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PURPOSE: This study investigated whether the oral vasopressin V2 receptor antagonist tolvaptan has beneficial effects on mortality in real-world congestive heart failure (CHF) patients with hypoperfusion (i.e. the wet-cold pattern), from the viewpoint of cardiorenal syndrome. METHODS: Data on 5511 consecutive CHF patients were extracted from the Tokyo CCU Network data registry. Congestion and hypoperfusion were defined by Nohria-Stevenson clinical profiles at the time of hospitalization. Propensity scores for tolvaptan use were calculated for each patient and used to assemble two matched cohorts of patients receiving tolvaptan or not in the CHF with and without hypoperfusion groups. RESULTS: Of the entire study cohort, 1073 patients (19%) had CHF with hypoperfusion (i.e. the wet-cold pattern). In-hospital mortality was significantly higher for CHF patients with than without hypoperfusion (log-rank, P < 0.001). The rate of tolvaptan use did not differ significantly between CHF patients with and without hypoperfusion (15% vs. 14%, respectively; P = 0.7848). In the propensity-matched CHF with hypoperfusion cohort, there was a significant association between the use of tolvaptan and a reduction in in-hospital mortality (log-rank, P = 0.0052). Conversely, in the matched CHF without hypoperfusion cohort, tolvaptan use was not associated with in-hospital mortality (log-rank, P = 0.4417). CONCLUSION: There was a significant association between the use of tolvaptan and a reduction in in-hospital mortality in CHF patients with, but not without, hypoperfusion. These findings hint at possible individualized therapies for patients with CHF.
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BACKGROUND: The efficacy of direct oral anticoagulants (DOACs) compared with warfarin for the treatment of venous thromboembolism (VTE), and the recurrence of VTE after discontinuation of anticoagulation therapy in research are limited.MethodsâandâResults: This retrospective study enrolled 893 patients with acute VTE between 2011 and 2019. The cohort was divided into the transient risk, unprovoked, continued cancer treatment, and cancer remission groups. The following were compared between DOACs and warfarin: composite outcome of all-cause death, VTE recurrence, bleeding and composite outcome of VTE-related death, recurrence and bleeding. In the continued cancer treatment group, more bleeding was seen in warfarin-treated patients than in patients treated with DOACs (53.2% vs. 31.2%, [P=0.048]). In addition, composite outcome of VTE-related death and recurrence after discontinuation of anticoagulation therapy (n=369) was evaluated. The continued cancer treatment group (multivariate analysis: HR: 3.62, 95% CI: 1.84-7.12, P<0.005) and bleeding-related discontinuation of therapy (HR: 2.60, 95% CI: 1.32-5.13, P=0.006) were independent predictors of the event after discontinuation of anticoagulation therapy. VTE recurrence after discontinuation of anticoagulation therapy in the cancer remission group was 1.6% and a statistically similar occurrence was found in the transient risk group (12.4%) (P=0.754). CONCLUSIONS: DOACs may decrease bleeding incidence in patients continuing to receive cancer treatment. In patients with bleeding-related discontinuation of anticoagulation therapy, VTE recurrence may increase. Discontinuation of anticoagulant therapy might be a treatment option in patients who have completed their cancer treatment.
