44, p=0.011), renal insufficiency (HR 1.07, per 10ml/min/1.73m2 decrease in estimated glomerular filtration, p=0.015), and hemoglobin (HR 1.15 per 1.0g/dl decrease, p<0.001) were strongly associated with non-CV death. Other predictors included ischemic etiology (HR 1.33, p=0.023), prior hospitalization for heart failure (HR 1.34, p=0.017), C-reactive protein (HR 1.04, p<0.001), and statin use (HR 0.70, p=0.016). CONCLUSIONS: The incidence of non-CV death was high in patients with AHF, accounting for 30% of long-term mortality. Furthermore, the proportion of non-CV death increased in the later follow-up phase. Better understanding of non-CV death and more comprehensive treatment of non-CV comorbidities are vital to further improving prognosis in AHF patients.

Left phrenic nerve injury during electrical isolation of left-sided pulmonary veins with the second-generation cryoballoon.

BACKGROUND: Phrenic nerve (PN) palsy (PNP) is the most frequent complication of cryoballoon ablation (CBA) of atrial fibrillation (AF). The major complication of this technique seems to be right-sided PN injury (PNI) following ablation of the right pulmonary veins (PVs). We sought to assess the incidence and prognosis of left-sided PNI during CBA. METHODS: CBA was performed in 448 patients with AF. During the ablation of the left-sided PVs, the PN was paced from the left subclavian vein with a pacing output just exceeding the threshold by 10 ∼ 20%. The right and left arm 12-lead electrocardiogram electrodes were positioned 5 cm above the xiphoid process and 16 cm along the left costal margin. The amplitude of the compound motor action potentials was recorded during the CBA. RESULTS: Two thousand one hundred seventy-eight CBA applications were delivered in 1,094 left-sided PVs. PNI occurred in 29 patients (6.5%); the PN could be captured by an increasing pacing output in 21 patients (4.7%), and premature termination of the freezing was required to avoid PNP in eight patients (1.8%). The PN function recovered before discharge; however, it took 7 months for one patient to completely recovery from the PNP. CONCLUSIONS: Left-sided PNP could be provoked during a left-sided CBA procedure. Assessment of the left PN during the CBA was necessary to prevent left-sided PNP.

Clinical assessment of cryoballoon ablation in cases with atrial fibrillation and a left common pulmonary vein.

INTRODUCTION: Pulmonary vein isolation (PVI) using a cryoballoon (CB) is a useful tool for treating atrial fibrillation (AF); however, the clinical efficacy of the CB has never been fully investigated in patients with a left common pulmonary vein (LCPV). METHODS AND RESULTS: Three hundred twenty-four consecutive paroxysmal AF patients underwent PVI with a CB. Three-dimensional computed tomography was performed in all patients before the ablation. The clinical outcomes of the AF ablation between patients with (Group A) and without an LCPV (Group B) were compared. An LCPV was observed in 27 (8%) patients. There were no significant differences in the procedure time (149 ± 45 min vs. 143 ± 40 min, respectively; P = 0.42) and percentage needing touch up ablation between the 2 groups (26% vs. 20%, respectively; P = 0.45). At a mean follow-up of 454 ± 195 days, 282 of 324 (87%) patients were free from any atrial tachyarrhythmias (ATs) after a single procedure. Twenty out of 27 (74%) Group A patients and 262 of 297 (88%) Group B patients were free from ATs (15-month Kaplan-Meier event free rate estimates, 77% and 89%, respectively; P = 0.02). A multivariate analysis identified the presence of an LCPV and the left atrial diameter as reliable predictors of recurrent ATs. CONCLUSIONS: The long-term clinical outcomes of ablation of AF with the CB was worse in patients with an LCPV than in those without. The presence of an LCPV and the LA size seemed to be reliable predictors of a worse outcome.

Incidence and predictors of in-hospital non-cardiac death in patients with acute heart failure.

