Forecasting the Acute Heart Failure Admissions: Development of Deep Learning Prediction Model Incorporating the Climate Information.

BACKGROUND: Climate is known to influence the incidence of cardiovascular events. However, their prediction with traditional statistical models remains imprecise. METHODS AND RESULTS: We analyzed 27,799 acute heart failure (AHF) admissions within the Tokyo CCU Network Database from January 2014 to December 2019. High-risk AHF (HR-AHF) day was defined as a day with the upper 10th percentile of AHF admission volume. Deep neural network (DNN) and traditional regression models were developed using the admissions in 2014-2018 and tested in 2019. Explanatory variables included 17 meteorological parameters. Shapley additive explanations were used to evaluate their importance. The median number of incidences of AHF was 12 (9-16) per day in 2014-2018 and 11 (9-15) per day in 2019. The predicted AHF admissions correlated well with the observed numbers (DNN: R2 = 0.413, linear regression: R2 = 0.387). The DNN model was superior in predicting HR-AHF days compared with the logistic regression model [c-statistics: 0.888 (95% CI: 0.818-0.958) vs 0.827 (95% CI: 0.745-0.910): P = .0013]. Notably, the strongest predictive variable was the 7-day moving average of the lowest ambient temperatures. CONCLUSIONS: The DNN model had good prediction ability for incident AHF using climate information. Forecasting AHF admissions could be useful for the effective management of AHF.

Prevalence and clinical characteristics of diabetic cardiomyopathy in patients with acute heart failure.

BACKGROUND AND AIMS: Diabetic cardiomyopathy refers to cases of diabetes mellitus (DM) complicated by cardiac dysfunction in the absence of cardiovascular disease and hypertension. Its epidemiology remains unclear due to the high rate of coexistence between DM and hypertension. Therefore, this study aimed to examine the prevalence and clinical characteristics of diabetic cardiomyopathy among patients with acute heart failure (HF). METHODS AND RESULTS: This multicenter, retrospective study included 17,614 consecutive patients with acute HF. DM-related HF was defined as HF complicating DM without known manifestations of coronary artery disease, significant valvular heart disease, or congenital heart disease, while diabetic cardiomyopathy was defined as DM-related HF without hypertension. Univariable and multivariable logistic regression analyses were performed to identify factors associated with in-hospital mortality. Diabetic cardiomyopathy prevalence was 1.6 % in the entire cohort, 5.2 % in patients with acute HF complicating DM, and 10 % in patients with DM-related HF. Clinical characteristics, including the presence of comorbidities, laboratory data on admission, and factors associated with in-hospital mortality, significantly differed between the diabetic cardiomyopathy group and the DM-related HF with hypertension group. The in-hospital mortality rate was significantly higher in patients with diabetic cardiomyopathy than in patients with DM-related HF with hypertension (7.7 % vs. 2.8 %, respectively; P < 0.001). CONCLUSION: The prevalence of diabetic cardiomyopathy was 1.6 % in patients with acute HF, and patients with diabetic cardiomyopathy were at high risk for in-hospital mortality. The clinical characteristics of patients with diabetic cardiomyopathy were significantly different than those of patients with DM-related HF with hypertension.

Association between physical performance during sit-to-stand motion and frailty in older adults with cardiometabolic diseases: a cross-sectional, longitudinal study.