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Tromboembolia Venosa , Trombosis de la Vena , Administración Oral , Anticoagulantes/uso terapéutico , Hemorragia/inducido químicamente , Humanos , Recurrencia , Estudios Retrospectivos , Tromboembolia Venosa/tratamiento farmacológico , Tromboembolia Venosa/epidemiología , Trombosis de la Vena/tratamiento farmacológico , Warfarina/uso terapéuticoRESUMEN
According to the guidelines for cardiogenic shock, norepinephrine is associated with fewer arrhythmias than dopamine and may be the better first-line vasopressor agent. This study aimed to evaluate the utility of norepinephrine vs. dopamine as first-line vasopressor agent for cardiovascular shock depending on the presence and severity of renal dysfunction at hospitalization. This was a secondary analysis of the prospective, multicenter Japanese Circulation Society Cardiovascular Shock Registry (JCS Shock Registry) conducted between 2012 and 2014, which included patients with shock complicating emergency cardiovascular disease at hospital arrival. The analysis included 240 adult patients treated with norepinephrine alone (n = 98) or dopamine alone (n = 142) as the first-line vasopressor agent. Primary endpoint was mortality at 30 days after hospital arrival. The two groups had similar baseline characteristics, including estimated glomerular filtration rate (eGFR), and similar 30-day mortality rates. The analysis of the relationship between 30-day mortality rate after hospital arrival and vasopressor agent used in patients categorized according to the eGFR-based chronic kidney disease classification revealed that norepinephrine as the first-line vasopressor agent might be associated with better prognosis of cardiovascular shock in patients with mildly compromised renal function at admission (0.0 vs. 22.6%; P = 0.010) and that dopamine as the first-line vasopressor agent might be beneficial for cardiovascular shock in patients with severely compromised renal function [odds ratio; 0.22 (95% confidence interval 0.05-0.88; P = 0.032)]. Choice of first-line vasopressor agent should be based on renal function at hospital arrival for patients in cardiovascular shock. Clinical Trial Registration: http://www.umin.ac.jp/ctr/, Unique identifier: 000008441.
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Idiopathic myocardial calcification is a rare disease. Herein, we report a case of massive idiopathic calcification; a 78-year-old woman presented with acute heart failure with preserved ejection fraction (HFpEF). Computed tomography and magnetic resonance imaging showed diffused calcified nodules in the myocardium. The patient was treated for HFpEF; however, the calcified nodules and diastolic dysfunction gradually progressed. She was hospitalized for heart failure with preserved ejection fraction 6 times before her death at the age of 84 years. The pathological report showed calcified nodules with surrounding collagen fibers in the myocardium and tiny calcifications within the myocytes. Thus, idiopathic myocardial calcification can result in HFpEF, while calcification and diastolic dysfunction can gradually worsen.
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Calcinosis/patología , Cardiomiopatías/patología , Miocardio/patología , Anciano , Calcinosis/complicaciones , Calcinosis/diagnóstico por imagen , Cardiomiopatías/complicaciones , Cardiomiopatías/diagnóstico por imagen , Progresión de la Enfermedad , Femenino , Fibrosis , Insuficiencia Cardíaca/etiología , HumanosRESUMEN
BACKGROUND: Many patients with emergent heart failure (HF) readmission have a delay between symptom onset and hospitalization. The present study aimed to characterize the interval between symptom onset and hospitalization in patients being readmitted for HF and to compare the clinical phenotypes of patients with delay before emergent readmission with those who presented to the hospital earlier. METHODS: Data for a total of 2073 consecutive patients was collected from the Tokyo CCU Network database; the patients were divided into delayed (those who sought medical help > 2 days after symptom onset; n = 271) and early groups (remaining patients; n = 1802), and their clinical characteristics and mode of presentation were compared. RESULTS: Age, sex, and laboratory findings including brain natriuretic peptide and serum creatinine levels were not significantly different between the two groups. Patients in the delayed group had greater chronic fluid retention and symptoms not associated with respiratory failure, whereas those in the early group were more likely to have acute respiratory distress, faster heart and respiration rates, and higher systolic blood pressure. CONCLUSIONS: More than one in ten patients with HF readmission delay seeking treatment > 2 days after symptom onset. Patients who delayed seeking treatment showed the phenotype of chronic fluid retention, whereas those who presented to the hospital earlier had the phenotype of acute respiratory failure.
