Sex Differences in Cardiovascular Disease-Related Hospitalization and Mortality in Japan　- Analysis of Health Records From a Nationwide Claim-Based Database, the Japanese Registry of All Cardiac and Vascular Disease (JROAD).

BACKGROUND: The prevalence of cardiovascular disease (CVD) is rising in Japan with its aging population, but there is a lack of epidemiological data on sex differences in CVD, including acute coronary syndrome (ACS), acute heart failure (AHF), and acute aortic disease. METHODS AND RESULTS: This retrospective study analyzed data from 1,349,017 patients (January 2012-December 2020) using the Japanese Registry Of All Cardiac and Vascular Diseases database. ACS patients were youngest on average (70.5±12.9 years) and had the lowest female proportion (28.9%). AHF patients had the oldest mean age (79.7±12.0 years) and the highest proportion of females (48.0%). Acute aortic disease had the highest in-hospital mortality (26.1%), followed by AHF (11.5%) and ACS (8.9%). Sex-based mortality differences were notable in acute aortic disease, with higher male mortality in Stanford Type A acute aortic dissection (AAD) with surgery (males: 14.2% vs. females: 10.4%, P<0.001) and similar rates in Type B AAD (males: 6.2% vs. females: 7.9%, P=0.52). Aging was a universal risk factor for in-hospital mortality. Female sex was a risk factor for ACS and acute aortic disease but not for AHF or Types A and B AAD. CONCLUSIONS: Sex-based disparities in the CVD-related hospitalization and mortality within the Japanese national population have been highlighted for the first time, indicating the importance of sex-specific strategies in the management and understanding of these conditions.

Efficacy of dotinurad in patients with severe renal dysfunction.

BACKGROUND: Although hyperuricemia is associated with the progression of chronic kidney disease (CKD), a reduction in CKD progression by uric acid (UA)-lowering therapy has been controversial. Recently, dotinurad, a uricosuric drug with selective urate reabsorption inhibitory properties, has been developed. However, its efficacy in lowering serum UA levels and its effects on renal function in patients with severe renal dysfunction are unclear. Thus, this study aimed to determine the effects of dotinurad on renal function in patients with severe renal dysfunction. METHODS: Data from 53 outpatients with hyperuricemia who newly received dotinurad between December 2020 and October 2022 were retrospectively analyzed. The mean baseline estimated glomerular filtration rate (eGFR) was 38.7 ± 17.0 mL/min/1.73 m2. The patients were divided into three groups based on their baseline eGFR: eGFR < 30 (n = 17), 30 ≤ eGFR < 45 (n = 17), and eGFR ≥ 45 (n = 19). RESULTS: The mean follow-up period was 9.8 ± 4.5 (range, 3-21) months. Serum UA levels significantly decreased in all groups. Although eGFR did not significantly change in patients with 30 ≤ eGFR < 45 and eGFR ≥ 45 (P = 0.918 and P = 0.535, respectively), it improved significantly in patients with eGFR < 30 (P = 0.032). The proportion of patients with improved eGFR was significantly higher in patients with eGFR < 30 (P = 0.038) than in patients with 30 ≤ eGFR < 45 and eGFR ≥ 45. In the multivariate logistic regression analysis, baseline eGFR < 30 and achieving a serum UA level of ≤ 6.0 mg/dL were significantly associated with improved eGFR (P = 0.033 and P = 0.015, respectively). CONCLUSIONS: Dotinurad may have UA-lowering effects and the potential to improve kidney function in patients with severe renal dysfunction.

Impact of Red Blood Cell Transfusion on Subsequent Cardiovascular Events in Patients with Acute Heart Failure and Anemia.

Red blood cell (RBC) transfusion therapy is often performed in patients with acute heart failure (AHF) and anemia; however, its impact on subsequent cardiovascular events is unclear. We examined whether RBC transfusion influences major adverse cardiovascular events (MACE) after discharge in patients with AHF and anemia.We classified patients with AHF and anemia (nadir hemoglobin level < 10 g/dL) according to whether they received RBC transfusion during hospitalization. The endpoint was MACE (composite of all-cause death, non-fatal acute coronary syndrome/stroke, or heart failure readmission) 180 days after discharge. For survival analysis, we used propensity score matching analysis with the log-rank test. As sensitivity analysis, we performed inverse probability weighting analysis and multivariable Cox regression analysis.Among 448 patients with AHF and anemia (median age, 81 years; male, 55%), 155 received RBC transfusion and 293 did not. The transfused patients had worse clinical features than the non-transfused patients, with lower levels of nadir hemoglobin and serum albumin and a lower estimated glomerular filtration rate. In the propensity-matched cohort of 87 pairs, there was no significant difference in the MACE-free survival rate between the 2 groups (transfused, 73.8% vs. non-transfused, 65.3%; P = 0.317). This result was consistent in the inverse probability weighting analysis (transfused, 76.0% vs. non-transfused, 68.7%; P = 0.512), and RBC transfusion was not significantly associated with post-discharge MACE in the multivariable Cox regression analysis (adjusted hazard ratio: 1.468, 95% confidence interval: 0.976-2.207; P = 0.065).In conclusion, this study suggests that RBC transfusions for anemia may not improve clinical outcomes in patients with AHF.

