Incidence of Hospitalization-Associated Disability in Older Patients With Heart Failure.

BACKGROUND: This study determined the incidence of hospitalization-associated disability (HAD) and its characteristics in older patients with heart failure in Japan.Methods and Results: Ninety-six institutions participated in this nationwide multicenter registry study (J-Proof HF). From December 2020 to March 2022, consecutive heart failure patients aged ≥65 years who were prescribed physical rehabilitation during hospitalization were enrolled. Of the 9,403 patients enrolled (median age 83.0 years, 50.9% male), 3,488 (37.1%) had HAD. Compared with the non-HAD group, the HAD group was older and had higher rates of hypertension, chronic kidney disease, and cerebrovascular disease comorbidity. The HAD group also had a significantly lower Barthel Index score and a significantly higher Kihon checklist score before admission. Of the 9,403 patients, 2,158 (23.0%) had a preadmission Barthel Index score of <85 points. Binomial logistic analysis revealed that age and preadmission Kihon checklist score were associated with HAD in patients with a preadmission Barthel Index score of ≥85, compared with New York Heart Association functional classification and preadmission cognitive decline in those with a Barthel Index score <85. CONCLUSIONS: This nationwide registry survey found that 37.1% of older patients with HF had HAD and that these patients are indicated for convalescent rehabilitation. Further widespread implementation of rehabilitation for older patients with heart failure is expected in Japan.

Clinical impact of non-lying time on hospital-associated functional decline in older patients undergoing transcatheter aortic valve implantation.

The purposes of the present study were: (1) to investigate the relationship between hospital-associated functional decline (HAFD) and non-lying time and (2) to clarify the optimal cut-off value for non-lying time associated with HAFD in older patients undergoing transcatheter aortic valve implantation (TAVI). From January 2021 to December 2022, patients admitted to a university hospital who underwent trans-femoral TAVI were consecutively recruited. We measured short physical performance battery (SPPB) pre and post-TAVI, and non-lying time from post-operative days 3-5. HAFD was defined as at least 1 point decrease in SPPB during pre and post-TAVI. Among 75 patients (47 female, mean age of 84.5 years) enrolled, 14 patients were classified as having HAFD. Non-lying time was significantly shorter in the HAFD group than in the non-HAFD group (371 min vs. 539 min, P < 0.001). Receiver-operating characteristic analysis determined an optimal cut-off value of 477 min for differentiating the patients more likely to experience HAFD (sensitivity, 75%; specificity, 92%; area under the curve, 0.798). The non-lying time could be one of the associated factors of HAFD in older patients with TAVI. Non-lying time of about 480 min (8 h) during hospitalization may be an initial target for preventing HAFD.

Exploring the factors associated with decreased dynamic balance ability in older patients with heart failure.

BACKGROUND: Older patients with heart failure (HF) have a higher prevalence of frailty and poorer dynamic balance ability than other community-dwelling older adults. However, the association of frailty and other clinical characteristics with dynamic balance ability in these patients remains unclear. OBJECTIVES: We aimed to determine the clinical characteristics associated with decreased dynamic balance ability in older patients with HF. METHODS: This observational study included patients aged ≥65 years who could walk independently and were admitted to our university hospitals to undergo a cardiac rehabilitation. The timed up and go test (TUG) was used to evaluate dynamic balance ability. Pearson's and Spearman's correlation analyses were performed to determine the relationships between TUG scores and clinical characteristics. A multiple regression model based on the forced entry method was used to determine independent predictors of TUG scores. RESULTS: Of the 183 participants in this study (94 women; mean age, 82.5 ± 8.1 years), 116 (61.7%) had frailty. Pearson's and Spearman's correlation analyses revealed that age, frailty, sex, knee extensor muscle strength, maximum calf circumference, and Mini-Mental State Examination-Japanese version (MMSE-J) score were significantly correlated with TUG score (p < 0.001). Further, multiple regression analysis showed that age (p < 0.001), frailty (p = 0.041), knee extensor muscle strength (p = 0.002), and MMSE-J score (p = 0.048) were independent predictors of TUG scores. CONCLUSION: Multiple factors, including age, frailty, knee extensor muscle weakness, and cognitive function impairment are independently associated with decreased dynamic balance ability in older patients with HF.

Prediction of stroke patients' bedroom-stay duration: machine-learning approach using wearable sensor data.

