Two-Year Clinical Outcome of MitraClip Transcatheter Edge-to-Edge Repair From the J-MITRA Registry Data.

BACKGROUND: The introduction of transcatheter edge-to-edge repair for moderate-to-severe or severe mitral regurgitation (MR) utilizing the MitraClip system became reimbursed and clinically accessible in Japan in April 2018. This study presents the 2-year clinical outcomes of all consecutively treated patients who underwent MitraClip implantation in Japan and were prospectively enrolled in the Japanese Circulation Society-oriented J-MITRA registry.Methods and Results: Analysis encompassed 2,739 consecutive patients enrolled in the J-MITRA registry with informed consent (mean age: 78.3±9.6 years, 1,550 males, STS risk score 11.7±8.9), comprising 1,999 cases of functional MR, 644 of degenerative MR and 96 in a mixed group (DMR and FMR). The acute procedure success rate was 88.9%. After MitraClip implantation, >80% exhibited an MR grade ≤2+ and the trend was sustained over the 2 years. Within this observation period, the mortality rate was 19.3% and the rate of heart failure readmissions was 20.6%. The primary composite endpoint, inclusive of cardiovascular death and heart failure readmission, was significantly higher in patients with functional MR than in with degenerative MR (32.0% vs. 17.5%, P<0.001). CONCLUSIONS: The 2-year clinical outcomes after MitraClip implantation were deduced from comprehensive data within an all-Japan registry.

In-Hospital Death and End-of-Life Status Among Patients With Adult Congenital Heart Disease　- A Retrospective Study Using the JROAD-DPC Database in Japan.

BACKGROUND: The end-of-life (EOL) status, including age at death and treatment details, of patients with adult congenital heart disease (ACHD) remains unclear. This study investigated the EOL status of patients with ACHD using a nationwide Japanese database.Methods and Results: Data on the last hospitalization of 26,438 patients with ACHD aged ≥15 years, admitted between 2013 and 2017, were included. Disease complexity (simple, moderate, or great) was classified using International Classification of Diseases, 10th Revision codes. Of the 853 deaths, 831 patients with classifiable disease complexity were evaluated for EOL status. The median age at death of patients in the simple, moderate, and great disease complexity groups was 77.0, 66.5, and 39.0 years , respectively. The treatments administered before death to patients in the simple, moderate, and great complexity groups included cardiopulmonary resuscitation (30.1%, 35.7%, and 41.9%, respectively), percutaneous cardiopulmonary support (7.2%, 16.5%, and 16.3%, respectively), and mechanical ventilation (58.7%, 72.2%, and 75.6%, respectively). Overall, 70% of patients died outside of specialized facilities, with >25% dying after ≥31 days of hospitalization. CONCLUSIONS: Nationwide data showed that patients with ACHD with greater disease complexity died at a younger age and underwent more invasive treatments before death, with many dying after ≥1 month of hospitalization. Discussing EOL options with patients at the appropriate time is important, particularly for patients with greater disease complexity.

Prevalence and temporal trends of prostate diseases among inpatients with cardiovascular disease: a nationwide real-world database survey in Japan.

Introduction: Benign prostate hyperplasia (BPH) and prostate cancer (PCa) are major prostate diseases that potentially share cardiometabolic risk factors and an elevated risk for cardiovascular disease (CVD). However, the prevalence of prostate diseases among patients with established CVD remains unclear. Materials and methods: This nationwide retrospective study assessed the prevalence and temporal trend of prostate diseases (i.e., BPH or PCa) among patients hospitalized for CVDs in Japan. We used a claims database (the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination), which included data on 6,078,487 male patients recorded from 1,058 hospitals between April 2012 and March 2020. We conducted the Cochran-Armitage trend test and calculated the adjusted odds ratio (aOR) with 95% confidence intervals (CIs). Results: The prevalence of prostate diseases over the entire study period was 5.7% (BPH, 4.4%; PCa, 1.6%). When dividing the overall cohort into age categories (<65, 65-74, and ≥75 years old), the prevalence was 1.1%, 4.7%, and 9.9%, respectively (P for trend <0.05). In addition, the annual prevalence showed a modest increasing trend over time. Patients admitted for heart failure (HF) were significantly associated with a higher incidence of coexisting prostate diseases than those admitted for non-HF causes [aOR 1.02 (95% CI, 1.01-1.03)] or acute coronary syndrome [aOR 1.19 (95% CI, 1.17-1.22)]. Conclusions: The nationwide real-world database revealed that the prevalence of prostate diseases is increasing among patients hospitalized for CVD, particularly HF. Attention to detailed causality and continued surveillance are needed to further clarify the clinical characteristics of prostate diseases among patients with CVD.

