Changes in characteristics and outcomes in Japanese patients with heart failure from the 2000s to the 2010s: The HIJ-HF cohorts.

BACKGROUND: The number of hospitalized patients with heart failure (HF) is increasing as a result of the increase in the elderly population in Japan. We evaluated changes in the characteristics and outcomes of HF patients hospitalized in the 2000s to the 2010s and discharged alive based on left ventricular ejection fraction (LVEF). METHODS: Pooled patient data were obtained from The Heart Institute of Japan Heart Failure studies (HIJ-HF I: 2001-2 and HIJ-HF II: 2013-4). We studied patients discharged alive from pooled data based on LVEF < 40% (HFrEF), 40-49% (HFmrEF), and ≥50% (HFpEF). The primary outcome was death from any cause, and the secondary outcomes were cardiac death and rehospitalization due to worsened HF. RESULTS: The proportion of HFpEF increased (35%-43%, p < 0.01), and the median ages of patients with HFmrEF (72-76 years, p < 0.01) or HFpEF (72-80 years, p < 0.01) increased from HIJ-HF I to HIJ-HF II. The use of angiotensin II receptor blockers, beta-blockers, statins, amiodarone, and erythropoietin increased, but nitrate and digoxin usage decreased. The adjusted survival rate and cardiac death-free rate were not significantly different between the 2000s and 2010s in any LVEF group, and the incidence of rehospitalization due to worsened HF was reduced in patients discharged alive from HIJ-HF I to HIJ-HF II [HFrEF: hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.51-0.89; HFmrEF: HR 0.89, 95% CI 0.68-1.16; and HFpEF: HR 0.77, 95% CI 0.61-0.97] with no significant interaction by LVEF groups. CONCLUSION: Our study demonstrated that age, the proportion of HFpEF, and guideline-recommended drug therapy use increased among hospitalized Japanese HF patients from the 2000s to the 2010s. The adjusted survival rate was not improved in any LVEF group, although the incidence of rehospitalization due to worsened HF was reduced.

Clinical implications of midventricular obstruction in patients with hypertrophic cardiomyopathy.

OBJECTIVES: We investigated the prevalence, clinical characteristics, and prognosis of hypertrophic cardiomyopathy (HCM) patients with midventricular obstruction (MVO). BACKGROUND: Previous descriptions of patients with MVO have been confined to case reports or small patient series, and this subgroup of HCM patients has therefore remained underrecognized. METHODS: The study population included 490 HCM patients. Left ventricular MVO was diagnosed when the peak midcavitary gradient was estimated to be ≥30 mm Hg. RESULTS: MVO was identified in 46 patients (9.4%). Patients with MVO were more likely to be symptomatic than those without. MVO was found to be an independent determinant of HCM-related death in multivariate models (hazard ratio [HR]: 2.23, p = 0.016), and this trend was especially pronounced for the combined endpoint of sudden death and potentially lethal arrhythmic events (HR: 3.19, p < 0.001). Apical aneurysm formation was identified in 28.3% of patients with MVO and strongly predicted HCM-related death (HR: 3.47, p = 0.008) and the combined endpoint of sudden death and potentially lethal arrhythmic events (HR: 5.08, p < 0.001). In addition, MVO without apical aneurysm was also identified as an independent determinant of the combined endpoint of sudden death and potentially lethal arrhythmic events (HR: 2.43, p = 0.045). CONCLUSIONS: This analysis identified MVO as an independent predictor of adverse outcomes, especially the combined endpoint of sudden death and potentially lethal arrhythmic events. Our results suggest that longer periods of exposure to MVO might lead to unfavorable consequences. They also support the principle that the presence of MVO in patients with HCM has important pathophysiological implications.

Clinical characteristics and outcome of hospitalized patients with congestive heart failure: results of the HIJC-HF registry.

BACKGROUND: Heart failure (HF) represents a major public health issue in an aging population. Although HF is a leading cause of morbidity and mortality in developed countries, the clinical features of HF in Japan remain unclear. METHODS AND RESULTS: This observational cohort study analyzed data from the Heart Institute of Japan--Department of Cardiology (HIJC)-HF Registry, which is based on a nationwide survey by the HIJC, Tokyo Women's Medical University and its affiliated hospitals. Of 3,578 consecutive patients (average age, 69.8 years; females 40.7%) hospitalized for HF between January 2001 and December 2002, 95.0% were followed up until the end of 2005 (median, 2.8 years). The 1- and 3-year mortality rates were 11.3% and 29.2%, respectively. Multivariate analysis revealed that advanced age (hazard ratio 1.71 [95% confidence interval 1.38-2.12]; p<0.001), symptomatic HF at hospital discharge (3.76 [2.30-6.17]; p<0.001), renal impairment (1.96 [1.50-2.57]; p=0.008), anemia (1.46 [1.18-1.80]; p=0.02) and low pulse pressure (2.88 [1.62-5.13]; p=0.0003) were significantly associated with total death. CONCLUSION: Although the long-term mortality rate for Japanese patients with HF is lower than in other countries, several markers are modifiable. The data demonstrate that continued improvements in the treatment of Japanese patients with HF are still needed.

[Long-term outcome and tolerability of carvedilol therapy in Japanese patients with chronic heart failure].

OBJECTIVES: Randomized controlled clinical studies in western countries have shown that the beta-blockers improve the survival of patients with chronic heart failure and are highly tolerable. The tolerability of beta-blocker therapy and the long-term prognosis for patients with chronic heart failure receiving beta-blockers remain unclear in Japan. In the present study, carvedilol was employed for the treatment of mild to severe chronic heart failure and the long-term prognosis of the patients was monitored to evaluate the tolerability and chronic efficacy of beta-blocker therapy in Japanese patients. METHODS: Three hundred and twenty-seven patients with chronic heart failure [Classes II to IV according to the New York Heart Association (NYHA) classification] were studied. Carvedilol was started at a dose of 1.25 to 5 mg/day and then increased to the final target dose of 20 mg/day, depending on its tolerability in each patient. The patients were monitored with respect to their NYHA classification, daily mean heart rate (evaluated by Holter electrocardiography), changes of the plasma brain natriuretic peptide level, and prognosis. They were followed up for a mean period of 4.4 +/- 1.8 years. RESULTS: Carvedilol was not tolerated by 21 of the 327 patients (6.4%), and was discontinued during the follow-up period in 38 patients (11.6%). The mean maintenance dose for the remaining 268 patients (82.0%), in whom treatment could be continued over the long term, was 14.1 +/- 7.5 mg. The NYHA classification and plasma brain natriuretic peptide level were significantly improved, and the daily mean heart rate was also significantly reduced in the 268 patients. Significant improvement was also observed in patients with severe heart failure (classes III or IV of the NYHA classification). The five-year survival rate of patients continuously treated with carvedilol was 83%, and their outcome was significantly better than that of those who could not tolerate the drug (49%; p < 0.001) or those who discontinued treatment prematurely (68%; p < 0.001). The treated group also had a significantly lower cardiac death rate than the intolerant group or discontinued group. CONCLUSIONS: Carvedilol was well tolerated by Japanese patients with chronic heart failure. Treatment with low-dose carvedilol may improve the symptoms and prognosis of patients with mild to severe chronic heart failure over the long term.