Background: The importance of being physically active and avoiding staying in bed has been recognized in stroke rehabilitation. However, studies have pointed out that stroke patients admitted to rehabilitation units often spend most of their day immobile and inactive, with limited opportunities for activity outside their bedrooms. To address this issue, it is necessary to record the duration of stroke patients staying in their bedrooms, but it is impractical for medical providers to do this manually during their daily work of providing care. Although an automated approach using wearable devices and access points is more practical, implementing these access points into medical facilities is costly. However, when combined with machine learning, predicting the duration of stroke patients staying in their bedrooms is possible with reduced cost. We assessed using machine learning to estimate bedroom-stay duration using activity data recorded with wearable devices. Method: We recruited 99 stroke hemiparesis inpatients and conducted 343 measurements. Data on electrocardiograms and chest acceleration were measured using a wearable device, and the location name of the access point that detected the signal of the device was recorded. We first investigated the correlation between bedroom-stay duration measured from the access point as the objective variable and activity data measured with a wearable device and demographic information as explanatory variables. To evaluate the duration predictability, we then compared machine-learning models commonly used in medical studies. Results: We conducted 228 measurements that surpassed a 90% data-acquisition rate using Bluetooth Low Energy. Among the explanatory variables, the period spent reclining and sitting/standing were correlated with bedroom-stay duration (Spearman's rank correlation coefficient (R) of 0.56 and -0.52, p < 0.001). Interestingly, the sum of the motor and cognitive categories of the functional independence measure, clinical indicators of the abilities of stroke patients, lacked correlation. The correlation between the actual bedroom-stay duration and predicted one using machine-learning models resulted in an R of 0.72 and p < 0.001, suggesting the possibility of predicting bedroom-stay duration from activity data and demographics. Conclusion: Wearable devices, coupled with machine learning, can predict the duration of patients staying in their bedrooms. Once trained, the machine-learning model can predict without continuously tracking the actual location, enabling more cost-effective and privacy-centric future measurements.

Study Design of the Japanese Association of Cardiac Rehabilitation Registry (J-CARRY)　- Protocol for a Prospective, Multicenter, Open Registry.

Background: Guidelines for the prevention and management of cardiovascular disease (CVD) highly recommend cardiac rehabilitation (CR) on the basis of abundant evidence of its effectiveness. However, the current understanding and dissemination of CR in Japan are far from sufficient. Methods and Results: The Japanese Association of Cardiac Rehabilitation Registry (J-CARRY) is an academic society-led prospective multicenter observational registry conducted by the Registration and Facility Accreditation System Committee of the Japanese Association of Cardiac Rehabilitation. Data are collected prospectively using an electronic data capture system. Items related to patients' clinical background and CR, as well as mortality and major adverse cardiac and cerebrovascular events, will be collected in all cases. This Registry started in May 2014, and the number of participating medical institutions is expected to increase to >30; the targeted number of cases exceeded 3,000 per year as of April 30, 2022. Focusing on late Phase II data collection is a novel and significantly different approach compared with previous studies. The results of this study are currently under investigation. Conclusions: J-CARRY will provide real-world data regarding the current status and prognosis of CVD in patients who undergo Phase II CR in Japan.

Second Nationwide Survey of Japanese Cardiac Rehabilitation Training Facilities During the Coronavirus Disease 2019 (COVID-19) Outbreak.

Background: We previously reported the results of a questionnaire survey of 37 cardiac rehabilitation (CR) training facilities conducted during April 2020, in Japan. Methods and Results: We conducted a second questionnaire survey in 38 CR training facilities to explore the preventive measures against Coronavirus Disease 2019 (COVID-19) after a nationwide state of emergency was declared and to investigate differences between the 2 surveys. No significant differences were observed, except for the requirement for patients to wear surgical masks during CR (P=0.01) in the second survey. Thirty-four facilities (89%) continued CR with innovations, 61% revised their instruction manuals (vs. 46% in the first survey), and, in 39%, patients requested resumption of ambulatory CR and training videos. Conclusions: In the second survey, 74% of facilities were unable to continue conventional group ambulatory CR; however, patients maintained their physical activity and exercise regimens and managed their illnesses with the aid of telephones and mobile devices.

The Acute-Phase Ambulation Program Improves Clinical Outcome for Acute Heart Failure.