BACKGROUND: Although physical performance tests of the lower extremities are used to assess sarcopenia and frailty, little is known about the mechanisms by which the parameters of ground reaction force (GRF) measured during sit-to-stand motion affect the frailty status in older adults. We aimed to examine the association between GRF parameters during sit-to-stand motion and the incidence of frailty in older adults. METHODS: This longitudinal study evaluated 319 outpatients aged ≥ 65 years with cardiometabolic diseases. The GRF parameters were measured using a motor function analyzer, in which the power, speed, and balance scores were calculated. Frailty was diagnosed using the modified version of the Cardiovascular Health Study (mCHS) and the Kihon Checklist (KCL). The independent associations between scores and frailty indices were assessed using multivariate binomial logistic regression analyses. Cox regression analysis was used to examine whether power and speed scores were associated with the incidence of frailty after adjusting for covariates. RESULTS: Logistic regression analyses adjusted for covariates showed that the power and speed scores were associated with frailty according to the mCHS criteria (power: OR = 0.37, 95% CI = 0.22-0.63; speed: OR = 0.64, 95% CI = 0.52-0.79) and KCL criteria (power: OR = 0.40, 95% CI = 0.26-0.62; speed: OR = 0.81, 95% CI = 0.69-0.96) at baseline. Receiver operating characteristic analyses revealed that the area under the curve values of power and speed scores for discriminating mCHS-defined frailty were 0.72 and 0.73. The Cox regression analysis showed that the speed score predicted the incidence of mCHS-defined (HR = 0.45, 95% CI = 0.22-0.92, P = 0.029) and KCL-defined (HR = 0.77, 95% CI = 0.60-0.99, P = 0.039) frailty, whereas the power score was associated with the incidence of KCL-defined frailty (HR = 0.72, 95% CI = 0.55-0.95, P = 0.02) after adjusting for covariates. CONCLUSIONS: The speed and power scores measured during sit-to-stand motion are predictive of frailty in older adults with cardiometabolic disease. Therefore, the GRF parameters measured during sit-to-stand motion could be an important indicator of frailty. Further studies are necessary to examine whether the GRF parameters can be improved by exercise or whether the changes in these parameters are associated with the improvement of frailty status.

[A case of deep vein thrombosis in an elderly patient whose symptoms were exacerbated after applying catheter-based thrombolytic therapy].

We herein report a 99-year-old woman with hypertension and dyslipidemia. From the beginning of August 20XX, significant edema from the left thigh to the toes had been observed, so she had consulted her previous doctor. She had been suspected of having cellulitis and was given antibiotics, but no improvement in her symptoms was noted, so she was transferred to our hospital. The edema of the lower leg was localized to the left lower leg only, and the D-dimer level was as high as 16.6 µg/mL at her visit to the emergency room, so deep vein thrombosis (DVT) was suspected, and the patient received immediate hospitalization. Continuous administration of undifferentiated heparin was started, and lower extremity venous ultrasound was performed. As a result, central-type DVT extending from the left iliac vein to the common iliac vein bifurcation was observed. However, despite administering inferior vena cava (IVC) filter into under the renal vein, and changing heparin to edoxaban 30 mg, no improvement in the lower limb edema was observed. Therefore, catheter-based thrombolysis (CDT) was started on day 11 of illness, and continuous administration of urokinase was started via the catheter. Heparin and edoxaban were not used in combination in order to reduce the risk of bleeding. The edema gradually improved, and after confirming that the thrombus had completely disappeared on lower extremity venous ultrasound, the catheter was removed on day 14 (day 24 of illness) after starting CDT. The IVC filter was also removed, and prescription of edoxaban 30 mg was restarted. Since the patient had used a walking frame at home, she started rehabilitation from the initiation of CDT therapy and was discharged once she was able to use a self-sustaining portable toilet. The basic treatment for DVT is anticoagulant therapy; however, a large amount of thrombosis was observed in the present case, and no marked improvement was observed with conventional anticoagulant therapy. As the patient was particularly elderly, and considering that it was important to improve the edema promptly in order to maintain her activities of daily living, we performed CDT treatment and concluded that it was very effective in this case. However, the CDT procedure for DVT has yet to be standardized, and there are few cases of CDT treatment, especially for such super-elderly patients. In the current aging society, the incidence of DVT diseases is increasing, and in cases such as the present case, anticoagulation therapy alone and CDT therapy should be considered and implemented after careful consideration of the bleeding risk.

Increased blood pressure variability is associated with probable rapid eye movement sleep behaviour disorder in elderly hypertensive patients.

