Home-based disease management program to improve psychological status in patients with heart failure in Japan.

BACKGROUND: A disease management program can reduce mortality and rehospitalization of patients with heart failure (HF), but little is known about whether it can improve psychological status. The purpose of this study was to determine the effects of home-based disease management on the psychological status of patients with HF. METHODS AND RESULTS: We randomly assigned patients hospitalized for HF to undergo either home-based disease management (n=79) or usual care (n=82). The mean age of the study patients was 76 years, 30% were female, and 93% were in NYHA class I or II. Home-based disease management was delivered by nurses via home visit and telephone follow-up to monitor symptoms and body weight and to educate patients. The primary endpoint was psychological status, including depression and anxiety assessed by the Hospital Anxiety and Depression Scale during follow-up of 1 year. Secondary endpoints included quality of life, all-cause death and hospitalization for HF. The intervention group had significantly lower depression (P=0.043) and anxiety (P=0.029) scores than the usual-care group. There were no significant differences in all-cause death [hazard ratio (HR) 1.02, 95% confidence interval (CI) 0.37-2.61, P=0.967]. However, hospitalization for HF was significantly lower in the intervention group than in the usual-care group (HR 0.52, 95% CI 0.27-0.96, P=0.037). CONCLUSIONS: Home-based disease management improved psychological status and also reduced rehospitalization for HF in patients with HF.

Carvedilol improves uptake-1 in patients with systolic congestive heart failure.

BACKGROUND: The sympathetic nervous system (SNS) of the whole body, including cardiac sympathetic nerves, is activated in patients with severe congestive systolic heart failure (CHF). Carvedilol can improve clinical status in such patients. This study aimed to determine how carvedilol acts on the SNS to improve CHF. METHODS AND RESULTS: Ten subjects (New York Heart Association criteria III) were treated using carvedilol at 2.5 mg/d for 1 week. Before and after treatment, subjects walked on a treadmill for 6 minutes, and plasma concentrations of carvedilol, norepinephrine, and 3,4-dihydroxyphenyl glycol were measured. After treatment, norepinephrine was decreased at rest (3.2 ± 0.3 pmole/mL to 2.1 ± 0.4 pmole/mL, P < 0.05), while standing (5.4 ± 1.2 to 3.3 ± 0.7 pmole/mL, P < 0.01) and during exercise (6.5 ± 1.3 pmole/mL to 5.1 ± 1.1 pmole/mL, P < 0.05). Regression lines for percentage changes in norepinephrine and 3,4-dihydroxyphenyl glycol were compared before and after treatment, showing steeper slopes after treatment (P < 0.05). Plasma carvedilol concentrations (1.8 ± 0.3 ng/mL) did not reach ß-adrenoceptor-blocking levels of effect. CONCLUSIONS: Carvedilol is considered to improve function of uptake-1 for the whole-body SNS, including the cardiac SNS, and does not seem to block adrenoceptors at such low doses in CHF patients. However, both effects seem to work at high doses in clinical settings.

Rationale and design of the Japanese heart failure outpatients disease management and cardiac evaluation (J-HOMECARE).

BACKGROUND: Although many studies have demonstrated the efficacy of disease management programs on mortality, morbidity, quality of life (QOL), and medical cost in patients with heart failure (HF), no study has focused on psychological status as an outcome of disease management. In addition, very little information is available on the effectiveness of disease management programs in other areas than the USA and Europe. METHODS: The Japanese Heart Failure Outpatients Disease Management and Cardiac Evaluation (J-HOMECARE) is a randomized controlled trial in which 156 patients hospitalized with HF will be randomized into usual care or a home-based disease management arm receiving comprehensive advice and counseling by visiting nurses during the initial 2 months and telephone follow-up for the following 4 months after discharge. This study evaluates depression and anxiety (Hospital Anxiety and Depression Scale), mortality, readmission due to HF, and QOL (Short Form-8). Data are collected during index hospitalization and then 2, 6, and 12 months after discharge. This study started in December 2007, and the final results are expected in 2011. CONCLUSION: The J-HOMECARE will provide important information on the efficacy of disease management for psychological status as well as the effective components of disease management for patients with HF. (ClinicalTrials.gov number, NCT01284400).

Excretions of urinary albumin and various proteins increase in hypertension.

AIMS: Hypertension causes proteinuria and is an important factor in the progress of renal dysfunction. Increases in various proteins in urine are caused by malfunction of the glomerulus and the renal tubules. In the present study, the effects of hypertension on urinary excretion levels of various proteins were investigated to show the tubular cell malfunction in hypertensive patients. METHODS AND SUBJECTS: The subjects included 55 non-diabetic hypertensive patients without previous treatment and 42 normotensive individuals without microalbuminuria. Total urinary protein/creatinine ratio was measured, and urinary proteins were analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE). FINDINGS: Total urinary protein/creatinine ratio was higher in hypertensive patients than in normotensive individuals (122.0+/-11.0 vs. 60.6+/-3.1 mg/gCr; p<0.001). SDS-PAGE resolved 15 protein fractions from the urine of both groups. Thirteen fractions were more intensely stained in samples from the hypertensive than from the normotensive. Two fractions did not differ between the groups. Hypertension increased the urinary excretion of various proteins including proteins of less than 40 kDa, called tubular proteins, in addition to albumin. CONCLUSIONS: Hypertension differently influenced the excretion of each urinary protein fraction. Tubular malfunction should be considered in hypertensive patients in addition to glomerular malfunction.