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BACKGROUND: The absence of high quality, large-scale data that indicates definitive mortality benefits does not allow for firm conclusions on the role of intravenous vasodilators in acute heart failure. We aimed to investigate the associations between intravenous vasodilators and clinical outcomes in acute heart failure patients, with a specific focus on patient profiles and type of vasodilators. METHODS: Data of 26,212 consecutive patients urgently hospitalised for a primary diagnosis of acute heart failure between 2009 and 2015 were extracted from a government-funded multicentre data registration system. Propensity scores were calculated with multiple imputations and 1:1 matching performed between patients with and without vasodilator use. The primary endpoint was inhospital mortality. RESULTS: On direct comparison of the vasodilator and non-vasodilator groups after propensity score matching, there were no significant differences in the inhospital mortality rates (7.5% vs. 8.8%, respectively; P=0.098) or length of intensive/cardiovascular care unit stay and hospital stay between the two groups. However, there was a substantial difference in baseline systolic blood pressure by vasodilator type; favourable impacts of vasodilator use on inhospital mortality were observed among patients who had higher systolic blood pressures and those who had no atrial fibrillation on admission. Furthermore, when compared to nitrates, the use of carperitide (natriuretic peptide agent) was significantly associated with worse outcomes, especially in patients with intermediate systolic blood pressures. CONCLUSIONS: In acute heart failure patients, vasodilator use was not universally associated with improved inhospital outcomes; rather, its effect depended on individual clinical presentation: patients with higher systolic blood pressure and no atrial fibrillation seemed to benefit maximally from vasodilators. TRIAL REGISTRATION: UMIN-CTR identifier, UMIN000013128.
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Presión Sanguínea/efectos de los fármacos , Insuficiencia Cardíaca/complicaciones , Edema Pulmonar/tratamiento farmacológico , Vasodilatación/efectos de los fármacos , Vasodilatadores/administración & dosificación , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/tratamiento farmacológico , Insuficiencia Cardíaca/fisiopatología , Humanos , Infusiones Intravenosas , Japón/epidemiología , Masculino , Pronóstico , Edema Pulmonar/etiología , Edema Pulmonar/mortalidad , Estudios Retrospectivos , Tasa de Supervivencia/tendenciasRESUMEN
Objective: This study aims to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) after unfractionated heparin (UFH) bolus for the treatment of intermediate-high-risk pulmonary embolism. Materials and Methods: On the basis of initial treatment, 81 patients were divided into two groups: DOAC after UFH bolus infusion group (group D; n=32) and conventional therapy group (group C; n=49). The frequency of recurrence of venous thromboembolism (VTE) and bleeding within 6 months were compared. In addition, hospitalization length and thrombus reduction rate in the pulmonary artery on computed tomography (CT) at the chronic phase were assessed. Results: Recurrence of VTE was found in one (3.1%) and three patients (6.1%) (P=1.00) in groups D and C, respectively, whereas no bleeding events was found in group D and 8.2% of patients in group C (P=0.15). Group D showed shorter hospitalization (7.2±2.3 days) than group C (15.7±9.9 days; P<0.001). In the subset of patients with serial CT assessment (group D, n=20; group C, n=38), almost all thrombus of pulmonary artery were disappeared and the thrombus reduction rates were similar between the two groups (group D, 99.5%; group C, 97.1%; P=0.59). Conclusion: DOAC administration immediately after UFH bolus treatment has the same efficacy and safety, whereas hospitalization days were significantly shorter than the conventional treatment group.
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OBJECTIVES: Heart failure with preserved ejection fraction (HFpEF) is now recognized as a geriatric syndrome with multifactorial pathophysiology and clinical heterogeneity rather than a solely left ventricular diastolic dysfunction. Because the pathophysiology of HFpEF is suggested to differ by age, this study compared the clinical characteristics and prognostic factors between HFpEF patients aged 65 to 84 years and those aged 85 years or older. DESIGN: Retrospective cohort study. SETTING: The Tokyo CCU Network including 73 hospitals in Tokyo, Japan. PARTICIPANTS: Individuals aged 65 years or older with HFpEF (N = 4305). MEASUREMENTS: Very old patients were defined as those aged 85 years or older. Potential risk factors for in-hospital mortality were selected by univariate analyses, and those with a P value <.10 were used in multivariate Cox regression analysis with forward selection (likelihood ratio) to identify significant factors. RESULTS: Prevalence of hypertension was significantly higher in very old patients, whereas prevalence of coronary artery disease, diabetes mellitus, hyperlipidemia, and smoking was significantly higher in patients aged 65 to 84 years. In very old patients, low systolic blood pressure (hazard ratio [HR] = .988), high serum creatinine level (HR = 1.34), and coexisting chronic obstructive pulmonary disease (COPD; HR = 2.01) were identified as independent risk factors for in-hospital mortality. In contrast, low systolic blood pressure (HR = .987) and low body mass index (HR = .935) were identified as independent risk factors in patients aged 65 to 84 years. CONCLUSION: Significant differences were observed in the clinical characteristics and prognostic factors for in-hospital mortality between HFpEF patients aged 65 to 84 and those 85 years and older. Of note, coexisting COPD was associated with significantly lower survival rate only in patients aged 85 years and older, suggesting the prognostic impact of concomitant pulmonary disease in HFpEF may increase with age. These results have implications for future research and management of older HFpEF patients. J Am Geriatr Soc 00:1-6, 2019. J Am Geriatr Soc 67:2123-2128, 2019.
