Since most of the randomized clinical trials for heart failure (HF) were designed to exclude elderly patients, limited data are available on their clinical characteristics, prognosis, and prognostic ...factors.
We compared clinical characteristics, prognosis, and prognostic factors among Stage C/D HF patients in our CHART-2 Study (N = 4876, mean 69 years, women 32%, 6.3-year follow-up) by age (G1, ≤64 years, N = 1521; G2, 65–74 years, N = 1510; and G3, ≥75 years, N = 1845).
From G1 to G3, the prevalence of women, left ventricular ejection fraction (LVEF) and plasma levels of B-type natriuretic peptide (BNP) increased (all P < 0.001). Similarly, 5-year mortality increased (9.9, 17.3 to 39.9%, P < 0.001) along with a decrease in proportion of cardiovascular death and an increase in non-cardiovascular death in both sexes. While all-cause and cardiovascular mortality was comparable between the sexes, women had significantly lower incidence of non-cardiovascular death than men in G2 and G3, which was attributable to the higher incidence of cancer death and pneumonia death in men than in women. Although NYHA functional class III-IV, chronic kidney disease, cancer, LVEF, and BNP had significant impacts on all-cause death in all groups, their impacts were less evident in G3 as compared with G1.
The elderly HF patients, as compared with younger HF patients, were characterized by more severe clinical background, increased proportion of non-cardiovascular death and worse prognosis with different impacts of prognostic factors across the age groups.
To diagnose resistant hypertension using self-measured blood pressure (BP) at home and office BP, and to evaluate the characteristics of resistant hypertensive patients.
The subjects were 528 ...hypertensive patients taking at least three or more different antihypertensive drugs. Subjects were classified into four groups (controlled hypertension, isolated office resistant hypertension, isolated home resistant hypertension and sustained resistant hypertension) on the basis of the cut-off values of home BP (135/85 mmHg) and office BP (140/90 mmHg). The relationship between each resistant hypertension group and various factors was analysed using univariate and multivariate analyses.
Of the 528 patients, 17.8% were classified with controlled hypertension, 16.1% with isolated office resistant hypertension, 23.5% with isolated home resistant hypertension and 42.6% with sustained resistant hypertension. The presence of hypercholesterolemia was found to have a significant and independent association with isolated office resistant hypertension. Higher office systolic blood pressure (SBP), a past history of ischaemic heart disease, and a lower prescription rate of potassium-sparing diuretics were found to have a significant and independent association with isolated home resistant hypertension. Patients with sustained resistant hypertension had a significantly lower prescription rate of potassium-sparing diuretics than those with controlled hypertension.
The present study demonstrated that resistant hypertension is mediated at least partly by the white-coat effect. Home BP measurements and other relevant factors associated with resistant hypertension, such as relatively higher office SBP, type of drugs prescribed, and cardiovascular complications, should be taken into account for the diagnosis and treatment of resistant hypertension.
Background
The new category of heart failure (HF), HF with mid‐range left ventricular ejection fraction (LVEF) (HFmrEF), has recently been proposed. However, the clinical features of HFmrEF, with ...reference to HF with preserved LVEF (HFpEF) and HF with reduced LVEF (HFrEF) in the same HF cohort, remain to be fully examined.
Methods and results
In the Chronic Heart Failure Analysis and Registry in the Tohoku District‐2 Study, we examined 3480 consecutive HF patients with echocardiography data consisting of 2154 HFpEF (LVEF ≥50%), 596 HFmrEF (LVEF 40–49%) and 730 HFrEF (LVEF <40%). While clinical characteristics and prognostic factors of HFmrEF were intermediate between HFpEF and HFrEF, prognosis of HFmrEF resembled HFpEF and the prognostic impact of cardiovascular medications in HFmrEF resembled that of HFrEF. Analysis of LVEF transition among the three groups revealed that HFmrEF and HFrEF dynamically transitioned to other categories, especially within 1 year, whereas HFpEF did not; HFmrEF at registration transitioned to HFpEF and HFrEF by 44% and 16% at 1 year, and 45% and 21% at 3 years, respectively. Landmark analysis demonstrated that, regardless of HF stages at registration, HFmrEF patients at 1 year had mortality comparable to that of HFpEF patients, which was better than HFrEF patients, but HFmrEF patients at registration had increased mortality when transitioned to HFrEF at 1 year.
Conclusions
These results indicate that clinical characteristics of HFmrEF are intermediate between HFpEF and HFrEF and that HFmrEF dynamically transitions to HFpEF or HFrEF, especially within 1 year, suggesting that HFmrEF represents a transitional status or an overlap zone between HFpEF and HFrEF, rather than an independent entity of HF.
