ObjectivesCurrent guidelines restrict the use of inotropes for the treatment for heart failure (HF) unless the patients are hypotensive or hypoperfused because of safety concerns. This study sought ...to characterise the contemporary real-world use of inotropes and associated long-term outcomes according to systolic blood pressure (sBP) and perfusion status.DesignA multicentre prospective cohort study.SettingThis study was nested from the Kyoto Congestive Heart Failure registry, which included consecutive Japanese patients admitted for HF.ParticipantsWe categorised 3995 patients into two groups: sBP ≥90 mm Hg and warm profile group, and sBP <90 mm Hg or cold profile group. In each group, patients were stratified across the use of inotropes within 24 hours of hospital presentation.Primary and secondary outcomesThe primary outcome was all-cause death throughout follow-up. Secondary outcomes included cardiovascular death throughout follow-up, all-cause death during index hospitalisation and after discharge, and HF hospitalisation.ResultsA total of 793 patients (20%) presented with sBP <90 mm Hg or cold profile, whereas 3202 patients had sBP ≥90 mm Hg and warm profile; 276 patients (35%) in the sBP <90 mm Hg/cold group and 312 patients (10%) in the sBP ≥90 mm Hg/warm group received initial inotropic treatment. Adjusted excess risk of inotrope use relative to no inotrope for the primary outcome measure was significant in the sBP ≥90 mm Hg/warm group (adjusted HR), 1.36; 95% CI 1.09 to 1.72, p=0.006) but not in the sBP <90 mm Hg/cold group (adjusted HR, 1.28, 95% CI 0.96 to 1.69, p=0.09). Risk for postdischarge all-cause death and HF hospitalisation was not significantly different between the patients with inotropes and no inotropes in both groups.ConclusionInotrope use in the absence of hypotension and hypoperfusion is still common, but associated with a worse long-term prognosis.Trial registration numberUMIN000015238.
The association between serum cholinesterase and prognosis in acute heart failure (AHF) remains to be elucidated. We investigated the serum cholinesterase level at discharge from hospitalization for ...AHF and its association with clinical outcomes in patients with AHF.
Among 4056 patients enrolled in the Kyoto Congestive Heart Failure multicentre registry, we analysed 2228 patients with available serum cholinesterase data. The study population was classified into three groups according to serum cholinesterase level at discharge: low tertile (<180 U/L, N = 733), middle tertile (≥180 U/L and <240 U/L, N = 746), and high tertile (≥240 U/L, N = 749). Patients in the low tertile had higher tricuspid pressure gradient, greater inferior vena cava diameter, and higher brain natriuretic peptide (BNP) levels than those in the high tertile. The cumulative 1-year incidence of the primary outcome measure (a composite endpoint of all-cause death and hospitalization for HF) was higher in the low and middle tertiles than in the high tertile 46.5% (low tertile) and 31.4% (middle tertile) vs. 22.1% (high tertile), P < 0.0001. After adjustment for 26 variables, the excess risk of the low tertile relative to the high tertile for the primary outcome measure remained significant (hazard ratio 1.37, 95% confidence interval 1.10-1.70, P = 0.006). Restricted cubic spline models below the median of cholinesterase demonstrated incrementally higher hazards at low cholinesterase levels.
Low serum cholinesterase levels are associated with congestive findings on echocardiography, higher BNP, and higher risks for a composite of all-cause death and HF hospitalization in patients with AHF.
Aims
There are no previous studies focusing on collaborative follow‐ups between hospitals and clinics for patients discharged after acute heart failure (AHF) in Japan. The purpose of this study was ...to determine the status of collaboration between hospitals and clinics for patients with AHF in Japan and to compare patient characteristics and clinical outcomes using a large Japanese observational database.