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Factores de Edad , Insuficiencia Cardíaca/mortalidad , Mortalidad Hospitalaria , Volumen Sistólico , Anciano , Anciano de 80 o más Años , Envejecimiento , Comorbilidad , Femenino , Insuficiencia Cardíaca/fisiopatología , Humanos , Masculino , Modelos de Riesgos Proporcionales , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Sistema de Registros , Estudios RetrospectivosRESUMEN
OBJECTIVE: This study compared outcomes after endovascular aneurysm repair (ER) and open surgical repair (OR) of ruptured descending thoracic aortic aneurysms (rDTAA) and ruptured abdominal aortic aneurysms (rAAA) through a nationwide analysis performed in Japan. METHODS: This was a national registry based retrospective comparative study using data from the Japanese Registry of all Cardiac and Vascular Diseases Diagnostic Procedure Combination (JROAD-DPC) database, a nationwide claim based database from more than 600 hospitals. Patients admitted to certificated teaching hospitals with rDTAA and rAAA and treated by either ER or OR between 1 April 2012 and 31 March 2015 were identified. A propensity score matched analysis was performed to compare ER and OR. RESULTS: About 40% of the total cohort (n = 8,302) were managed conservatively for various reasons, including limited options in primary care facilities in certain areas. In total, 983 patients had rDTAA (OR = 511; ER = 472) and 2,320 (OR = 1,754; ER = 566) had rAAA. Altogether, 604 and 1,080 patients were matched with rDTAA and rAAA, respectively. Compared with OR, ER was associated with significantly better in hospital mortality in patients with rDTAA (ER = 22.5%; OR = 29.8% [p < .001]) and similar mortality for those with rAAA (ER = 25.7%; OR = 24.3% [p = .57]). ER involved significantly shorter hospital stays for rDTAA (ER = 25.5; OR = 32 days [p < .001]) and rAAA (ER = 16; OR = 21 days [p < .001]). The median Barthel Index at discharge was ≥75/100 for all groups, and there were no differences between ER and OR. Total medical costs were significantly lower for ER for rDTAA (ER = ¥6.47 million, OR = ¥7.28 million [p < .001]) but were higher for rAAA (ER = ¥4.65 million; OR = ¥3.43 million [p < .001]). CONCLUSION: A Japanese nationwide observational study showed that in hospital outcomes for ER vs. OR were more favourable for rDTAA and comparable for rAAA. ER resulted in an equivalently favourable functional status at discharge and significantly shorter hospital stays.