Effects of temperature and humidity on cerebrovascular disease hospitalization in a super-aging society.

Weather conditions influence the incidence of cardiovascular disease. However, few studies have investigated the association between weather temperature and humidity and cerebrovascular disease hospitalizations in a super-aging society. We included 606,807 consecutive patients with cerebrovascular disease admitted to Japanese acute-care hospitals between 2015 and 2019. The primary outcome was the number of cerebrovascular disease hospitalizations per day. Multilevel mixed-effects linear regression models were used to estimate the association of mean temperature and humidity, 1 day before hospital admission, with cerebrovascular disease hospitalizations, after adjusting for air pollution, hospital, and patient demographics. Lower mean temperatures and humidity < 70% or humidity ≧ 70% are associated with an increased incidence of cerebrovascular disease hospitalization (coefficient, - 1.442 [- 1.473 to - 1.411] per °C, p < 0.001, coefficient, - 0.084 [- 0.112 to - 0.056] per%, p < 0.001, and coefficient, 0.136 [0.103 to 0.168] per %, p < 0.001, respectively). Lower mean temperatures and extremely lower or higher humidity are associated with an increased incidence of cerebrovascular disease hospitalization in a super-aging society.

Trends in Unplanned Admissions of Patients With Adult Congenital Heart Disease Based on the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination Study.

BACKGROUND: The prevalence of adult congenital heart disease (ACHD) is increasing rapidly and in particular, patients who underwent complicated surgeries are reaching their youth and middle age. Therefore, the need for ACHD treatment will increase, but the current medical situation is unknown. In this study we assessed trends in unplanned admissions in patients with ACHD in Japan.Methods and Results: From the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination, a nationwide claim-based database, we selected patients aged >15 years with CHD defined by the International Classification of Diseases, 10th Revision codes. We identified 39,676 admissions between April 2012 and March 2018; 10,444 (26.3%) were unplanned. Main diagnoses were categorized into 3 degrees of complexity (severe, moderate, and mild) and other. Among unplanned admissions, the proportion of the severe group increased with time. Patients in the mild group were significantly older than those in the moderate and severe groups (median age: 70.0, 39.0, and 32.0 years, respectively). There were 765 deaths during hospitalization (overall mortality rate, 7.3%). The odds ratio of death during admission was significantly higher in patients aged >50 years, especially in the moderate group. CONCLUSIONS: Patients with moderate or severe ACHD tended to experience unplanned admissions at a younger age. In anticipation of greater numbers of new, severe patients, we need to prepare for their increasing medical demands.

Management and Outcomes of Acute Heart Failure Hospitalizations in Japan.

BACKGROUND: Heart failure (HF) is a global burden on healthcare systems, but the literature regarding nationwide trends in the care and outcomes of HF hospitalization in Japan is limited. Therefore, we aimed to investigate the trends in patient characteristics, treatment patterns, and outcomes of patients hospitalized with acute HF.Methods and Results: We used data from the Japanese Registry of All Cardiac and Vascular Diseases and the Diagnosis Procedure Combination database between April 2012 and March 2021 to analyze 840,357 patients aged ≥18 years who were hospitalized with an acute HF diagnosis. Over the study period (2012-2020), the mean (±standard deviation) age increased from 78.9 (±11.9) years to 80.9 (±11.8) years (P for trend <0.001), the proportion of female patients decreased from 48.7% to 47.5% (P for trend=0.02), crude in-hospital mortality rate decreased from 11.5% to 10.9%, and 30-day HF readmissions decreased from 7.4% to 7.0% (both P for trend <0.001). The reduction in outcomes was more apparent in the older age groups. The standardized outcomes demonstrated the same trends as the crude outcomes. CONCLUSIONS: Our nationwide hospital admission analysis clarified that patients hospitalized with acute HF were getting older, but mortality and readmission rates also decreased, especially in older patients during the 2010s.

