Pilot study of bisoprolol 8mg transdermal patch at bedtime before coronary computed tomography angiography.

BACKGROUND: Coronary computed tomography angiography (CCTA) is recommended for first-line evaluation of stable coronary artery disease, and there is a standard protocol to control heart rate (HR) in guidelines. However, time is required to decrease HR to the recommended ≤60 beats per minute (bpm). We investigated whether the bisoprolol 8mg transdermal patch at bedtime on the day before CCTA can achieve a target HR and simplify the CCTA process. METHODS: We randomly assigned 63 patients with an HR of ≥70 bpm and systolic blood pressure ≥120mmHg to a standard protocol group (n=33) or a group (n=30) that applied a bisoprolol 8mg transdermal patch (Bis) at bedtime on the day before CCTA evaluation. The primary endpoint was a change in HR between enrollment in the study and the time of CCTA evaluation. The secondary endpoints were elapsed time from arrival at the CCTA suite to starting CCTA image acquisition, and the rates of oral metoprolol and intravenous landiolol administration (UMIN00035246). RESULTS: Baseline characteristics did not significantly differ between two groups. HR was significantly lower upon arrival at the CCTA suite in Bis, than standard protocol group (67.5±7.8 bpm vs. 75.0±10.6 bpm; p=0.00002), and the amount of elapsed time from arrival to the start of CCTA evaluation was also significantly decreased in Bis group (76.9±34.9min vs. 94.8±29.2min; p=0.0356). Rates of oral metoprolol and intravenous landiolol administration did not significantly differ between two groups (63.3% vs. 83.3%, p=0.143 and 36.7% vs. 60.0%, p=0.12, respectively). CONCLUSIONS: The bisoprolol 8mg transdermal patch lowered HR and decreased the amount of time needed for CCTA, thus streamlining the evaluation process.

Development of an inter-professional educational program for home care professionals: Evaluation of short-term effects in suburban areas.

Objective　To examine the short-term effects of an inter-professional educational program developed for physicians and other home care specialists to promote home care in the community.Methods　From March 2012 to January 2013, an inter-professional educational program (IEP) was held four times in three suburban areas (Kashiwa city and Matsudo city in the Chiba prefecture, and Omori district in the Ota ward). This program aimed to motivate physicians to increase the number of home visits and to encourage home care professionals to work together in the same community areas by promoting inter-professional work (IPW). The participants were physicians, home-visit nurses, and other home care professionals recommended by community-level professional associations. The participants attended a 1.5-day multi-professional IEP. Pre- and post-program questionnaires were used to collect information on home care knowledge and practical skills (26 indexes, 1-4 scale), attitudes toward home care practice (4 indexes, 1-6 scale), and IPW (13 indexes, 1-4 scale). Data from all of the participants without labels about the type of professionals were excluded, and both pre-test and post-test responses were used in the analysis. A Wilcoxon signed-rank test and a paired t-test were conducted to compare pre- and post-program questionnaire responses stratified for physicians and other professionals, and the effect size was calculated.Results　The total number of participants for the four programs was 256, and data from 162 (63.3%) were analyzed. The physicians numbered 19 (11.7%), while other professionals numbered 143 (88.3%). Attending this program helped participants obtain home care knowledge of IPW and a practical view of home care. Furthermore, indexes about IPW consisted of two factors: cooperation and interaction; non-physician home care professionals increased their interactions with physicians, other professionals increased their cooperation with other professionals, and physicians increased their cooperation with other physicians.Conclusion　Short-term effects to motivate physicians to increase home visits were limited. However, physicians obtained a practical view of home care by attending the IEP. Also, the participation of physicians and other home care professionals in this program triggered the beginning of IPW in suburban areas. This program is feasible when adapted for regional differences.

Association between level of brachial-ankle pulse wave velocity and onset of activities of daily living impairment in community-dwelling older individuals.