PURPOSE: An increased blood pressure variability (BPV) has been reported to be associated with older age and cognitive dysfunction; however, associations between increased BPV and rapid eye movement sleep behaviour disorder (RBD) has not been thoroughly investigated in patients without clinical Lewy body diseases. MATERIALS AND METHODS: In frailty outpatient clinic, we evaluated ambulatory BP, RBD screening questionnaire (RBDSQ), and beat-to-beat heart rate variability during positional change from sitting to standing in 112 elderly hypertensive patients. RESULTS: The mean age was 81.2 ± 6.3 years (68% male). There were 15 patients who had probable RBD (RBDSQ scores ≥ 5). Patients with RBD had a greater body mass index, coefficient of variation (CV) in 24-h diastolic BP (23.5 ± 6.1 versus 18.7 ± 5.8, p = 0.005), awake diastolic BP (23.0 ± 7.7 versus 18.6 ± 6.2, p = 0.017), and nocturnal systolic BP (14.9 ± 5.5 versus 12.0 ± 4.4, p = 0.025) compared with those without RBD, while systolic BP, diastolic BP, and cognitive function did not differ significantly between patients with and without RBD. Patients with RBD exhibited larger orthostatic BP fall compared with patients without RBD (-4.9 ± 11.0 versus 7.5 ± 11.8, p = 0.009) and lower CV of R-R intervals while standing (1.3 ± 0.6 versus 2.4 ± 1.5, p = 0.039). Multiple regression analysis revealed that patients with RBD had significantly greater CV of nocturnal systolic BP independent of age, sex, BMI, history of diabetes and dyslipidaemia, and use of antihypertensive drugs (p = 0.008). CONCLUSION: An increased BPV in ambulatory BP, associated with autonomic dysfunction, can be observed in patients with probable RBD even in elderly patients without clinical presentation of Lewy body diseases.

[Posture-dependent left ventricular outflow tract obstruction in a case of Lewy body dementia that presented with transient loss of consciousness].

An 80-year-old woman with a history of hypertrophic obstructive cardiomyopathy and Lewy body dementia was admitted to our hospital with a first episode of syncope while walking. The pressure gradient of left ventricular outflow tract (LVOT) had been stable at nearly 10 mmHg for 3 years before the admission. We evaluated the cause of syncope. Echocardiography showed that the pressure gradient of LVOT was unchanged, even in the supine position ergometer exercise test. Although the head-up tilt test revealed a drop in blood pressure of 44 mmHg systolic and 23 mmHg diastolic, she was asymptomatic during the test. The orthostatic hypotension was considered to be a manifestation of autonomic failure due to Lewy body dementia; however, it was insufficient to explain the syncope on exertion. Echocardiography in a sitting-up position showed that the pressure gradient of LVOT was exacerbated to 41 mmHg, which might be the cause of syncope while walking. Orthostatic hypotension, especially in patients with Lewy body dementia, is a common cause of syncope in the elderly. However, we should keep in mind that the exacerbation of LVOT obstruction due to posture-dependent fluid shift can be a cause of syncope in patients with hypertrophic cardiomyopathy or sigmoid-shaped interventricular septum. In such patients, echocardiography in a sitting-up position can be an effective tool to diagnose the cause of syncope.

Factors contributing to energy loss in left ventricle during diastolic and systolic phases in elderly patients.

BACKGROUND: The change of left ventricular function deteriorated with age because of gradual increases of blood pressure may result in increased energy loss (EL) in left ventricle (LV). The present study investigated EL in LV among hypertensive elderly patients and examined factors contributing to EL. METHODS: A single-center retrospective study was performed on elderly hypertensive outpatients (≥65 years) who underwent echocardiography (N = 105). EL in the LV was measured using a vector flow mapping system, and factors affecting peak EL during the early-diastolic phase (ED-EL), late-diastolic phase (LD-EL), and systolic phase (Sys-EL) were evaluated. RESULT: Mean age was 79.9 ± 6.4 years (male 43%). Mean ED-EL, LD-EL, and Sys-EL were 42.1 ± 46.7, 75.6 ± 60.2, and 40.4 ± 40.2 mJ/N/s. In a stepwise regression analysis, the E/e'(lateral) (unstandardized B = 0.005, 95%CI -0.03 to 0.007, standardized ß = 0.434, P < .001) was identified as factors affecting ED-EL. The factors affecting LD-EL were E/A ratio (B = -0.122, 95%CI -0.176 to -0.068, ß = -0.470, P < .001) and time velocity integral (TVI) in LVOT (unstandardized B = 0.002, 95%CI 0.000 to 0.004, ß = 0.247, P = .021). The factors influencing Sys-EL were TVI in LVOT (B = 0.002, 95%CI 0.001 to 0.004, ß = 0.390, P < .001), E/A ratio (B = -0.054, 95%CI -0.093 to -0.015, ß = -0.258, P = .008), left ventricular outflow tract (LVOT) diameter (B = -0.006, 95%CI -0.010 to -0.002, ß = -0.307, P = .006), and left ventricular mass index (B = 0.000, 95%CI 0.000 to 0.001, ß = 0.208, P = .039). CONCLUSION: Peak EL in the LV was higher during diastolic phase than systolic phase among elderly hypertensive patients. Peak EL both during late-diastolic phase and systolic phase was affected by systolic blood flow in LVOT and LV transmitral flow pattern.