Methods and results
Of 4056 consecutive patients hospitalized for AHF in the Kyoto Congestive Heart Failure registry, we analysed 2862 patients discharged to go home, who were divided into 1674 patients (58.5%) followed up at hospitals with index hospitalization (hospital follow‐up group) and 1188 (41.5%) followed up in a collaborative fashion with clinics or other general hospitals (collaborative follow‐up group). The primary outcome was a composite of all‐cause death or heart failure (HF) hospitalization within 1 year after discharge. Previous hospitalization for HF and length of hospital stay longer than 15 days were associated with hospital follow‐up. Conversely, ≥80 years of age, hypertension, and cognitive dysfunction were associated with collaborative follow‐up. The cumulative 1‐year incidence of the primary outcome, all cause death, and cardiovascular death were similar between the hospital and collaborative follow‐up groups (31.6% vs. 29.6%, P = 0.51, 13.1% vs, 13.9%, P = 0.35, 8.4% vs. 8.2%, P = 0.96). Even after adjusting for confounders, the difference in risk for patients in the hospital follow‐up group relative to those in the collaborative follow‐up group remained insignificant for the primary outcome, all‐cause death, and cardiovascular death (HR: 1.11, 95% CI: 0.97–1.27, P = 0.14, HR: 1.10, 95% CI: 0.91–1.33, P = 0.33, HR: 0.96, 95% CI: 0.87–1.05, P = 0.33). The cumulative 1‐year incidence of HF hospitalization was higher in the hospital follow‐up group than in the collaborative follow‐up group (25.5% vs. 21.3%, P = 0.02). The risk of HF hospitalization was higher in the hospital follow‐up group than in the collaborative follow‐up group (HR: 1.19, 95% CI: 1.01–1.39, P = 0.04).
Conclusions
In patients hospitalized for AHF, 41.5% received collaborative follow‐up after discharge. The risk of HF hospitalization was higher in the hospital follow‐up group than in the collaborative follow‐up, although risk of the primary outcome, all‐cause death, and cardiovascular death were similar between groups.
Abstract
Aims
The use of tolvaptan is increasing in clinical practice in Japan. However, the characteristics of patients who used tolvaptan and the timing of its use in patients with acute heart ...failure (AHF) are not fully elucidated.
Methods and results
Among consecutive 4056 patients in the Kyoto Congestive Heart Failure registry, we analysed 3802 patients after excluding patients on dialysis, prior or unknown tolvaptan use at admission, and unknown timing of tolvaptan use, and we divided them into two groups: tolvaptan use (
N
= 773) and no tolvaptan use (
N
= 3029). The prevalence of tolvaptan use varied widely from 48.7% to 0% across the participating centres. Factors independently associated with tolvaptan use were diabetes, poor medical adherence, oedema, pleural effusion, hyponatraemia, estimated glomerular filtration rate < 30 mL/min/1.73 m
2
, moderate/severe tricuspid regurgitation, dobutamine infusion within 24 h, and additional inotropes infusion beyond 24 h after admission. The mortality rate at 90 days after admission was significantly higher in the tolvaptan use group than in the no tolvaptan use group (14.3% vs. 8.6%,
P
= 0.049). However, after adjustment, the excess mortality risk of tolvaptan use relative to no tolvaptan use was no longer significant (hazard ratio = 1.53, 95% confidence interval = 0.77–3.02,
P
= 0.22). Patients with tolvaptan use had a longer hospital stay median (interquartile range): 22 (15–34) days vs. 15 (11–21) days,
P
< 0.0001 and a higher prevalence of worsening renal failure (47.0% vs. 31.8%,
P
< 0.0001) and worsening heart failure (24.8% vs. 14.4%,
P
< 0.0001) than those without.
Conclusions
AHF patients with tolvaptan use had more congestive status with poorer in‐hospital outcomes and higher short‐term mortality than those without tolvaptan use.
Clinical Trial Registration:
https://clinicaltrials.gov/ct2/show/NCT02334891
(NCT02334891) and
https://upload.umin.ac.jp/cgi‐open‐bin/ctr_e/ctr_view.cgi?recptno=R000017241
(UMIN000015238).
Aims
Over the last decade, major developments in medicine have led to significant changes in the clinical management of heart failure patients. This study was designed to evaluate the recent trends ...in clinical characteristics, management, and short‐term and long‐term prognosis of patients with acute decompensated heart failure (ADHF) in Japan.
Methods and results
The Kyoto Congestive Heart Failure study is a prospective, observational, multicentre cohort study, enrolling consecutive ADHF patients from 19 participating hospitals in Japan from November 2014 to March 2016. A total of 4000 patients will be enrolled into the study and patients' anthropometric, socio‐economic, and clinical data from hospital admission to discharge will be collected. In addition, in a pre‐determined subgroup of patients (n=1500), a longitudinal follow‐up for 2 years is scheduled.