AIM: The purpose of the present study was to clarify the longitudinal association between brachial-ankle pulse wave velocity (baPWV) and the onset of impairment in activities of daily living (ADL) among community-dwelling individuals. METHODS: Deaths and the onsets of ADL impairment during 3 years were followed for 450 individuals without ADL impairment at entry who were aged 65 years or older (men : women 181:269; mean age 77 years). They were dichotomized on the median baPWV value at entry. RESULTS: Within 3 years, 28 died and 60 had an onset of ADL impairment. The high baPWV group had a higher incidence of deaths (high baPWV group vs low baPWV group, 9.3% vs 3.1%) and ADL impairment (high baPWV group vs low baPWV group, 20.7% vs 9.3%). After adjustment for age, sex and systolic blood pressure, as compared with the low baPWV group, the high baPWV group had increased risk for mortality (adjusted odds ratio 3.22; 95% confidence interval 1.26-8.22) and the onset of ADL impairment (adjusted odds ratio 1.94; 95% confidence interval 1.03-3.63). When the onset of ADL impairment was grouped according to medical conditions that preceded/accompanied the onset of ADL impairment, elevated baPWV was associated with increased risk for the onset of ADL impairment after/accompanying fall/fracture. CONCLUSIONS: The assessment of arterial stiffness by baPWV contributes to identifying functionally independent community-dwelling older individuals at risk for ADL impairment, in particular ADL impairment associated with fall/fracture, as well as for mortality. Geriatr Gerontol Int 2015; 15: 840-847.

[Development of a home care educational program for community physicians and other professionals-a trial in Kashiwa City].

From May to October 2011, we conducted an 8-day homecare educational program for physicians, dentists, pharmacists, visiting nurses, long-term care managers, and hospital staff in Kashiwa city, Chiba, which was primarily intended to increase home visits by physicians. The characteristics of the program were as follows: 1) active and busy community physician participation, 2) attendance of practical training by physicians, 3) interprofessional discussion, 4) recruitment of participants from the same city, 5) recommendation of participant recruitment by a community-level professional association such as Kashiwa City Medical Association. By comparison of the pre- and post-program questionnaires completed by participants, the motivation for homecare practice, knowledge about homecare, and interactions with other professionals have increased. We will further standardize and generalize this program in order to contribute to homecare promotion in Japan.

Interactions of household composition and required care level with functional and cognitive status among disabled Japanese elderly living in a suburban apartment complex.

AIM: In the forthcoming super-aging society, the appropriate assessment of functional and cognitive conditions of disabled elderly people will become increasingly significant in providing care services. Care level and household composition would be key factors to assess function. There might also be an interaction between the two factors with the function. The present study examined the associations of household composition and care level with functional and cognitive status among the disabled elderly living in a suburban apartment complex with a high rate of aged residents (39% in 2009). METHODS: Participants were 190 disabled elderly persons aged 65 years and over who lived in the apartment complex. Cross-sectional data were collected between May 2009 and August 2010, including care level, household composition, basic activities of daily living (BADL), instrumental activities of daily living (IADL) and the independence level in relation to cognitive status. Lower scores meant less independence in BADL and IADL, and as determined by the cognitive/independence scale. RESULTS: Approximately half of the participants lived alone. Generalized linear model procedure showed significant interactions with the BADL score and cognitive/independence scale between household composition and care level. Scores for BADL and the cognitive/independence scale in groups receiving a higher care level were lower; however, the slope of the trend for the elderly living alone was more gradual than for the elderly living with others. CONCLUSION: It is important for health-care providers to assess in detail the status of the disabled elderly considering both their household composition and care level in planning and providing assistance for them.

[Home medical care center project for an aging society].

We have to create a new paradigm for home medical care system towards a historical increase of elderly population in Japan. Tokyo University and Chiba University have been collaborating to erect a home medical care support center in Kashiwa, Chiba prefecture. We have been constructing a support center as well as a home care doctor system, and also created a teaching course for GPs to learn a home care doctor activity. We have also been constructing a regional network system called IT Net in Chiba, which connects all the entire medical and care staff. We will expand this model in many places and to instruct medical students and residents there in the near future.