Ezetimibe Lipid-Lowering Trial on Prevention of Atherosclerotic Cardiovascular Disease in 75 or Older (EWTOPIA 75): A Randomized, Controlled Trial.

BACKGROUND: Evidence regarding the primary prevention of coronary artery disease events by low-density lipoprotein cholesterol (LDL-C) lowering therapy in older individuals, aged ≥75 years, is insufficient. This trial tested whether LDL-C-lowering therapy with ezetimibe is useful for the primary prevention of cardiovascular events in older patients. METHODS: This multicenter, prospective, randomized, open-label, blinded end-point evaluation conducted at 363 medical institutions in Japan examined the preventive efficacy of ezetimibe for patients aged ≥75 years, with elevated LDL-C without history of coronary artery disease. Patients, who all received dietary counseling, were randomly assigned (1:1) to receive ezetimibe (10 mg once daily) versus usual care with randomization stratified by site, age, sex, and baseline LDL-C. The primary outcome was a composite of sudden cardiac death, myocardial infarction, coronary revascularization, or stroke. RESULTS: Overall, 3796 patients were enrolled between May 2009 and December 2014, and 1898 each were randomly assigned to ezetimibe versus control. Median follow-up was 4.1 years. After exclusion of 182 ezetimibe patients and 203 control patients because of lack of appropriate informed consent and other protocol violations, 1716 (90.4%) and 1695 (89.3%) patients were included in the primary analysis, respectively. Ezetimibe reduced the incidence of the primary outcome (hazard ratio [HR], 0.66; 95% CI, 0.50-0.86; P=0.002). Regarding the secondary outcomes, the incidences of composite cardiac events (HR, 0.60; 95% CI, 0.37-0.98; P=0.039) and coronary revascularization (HR, 0.38; 95% CI, 0.18-0.79; P=0.007) were lower in the ezetimibe group than in the control group; however, there was no difference in the incidence of stroke, all-cause mortality, or adverse events between trial groups. CONCLUSIONS: LDL-C-lowering therapy with ezetimibe prevented cardiovascular events, suggesting the importance of LDL-C lowering for primary prevention in individuals aged ≥75 years with elevated LDL-C. Given the open-label nature of the trial, its premature termination and issues with follow-up, the magnitude of benefit observed should be interpreted with caution. Clinical Registration: URL: https://www.umin.ac.jp. Unique identifier: UMIN000001988.

Effects of glycemic control on in-hospital mortality among acute heart failure patients with reduced, mid-range, and preserved ejection fraction.

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.

Prevalence of frailty, cognitive impairment, and sarcopenia in outpatients with cardiometabolic disease in a frailty clinic.

BACKGROUND: Although frailty and cognitive impairment are critical risk factors for disability and mortality in the general population of older inhabitants, the prevalence and incidence of these factors in individuals treated in the specialty outpatient clinics are unknown. METHODS: We recently established a frailty clinic for comprehensive assessments of conditions such as frailty, sarcopenia, and cognition, and planned 3-year prospective observational study to identify the risk factors for progression of these aging-related statuses. To date, we recruited 323 patients who revealed symptoms suggestive of frailty mainly from a specialty outpatient clinic of cardiology and diabetes. Frailty status was diagnosed by the modified Cardiovascular Health Study (mCHS) criteria and some other scales. Cognitive function was assessed by Mini-Mental State Examination (MMSE), Japanese version of the Montreal Cognitive Assessment (MoCA-J), and some other modalities. Sarcopenia was defined by the criteria of the Asian Working Group for Sarcopenia (AWGS). In this report, we outlined our frailty clinic and analyzed the background characteristics of the subjects. RESULTS: Most patients reported hypertension (78%), diabetes mellitus (57%), or dyslipidemia (63%), and cardiovascular disease and probable heart failure also had a higher prevalence. The prevalence of frailty diagnosed according to the mCHS criteria, cognitive impairment defined by MMSE (≤27) and MoCA-J (≤25), and of AWGS-defined sarcopenia were 24, 41, and 84, and 31%, respectively. The prevalence of frailty and cognitive impairment increased with aging, whereas the increase in sarcopenia prevalence plateaued after the age of 80 years. No significant differences were observed in the prevalence of frailty, cognitive impairment, and sarcopenia between the groups with and without diabetes mellitus, hypertension, or dyslipidemia with a few exceptions, presumably due to the high-risk subjects who had multiple cardiovascular comorbidities. A majority of the frail and sarcopenic patients revealed cognitive impairment, whereas the frequency of suspected dementia among these patients were both approximately 20%. CONCLUSIONS: We found a high prevalence of frailty, cognitive impairment, and sarcopenia in patients with cardiometabolic disease in our frailty clinic. Comprehensive assessment of the high-risk patients could be useful to identify the risk factors for progression of frailty and cognitive decline.