BACKGROUND: Patients with acute heart failure (AHF) commonly have multiple co-morbidities, and some of these patients die in the hospital from causes other than aggravated heart failure. However, limited information is available on the mode of death in patients with AHF. Therefore, the present study was performed to determine the incidence and predictors of in-hospital non-cardiac death in patients with AHF, using the Acute Decompensated Heart Failure Syndromes (ATTEND) registry Methods: The ATTEND registry included 4842 consecutive patients with AHF admitted between April 2007-September 2011. The primary endpoint of the present study was in-hospital non-cardiac death. A stepwise regression model was used to identify the predictors of in-hospital non-cardiac death. RESULTS: The incidence of all-cause in-hospital mortality was 6.4% ( n=312), and the incidence was 1.9% ( n=93) and 4.5% ( n=219) for non-cardiac and cardiac causes, respectively. Old age was associated with in-hospital non-cardiac death, with a 42% increase in the risk per decade (odds 1.42, p=0.004). Additionally, co-morbidities including chronic obstructive pulmonary disease (odds 1.98, p=0.034) and anaemia (odds 1.17 (per 1.0 g/dl decrease), p=0.006) were strongly associated with in-hospital non-cardiac death. Moreover, other predictors included low serum sodium levels (odds 1.05 (per 1.0 mEq/l decrease), p=0.045), high C-reactive protein levels (odds 1.07, p<0.001) and no statin use (odds 0.40, p=0.024). CONCLUSIONS: The incidence of in-hospital non-cardiac death was markedly high in patients with AHF, accounting for 30% of all in-hospital deaths in the ATTEND registry. Thus, the prevention and management of non-cardiac complications are vital to prevent acute-phase mortality in patients with AHF, especially those with predictors of in-hospital non-cardiac death.

Clinical profile, management, and mortality in very-elderly patients hospitalized with acute decompensated heart failure: An analysis from the ATTEND registry.

BACKGROUND: Acute decompensated heart failure (ADHF) is a leading cause of hospitalization among the elderly. Discussion of optimal management of ADHF in older patients is a growing health care priority. The aim of this study was to examine the clinical profile, management, and mortality in patients admitted with ADHF according to age. METHODS: We analyzed 4824 patients enrolled in the Acute Decompensated Heart Failure Syndromes registry from April 2007 to December 2011. Patient characteristics, management, and in-hospital outcomes were compared among four age groups (<65, 65-74, 75-84, and ≥85 years). RESULTS: The mean age of the overall population was 73 years; approximately 20% were aged ≥85 years. Older patients were more likely to be women and have preserved left ventricular ejection fraction (LVEF) and decreased renal function. Intravenous treatments were well administered in both young and elderly patients irrespective of LVEF. Invasive procedures were less frequently performed in the eldest group. The median length of hospital stay was 21 days, and in-hospital cardiac death in the eldest group was four-fold higher than that in the youngest group (2.2% vs. 8.9%, P<0.001). CONCLUSIONS: Clinical characteristics of ADHF differ considerably with age, and cardiac death increases linearly with age. Despite a higher rate of preserved systolic function in very-elderly individuals aged ≥85 years, in-hospital mortality was higher, suggesting that more suitable treatments for the elderly might be needed.

High-dose statin therapy with rosuvastatin reduces small dense LDL and MDA-LDL: The Standard versus high-dose therApy with Rosuvastatin for lipiD lowering (SARD) trial.

BACKGROUND: Cardiovascular events (CV) continue to occur due to residual risks in high-risk patients in spite of substantial reductions in the low-density lipoprotein cholesterol (LDL) with statins. It has been reported that the small-dense LDL (sd-LDL) components of high atherogenic particles are associated with an increased risk of CV, more than large buoyant LDL. However, there are few reports regarding the effects of high-dose statin therapy in improving atherogenic lipoproteins. METHODS AND RESULTS: In this prospective, randomized, open-label, multicenter study, a total of 111 high-risk patients were randomly assigned to two groups. In the high-dose therapy group, 58 patients were administered 5mg of rosuvastatin per day for four weeks, after which the dose was titrated to 10mg for the following eight weeks. In the low-dose therapy group, 53 patients were given 2.5mg for 12 weeks. We evaluated the lipid profiles, including the levels of sd-LDL, malondialdehyde-modified LDL-cholesterol (C) (MDA-LDL) as oxidized-LDL, and remnant-like particle-cholesterol. The LDL-C, non-high-density lipoprotein (HDL), and LDL-C/HDL-C ratio were decreased in the high-dose therapy group (p<0.01). Moreover, the sd-LDL and MDA-LDL levels were significantly reduced in the high-dose therapy group (p<0.05). There were no serious adverse events in either group. CONCLUSIONS: High-dose statin therapy significantly reduced the sd-LDL and MDA-LDL components of atherosclerotic lipoproteins without adverse events in comparison with low-dose statin therapy.