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Aneurisma de la Aorta Abdominal/cirugía , Aneurisma de la Aorta Torácica/cirugía , Rotura de la Aorta/cirugía , Implantación de Prótesis Vascular , Procedimientos Endovasculares , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/mortalidad , Rotura de la Aorta/diagnóstico por imagen , Rotura de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Análisis Costo-Beneficio , Bases de Datos Factuales , Procedimientos Endovasculares/efectos adversos , Procedimientos Endovasculares/mortalidad , Femenino , Costos de Hospital , Mortalidad Hospitalaria , Humanos , Japón , Tiempo de Internación , Masculino , Complicaciones Posoperatorias/etiología , Recuperación de la Función , Sistema de Registros , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVES: To improve outcome for ruptured aortic aneurysms (rAAs), centralization of treatment is potentially effective. However, there is no nationwide survey for the current managements and outcomes of rAA in Japan. The aim of this study was to assess the volume-outcome relationship for rAA treatment using the nationwide claim-based database. METHODS: Using the Japanese Registry of All cardiac and vascular Diseases-Diagnostic Procedure Combination database, we identified patients admitted to 564 certified teaching hospitals with rAA between 1 April 2012 and 31 March 2015. Institutional case volume (cardiovascular surgeries per year) was categorized into quartiles (lowest, low, high and highest), and the odds ratios (ORs) for in-hospital mortality and neurological status at discharge were analysed for each quartile. RESULTS: Of 7086 eligible patients, 3925 (55.4%) died in hospital. Mortality rates decreased from 69.4% in the lowest volume to 43.8% in the highest volume category (P < 0.001). The favourable impact of institutional case volume was sustained even after adjustment for covariates [low volume: OR 0.83, 95% confidence interval (CI) 0.65-1.07; P = 0.147; high volume: OR 0.69, 95% CI 0.54-0.89; P = 0.005; and highest volume: OR 0.55, 95% CI 0.42-0.72; P < 0.001 vs lowest volume]. Additionally, other 3 institutional parameters (increased aortic surgery volume, cardiovascular surgeons' volume and certified cardiologists' volume) were consistently associated with reduced in-hospital mortality. The rate of coma at discharge was the lowest in the highest volume group (P < 0.001). Increased institutional volume was associated with lower in-hospital mortality. CONCLUSION: Establishing regionally tailored systems to transfer patients to high-volume centres is needed to improve outcomes.
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Aneurisma de la Aorta Abdominal/cirugía , Rotura de la Aorta/cirugía , Sistema de Registros , Anciano , Anciano de 80 o más Años , Aneurisma de la Aorta Abdominal/diagnóstico , Aneurisma de la Aorta Abdominal/epidemiología , Rotura de la Aorta/diagnóstico , Rotura de la Aorta/epidemiología , Bases de Datos Factuales , Femenino , Mortalidad Hospitalaria/tendencias , Humanos , Incidencia , Japón/epidemiología , Masculino , Oportunidad Relativa , Alta del Paciente/tendencias , Pronóstico , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: No agents have been proven to improve survival in heart failure with preserved ejection fraction (HFpEF), but the phenotypic diversity of HFpEF suggests it may be possible to identify specific HFpEF phenotypes that will benefit from certain treatments. This study compared the risk factors for and prognostic impacts of treatments on in-hospital mortality between HFpEF patients with (+) and without (-) high blood pressure (HBP). METHODS: Data on 2238 consecutive HFpEF patients were extracted from Tokyo CCU Network data registry and analysed. HFpEF was defined as an ejection fraction greater than or equal to 50%; HBP was defined as elevated systolic blood pressure (>140âmmHg) at admission. Potential risk factors for in-hospital mortality were selected by univariate analyses and those with Pâ<â0.10 were used in multivariate Cox regression analysis with forward selection (likelihood ratio) to identify significant factors. RESULTS: In-hospital mortality was significantly lower for HFpEF + HBP than HFpEF - HBP patients (log-rank, Pâ<â0.001). Independent risk factors for in-hospital mortality in HFpEF + HBP patients were older age (hazard ratio 1.069) and in-hospital treatment without beta-blockers (hazard ratio 7.946), whereas older age (hazard ratio 1.035), higher C-reactive protein (hazard ratio 1.047), higher B-type natriuretic peptide (hazard ratio 1.000) and in-hospital treatment without diuretics (hazard ratio 4.201) were identified as independent risk factors in HFpEF - HBP patients. CONCLUSION: There were significant differences in prognostic factors, including beta-blocker and diuretic treatments, for in-hospital mortality between HFpEF patients with and without HBP. These findings suggest possible individualized therapies for patients with HFpEF.
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Antagonistas Adrenérgicos beta/uso terapéutico , Diuréticos/uso terapéutico , Insuficiencia Cardíaca , Hipertensión , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Humanos , Hipertensión/complicaciones , Hipertensión/tratamiento farmacológico , Pronóstico , Factores de Riesgo , Volumen Sistólico/fisiologíaRESUMEN
Pericardiocentesis is a definitive strategy to remove pericardial effusion. In this report, we present a rare case of a 23-year-old man with sudden delayed hemorrhagic shock due to branch bleeding of the left internal thoracic artery (LITA) two days after undergoing pericardiocentesis. Angiography, embolization, and drainage were effective. As far as we know, this is the first report that shows delayed bleeding due to branch injury of the LITA as a possible complication after pericardiocentesis.