Impact of age on left ventricular geometry and diastolic function in elderly patients with treated hypertension.

PURPOSE: Left ventricular (LV) remodelling is observed in numerous patients with hypertension and is a principal cause of heart failure in elderly patients. The aim of this study was to determine the relationships between age and structural/functional LV remodelling observed in elderly hypertensive patients. METHODS: A total of 557 elderly hypertensive patients (mean age: 74.0 ± 8.6 years) with preserved LV systolic function underwent echocardiography and 24-hour blood pressure (BP) measurement. RESULTS: Overall, 41.1% of patients had LV hypertrophy, 77.9% had increased relative wall thickness (RWT) defined as RWT >0.42, and 31.8% had both. Logistic analysis of the entire study population showed that increased RWT was associated with both 24-hour systolic BP (odds ratio (OR) 1.38, 95% confidence interval (CI) 1.12 to 1.70) and age (OR 1.32, 95%CI 1.08 to 1.61), whereas increased RWT was associated only with age (OR 1.61, 95%CI 1.23 to 2.11) after excluding patients with LV hypertrophy. Univariate and multivariate linear regression analyses of all patients showed that LV diastolic echocardiographic parameters were consistently associated with age (p ≤ .001) alone, even considering LV structural changes. CONCLUSIONS: Age was independently correlated with LV concentric/functional changes regardless of LV hypertrophy, suggesting that ageing is independently involved in the progression of LV remodelling.

Gender-Adjustment and Cutoff Values of Cornell Product in Hypertensive Japanese Patients.

In the Japanese population, the electrocardiographic (ECG) Cornell voltage and product predict cardiovascular events at lower values (Cornell voltage of 2.04 mV in males and 1.71 mV in females, and Cornell product of 158.7 mV× msec) than in the guidelines (2.8 mV, 2.0 mV, and 244 mV× msec, respectively). We evaluated the ECG criteria for left ventricular hypertrophy (LVH) corresponding to echocardiographic LVH (Echo-LVH) in Japanese patients.We reviewed data on 345 consecutive hypertensive patients who underwent echocardiography, and evaluated the Cornell voltage (S in leads V3 + R in leads aVL), Cornell product [ (Cornell voltage + 0.6 mV for females) × QRS duration], and left ventricular mass index (LVMI) (Echo-LVH: LVMI ≥ 116 g/m2 in males and ≥ 96 g/m2 in females).The mean age was 63.8 ± 12.5 years (174 males/172 females). Echo-LVH was found in 22.7% of males and 37.2% of females. The equations for estimating LVMI from the Cornell voltage were (1) LVMI = 14.5 × Cornell voltage + 78.9 for males and (2) LVMI = 21.5 × Cornell voltage + 61.5 for females. The Cornell voltage corresponding to Echo-LVH was 2.6 mV in males and 1.6 mV in females, which were below the guideline levels and close to the values indicating cardiovascular risk. The equation for estimating LVMI from the Cornell product was LVMI = 0.15 × Cornell product + 68.8. The Cornell product corresponding to Echo-LVH was 170 mV× msec (sensitivity: 0.730, specificity: 0.601), which was also close to the cardiovascular risk level.Cornell voltage and product values indicating Echo-LVH are lower than those in the current guidelines and closer to the cardiovascular risk levels.

