Prognostic impact of nutritional status and physical capacity in elderly patients with acute decompensated heart failure.

AIMS: Nutritional status as well as physical capacity is related to prognosis in patients with heart failure. The purpose of this study was to explore a simple prognostic indicator in patients with acute decompensated heart failure (ADHF) by including both nutritional status and physical capacity. METHODS AND RESULTS: Patients hospitalized with ADHF (N = 203; mean age, 81 years) were enrolled. We evaluated the geriatric nutritional risk index (GNRI) on hospital admission and at discharge. A GNRI score < 92 was defined as malnutrition. Physical capacity was evaluated by simple walking test to determine if patients could walk 200 m, with a Borg scale score ≤ 13, without critical changes in vital signs. Primary endpoints were mortality and heart failure rehospitalization within 2 years. A total of 49% and 48% of patients showed malnutrition on admission and at discharge, respectively. Malnutrition at discharge was more strongly related to mortality [hazard ratio (HR) 3.382, 95% confidence interval (CI) 1.900-6.020, P < 0.0001)] than that on admission (HR 2.448, 95% CI 1.442-4.157, P = 0.001) by univariable analysis. Malnutrition at discharge was related to mortality (HR 2.370, 95% CI 1.166-4.814, P = 0.02), but malnutrition on admission was not related (HR 1.538, 95% CI 0.823-2.875, P = 0.18) by multivariable analysis. Almost half of patients (45%) could not walk 200 m, which was significantly related to mortality by univariable analysis (HR 3.303, 95% CI 1.905-5.727, P < 0.0001), but was not by multivariable analysis (HR 1.990, 95% CI 0.999-3.962, P = 0.05). The combined index including both GNRI and simple walking test was an independent and stronger predictor of mortality than either index alone by multivariable analysis (HR 2.249, 95% CI 1.362-3.716, P < 0.01). Neither malnutrition nor low physical capacity was related to heart failure rehospitalization by univariable analysis (HR 0.702, 95% CI 0.483-1.020, P = 0.06; HR 1.047, 95% CI 0.724-1.515, P = 0.81, respectively). Malnutrition at discharge significantly reduced heart failure rehospitalization by multivariable analysis (HR 0.431, 95% CI 0.266-0.698, P < 0.01). When patients were classified into Group G (both nutritional status and physical capacity at discharge were good), Group E (either was good), and Group B (both were bad), mortality rates were significantly different among the groups (log rank P < 0.0001). CONCLUSION: A simple indicator including both nutritional status and physical capacity may predict 2 year mortality in elderly patients with ADHF.

Impact of Angioscopic Evaluation for Femoropopliteal In-Stent Restenosis Before and After Excimer Laser Atherectomy.

In-stent restenosis (ISR) is a prevalent problem following stenting of femoropopliteal lesions. A potential novel treatment modality for ISR including excimer laser atherectomy (ELA) has become available. We performed ELA for in-stent chronic total occlusion (CTO) of femoropopliteal lesions and evaluated lesion morphology before and after ELA by angioscopy in 2 patients. The angioscopic findings clearly showed removal of in-stent thrombi after ELA. Thus, ELA may be effective for in-stent CTO of femoropopliteal lesions. This is the first report describing the direct visualization of ELA effect for vaporization of thrombi in femoropopliteal in-stent lesions by angioscopy.

Successful treatment with tacrolimus in a case of lung-dominant connective tissue disease.

A 49-year-old man with dyspnea was found to have reticular opacities and ground-glass attenuation with traction bronchiectasis or bronchiolectasis on computed tomography. The patient met the criteria for lung-dominant connective tissue disease (LD-CTD) and histopathologically exhibited a chronic fibrotic interstitial pneumonia illustrating framework of a usual interstitial pneumonia-like pattern. Due to worsening of the disease, therapy was initiated with corticosteroids in combination with cyclosporine A. However, treatment with these drugs was ineffective. Pirfenidone and intravenous cyclophosphamide therapy also proved ineffective. The cyclosporine A was therefore switched to tacrolimus, and the patient's disease improved, allowing for a reduction in the dose of the corticosteroids. Our experience in this case suggests that treatment with tacrolimus might be useful for treating refractory LD-CTD even when histopathologically chronic fibrotic interstitial pneumonia is evident.