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This is a case of an 86-year-old woman with gradually progressive dyspnoea and hypoxaemia that occurred after a cardiac surgery. It was underdiagnosed for several years, but diagnosis was triggered by the finding of hypoxaemia even during supplemental oxygen administration when in the upright position, such as when taking a shower, that rapidly improved when the patient returned to the supine position. A thorough workup disclosed platypnoea-orthodeoxia syndrome (POS) associated with right-to-left shunting through a patent foramen ovale (PFO). Percutaneous closure of the PFO was performed. After treatment, the patient's arterial oxygen saturation gradually recovered to 98% on room air while she was in the sitting position and her symptoms disappeared. Reviewing this case retrospectively, we determined that the deviation of the spine with kyphosis progression had apparently proceeded as POS worsened over time. We therefore hypothesised that kyphosis progression had played a major role in the POS progression.
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Disnea/fisiopatología , Foramen Oval Permeable/fisiopatología , Defectos del Tabique Interatrial/fisiopatología , Cifosis/fisiopatología , Anciano de 80 o más Años , Cateterismo Cardíaco , Progresión de la Enfermedad , Disnea/etiología , Ecocardiografía Transesofágica , Femenino , Foramen Oval Permeable/diagnóstico por imagen , Defectos del Tabique Interatrial/diagnóstico por imagen , Defectos del Tabique Interatrial/terapia , Humanos , Cifosis/complicaciones , Cifosis/diagnóstico por imagen , Intervención Coronaria Percutánea , Postura/fisiología , Síndrome , Resultado del TratamientoRESUMEN
Japan is facing problems associated with "heart failure (HF) pandemics" and bed shortages in core hospitals that can accommodate patients with acute HF. The prognosis is currently unknown for acute HF patients who were transferred from core hospitals to collaborating hospitals during the very early treatment phase and whose treatment strategies are in place.We enrolled 166 acute HF patients who were hospitalized between January 1, 2015, and December 31, 2015, and compared the conditions of transferred patients (n = 53, median duration before transfer = 6 days) and nontransferred patients (n = 113). The transferred and nontransferred patients had similar one-year mortality rates (24.5% versus 19.5%, log-rank P = 0.27) and composite one-year mortality and HF readmission rates (35.8% versus 31.0%, log-rank P = 0.32). Multivariate analysis determined that patient transfers were not associated with a higher composite endpoint (hazard ratio, 1.08; 95% confidence interval, 0.58-1.99, P = 0.82). Transferred patients with low composite congestion scores (CCSs) had significantly lower composite endpoints than those with high CCSs (23.5% versus 57.9%, log-rank P = 0.005).Acute HF patients who were transferred did not have inferior prognoses compared with nontransferred patients when the treatment strategies were correctly assumed by cardiologists. The implementation of early and strict decongestion strategies before transfer may be important for reducing cardiovascular events.
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Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/terapia , Hospitalización/estadística & datos numéricos , Transferencia de Pacientes/métodos , Transferencia de Pacientes/estadística & datos numéricos , Enfermedad Aguda , Anciano , Anciano de 80 o más Años , Femenino , Insuficiencia Cardíaca/diagnóstico , Hospitalización/tendencias , Humanos , Japón/epidemiología , Masculino , Mortalidad/tendencias , Readmisión del Paciente/estadística & datos numéricos , Prevalencia , Pronóstico , Análisis de SupervivenciaRESUMEN
BACKGROUND: The clinical impact of a decrease in impedance during radiofrequency catheter ablation (RFCA) has not been fully clarified. The aim of the study was to analyze the impact of impedance decrease and to determine its optimal cutoff value during RFCA. METHODS: We evaluated 34 consecutive patients (total 3264 lesions, mean age 66 ± 8.7 years, 10 females) who underwent their first ablation for atrial fibrillation (AF). The impedance decrease, average contact force (CF), application time, force-time integral (FTI), product of impedance decrease and application time (PIT), and the product of impedance decrease and FTI (PIFT) were measured for all lesions. Levels of cardiac troponin I (TrpI) were measured for assessment of myocardial injury. The incidence of intraprocedural pulmonary vein-left atrium reconnection or dormant conduction (reconnection) was determined. The relationships between the ablation parameters and the increase in TrpI (ΔTrpI) were evaluated. The predictive value of the parameters for reconnection was assessed using receiver operating characteristic (ROC) curve analysis. RESULTS: Reconnection was detected in 18 patients. Average FTI and PIT were significantly correlated with ΔTrpI (FTI: r2 = .19, P = .0090, PIT: r2 = .21, P = .0058). PIFT was correlated with ΔTrpI and was the best of the three indexes (PIFT: r2 = .29, P = .0010). In ROC curve analysis, the area under the curve for predicting reconnection was 0.71 and the optimal cutoff value was 5200 for PIFT (sensitivity 78%, specificity 63%). CONCLUSION: The combination of CF and a decrease in impedance could be important in the evaluation of myocardial lesions and reconnection during RFCA.