Correlation of Pre- and In-Hospital Systolic Blood Pressure in Acute Heart Failure Patients and the Prognostic Implications　- Report From the Tokyo Cardiac Care Unit Network Emergency Medical Service Database.

BACKGROUND: Systolic blood pressure (SBP) is an important prognostic indicator for patients with acute heart failure (AHF). However, its changes and the effects in the different phases of the acute management process are not well known.Methods and Results:The Tokyo CCU Network prospectively collects on-site information about AHF from emergency medical services (EMS) and the emergency room (ER). The association between in-hospital death and SBP at 2 different time points (on-site SBP [measured by EMS] and in-hospital SBP [measured at the ER; ER-SBP]) was analyzed. From 2010 to 2012, a total of 5,669 patients were registered and stratified into groups according to both their on-site SBP and ER-SBP: >160 mmHg; 100-160 mmHg; and <100 mmHg. In-hospital mortality rates increased when both on-site SBP and ER-SBP were low. After multivariate adjustment, both SBPs were inversely associated with in-hospital death. Notably, the risk for patients with ER-SBP of 100-160 mmHg (intermediate risk) differed according to their on-site SBP; those with on-site SBP <100 or 100-160 mmHg were at higher risk (OR, 7.39; 95% CI, 4.00-13.6 and OR, 2.73; 95% CI, 1.83-4.08, respectively [P<0.001 for both]) than patients with on-site SBP >160 mmHg. CONCLUSIONS: Monitoring changes in SBP assisted risk stratification of AHF patients, particularly patients with intermediate ER-SBP measurements. (Circ J 2016; 80: 2473-2481).

Waon Therapy for Managing Chronic Heart Failure　- Results From a Multicenter Prospective Randomized WAON-CHF Study.

BACKGROUND: Waon therapy improves heart failure (HF) symptoms, but further evidence in patients with advanced HF remains uncertain. METHODS AND RESULTS: In 19 institutes, we prospectively enrolled hospitalized patients with advanced HF, who had plasma levels of B-type natriuretic peptide (BNP) >500 pg/ml on admission and BNP >300 pg/ml regardless of more than 1 week of medical therapy. Enrolled patients were randomized into Waon therapy or control groups. Waon therapy was performed once daily for 10 days with a far infrared-ray dry sauna maintained at 60℃ for 15 min, followed by bed rest for 30 min covered with a blanket. The primary endpoint was the ratio of BNP before and after treatment. In total, 76 Waon therapy and 73 control patients (mean age 66 years, men 61%, mean plasma BNP 777 pg/ml) were studied. The groups differed only in body mass index and the frequency of diabetes. The plasma BNP, NYHA classification, 6-min walk distance (6MWD), and cardiothoracic ratio significantly improved only in the Waon therapy group. Improvements in NYHA classification, 6MWD, and cardiothoracic ratio were significant in the Waon therapy group, although the change in plasma BNP did not reach statistical significance. No serious adverse events were observed in either group. CONCLUSIONS: Waon therapy, a holistic soothing warmth therapy, showed clinical advantages in safety and efficacy among patients with advanced HF.

Automated office blood pressure measurement with the assistance of an instructional video in patients with hypertension.

OBJECTIVES: Automated office blood pressure (AOBP) measurement often requires assistance. Accompanied by an instructional video, AOBP measurement could be performed independently by patients. DESIGN AND METHODS: Seventy-five patients with hypertension were enrolled. AOBP was measured three times at 1-min intervals after 5 min of rest by an automated BP measurement device with the assistance of an animated instructional video. The video was designed originally to instruct patients on the way to measure BP appropriately. Perceived stress was evaluated using a questionnaire after the AOBP measurement. Office BP was measured three times using the same device. Home BP measurement was performed on 5 consecutive days. RESULTS: The mean age of the patients was 74.5 ±â€…10.6 years, and 96% were taking antihypertensive drugs. Mean AOBP, office BP and home BP measurements were 135.2 ±â€…17.2/81.3 ±â€…11.1, 139.3 ±â€…16.3/78.6 ±â€…10.9 and 129.2 ±â€…16.7/72.7 ±â€…8.9 mmHg, respectively. Regarding SBP, the mean AOBP was significantly lower than office BP ( P  = 0.005) and higher than home BP ( P  = 0.004). The differences in SBP and DBP between AOBP and home BP measurements were significantly related to patients' perceived stress when performing AOBP measurements ( r  = 0.289; P  = 0.013 and r  = 0.328; P  = 0.004). In a multivariate analysis, patients' perceived stress was a significant predictor of the difference between AOBP and home BP ( P  = 0.013), even after adjusting for age, sex, BMI and mean of AOBP and home BP. CONCLUSION: AOBP values measured with the assistance of an instructional video were between conventional office and home BP measurements. Perceived stress during AOBP measurement was related to the difference in AOBP from home BP.