Long-Term Follow-up Study of Hospitalizations for Acute Coronary Syndrome in Kobe-City and Other Districts Under the Hyogo Smoking Ban Legislation　- A Nationwide Database Study.

BACKGROUND: Hyogo Prefecture has managed smoking ban legislation with partial restrictions in public places (Hyogo-L) since 2013. Previous studies have reported a significant decrease in admissions for acute coronary syndrome (ACS) in Kobe-city, but not in other districts of Hyogo Prefecture in the 2 years after Hyogo-L. The aim of the present study was to define the long-term effect of Hyogo-L.Methods and Results: The JROAD-DPC dataset was used to collect information on the number of hospitalizations for ACS in Hyogo Prefecture, and in Osaka-city without smoking ban legislation, from April 2013 to March 2020. Poisson regression analysis was performed to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs). ACS records of 3,101 in Kobe-city, 11,375 in areas of Hyogo Prefecture other than Kobe-city and 11,079 in Osaka-city were collected for admissions. The incidence of ACS reduced significantly over time in Kobe-city [IRR (95% CI); 0.96 (0.94-0.97)], but did not reduce in the others. The decrease in Kobe-city was observed in ACS patients without smoking, hypertension, and hyperlipidemia, but not in those with such risk factors. CONCLUSIONS: The long-term ACS reduction or non-reduction under Hyogo-L was determined at the initial period and the same scenario continued, supporting the importance of legislation and compliance with the smoking ban. The lowering effect was remarkable in ACS patients without risk factors such as non-smoking.

Satisfaction Survey for Regional Clinical Pathway for Stroke Patients in Acute and Rehabilitation Hospitals in Japan.

Objectives: We collected opinions about the use of a stroke-specific regional clinical pathway for facilitating collaboration between acute and rehabilitation hospitals in Japan. Methods: The study surveys were administered in acute hospitals designated as primary stroke centers and certified by the Japan Stroke Association (n=961) and in rehabilitation hospitals affiliated with the Kaifukuki Rehabilitation Ward Association (n=1237). The survey collected information on interfacility collaboration when caring for patients admitted during the acute phase following non-traumatic stroke from April 2020 to March 2021. We examined the pathway's usefulness and challenges relative to facility type using the χ2 test. Results: Of 422 acute hospitals and 223 rehabilitation hospitals that responded to our survey, 259 (62.1%) acute hospitals and 164 (85.4%) rehabilitation hospitals used the pathway. Fewer rehabilitation hospitals than acute hospitals considered that the pathway was useful (52.0% vs. 63.8%, P=0.02). Fewer rehabilitation hospitals did not experience pathway-related problems when compared with acute hospitals (38.0% vs. 55.8%, P<0.01). Conclusions: Personnel at rehabilitation hospitals were less satisfied with the regional clinical care pathway than those in acute hospitals. These results suggest that the current stroke-specific regional clinical pathway could be improved.

Transvenous lead extraction versus surgical lead extraction or conservative treatment for cardiac implantable electronic device infections: Propensity score-weighted analyses of a nationwide claim-based database.

INTRODUCTION: Infection is one of the most important complications associated with cardiac implantable electronic device (CIED) therapy. The number of reports comparing the outcomes of transvenous lead extraction (TLE), surgical lead extraction, and conservative treatment for CIED infections using a real-world database is limited. This study investigated the association between the treatment strategies for CIED infections and their outcomes. METHODS: We performed a retrospective analysis of 3605 patients with CIED infections admitted to 681 hospitals using a nationwide claim-based database collected between April 2012 and March 2018. RESULTS: We divided the 3605 patients into TLE (n = 938 [26%]), surgical lead extraction (n = 182 [5.0%]), and conservative treatment (n = 2485 [69%]) groups. TLE was performed more frequently in younger patients and at larger hospitals (p for trend < .001 for both). The rate of TLE increased during the study period, whereas that of surgical lead extraction decreased (p for trend < .001 for both). TLE was associated with lower in-hospital mortality (vs. surgical lead extraction: odds ratio [OR], 0.20; 95% CI, 0.06-0.70; vs. conservative treatment: OR, 0.45; 95% CI: 0.22-0.94) and lower 30-day readmission rates (vs. surgical lead extraction: OR, 0.18; 95% CI: 0.06-0.56; vs. conservative treatment: OR, 0.06; 95% CI, 0.03-0.13) in propensity score-weighted analyses. CONCLUSIONS: Only 26% of patients hospitalized for CIED infections received TLE. TLE was associated with significantly lower in-hospital mortality and 30-day recurrence rates than surgical lead extraction and conservative treatment, suggesting that TLE should be more widely recommended as a first-line treatment for CIED infections.