We herein report two cases of acute respiratory distress syndrome (ARDS) with high values of Chlamydophila pneumoniae-specific antibodies. In the first case (a 65-year-old man), high levels of ...anti-C. pneumoniae antibodies (IgG and IgA) were detected on admission, and the anti-C. pneumoniae IgA level rose by Day 30. The patient was successfully treated with quinolone and steroids. In the second case (an 85-year-old man), abnormally high levels of anti-C. pneumoniae IgM were detected on admission. The patient did not recover, despite receiving treatment with several antibiotics and anti-inflammatory agents. Neither of the patients displayed other pathogen-specific antigens or antibodies. Chlamydophila pneumonia is usually mild, although it can cause severe interstitial pneumonia and ARDS in reinfected patients and the elderly.
Abstract
Aims
The temporal changes and sex differences in post-traumatic stress disorder (PTSD) after natural disasters remain unclear. Therefore, we examined the prevalence, prognostic impacts, and ...determinant factors of PTSD after the Great East Japan Earthquake (GEJE) of 11 March 2011 in cardiovascular (CV) patients registered in the Chronic Heart Failure Analysis and Registry in the Tohoku District (CHART)-2 Study (n = 10 219), with a special reference to sex.
Methods and results
By self-completion questionnaires of the Japanese-language version of the Impact of Event Scale–Revised (IES-R-J), the prevalence of PTSD, defined as IES-R-J score ≥25, was 14.8, 15.7, 7.4, and 7.5% in 2011, 2012, 2013, and 2014, respectively. The PTSD rate was higher in women than in men in all years (all P < 0.01). During a median 3.5-year follow-up period, the patients with PTSD in 2011 more frequently experienced a composite of all-cause death and hospitalization for acute myocardial infarction, stroke, and heart failure than those without PTSD adjusted hazard ratio (aHR) 1.27, P < 0.01. Importantly, the prognostic impacts of PTSD on all-cause death (aHR 2.10 vs. 0.87, P for interaction = 0.03) and CV death (aHR 3.43 vs. 0.90, P for interaction = 0.02) were significant in women but not in men. While insomnia medication was a prominent determinant factor of PTSD in both sexes during 2011–14, economic poverty was significantly associated with PTSD only in men.
Conclusion
After the GEJE, marked sex differences existed in the prevalence, prognostic impacts, and determinant factors of PTSD, suggesting the importance of sex-sepcific mental stress care in disaster medicine.
In the Japan Home versus Office Blood Pressure Measurement Evaluation (J-HOME) study, we examined the current situation with respect to the prescription of diuretics, including the prevalence of ...diuretic treatment and the dosages used for patients with essential hypertension in primary care settings. Of the 3,400 hypertensive patients included in the study, 315 (9.3%) patients (mean age: 66.9+/-10.4 years; males: 43.5%) were prescribed diuretics. Compared with patients who were not using diuretics, those who were using diuretics were more obese and had more complications. The most commonly prescribed diuretic among the 331 prescriptions in the 315 diuretic users was trichlormethiazide (44%), followed by indapamide (15%) and spironolactone (14%). Among patients being treated with diuretics, monotherapy was used in only 5% of patients; in the majority of patients combination therapy including diuretics (95%) was used. Relatively low dosages of diuretics were generally used. There was a difference between the actual dosages prescribed and those recommended by the Japanese Society of Hypertension (JSH) guidelines or the product information approved in Japan. Compared with previous estimates of the prevalence of diuretic use in hypertensives in Japan (4.0-5.4%), the rate in the J-HOME study (9.3%) was higher. This may be attributable at least in part to the results of the many published, large-scale intervention trials confirming the clinical significance of diuretics. Although a relatively high dosage is recommended in the diuretic product information and in the JSH guidelines, dosages of diuretics should be reconsidered in Japan.
To evaluate the prevalence of masked uncontrolled and treated white-coat hypertension defined according to the average of morning and evening home blood pressure values.
The study population ...consisted of 3303 essential hypertensive outpatients receiving antihypertensive treatment in Japan. Information on the characteristics of the patients was collected by a physician's self-administrated questionnaire. The office blood pressure value was calculated as the average of the four readings in two visits. All patients were asked to measure their blood pressure once every morning and once every evening. In the study, we included patients with at least three measurements in the morning and in the evening, respectively. The average of all home blood pressure values was taken as the home blood pressure value.