It remains unclear whether the acute-phase ambulation program (AAP) improves the prognosis of heart failure (HF) patients. We examined the association between the initiation of AAP and the prognosis of patients with worsening HF. We enrolled 560 consecutive patients admitted due to worsening HF from March 2019 to April 2021. Our hospital introduced AAP in May 2020, but we did not perform AAP until April 2020. We retrospectively compared cardiac events within 180 days after discharge between patients admitted before April 2020 (conventional group) and after May 2020 (AAP group). Primary endpoints were all-cause mortality and readmission for worsening HF. The Kaplan-Meier survival curves showed a significantly lower event rate in the AAP group in HF readmission or the primary endpoint (p = 0.020 and p = 0.014). The occurrence of the primary endpoint was associated with age, history of HF, systolic blood pressure, medications including renin-angiotensin system inhibitors or angiotensin receptor blocker, hemoglobin, NT-proBNP, and AAP participation. After adjusting for these parameters and sex, participation in AAP was an independent factor associated with a reduced risk of primary endpoint occurrence (hazard ratio of 0.62 (0.41-0.95), p = 0.028). The AAP for patients with acute HF might lead to improved short-term prognosis and should be considered for implementation.

Poor walking ability outcome and activities of daily living improvement in patients undergoing cardiac rehabilitation during COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has had wide-ranging impacts across international healthcare systems and direct impacts on rehabilitation professionals. Few outcome data for cardiac patients undergoing rehabilitation programs during the COVID-19 pandemic are available. AIM: We conducted a study to compare the effect of modified rehabilitation therapies mainly performed in wards versus conventional therapies mainly performed in rehabilitation units in which exercise on a treadmill and cardiopulmonary exercise testing were available. DESIGN: Observational study. SETTING: University hospital. POPULATION: Fifty-five consecutive inpatients admitted to a university hospital and underwent a cardiac rehabilitation program from August 2019 to June 2020. METHODS: The patients were divided into two groups: those admitted during the COVID-19 outbreak (Group A, N.=28) and those admitted before the COVID-19 outbreak (Group B, N.=27). The evaluation included age, sex, duration of the rehabilitation intervention program, days before initiation of the rehabilitation program, functional status, and Functional Independence Measure (FIM) Score. RESULTS: A higher proportion of patients in Group A than B underwent a cardiac rehabilitation program provided in wards (88.5% vs. 48.8%, respectively). Group A showed a significantly lower 6-minute walking distance and walking speed than Group B at discharge (P=0.031 and 0.014, respectively). Group A showed a significantly shorter exercise time using an ergometer than Group B (P=0.028). CONCLUSIONS: The difference in the cardiac rehabilitation location during the COVID-19 pandemic may affect the rehabilitation contents and lead to less improvement in physical function. CLINICAL REHABILITATION IMPACT: A cardiac rehabilitation program was performed mainly in wards instead of in rehabilitation units during the COVID-19 pandemic. Walking abilities were adversely affected by the modified cardiac rehabilitation program.

Clinical outcomes of two-stage revision total knee arthroplasty in infected cases with antibiotic-loaded cement spacers produced using a handmade silicone mold.

PURPOSE: This study assessed the clinical outcomes of periprosthetic joint infection patients who underwent two-stage revision total knee arthroplasty with antibiotic-loaded cement spacers fabricated using a handmade silicone mold. MATERIALS AND METHODS: This study included seven patients (average age 77 years, average follow-up time 54 months) who underwent surgery at our hospital between 2009 and 2013. Clinical outcomes including knee scores, function scores, knee range of motion, and walking ability at the final observation, period from the primary total knee arthroplasty to implant removal, period from implant removal to revision total knee arthroplasty, and follow-up period after revision total knee arthroplasty were investigated. RESULTS: At the final follow-up, the average knee range of motion was 99°, with no significant differences at each stage; average knee and function scores were 84 and 77, respectively. With cement spacers, five patients were able to walk with a t-cane. No recurrence of infection was observed. CONCLUSIONS: The clinical outcomes of the current case series demonstrated good knee function with preserved walking ability, without any recurrence of periprosthetic joint infection. This study suggests that using a handmade silicone mold could be an effective option for periprosthetic joint infection after a total knee arthroplasty.

Impact of heart failure severity on bone mineral density among older patients with heart failure.