Benefits of guideline-directed medical therapy to loop diuretics in management of heart failure.

BACKGROUND: We sought to compare the outcomes of patients receiving combination therapy of diuretics and neurohormonal blockers, with a matched cohort with monotherapy of loop diuretics, using real-world big data. METHODS: This study was based on the Diagnosis Procedure Combination database in the Japanese Registry of All Cardiac and Vascular Datasets (JROAD-DPC). After exclusion criteria, we identified 78,685 patients who were first hospitalized with heart failure (HF) between April 2015 and March 2017. Propensity score (PS) was estimated with logistic regression model, with neurohormonal blockers (angiotensin-converting enzyme inhibitor : ACEi or angiotensin receptor blocker : ARB, ?-blockers and mineralocorticoid receptor antagonists : MRA) as the dependent variable and 24 clinically relevant covariates to compare the in-hospital mortality between monotherapy of loop diuretics and combination therapies. RESULTS: On PS-matched analysis, patients with ACEi?/?ARB, ?-blockers, and MRA had lower total in-hospital mortality and in-hospital mortality within 7 days, 14 days and 30 days. In the sub-group analysis, regardless of clinical characteristics including elderly people and cancer, patients treated with a combination of loop diuretics and neurohormonal blockers had significantly lower in-hospital mortality than matched patients. CONCLUSIONS: Our data indicate the benefits of guideline-directed medical therapy to loop diuretics in the management of HF. J. Med. Invest. 70 : 41-53, February, 2023.

Impact of seasonal variation on hospital admission and in-hospital mortality of acute cardiovascular diseases: a contemporary nationwide database study.

PURPOSE: Whether acute cardiovascular diseases (CVDs), such as acute heart failure (AHF), acute myocardial infarction (AMI), and acute aortic dissection (AAD), have distinct seasonal variations in the number of hospitalizations and in-hospital mortality was investigated using a nationwide database in Japan. METHODS: The hospitalized patients with AHF, AMI, and AAD between April 2012 and March 2020 were identified. Multilevel mixed-effects logistic regression was conducted and adjusted odds ratio (aOR) was calculated. Also, the Poisson regression model was conducted to calculate the peak-to-trough ratio (PTTR) with peak month. RESULTS: Patients identified were as follows: 752,434 AHF patients (median age, 82 years; male, 52.2%), 346,110 AMI patients (median age, 71 years; male, 72.2%), and 118,538 AAD patients (median age, 72 years; male, 58.0%). The monthly proportion of hospitalized patients was the highest in winter and the lowest in summer in all three diseases. Based on aOR, 14-day mortality was the lowest in spring for AHF, summer for AMI, and spring for AAD. Furthermore, the PTTRs with peak month were 1.24 for AHF in February, 1.34 for AMI in January, and 1.33 for AAD in February. CONCLUSIONS: A clear seasonal pattern was observed in the number of hospitalizations and in-hospital mortality of all acute CVDs, independent of confounders.

Clinical Predictors of Pacing Device Implantation in Implantable Cardiac Monitor Recipients for Unexplained Syncope.

Background: Implantable cardiac monitors (ICMs) help investigate the cause of unexplained syncope, but the probability and predictors of needing a pacing device thereafter remain unclear. Methods: We retrospectively analyzed the data of patients who received ICM insertion for unexplained syncope with suspected arrhythmic etiology. The data were obtained from a nationwide database obtained between April 1, 2012 and March 31, 2020. Multivariable mixed-effects survival analysis was performed to identify predictors of pacing device implantation (PDI), and a risk score model was developed accordingly. Results: In total, 2905 patients (age: 72 years [range: 60-78]) implanted with ICMs to investigate the cause of syncope were analyzed. During the median follow-up period of 128 days (range: 68-209) days, 473 patients (16%) underwent PDI. Older age, history of atrial fibrillation, bundle branch block (BBB), and diabetes were independent predictors of PDI in multivariable analysis. A risk score model was developed with scores ranging from 0 to 32 points. When patients with the lowest quartile score (0-13 points) were used as a reference, those with higher quartiles had a higher risk of PDI (second quartile: 14-15 points, hazard ratio [HR]: 3.86, 95% confidence interval [CI]: 2.62-5.68; third quartile: 16-18 points, HR: 4.67, 95% CI: 3.14-6.94; fourth quartile: 19-32 points, HR: 6.59, 95% CI: 4.47-9.71). Conclusions: The 4 identified predictors are easily assessed during the initial evaluation of patients with syncope. They may help identify patients with a higher risk of requiring permanent PDI.