Turbulent left-to-right shunt flow through the interatrial septum suggesting high left atrial pressure in patients with heart failure with preserved ejection fraction.

Lutembacher's syndrome is a combination of interatrial septal (IAS) defect or patent foramen ovale (PFO), associated with mitral stenosis. High left atrial (LA) pressure in mitral stenosis exaggerates left-to-right shunt in patients with interatrial communication. We present a case of heart failure with preserved ejection fraction. Echocardiography revealed normal left ventricular systolic function without mitral stenosis and turbulent left-to-right shunt through the IAS. The peak velocity of the shunt flow was 2.3 m/s and the estimated pressure gradient was 22 mmHg, indicating high LA pressure. The presence of turbulent left-to-right shunt through the IAS is helpful for detecting high LA pressure.

Abdominal visceral fat thickness measured by ultrasonography predicts the presence and severity of coronary artery disease.

Abdominal visceral fat plays a critical role in the pathogenesis of metabolic syndrome, which is a risk factor for coronary artery disease (CAD). Ultrasonography (US) distinctively quantifies visceral fat and subcutaneous fat. We measured the maximum preperitoneal visceral fat thickness (Vmax) and the minimum subcutaneous fat thickness (Smin) by US in 185 patients who underwent coronary angiography. Although the 144 patients with CAD had larger Vmax (8.8 ± 3.6 vs. 6.4 ± 2.8 mm; p < 0.001) than those without, there was no difference in Smin. Vmax of 6.9 mm or higher was an independent predictor of CAD (odds ratio, 3.710, p = 0.008) by multiple logistic regression analysis. Vmax significantly correlated with the number of diseased vessels. Assessment of abdominal visceral fat by US gives us incremental information beyond conventional risk factors for predicting CAD in routine clinical practice.

Association between brachial-ankle pulse wave velocity and 3-year mortality in community-dwelling older adults.

With aging, arterial stiffness increases and results in cardiovascular diseases. Recently, high brachial-ankle pulse wave velocity (baPWV), measured using a new noninvasive device to estimate arterial stiffness, was reported to be associated with the prevalence of cardiovascular diseases. The purpose of this study was to clarify the association between baPWV with 3-year mortality in community-dwelling older adults and to determine the cutoff value of baPWV in terms of mortality. A total of 530 subjects aged 65 years or older (men/women, 207:323; mean age, 76 years) participated. They were dichotomized by the median value of baPWV. Within 3 years, 30 deaths occurred, including 11 cardiovascular deaths. The high-baPWV group had a higher incidence of total deaths (high-baPWV group vs. low-baPWV group, 8.3 vs. 3.0%, respectively) and cardiovascular deaths (high-baPWV group vs. low-baPWV group, 3.8 vs. 0.4%, respectively). A high-baPWV level was associated with an increased risk of 3-year total mortality after adjustment for age, sex and systolic blood pressure (hazard ratio for high baPWV vs. low baPWV=2.98, 95% CI=1.25-7.07) and with an increased risk of 3-year cardiovascular mortality (hazard ratio for high baPWV vs. low baPWV=10.01, 95% CI=1.21-82.49). A receiver-operating characteristic curve showed that the optimal cutoff value of baPWV for total mortality was 19.63 m s(-1), and for cardiovascular mortality it was 19.63 m s(-1). This study provides a preliminary finding that assessment of arterial stiffness by baPWV might be a useful method to predict mortality risk in community-dwelling older adults. Large longitudinal studies for extended periods of time are necessary to confirm the association.

Plasma adiponectin levels and left ventricular remodeling in hypertrophic cardiomyopathy.