Conclusions
The Kyoto Congestive Heart Failure study will provide valuable information regarding patients with ADHF in the real‐world clinical practice of Japan and will be indispensable for future clinical and policy decision‐making with respect to heart failure.
Aims
Several studies demonstrated that tricuspid regurgitation (TR) is associated with poor clinical outcomes. However, data on patients with TR who experienced acute heart failure (AHF) remains ...scarce. The purpose of this study is to evaluate the association between TR and clinical outcomes in patients admitted with AHF, using a large‐scale Japanese AHF registry.
Methods and results
The current study population consisted of 3735 hospitalized patients due to AHF in the Kyoto Congestive Heart Failure (KCHF) registry. TR grades were assessed according to the routine clinical practice at each participating centre. We compared the baseline characteristics and outcomes according to the severity of TR. The primary outcome was all‐cause death. The secondary outcome was hospitalization for heart failure (HF). The median age of the entire study population was 80 (interquartile range: 72–86) years. One thousand two hundred five patients (32.3%) had no TR, while mild, moderate, and severe TR was found in 1537 patients (41.2%), 776 patients (20.8%), and 217 patients (5.8%), respectively. Pulmonary hypertension, significant mitral regurgitation, and atrial fibrillation/flutter were strongly associated with the development of moderate/severe of TR, while left ventricular ejection fraction <50% was inversely associated with it. Among 993 patients with moderate/severe TR, the number of patients who underwent surgical intervention for TR within 1 year was only 13 (1.3%). The median follow‐up duration was 475 (interquartile range: 365–653) days with 94.0% follow‐up at 1 year. As the TR severity increased, the cumulative 1 year incidence of all‐cause death and HF admission proportionally increased (14.8%, 20.3%, 23.4%, 27.0% and 18.9%, 23.0%, 28.5%, 28.4% in no, mild, moderate, and severe TR, respectively). Compared with no TR, the adjusted risks of patients with mild, moderate, and severe TR were significant for all‐cause death (hazard ratio 95% confidence interval: 1.20 1.00–1.43, P = 0.0498, 1.32 1.07–1.62, P = 0.009, and 1.35 1.00–1.83, P = 0.049, respectively), while those were not significant for hospitalization for HF (hazard ratio 95% confidence interval: 1.16 0.97–1.38, P = 0.10, 1.19 0.96–1.46, P = 0.11, and 1.20 0.87–1.65, P = 0.27, respectively). The higher adjusted HRs of all the TR grades relative to no TR were significant for all‐cause death in patients aged <80 years, but not in patients aged ≥80 years with significant interaction.
Conclusions
In a large Japanese AHF population, the grades of TR could successfully stratify the risk of all‐cause death. However, the association of TR with mortality was only modest and attenuated in patients aged 80 or more. Further research is warranted to evaluate how to follow up and manage TR in this elderly population.
Aims
Little is known about the association between the starting of or dose changes in loop diuretics during acute heart failure (AHF) hospitalization and post‐discharge outcomes. We investigated the ...clinical impact of starting loop diuretics and changing the loop diuretics dose during hospitalization on post‐discharge outcomes.
Methods and results
From the Kyoto Congestive Heart Failure registry, 3665 consecutive patients hospitalized for HF and discharged alive were included in this study. We analysed 1906 patients without loop diuretics on admission and were discharged alive and 1759 patients who received loop diuretics on admission and were discharged alive. The primary outcome measure was all‐cause death. Of the 1906 patients without loop diuretics on admission, 1366 (71.7%) patients started loop diuretics during the index AHF hospitalization. Starting loop diuretics was not associated with lower post‐discharge mortality adjusted hazard ratio (HR) 0.92, 95% confidence interval (CI) 0.68–1.25. Of the 1759 patients who received loop diuretics on admission, loop diuretic dose was decreased in 23.8%, unchanged in 44.6%, and increased in 31.6% of the patients. Changes in the dose at discharge compared with no change in dose were not associated with lower risk of post‐discharge mortality (decrease relative to no change: adjusted HR 0.98, 95% CI 0.76–1.28; increase relative to no change: adjusted HR 1.00, 95% CI 0.78–1.27). Compared with no loop diuretics at discharge, a loop diuretics dose of ≥80 mg at discharge was associated with higher post‐discharge mortality risk.
Conclusions
In patients with AHF, we found no association between the starting of loop diuretics and post‐discharge outcomes and between dose changes and post‐discharge outcomes.
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