The study aimed to identify factors related to bone mineral density (BMD) among older patients with heart failure (HF). A total of 70 consecutive patients with HF aged 65 years or older who were admitted to an acute hospital due to worsening condition were enrolled before discharge. BMD of the femoral neck was evaluated using the DEXA method. Physical function, as well as echocardiographic and laboratory findings including biomarker of HF severity were collected. Bivariate and multiple regression analyses were employed to determine the association between BMD and the clinical variables. Bivariate analysis determined that age, grip strength, walking speed, serum albumin, and N-terminal pro B-type natriuretic peptide (NT-proBNP) were significantly correlated with BMD (P < 0.01), whereas other clinical parameters were not. The multiple regression analysis identified NT-proBNP as an independent related factor for BMD after adjusting with confounding clinical variables. NT-proBNP was independently related to BMD among older patients with HF. Our results suggest the inclusion of bone fracture prevention strategies in disease management programs, especially for older patients with HF.

Nationwide Survey of Japanese Cardiac Rehabilitation Training Facilities During the Coronavirus Disease 2019 Outbreak.

Background: Since the reporting of a cluster outbreak of coronavirus disease 2019 (COVID-19) in sports gyms, the Japanese Association of Cardiac Rehabilitation (CR) shared a common understanding of the importance of preventing patients and healthcare providers from contracting COVID-19. This questionnaire survey aimed to clarify the status of CR in Japan during the COVID-19 outbreak. Methods and Results: An online questionnaire survey was conducted in 37 Japanese CR training facilities after the national declaration of a state of emergency in 7 prefectures. Among these facilities, 70% suspended group ambulatory CR and 43% suspended cardiopulmonary exercise testing (CPX). In contrast, all facilities maintained individual inpatient CR. Of the 37 facilities, 95% required CR staff to wear a surgical mask during CR. In contrast, 50% of facilities did not require patients to wear a surgical mask during CR. Cardiac telerehabilitation was only conducted by a limited number of facilities (8%), because this method was still under development. In our survey, 30% of the facilities not providing cardiac telerehabilitation had specific plans for its future use. Conclusions: Our data demonstrate that ambulatory CR and CPX were suspended to avoid the spread of COVID-19. In the future, we need to consider CR resumption and develop new technologies for cardiovascular patients, including cardiac telerehabilitation.

Impact of physical function on indeterminable anaerobic threshold in patients with heart failure.

BACKGROUND: Anaerobic threshold (AT) during cardiopulmonary exercise testing (CPET) is not always determinable in patients with heart failure (HF). However, little is known about the clinical features of patients with HF who have indeterminable AT. Therefore, the present study aimed to clarify the clinical features of such patients. METHODS: A total of 70 patients with HF (58 males; age: 68±12 years) who underwent CPET during hospitalization were divided into two groups: determinable AT (n=50) and indeterminable AT (n=20). Physical function, echocardiographic results, and laboratory findings were subsequently determined. RESULTS: Univariate analyses showed that the indeterminable AT group had significantly higher age and left ventricular ejection fraction, and significantly lower body mass index, calf circumference, handgrip strength, walking speed, serum hemoglobin, and serum albumin than the determinable AT group. Multiple logistic regression analysis identified handgrip strength and walking speed as independent predictive factors for indeterminable AT. Receiver-operating characteristic analyses revealed that handgrip strength of 21.2 kg and walking speed of 0.97 m/s were optimal cutoff values for differentiating patients who were likely to experience indeterminable AT. CONCLUSIONS: The present study identified handgrip strength and walking speed as powerful predictors for indeterminable AT with HF.

Effect of cardiac rehabilitation on circulating microRNA expression in heart failure: a preliminary study.

OBJECTIVES: There are benefits of exercise-based cardiac rehabilitation (CR) in patients with heart failure (HF), but their underlying molecular mechanisms remain elusive. The effect of CR on the expression profile of circulating microRNAs (miRNAs), which are short noncoding RNAs that regulate posttranscriptional expression of target genes, is unknown. If miRNAs respond to changes following CR for HF, then serum profiling of miRNAs may reveal cardioprotective mechanisms of CR. METHODS: This study enrolled three hospitalized patients with progressed systolic HF and three normal volunteer controls. In patients, CR was initiated after improvement of HF, which included 2 weeks of bicycle ergometer and resistance exercises. Genome-wide expression profiling of circulating miRNAs was performed using microarrays for the patients (mean±SD age, 60.0±12.2 years) and controls (58.7±0.58 years). Circulating miRNA expression profiles were compared between patients with HF before and after CR and the controls. RESULTS: Expression levels of two miRNAs were significantly different in patients before CR compared with controls and patients after CR. The expression of hsa-miR-125b-1-3p was significantly downregulated and that of hsa-miR-1290 was significantly upregulated in patients before CR. CONCLUSIONS: When performing CR, expression of certain circulating miRNAs in patients with HF is restored to nonpathological levels. The benefits of CR for HF may result from regulation of miRNAs through multiple effects of gene expression.