Adiponectin, which is an adipose-derived protein with antiatherosclerogenic activities, has been reported to be elevated in patients with heart failure. However, there are no reports on the significance of adiponectin in patients with hypertrophic cardiomyopathy (HCM). The purpose of this study was to elucidate the clinical significance of plasma adiponectin levels in HCM patients. Clinical characteristics, echocardiographic parameters, and levels of plasma B-type natriuretic peptide (BNP) and adiponectin were evaluated in 106 HCM patients. The plasma adiponectin levels were 10.8 +/- 6.3 (range, 2.7-37.3) microg/mL. Plasma adiponectin levels were positively related to age and inversely related to body mass index (BMI). Among echocardiographic parameters, % fractional shortening (r = -0.20, P = 0.03) and maximum LV wall thickness (r = -0.23, P = 0.02) were inversely related to plasma adiponectin levels. A significant correlation between plasma adiponectin levels and BNP levels was also observed (r = 0.27, P = 0.005). In multivariate analysis, BMI, % fractional shortening, and plasma BNP levels were independent predictors of plasma adiponectin levels. Plasma adiponectin levels are associated with impaired LV systolic function in HCM patients, but not with the LV outflow gradient. Together with BNP, adiponectin can be a useful biomarker for assessing disease severity in HCM patients.

3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors prevent the progression of renal dysfunction in Japanese hypertensive patients.

AIM: The aim was to determine whether the use of statins prevents the progression of chronic kidney disease (CKD) in hypertensive patients. METHODS: We retrospectively reviewed data obtained from hypertensive patients, and subjects with diabetes mellitus and those undergoing hemodialysis were excluded. At total of 227 patients were enrolled (83 men, mean age 73 years) and 90% of the patients were of CKD stage 2 or 3. The patients were divided into two groups: those treated with statins (n = 93) and those not treated with statins (n = 134). Renal function was evaluated by estimated glomerular filtration rate (eGFR). RESULTS: The statin group and the non-statin group were similar in age, sex, blood pressure, follow-up period and prescriptions of antihypertensive medicines. The eGFR in the statin group increased from 62 +/- 14 to 66 +/- 15 (mL/min per 1.73 m(2)), whereas it decreased in the non-statin group from 69 +/- 16 to 64 +/- 18 (mL/min per 1.73 m(2)). The annual eGFR improved in the statin group (2.5 +/- 6.6 mL/min per 1.73 m(2)/year), but decreased in the non-statin group (-3.3 +/- 6.6 mL/min per 1.73 m(2)/year) (P < 0.001). When the patients were divided into two groups by low-density lipoprotein (LDL) cholesterol levels at the second evaluation, annual eGFR improved in the group of LDL to below 100 mg/dL (n = 99) (0.4 +/- 7.2 mL/min per 1.73 m(2)/year), but decreased in the other group (n = 128) (-1.9 +/- 7.0 mL/min per 1.73 m(2)/year) (P = 0.018). CONCLUSION: Lipid-lowering intervention with statins inhibits the progression of CKD in hypertensive patients.

Hypertrophic cardiomyopathy in the elderly.

Hypertrophic cardiomyopathy (HCM) is a relatively common genetic cardiac disorder with heterogeneous morphological, functional and clinical features. Although the risk of sudden death and incapacitating symptoms in young patients has been focused upon, the disease has been found with increasing frequency in elderly patients. However, there have been few studies on clinical features of HCM in the elderly. We established a cardiomyopathy registration study in Kochi Prefecture, which is one of the most aged communities in Japan, to provide detailed descriptions of the clinical features of HCM in a community-based patient cohort. The unselected regional HCM population consisted largely of elderly patients (70% of the study cohort being >or=60 years of age at registration), although HCM has been regarded largely as a disease of the young. Cardiac hypertrophy that becomes clinically apparent late in life can be a genetic disorder, and mutations in the cardiac myosin-binding protein C gene are the most common cause of late-onset or elderly HCM. In the morphological features, sarcomere gene defects seem to have a predilection for a crescent-shaped left ventricular cavity with reversed septal curvature even in elderly patients, although an ovoid left ventricular shape was frequently seen in elderly patients in previous clinical studies on morphological characteristics of HCM. In middle-aged or elderly patients with HCM, heart failure and embolic events, which were strongly associated with atrial fibrillation, were very important. It is important to manage HCM patients from the standpoint of longitudinal evolution in order to prevent those clinical complications.