Contexte: Les moniteurs cardiaques implantables (MCI) aident à déterminer la cause d'une syncope inexpliquée, mais la probabilité et les facteurs prédictifs du besoin d'un dispositif de stimulation cardiaque par la suite demeurent incertains. Méthodologie: Nous avons analysé de façon rétrospective les données de patients s'étant fait implanter un MCI après une syncope inexpliquée et chez lesquels une étiologie d'arythmie était soupçonnée. Les données proviennent d'une base de données nationale et s'étendent du 1er avril 2012 au 31 mars 2020. Une analyse de survie multivariable à effets mixtes a été effectuée pour cibler les facteurs prédictifs de l'implantation d'un dispositif de stimulation cardiaque (IDSC), et un modèle de score de risque a été conçu en conséquence. Résultats: Au total, les cas de 2905 patients (âge : 72 ans [écart interquartile (ÉI) : 60-78]) ayant reçu un MCI pour déterminer la cause de la syncope ont été analysés. Durant la période de suivi médiane de 128 jours (ÉI : 68-209), 473 patients (16 %) ont subi une IDSC. L'âge avancé, les antécédents de fibrillation auriculaire, le bloc de branche et le diabète étaient des facteurs prédictifs indépendants de l'IDSC dans l'analyse multivariable. Un modèle de score de risque a été conçu, les scores allant de 0 à 32 points. Lorsque les patients ayant un score dans le quartile inférieur (0 à 13 points) étaient utilisés à titre de référence, ceux ayant un score dans les quartiles supérieurs avaient un risque plus élevé d'IDSC (deuxième quartile : 14-15 points, rapport des risques instantanés [RRI] : 3,86, intervalle de confiance [IC] à 95 % de 2,62 à 5,68; troisième quartile : 16-18 points, RRI : 4,67, IC à 95 % de 3,14 à 6,94; quatrième quartile : 19-32 points, RRI : 6,59, IC à 95 % de 4,47 à 9,71). Conclusions: Les quatre facteurs prédictifs ciblés sont faciles à évaluer durant l'évaluation initiale des patients ayant subi une syncope. Ils peuvent aider à repérer les patients présentant un risque plus élevé d'avoir besoin d'un dispositif de stimulation cardiaque permanent.

Relationship between the volume of cases and in-hospital mortality in patients with cardiogenic shock receiving short-term mechanical circulatory support.

BACKGROUND: We examined the relationship between annual case volume at each hospital and outcome in cardiogenic shock (CS) patients receiving mechanical circulatory support (MCS) devices. METHODS: This cross-sectional study used the Japanese nationwide database to identify patients receiving short-term MCS for CS between April 2012 and March 2020. Of 65,837 patients, 3 subcohorts were created; the intra-aortic balloon pump (IABP) alone (n = 48,643), the extracorporeal membrane oxygenation (ECMO) (n = 16,871), and the Impella cohorts (n = 696). RESULTS: The median annual case volume was 13.5 (7.4-22.1) in the IABP alone cohort, 6.4 (3.4-11.0) in the ECMO cohort, and 7.5 (4.0-10.7) in the Impella cohort. The highest quintile for the volume of cases in the IABP alone and ECMO had the lowest in-hospital mortality (IABP alone, 25.1% in quintile 1 vs 15.2% in quintile 5; ECMO, 73.7% in quintile 1 in 67.4% in quintile 5). Adjusted ORs for in-hospital mortality decreased as case volume increased (IABP alone, 0.63 [0.58-0.68] in quintile 5; ECMO, 0.73 [0.65-0.82] in quintile 5, with the lowest quintile as reference) but did not decrease significantly in the Impella (0.90 [0.58-1.39] in tertile 3, with the lowest tertile as reference). In the continuous models with the case volume as a continuous variable, adjusted ORs for in-hospital mortality decreased to 28 IABP cases/year and 12 ECMO cases/year. They did not decrease or became almost flat above that. CONCLUSIONS: Higher volumes of IABP and ECMO are associated with a lower mortality. There is an upper limit to the decline. Centralizing patients with refractory CS in a particular hospital might improve patient outcomes in each region.