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Objective: Although deep vein thrombosis (DVT) followed by pulmonary thromboembolism (PE) is a critical complication during pregnancy, there have been few reports about its intrapartum management. We evaluated intrapartum management by using a temporary inferior vena cava filter (IVCF) in pregnant women with PE/DVT. Materials and Methods: Eleven women with PE/DVT during pregnancy between January 2004 and December 2016 were included. The patients were hospitalized for intravenous unfractionated heparin infusion after acute PE/DVT onset. Seven patients were discharged and continued treatment with subcutaneous injection of heparin at the outpatient unit. IVCF was implanted 1-3 days before delivery in 10 patients. Anticoagulant therapy was discontinued 6-12 h before delivery. We retrospectively analyzed rates of maternal or perinatal death, and recurrence of symptomatic PE/DVT. Results: One patient was diagnosed as having PE/DVT and 10 had DVT alone. One patient suffered hemorrhagic shock during delivery; however, maternal or perinatal death and recurrence of symptomatic PE/DVT did not occur in any patient. Conclusion: Maternal or perinatal death and recurrence of symptomatic PE/DVT was not seen in women diagnosed as having PE/DVT during pregnancy and treated with anticoagulant therapy and IVCF.
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The relationship between glycemic control and outcome in patients with heart failure (HF) remains contentious. A recent study showed that patients with HF with mid-range ejection fraction (HFmrEF) more frequently had comorbid diabetes relative to other patients. Herein, we examined the association between glycosylated hemoglobin (HbA1c) and in-hospital mortality in acute HF patients with reduced, mid-range, and preserved EF. A multicenter retrospective study was conducted on 5205 consecutive patients with acute HF. Potential risk factors for in-hospital mortality were selected by univariate analyses; then, multivariate Cox regression analysis with backward stepwise selection was performed to identify significant factors. Kaplan-Meier survival curves and log-rank testing were used to compare in-hospital mortality between groups. Across the study cohort, 44% (2288 patients) had reduced EF, 20% had mid-range EF, and 36% had preserved EF. The overall in-hospital mortality rate was 4.6%, with no significant differences among the HF patients with reduced, mid-range, and preserved EF groups. For patients with HFmrEF, higher HbA1c level was a significant risk factor for in-hospital mortality (hazard ratio 1.387; 95% confidence interval 1.014-1.899; P = 0.041). In contrast, HbA1c was not an independent risk factor for in-hospital mortality in HF patients with preserved or reduced EF. In conclusion, HbA1c is an independent risk factor for in-hospital mortality in acute HF patients with mid-range EF, but not in those with preserved or reduced EF. Elucidation of the pathophysiological mechanisms behind these findings could facilitate the development of more effective individualized therapies for acute HF.