Relationship between blood pressure and cognitive impairment in elderly outpatients with cardiometabolic diseases.

AIM: The aim of this study was to clarify the relationship between high or low blood pressure (BP) and cognitive function in elderly outpatients with cardiometabolic diseases. METHODS: We evaluated the association between BP and the Dementia Assessment Sheet for Community-based Integrated Care System-21 items (DASC-21), Mini Mental State Examination (MMSE), and Montreal Cognitive Assessment Tool (MoCA) (N = 677). RESULTS: The patients' mean age was 79.2 ± 6.3 years (male 35.3%), and BP was 132.1 ± 18.1/73.5 ± 12.2 mmHg. Systolic BP (SBP) was linearly related to the DASC-21 score (r = -0.122, P = 0.004), but not to the MMSE score (P = 0.101) or MoCA score (P = 0.802). Multiple linear regression analysis showed that lower SBP was significantly related to the DASC-21 score, even after controlling for confounding factors (B = -0.411 per 10 mmHg; 95% confidence interval [CI], -0.673 to -0.149; P = 0.002). Moreover, logistic regression analysis showed that lower SBP was associated with DASC-21 ≥ 31 (odds ratio = 0.838 per 10 mmHg, P = 0.048). An MMSE score ≤23 was significantly associated with higher SBP in patients without a history of hypertension but with lower SBP in those with hypertension, those on hypertensive medication, and those with dyslipidemia. CONCLUSION: Higher BP was associated with a higher prevalence of probable dementia in those without a history of hypertension, even in late life. In those with hypertension and those taking antihypertensives with comorbidities of stroke or heart failure, lower BP was associated with probable dementia, which was largely dependent on reduced activities of daily living, as measured by the DASC-21 score. Geriatr Gerontol Int 2024; 24: 110-117.

Association of pulse pressure and mean blood pressure to frailty, sarcopenia, and cognitive dysfunction in elderly outpatients with history of hypertension.

This study aimed to evaluate the relationship between pulse pressure (PP) and sarcopenia, frailty, and cognitive function in elderly patients with hypertension. We evaluated 435 elderly patients with a history of hypertension who visited the frail outpatient clinic between July 2015 and October 2021. Data at the 1-, 2-, and 3-year follow-ups were available for 222, 177, and 164 patients, respectively. Sarcopenia, frailty, and cognitive function, including Mini-Mental State Examination (MMSE) scores, were evaluated. The patients' mean age was 79.2 ± 6.3 years (male, 34.9%). PP and mean blood pressure (BP) were 60.1 ± 13.6 mmHg and 94.1 ± 13.0 mmHg, respectively. At baseline, lower PP was associated with probable dementia (MMSE score ≤23 points) (OR = 0.960 per 1 mmHg increase; 95% CI, 0.933-0.989; P = 0.006) in the model adjusted for conventional confounding factors and comorbidities, whereas higher PP was associated with low handgrip strength (OR = 1.018 per 1 mmHg increase; 95% CI, 1.001-1.036; P = 0.041). In multivariate-adjusted logistic regression analysis of patients with preserved handgrip strength at baseline, reductions in PP (OR = 0.844; 95% CI, 0.731-0.974; P = 0.020) and mean BP (OR = 0.861; 95% CI, 0.758-0.979; P = 0.022) were significantly associated with the incidence of low handgrip strength at 3 years. In conclusion, a higher PP induced by increased arterial stiffness was associated with lower handgrip strength, whereas a lower PP was associated with probable dementia. Reduced PP was associated with decreased handgrip strength after three years.