The mean value of home systolic/diastolic blood pressure was 136.8/79.3 mmHg, and the mean value of office systolic/diastolic blood pressure was 142.8/80.6 mmHg. Of the 3303 patients, 758 (23.0%) had controlled hypertension (home <135/85 mmHg and office <140/90 mmHg), 628 (19.0%) had masked uncontrolled hypertension (home > or =135/85 mmHg and office <140/90 mmHg), 640 (19.4%) had treated white-coat hypertension (home <135/85 mmHg and office > or =140/90 mmHg), and 1277 (38.7%) had uncontrolled hypertension (home > or =135/85 mmHg and office > or =140/90 mmHg).
Treated white-coat hypertension and masked uncontrolled hypertension were often observed in clinical settings. Physicians need to understand the prevalence of such patients to prevent inadequate diagnosis and treatment in them.
Although several factors, including heart failure (HF) and inflammation, are known to increase the incidence of cancer, it remains unknown whether HF may increase cancer mortality, especially with a ...reference to inflammation.
We examined 8843 consecutive cardiovascular patients without a prior history of cancer in our CHART-2 Study (mean 68 yrs., female 30.9%). As compared with patients without HF (Stage A/B, N = 4622), those with HF (Stage C/D, N = 4221) were characterized by higher prevalence of diabetes, previous myocardial infarction, atrial fibrillation, and stroke. During the median 6.5-year follow-up (52,675 person-years), 282 cancer deaths occurred. HF patients had significantly higher cancer mortality than those without HF in both the overall (3.7 vs, 2.8%, hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.12–1.79, P = 0.004) and the propensity score-matched cohorts (HR 1.46, 95%CI 1.10–1.93, P = 0.008), which was confirmed in the competing risk models. The multivariable Cox proportional hazard model in the matched cohort showed that HF was associated with increased cancer mortality in patients with C-reactive protein (CRP) ≥ 2.0 mg/L (HR 1.87, 95%CI 1.18–2.96, P = 0.008) at baseline, but not in those with CRP < 2.0 mg/L (HR 0.89, 95%CI 0.54–1.45, P = 0.64) (P for interaction = 0.03). Furthermore, temporal changes in CRP levels were associated with cancer death in the overall cohort; HF patients with CRP ≥ 2.0 mg/L at both baseline and 1-year had significantly increased cancer death, while those with CRP ≥ 2.0 mg/L at baseline and < 2.0 mg/L at 1-year not.
These results provide the first evidence that HF is associated with increased cancer death, especially when associated with prolonged inflammation.
•We examined whether heart failure (HF) increases cancer mortality.•HF patients had significantly higher cancer mortality than those without HF.•Temporal changes in C-reactive protein levels were associated with cancer death.
Few simple risk models, without echocardiography have been developed for patients with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) (HFpEF).
To develop a risk score to ...predict all-cause death for HFpEF patients, we examined 1277 HF patients with LVEF ≥50% and BNP ≥100 pg/ml in the CHART-2 Study, a large-scale prospective cohort study for HF in Japan. We selected the optimal subset of covariates for the score with Cox proportional hazard models and random survival forests (RSF).
During the median 5.7-year follow-up, 576 deaths occurred. Cox models and RSF analyses consistently indicated age ≥75 years, albumin <3.7 g/dl, anemia, BMI <22 kg/m2, BNP ≥300 pg/ml (or NT-proBNP ≥1400 pg/ml), and BUN ≥25 mg/dl, as the important 6 prognostic variables. Incorporating these 6 variables, we developed a scoring system (3A3B score, with 2 points given to age ≥75 years and 1 point to the others based on the hazard ratios. The discrimination ability of the risk score was excellent (c-index 0.708). Regarding model goodness-of-fit, the overall gradient in 5-year risk was well captured by the score. The predictive accuracy of the 3A3B score was confirmed in the external validation cohorts from the TOPCAT trial (N = 835, c-index 0.652) and the ASIAN-HF registry (N = 170, c-index 0.741).
We developed a simple risk score to predict long-term prognosis of HFpEF patients. The 3A3B score, comprising 6 commonly available parameters in daily practice, has potential utility in the risk stratification and management of HFpEF patients.
•We developed the 3A3B risk score to predict long-term prognosis of HFpEF patients.•The 3A3B score consists only 6 items (age, albumin, anemia, BMI, BNP/NT-proBNP, and BUN).•The discrimination ability of the risk score is excellent in both the derivation and the validation cohorts.•The overall gradient in 5-year risk is well captured by the score.
PDF