Effects of Phase II Comprehensive Cardiac Rehabilitation on Risk Factor Modification and Exercise Capacity in Patients With Acute Coronary Syndrome　- Results From the JACR Registry.

Background: Cardiac rehabilitation (CR) is categorized as a Class I recommendation in guidelines for the management of patients with acute coronary syndrome (ACS); however, nationwide studies on CR in patients with ACS remain limited in Japan. Methods and Results: The Japanese Association of Cardiac Rehabilitation (JACR) Registry is a nationwide, real-world database for patients participating in CR. From the JACR Registry database, we analyzed 924 patients participating in Phase II CR in 7 hospitals between September 2014 and December 2016. The mean age of patients was 65.9±12.0 years, and 80% were male. The prevalence of ST-elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina pectoris (UAP) was 58%, 9%, and 33%, respectively. The prevalence of hypertension, diabetes, dyslipidemia, current smoking, and a family history was 55%, 27%, 67%, 21%, and 10%, respectively. Among the entire CR cohort at baseline, 96%, 78%, and 92% were treated with aspirin, ß-blockers, and statins, respectively. After CR, the values of body mass index, the lipid profile, and exercise capacity significantly improved in the STEMI, NSTEMI and UAP groups. Conclusions: In the JACR Registry, a high rate of guideline-recommended medications at baseline and improvements in both coronary risk factors and exercise capacity after CR were observed in patients with ACS.

Predictive impact of early mobilization on rehospitalization for elderly Japanese heart failure patients.

The aim of this study was to determine whether early mobilization was associated with rehospitalization among elderly heart failure patients. We measured the time from admission to mobilization and other clinical characteristics for 190 heart failure patients (mean age, 80.7 years). The primary outcome was heart failure rehospitalization. Kaplan-Meier survival curves were plotted and the hazard ratios for rehospitalization were determined using Cox proportional hazards regression models. During a median follow-up period of 750 days, 58 patients underwent rehospitalization. The time from admission to mobilization was significantly longer for these patients than for those who were not rehospitalized. Univariate and multivariate Cox proportional hazards analyses showed that the time from admission to mobilization was an independent predictor of rehospitalization, and receiver-operating characteristic analysis determined an optimal cutoff value of 3 days for differentiating the patients more likely to experience a subsequent cardiac event (sensitivity, 76%; specificity, 69%; area under the curve, 0.667). Kaplan-Meier survival curve analysis showed a significantly lower event rate in the ≤ 3-day group (p = 0.001, log-rank test). In conclusion, the time from admission to mobilization may be one of the strongest predictors of rehospitalization in elderly heart failure patients. Early mobilization within 3 days may be an initial target for the acute phase treatment of heart failure.

The difference in determinant factor of six-minute walking distance between sarcopenic and non-sarcopenic elderly patients with heart failure.

BACKGROUND: The purpose of this study was to identify the factors determining exercise capacity in elderly patients with heart failure (HF) with and without sarcopenia. METHODS: We studied 186 consecutive patients with HF who met the criteria of being >60 years, with no physical disability. During hospitalization, we measured the 6-min walking distance (6MWD) and other physical functional parameters and evaluated echocardiographic and laboratory measurements indicating the severity of HF. First, we divided patients into two groups (the sarcopenia group and the nonsarcopenia group) according to the presence of sarcopenia defined as fulfilling more than or equal to two criteria-body mass index <18.5, walking speed <0.8m/s, and grip strength <26kg in males, or <18kg in females. Then the association between the 6MWD and the clinical variables mentioned above was analyzed by univariate and multiple logistic regression analyses. RESULTS: The sarcopenia group comprised 77 patients (41.2%). In univariate analysis, age, grip strength, walking speed, and knee extensor muscle strength were significantly correlated with the 6MWD (p<0.05), whereas other clinical parameters were not. In multivariate analysis, walking speed was selected as an independent factor determining the 6MWD in both groups; however, knee extensor muscle strength was selected as an independent factor determining the 6MWD only in the sarcopenia group. CONCLUSION: We demonstrated that knee extensor muscle strength was an independent factor determining exercise capacity-especially in elderly patients with HF with sarcopenia, and provided useful information in terms of exercise prescription.