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Glucemia/metabolismo , Diabetes Mellitus/epidemiología , Hemoglobina Glucada/metabolismo , Insuficiencia Cardíaca/sangre , Volumen Sistólico/fisiología , Enfermedad Aguda , Anciano , Causas de Muerte/tendencias , Comorbilidad , Diabetes Mellitus/sangre , Femenino , Estudios de Seguimiento , Índice Glucémico , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/mortalidad , Mortalidad Hospitalaria/tendencias , Humanos , Japón/epidemiología , Masculino , Estudios Retrospectivos , Factores de RiesgoRESUMEN
Guideline-directed medical therapy (GDMT) is recommended for patients with heart failure with reduced ejection fraction (HFrEF). However, the prognostic impact of medication optimization at the time of discharge in patients hospitalized with heart failure (HF) is unclear. We analyzed 534 patients (73 ± 13 years old) with HFrEF. The status of GDMT at the time of discharge (prescription of angiotensin converting enzyme inhibitor [ACE-I]/angiotensin receptor blocker [ARB] and ß blocker [BB]) and its association with 1-year all-cause mortality and HF readmission were investigated. Patients were divided into 3 groups: those treated with both ACE-I/ARB and BB (Both group: n = 332, 62%), either ACE-I/ARB or BB (Either group: n = 169, 32%), and neither ACE-I/ARB nor BB (None group: n = 33, 6%), respectively. One-year mortality, but not 1-year HF readmission rate, was significantly different in the 3 groups, in favor of the Either and Both groups. A favorable impact of being on GDMT at the time of discharge on 1-year mortality was retained even after adjustment for covariates (Either group: hazard ratio [HR] 0.44, 95% confidence interval [CI] 0.21 to 0.90, p = 0.025 and Both group: HR 0.29, 95% CI 0.13-0.65, p = 0.002, vs None group). For 1-year HF readmission, no such association was found. In conclusion, optimization of GDMT before the time of discharge was associated with a lower 1-year mortality, but not with HF readmission rate, in patients hospitalized with HFrEF.
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Antagonistas Adrenérgicos beta/uso terapéutico , Antagonistas de Receptores de Angiotensina/uso terapéutico , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Adhesión a Directriz/estadística & datos numéricos , Insuficiencia Cardíaca/tratamiento farmacológico , Readmisión del Paciente/estadística & datos numéricos , Volumen Sistólico , Anciano , Anciano de 80 o más Años , Estudios de Casos y Controles , Femenino , Insuficiencia Cardíaca/fisiopatología , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Mortalidad , Alta del Paciente , Guías de Práctica Clínica como Asunto , Pronóstico , Modelos de Riesgos ProporcionalesRESUMEN
Aims: Some studies have shown that the type of atrial fibrillation (AF), whether paroxysmal AF (PAF) or persistent or permanent AF (PeAF), affects the incidence of ischaemic stroke. This study sought to determine the relationship between the AF pattern and the severity and brain volume of infarction in an AF population including transient ischaemic attack (TIA) patients. Methods and results: This was a retrospective observational study. We studied 161 consecutive patients who were admitted to our stroke care unit with cardiogenic embolism or TIA related to non-valvular AF (age 79 ± 9.5, 78 females, and 87 PAF patients). We evaluated the differences in severity and infarct volume between the types of AF. Additionally, we divided the patients into three groups according to severe stroke (n = 38), TIA (n = 28), and those who were neither (stroke, n = 95) for the assessment of the predictors of severe stroke and TIA. Persistent or permanent atrial fibrillation patients with acute cardiogenic stroke or TIA had worse peak National Institute of Health Stroke Scale (NIHSS) scores [PAF median 4 (range 3-14), PeAF 17 (5.8-25); P < 0.0001] and worse NIHSS scores at discharge [PAF 2.0 (1-7), PeAF 11 (3-22); P < 0.0001]. Their infarct brain volume assessed by computed tomography or magnetic resonance imaging was also larger [PAF 4.4 (1.1-32) mL, PeAF 64 (6.9-170) mL; P < 0.0001]. Multivariate analysis of severe stroke vs. non-severe stroke patients showed that having PeAF was the only independent predictor of severe stroke [odds ratio (OR) 4.27, 95% confidence interval (CI) 1.91-10.2; P = 0.0003]. Comparison of TIA vs. non-TIA patients showed that PeAF (OR 0.120, 95% CI 0.0230-0.444; P = 0.0008) and anticoagulant use (OR 8.24, 95% CI 2.15-40.8; P = 0.0018) were independent predictors of TIA. Conclusion: Cardiogenic emboli due to non-valvular PeAF are associated with a worse acute clinical course and greater volume of infarction than those due to PAF.