Clinical profiles of hypertrophic cardiomyopathy with apical phenotype--comparison of pure-apical form and distal-dominant form.

BACKGROUND: Hypertrophic cardiomyopathy (HCM) with an apical phenotype, in which hypertrophy of the myocardium predominantly involves the apex of the left ventricle, is not uncommon in Japan, but its morphologic variations are not well recognized. The aim of this study was to investigate if these variations have different clinical characteristics although they are still confused to be the same. METHODS AND RESULTS: Patients with the apical phenotype were divided into 2 groups, the "pure-apical" form and the "distal-dominant" form, and their clinical profiles were compared. From the study cohort of 264 patients with HCM, 80 (30%) were classified as having the apical phenotype: 51 with the pure-apical form and 29 with the distal-dominant form. The age at diagnosis was approximately 60 years, and in both groups the majority were male. The distal-dominant group had a significantly larger left atrial diameter (43 vs 39 mm) and higher ratio of proven familial HCM (28 vs 6%), and were more symptomatic (New York Heart Association >or=3) at presentation (17 vs 0%). The event-free rate of cardiovascular events in patients with the distal-dominant form was significantly worse (log-rank P=0.012) than that in patients with the pure-apical form (follow-up period: asymptotically approximately 5 years). CONCLUSIONS: The 2 phenotypes of apical HCM should be recognized and distinguished clinically.

B-type natriuretic peptide is predictive of hospitalization in community-dwelling elderly without heart diseases.

AIM: To examine prospectively the relationship between plasma B-type natriuretic peptide (BNP) levels in community-dwelling elderly and their hospitalization. METHODS: A total number of 644 subjects aged 65 years or older were recruited from the annual community health examinations. Those with a history of stroke or neurological findings were not included. After excluding those with old myocardial infarction, left ventricular dysfunction, moderate or severe valvular disorders, atrial fibrillation, renal insufficiency, and history of hospitalization within 1 year, 602 participants (226 men, 376 women; mean age, 80.3 +/- 6.2 years) remained eligible for this study. Antihypertensive medications, activities of daily living (ADL) score and history of hospitalization were assessed by annual interview. Measurement of casual blood pressure, Mini-Mental State Examination, electrocardiography and echocardiography were performed. Plasma BNP, serum creatinine, total cholesterol, albumin and hemoglobin A1c levels were also examined. A follow-up survey was performed for the occurrence and reasons for hospitalization. RESULTS: During a median follow up of 37 months, 112 subjects were hospitalized. After adjustment for conventional risk factors of hospitalization using the Cox proportional hazard model, each increment of 1 standard deviation in log BNP levels was associated with a 36% increase in the risk of hospitalization (P = 0.02). Plasma BNP levels were significantly higher in the hospitalized subjects due to stroke, heart diseases, dementia, pneumonia and also difficulty to live alone than those of the subjects without hospitalization. CONCLUSION: Plasma BNP level is a very useful biochemical marker predictive of future hospitalization in community-dwelling independent elderly people without apparent heart diseases.

[Severe pulmonary hypertension and congestive heart failure in an elderly patient with Basedow's disease].

An 83-year-old woman was admitted to our hospital with dyspnea. A chest X-ray showed cardiomegaly and pulmonary congestion. An echocardiogram revealed severe tricuspid regurgitation and markedly elevated transtricuspid pressure gradient of 103 mmHg. There was no left ventricular systolic or diastolic dysfunction. Laboratory evaluation revealed elevated free T4 and suppressed TSH levels. Serum level of anti-TSH receptor antibody was significantly elevated. A thyroid echogram demonstrated increased internal flow pattern in the thyroid gland. As a result of these findings, she was given a diagnosis of Basedow's disease associated with severe pulmonary hypertension and congestive heart failure. After treatment for hyperthyroidism with thiamazole, propranolol, furosemide, and warfarin, she made good recovery with gradual resolution of pulmonary hypertension. The severity of pulmonary hypertension in this case was significantly higher than that in previous reports, possibly because of concomitant minor pulmonary embolism, thiamine deficiency and anemia. In summary, we report a rare case of Basedow's disease with severe and reversible pulmonary hypertension that appeared in very old age.