Comparison of clinical characteristics and prognostic factors in patients with heart failure with preserved ejection fraction with and without renal dysfunction.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) with renal dysfunction (RD) is considered to be a specific phenotype of HFpEF. This study aimed to compare the clinical characteristics and prognostic factors for in-hospital mortality between HFpEF-diagnosed patients with and without RD. METHODS: This multicenter retrospective study included 5867 consecutive patients with acute HFpEF. RD was defined by an estimated glomerular filtration rate (eGFR) of <60 mL/min per 1.73 m2. Kaplan-Meier survival curves and log-rank tests were used to compare the in-hospital mortality between the groups. Univariable and multivariable Cox regression analyses were performed to identify significant prognostic factors. RESULTS: Across the study cohort, 68% of patients had RD. In-hospital mortality was significantly higher in HFpEF patients with RD than in those without RD. The comorbidities and laboratory data differed significantly between the groups. Independent prognostic factors for in-hospital mortality in the HFpEF patients with RD were age (hazard ratio [HR], 1.039), systolic blood pressure (HR, 0.991), eGFR (HR, 0.981), C-reactive protein (CRP; HR, 1.028), diuretics (HR, 0.374), angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACE-I/ARBs; HR, 0.680), and beta-blockers (HR, 0.662). In HFpEF patients without RD, age (HR, 1.039), systolic blood pressure (HR, 0.979), and ACE-I/ARBs (HR, 0.373) were independent prognostic factors. CONCLUSIONS: Significant differences in the clinical characteristics and prognostic factors, such as CRP and beta-blockers, were observed between the HFpEF patients with and without RD. These results have implications for future research and may help guide individualized patient management strategies.

DASC-21 score and the risk of in-hospital death in elderly patients with heart failure.

AIM: We investigated whether the Dementia Assessment Sheet for Community-based Integrated Care System-21 Items (DASC-21), a questionnaire that assesses cognitive function, including activities of daily living (ADL), was predictive of in-hospital death and prolonged hospital stay in elderly patients hospitalized for heart failure. METHODS: We retrospectively assessed the DASC-21 score at the time of admission, in-hospital death, length of hospital stay, and change in the Barthel index in 399 patients hospitalized for heart failure between 2016 and 2019. RESULTS: The mean patient age was 85.8 ± 7.7 years (61.3% women). The median DASC-21 score was 38 (64.7% higher than 31). On multivariate logistic regression analysis, a higher DASC-21 score was associated with an increased risk of in-hospital death (odds ratio [OR] = 1.045 per 1 point increase, 95% confidence interval [CI]: 1.010-1.081, P = 0.012), even after adjusting for confounding factors, including atrial fibrillation, ejection fraction, and B-type natriuretic peptide. Difficulties (3 or 4) with the self-management of medication in instrumental ADL inside the home (OR = 3.28, 95% CI: 1.05-10.28, P = 0.042), toileting (OR = 3.66, 95% CI: 1.19-11.29, P = 0.024), grooming (OR = 6.47, 95% CI: 2.00-20.96, P = 0.002), eating (OR = 7.96, 95% CI: 2.49-25.45, P < 0.001), and mobility in physical ADL (OR = 5.99, 95% CI: 1.85-19.35, P = 0.003) were identified as risk factors for in-hospital death. Patients in the highest tertile of the DASC-21 score had a significantly longer hospital stay (P = 0.006) and a greater reduction in the Barthel index (P < 0.001). CONCLUSIONS: In elderly patients hospitalized for heart failure, higher DASC-21 scores were associated with an increased risk of in-hospital death, prolonged hospital stay, and impaired ADL. Geriatr Gerontol Int 2024; 24: 546-553.

[Acute decompensated heart failure].

Acute decompensated heart failure (ADHF) is common in the elderly, who often have various heart diseases and co-morbidities. Another term, acute heart failure syndrome (AHFS) means that it is an association of heart conditions and that it must be treated immediately. An overview of ADHF treatment begins with common hyperacute-phase treatments including advanced cardiac life support, alleviation of dyspnea, and alleviation of congestion and/or hypo-perfusion. Non-invasive positive-pressure ventilation (NPPV) is often effective for dyspnea. Congestion and hypo-perfusion are assessed with Nohria-Stevenson classification, and should be properly adjusted. Then, the patients are treated differently, dependent on the clinical scenario, which helps to discriminate cardiac failure and vascular failure. After echocardiography, specific treatment for specific heart disease is performed.