Prognosis in Patients With Cardiogenic Shock Who Received Temporary Mechanical Circulatory Support.

Background: Temporary mechanical circulatory support (MCS) is often used in patients with cardiogenic shock (CS), and the type of MCS may vary by cause of CS. Objectives: This study sought to describe the causes of CS in patients receiving temporary MCS, the types of MCS used, and associated mortality. Methods: This study used a nationwide Japanese database to identify patients receiving temporary MCS for CS between April 1, 2012, and March 31, 2020. Results: Of 65,837 patients, the cause of CS was acute myocardial infarction (AMI) in 77.4%, heart failure (HF) in 10.9%, valvular disease in 2.7%, fulminant myocarditis (FM) in 2.5%, arrhythmia in 4.5%, and pulmonary embolism (PE) in 2.0% of cases. The most commonly used MCS was an intra-aortic balloon pump alone in AMI (79.2%) and in HF (79.0%) and in valvular disease (66.0%), extracorporeal membrane oxygenation with intra-aortic balloon pump in FM (56.2%) and arrhythmia (43.3%), and extracorporeal membrane oxygenation alone in PE (71.5%). Overall in-hospital mortality was 32.4%; 30.0% in AMI, 32.6% in HF, 33.1% in valvular disease, 34.2% in FM, 60.9% in arrhythmia, and 59.2% in PE. Overall in-hospital mortality increased from 30.4% in 2012 to 34.1% in 2019. After adjustment, valvular disease, FM, and PE had lower in-hospital mortality than AMI: valvular disease, OR: 0.56 (95% CI: 0.50-0.64); FM: OR: 0.58 (95% CI: 0.52-0.66); PE: OR: 0.49 (95% CI: 0.43-0.56); whereas HF had similar in-hospital mortality (OR: 0.99; 95% CI: 0.92-1.05) and arrhythmia had higher in-hospital mortality (OR: 1.14; 95% CI: 1.04-1.26). Conclusions: In a Japanese national registry of patients with CS, different causes of CS were associated with different types of MCS and differences in survival.

Impact of Low Body Mass Index on Cardiac Tamponade During Catheter Ablation for Atrial Fibrillation.

BACKGROUND: Cardiac tamponade is a potentially fatal complication of catheter ablation for atrial fibrillation (AF). OBJECTIVES: This study aimed to evaluate the impact of body mass index (BMI) on cardiac tamponade during AF ablation. METHODS: Patients who underwent catheter ablation for AF between April 1, 2016 and March 31, 2018 were analyzed using a Japanese nationwide claims database. Mixed-effects multivariable Poisson regression analysis was performed to investigate the association between BMI and cardiac tamponade. RESULTS: A total of 59,789 hospitalizations (age 65.6 ± 10.4 years, 29% women) with catheter ablation for AF were analyzed. Cardiac tamponade occurred in 647 patients (1.1%). Multivariable analysis revealed that being underweight (BMI <18.5 kg/m2) was associated with an increased risk of cardiac tamponade (relative risk [RR]: 1.42; 95% CI: 1.03-1.95) when compared with having a normal weight (BMI ≥18.5 and <25 kg/m2). Other characteristics that were associated with an increased risk of cardiac tamponade were age ≥75 years, female sex, and a history of heart failure, hypertension, diabetes, and dialysis treatment. CONCLUSIONS: In this analysis of a large nationwide database of patients with AF who underwent ablation, being underweight was independently associated with an increased risk of cardiac tamponade during AF ablation. Clinicians should consider the higher risk of cardiac tamponade in the underweight population and take appropriate measures to reduce this risk.

Comparison of care and outcomes for myocardial infarction by heart failure status between United Kingdom and Japan.