Four blood pressure indexes and the risk of stroke and myocardial infarction in Japanese men and women: a meta-analysis of 16 cohort studies.

BACKGROUND: Information has been sparse on the comparison of 4 blood pressure (BP) indexes (systolic BP [SBP], diastolic BP, pulse pressure, and mean BP [MBP]) in relation to long-term incidence of stroke and myocardial infarction, particularly in middle-aged and older Asians. METHODS AND RESULTS: The Japan Arteriosclerosis Longitudinal Study Group conducted a meta-analysis of 16 cohort studies in Japan. A total of 48,224 men and women 40 to 89 years of age participated at baseline, and 1231 stroke events and 220 myocardial infarction events occurred during an average 8.4-year follow-up. Multivariate-adjusted hazard ratios with a 1-SD higher value for each BP index were determined by Poisson regression. Analyses were also done in 4 age-sex groups. All 4 BP indexes were significantly related to all stroke risk. Stroke risk was most strongly related to MBP and SBP in both sexes and most weakly related to pulse pressure. Both stroke subtypes, ischemic and hemorrhagic, were most strongly related to MBP and SBP in both sexes. In addition, in men and women 70 to 89 years of age, MBP or SBP showed the strongest relation to all stroke risk. Myocardial infarction risk was most strongly related to SBP or MBP in both sexes. For any end points in any age-sex groups, pulse pressure was not the strongest predictor. CONCLUSIONS: The long-term incident risk of stroke and myocardial infarction associated with high BP in East Asian populations should be assessed mainly on the basis of SBP. MBP also may be an important predictor, but pulse pressure is a less important predictor for cardiovascular disease risk.

Improvement in prognosis of dilated cardiomyopathy in the elderly over the past 20 years.

BACKGROUND AND PURPOSE: Although dilated cardiomyopathy (DCM) had a poor prognosis in the past, recent studies have shown better survival. However, little is known about the improvement of prognosis in the elderly. This study sought to clarify the changes in prognosis in elderly patients with DCM over the past 20 years. METHODS AND SUBJECTS: We studied 54 consecutive patients with DCM (38 men and 16 women, aged 65-83 years) who were diagnosed at over 65 years of age. The patients were divided into two groups (group A: 12 patients diagnosed before 1990; group B: 42 patients diagnosed after 1990) because after 1990, based on growing evidence from large-scale, randomized clinical studies, we intentionally increased the use of angiotensin-converting enzyme inhibitors (ACEI) and then beta-blockers at our hospital. RESULTS: There were no significant differences in age, gender, NYHA functional class, and the prevalence of atrial fibrillation and ventricular tachycardia between the two groups. Left ventricular (LV) size assessed by echocardiography was larger (LV end-diastolic diameter, 67+/-5.9 versus 62+/-6.6 mm; p=0.039) and LV ejection fraction measured by left ventriculography was lower (ejection fraction, 24+/-9 versus 35+/-10%; p=0.004) in group A. ACEI/angiotensin II type 1 receptor blockers (ARB) (0% versus 88%) or beta-blockers (0% versus 52%) were more frequently used in group B. Antiarrhythmics (class Ia or Ib) (75% versus 14%) were less often used in group B. The 5- and 10-year event-free survival rates for cardiac death were 75.4% and 22.0% in group A versus 81.2% and 71.3% in group B (log-rank test, p=0.014). CONCLUSIONS: The prognosis of DCM patients in the elderly has significantly improved over the past 20 years. The advances in the pharmacologic treatment and earlier diagnosis may have contributed to the better survival.