Simultaneous analysis of human plasma catecholamines by high-performance liquid chromatography with a reversed-phase triacontylsilyl silica column.

The clinical importance of simultaneous analysis of 3,4-dihydroxyphenylglycol with other human plasma catecholamines has been investigated to better understand the sympathetic nervous system. However, previous reports have had analytical difficulties with both resolution and extraction. The current study uses a reversed-phase triacontylsilyl silica (C30) column under the mobile phase condition without ion-pair reagents to separate catecholamines and their metabolites, with above 91% recoveries for intra-assay, above 85% for inter-assay, and less than 10% (n=5) coefficient of variation. Lower detection limits (S/N=4) and quantification limits (S/N=6) were 40 and 100 pg/mL for norepinephrine, 3,4-dihydroxyphenylglycol, and 3,4-dihydroxyphenylalanine, 10 and 20 pg/mL for epinephrine, 10 and 40 pg/mL for dopamine. Linear ranges were from 40 to 5000 pg/mL for norepinephrine and 3,4-dihydroxyphenylalanine, from 100 to 5000 pg/mL for 3,4-dihydroxyphenylglycol, and from 10 to 2000 pg/mL for epinephrine and dopamine. The C30 column may prove clinically useful, as it provides a convenient and simultaneous method of evaluation of human plasma catecholamines.

High-sodium diets in Japanese evacuation centers increase blood pressures of evacuees.

AIMS: High blood pressure after a natural disaster is tentatively considered to be due to elevation of sympathetic nerve activity. A volcano in Japan erupted on March 31, 2000, and people living in the vicinity of the volcano were evacuated to safe shelters. We found that many evacuees developed high blood pressure while staying at evacuation centers. The aim of this study was to investigate why their blood pressures stayed elevated. METHODS AND SUBJECTS: Sixty-five evacuees, who were staying evacuation centers for 4 months, were examined for blood pressure, urinary sodium excretion, urinary potassium excretion, and plasma and urinary catecholamines. RESULTS: Associations were found between systolic blood pressure and sodium excretion (r = 0.311, p < 0.05) and between systolic blood pressure and the ratio of urinary sodium to urinary potassium (r = 0.320, p < 0.05). However, no association was found between blood pressure and plasma and urinary catecholamines (NE, DHPG and MHPG). CONCLUSION: High sodium consumption was thought to be an important factor in the elevation of blood pressure of the evacuees after acute phase reactions.

Measurement of carvedilol in plasma by high-performance liquid chromatography with electrochemical detection.

Carvedilol is a beta/alpha1-adrenoceptor blocker. A sensitive method for measuring plasma levels of carvedilol in human administrated low doses is needed since its plasma concentration is low. We measured carvedilol and carvedilol M21-aglycon using high-performance liquid chromatography (HPLC) with electrochemical detection. The amperometric detector was operated at 930 mV versus Ag/AgCl. Mean coefficients of variation (n = 5) for carvedilol and M21-aglycon were 4.0 and 7.7% (intra) and 6.1 and 6.7% (inter), respectively. The lower limit of quantification for each analyte was 0.10 ng/ml (signal-to-noise ratio = 3). This lower limit of quantification for carvedilol was sufficient for clinical use.

Different coronary blood flow increase in left ventricular hypertrophy due to hypertension compared to hypertrophic cardiomyopathy at elevated heart rate.

Coronary vasodilator reserve (CVR) is reduced in patients with left ventricular hypertrophy (LVH). However, it is not clear whether there is any difference between the coronary blood flow increase in LVH caused by hypertension (HTH) and that caused by hypertrophic cardiomyopathy (HCM) when the heart rate increases. In this study, 16 subjects with HTH, 10 subjects with HCM, and 10 subjects with normotension (NT) were investigated. Average peak velocities at rest, at pacing, and at dilatation were measured using a Doppler catheter placed at the left descending coronary artery to calculate coronary blood flow (CBF) and CVR. CVR at rest was identical in the HTH and HCM groups, and in both cases was lower than the resting CVR in NT subjects. There were significant differences in the CVR values at a pacing rate of 120 beats/min among the groups. These values were lowest in HCM, highest in NT, and intermediary in HTH subjects. And the percent increase in CBF in HCM at that pacing rate was higher than that in HTH (p < 0.05) or NT (p < 0.05). There was no difference in the percent increase in CBF at this pacing rate between the HTH and NT groups. The effects of elevated heart rate on the percent increase in CBF were different between the HTH and HCM groups. We conclude that cardiac hypertrophy has qualitatively different effects on coronary circulation depending on whether patients have HTH or HCM.