AIMS: Prognosis for ST-segment elevation myocardial infarction (STEMI) is worse when heart failure is present on admission. Understanding clinical practice in different health systems can identify areas for quality improvement initiatives to improve outcomes. In the absence of international comparison studies, we aimed to compare treatments and in-hospital outcomes of patients admitted with ST elevation myocardial infarction (STEMI) by heart failure status in two healthcare-wide cohorts. METHODS AND RESULTS: We used two nationwide databases to capture admissions with STEMI in the United Kingdom (Myocardial ischemia National Audit Project, MINAP) and Japan (Japanese Registry of All Cardiac and Vascular Diseases-Diagnostic Procedure Combination, JROAD-DPC) between 2012 and 2017. Participants were stratified using the HF Killip classification into three groups; Killip 1: no congestive heart failure, Killip 2-3: congestive heart failure, Killip 4: cardiogenic shock. We calculated crude rate and case mix standardized risk ratios (CSRR) for use of treatments and in-hospital death. Patients were younger in the United Kingdom (65.4 [13.6] vs. 69.1 [13.0] years) and more likely to have co-morbidities in the United Kingdom except for diabetes and hypertension. Japan had a higher percentage of heart failure and cardiogenic shock patients among STEMI during admission than that in the United Kingdom. Primary percutaneous coronary intervention (pPCI) rates were lower in the United Kingdom compared with Japan, especially for patients presenting with Killip 2-3 class heart failure (pPCI use in patients with Killip 1, 2-3, 4: Japan, 86.2%, 81.7%, 78.7%; United Kingdom, 79.6%, 58.2% and 79.9%). In contrast, beta-blocker use was consistently lower in Japan than in the United Kingdom (61.4% vs. 90.2%) across Killip classifications and length of hospital stay longer (17.0 [9.7] vs. 5.0 [7.4] days). The crude rate of in-hospital mortality increased with increasing Killip class group. Both the crude rate and CSRR was higher in the United Kingdom compared with Japan for Killip 2-3 (15.8% vs. 6.4%, CSRR 1.80 95% CI 1.73-1.87, P < 0.001), and similar for Killip 4 (36.9% vs. 36.3%, CSRR 1.11 95% CI 1.08-1.13, P < 0.001). CONCLUSIONS: Important differences in the care and outcomes for STEMI with heart failure exist between the United Kingdom and Japan. Specifically, in the United Kingdom, there was a lower rate of pPCI, and in Japan, fewer patients were prescribed beta blockers and hospital length of stay was longer. This international comparison can inform targeted quality improvement programmes to narrow the outcome gap between health systems.

Temporal Trends and Regional Variations in Cardiovascular Care in Japan, 2010-2019.

Cardiovascular diseases are a major cause of mortality worldwide. Nonetheless, the current trend in cardiology hospitals in Japan has not been comprehensively explored.This descriptive study used the Japanese Registry of All Cardiac and Vascular Diseases database during 2010-2019. The nationwide 10-year trend in cardiovascular medical care systems was described in detail corresponding to the regions in Japan.Cardiovascular facilities and the number of cardiology beds, hospitalized patients, and cardiologists increased during 2010-2019. There were regional differences in the number of patients and cardiologists per bed, but the differences in the number of hospitalized patients per cardiologist decreased among the regions. Of the three major acute cardiovascular diseases, patients hospitalized with heart failure per cardiologist have been increasing. However, the in-hospital mortality rates have not changed over the last decade (8.6% for acute myocardial infarction, 7.7% for heart failure, and 12.7% for acute aortic dissection in 2019).There was an increasing trend in the availability of cardiovascular care resources in Japan during 2010-2019. This study provides a comprehensive summary of the current cardiovascular care and the follow-up required in the future.

Study Protocol of Cardiac Rehabilitation for Acute Myocardial Infarction From the JROAD/JROAD-DPC Database　- JROAD-CR.

Background: Although cardiac rehabilitation (CR) has been reported to be effective for improving the prognosis of acute myocardial infarction (AMI), more patients must participate in CR during admission and as outpatients. Factors contributing to, and countermeasures against, the low CR participation rate need to be identified. Here we describe the protocol for a study designed to evaluate the effectiveness and problems of CR for AMI from the Japanese Registry of All Cardiac and Vascular Diseases (JROAD) and the JROAD-Japanese Diagnosis Procedure Combination system (JROAD-DPC) database. Methods and Results: This is a multicenter retrospective cohort study that will use the JROAD/JROAD-DPC database to evaluate the effectiveness of CR for AMI (JROAD-CR). Five thousand patients with AMI who were admitted to hospitals registered in the JROAD database in 2014 will be investigated with regard to their baseline characteristics, AMI severity and treatment, examination results, history of CR, and prognosis up to 5 years. We will also investigate the presence, quantity, and quality of CR, and evaluate the effectiveness of CR with respect to cost, exercise tolerance, and prognosis during admission and follow-up. Conclusions: The JROAD-CR study will seek to reveal the effectiveness of CR for AMI in the era of early reperfusion therapy and shortened hospitalization.

Differences in patient characteristics, clinical practice and outcomes of cardiac implantable electric device therapy between Japan and the USA: a cross-sectional study using data from nationally representative administrative databases.

OBJECTIVES: To identify differences in patient characteristics, clinical practice and outcomes of cardiac implantable electronic device (CIED) therapy between Japan and the USA. DESIGN: A cross-sectional study. SETTING: Nationally representative administrative databases from Japan and the USA containing hospitalisations with first-time implantations of pacemakers, implantable cardioverter-defibrillators (ICD) and cardiac-resynchronisation therapy with or without defibrillators (CRTP/CRTD). PARTICIPANTS: Patients hospitalised with first-time implantations of CIEDs. OUTCOME MEASURES: In-hospital mortality, in-hospital complication and 30-day readmission rates. RESULTS: Overall, 107 339 (median age 78 (71-84), 48 415 women) and 295 584 (age 76 (67-83), 127 349 women) records with CIED implantations were included from Japan and the USA, respectively. Proportion of women in defibrillator recipients was lower in Japan than in the USA (ICD, 21% vs 28%, p<0.001; CRTD, 24% vs 29%, p<0.001). Length of stay after CIED implantation was longer in Japan than in the USA for all device types (conventional pacemaker, 8(7-11) vs 1 (1-3) days, p<0.001; leadless pacemaker, 5 (3-9) vs 2 (1-5) days, p<0.001; ICD, 8 (7-11) vs 1 (1-3) days, p<0.001, CRTP, 9 (7-13) vs 2 (1-4) days, p<0.001; CRTD, 9 (8-14) vs 2 (1-4) days, p<0.001). In-hospital mortality after CIED implantation was similar between Japan and the USA ((OR) (95% CI), conventional pacemaker 0.58 (0.83 to 1.004); ICD 0.77 (0.57 to 1.03); CRTP 0.85 (0.51 to 1.44); CRTD 1.11 (0.81 to 1.51)), except that after leadless pacemaker implantation in Japan was lower than that in the USA (0.32 (0.23 to 0.43)). 30-day readmission rates were lower in Japan than in the USA for all device types (conventional pacemaker 0.55 (0.53 to 0.57); leadless pacemaker 0.50 (0.43 to 0.58); ICD 0.54 (0.49 to 0.58); CRTP 0.51 (0.42 to 0.62); CRTD 0.57 (0.51 to 0.64)). CONCLUSIONS: International variations in patient characteristics, practice and outcomes were observed. In-hospital mortality after CIED implantation was similar between Japan and the USA, except in cases of leadless pacemaker recipients.

Clinical picture of the duration of venoarterial extracorporeal membrane oxygenation: analysis from JROAD-DPC.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been widely used for critically ill patients all over the world; however, comprehensive survey regarding the relationship between VA-ECMO duration and prognosis is limited. We conducted a survey of VA-ECMO patients in the Japanese Registry of All Cardiac and Vascular Diseases-Diagnosis Procedure Combination (JROAD-DPC), which was a health insurance claim database study among cardiovascular centers associated with the Japan Circulation Society, between April 2012 and March 2016. Out of 13,542 VA-ECMO patients, we analyzed 5766 cardiovascular patients treated with VA-ECMO. 68% patients used VA-ECMO only for 1 day and 93% had VA-ECMO terminated within 1 week. In multivariate analysis, the hazard ratio of 1-day support was significantly high at 1.72 (95% confidence intervals; 95% CI 1.53-1.95) (p < 0.001), while that of 2-day [0.60 (95% CI 0.49-0.73)], 3-day [0.75 (95% CI 0.60-0.94)], 4-day [0.43 (95% CI 0.31-0.60)] and 5-day support [0.62 (95% CI 0.44-0.86)] was significantly low. Comprehensive database analysis of JROAD-DPC revealed that cardiovascular patients who were supported with VA-ECMO for 2-5 days showed lower mortality. The optimal VA-ECMO support window should be investigated in further studies.