Postprandial Hyperchylomicronemia and Thin-Cap Fibroatheroma in Nonculprit Lesions.

Objective- Although postprandial hypertriglyceridemia can be a risk factor for coronary artery disease, the extent of its significance remains unknown. This study aimed to investigate the correlation between the postprandial lipid profiles rigorously estimated with the meal tolerance test and the presence of lipid-rich plaque, such as thin-cap fibroatheroma (TCFA), in the nonculprit lesion. Approach and Results- A total of 30 patients with stable coronary artery disease who underwent a multivessel examination using optical coherence tomography during catheter intervention for the culprit lesion were enrolled. Patients were divided into 2 groups: patients with TCFA (fibrous cap thickness ≤65 µm) in the nonculprit lesion and those without TCFA. Serum remnant-like particle-cholesterol and ApoB-48 (apolipoprotein B-48) levels were measured during the meal tolerance test. The value of remnant-like particle-cholesterol was significantly greater in the TCFA group than in the non-TCFA group ( P=0.045). Although the baseline ApoB-48 level was similar, the increase in the ApoB-48 level was significantly higher in the TCFA group than in the non-TCFA group ( P=0.028). In addition, the baseline apolipoprotein C-III levels was significantly greater in the TCFA group ( P=0.003). These indexes were independent predictors of the presence of TCFA (ΔApoB-48: odds ratio, 1.608; 95% confidence interval, 1.040-2.486; P=0.032; apolipoprotein C-III: odds ratio, 2.581; 95% confidence interval, 1.177-5.661; P=0.018). Conclusions- Postprandial hyperchylomicronemia correlates with the presence of TCFA in the nonculprit lesion and may be a residual risk factor for coronary artery disease.

Blunted renal vasoconstriction in patients with subclinical contrast-induced renal injury.

Contrast media are considered to cause acute kidney injury by activating various factors that induce renal vasoconstriction. We analysed the renal microvascular haemodynamic response using the Doppler flow wire method. Then changes in urinary liver-type fatty acid-binding protein levels following contrast medium administration were compared between groups with or without a micro-injury of the kidney. In the group without renal micro-injury, the average peak velocity (APV) decreased significantly, whereas the renal artery resistance index (RI) increased significantly following contrast medium administration. In contrast, there was no significant change in either the APV or RI in the group with a renal micro-injury. A blunted microvascular response was found in the micro-injury group, whereas microvascular resistance increased in the non-micro-injury group.

Intima-Media Thickness in the Carotid Bifurcation is Related to Silent Brain Infarction: A Cross-Sectional Study.

AIMS: Carotid intima-media thickness (IMT) measurement is used to assess subclinical atherosclerosis. We aimed to examine the association between the maximum IMT by location and the occurrence of silent brain infarction (SBI). METHODS: Overall, 280 Japanese individuals (92 females, 52.6±5 years old) underwent a medical check-up at our hospital in Tokyo in 2015. Carotid IMT was measured at each site on ultrasound images (common carotid artery [CCA], internal carotid artery, or bifurcation). The risk factors for arterial dysfunction were evaluated. SBI was assessed using magnetic resonance imaging (MRI). The cross-sectional relationship between carotid maximum IMT and SBI was evaluated. RESULTS: Of the 280 individuals, 18 (6.4%) were diagnosed with SBI on MRI. The mean age of the SBI(-) and SBI(+) groups was 51.9±10.6 and 63.6±18.6 years, respectively. The correlation coefficients between the carotid maximum IMT at each location were very weak (correlation coefficient range: 0.180-0.253). The percentage of participants with SBI increased significantly with increasing maximum CCA and bIMT values. After adjusting for confounders, SBI was found to be significantly associated with the maximum bIMT (per 0.1-mm increase) (adjusted odds ratio [aOR], 1.10; 95% confidence interval [CI]: 1.03-1.17). When bIMT was categorized according to three groups (＜1.0 mm, 1.0-＜2.0 mm, and ≥ 2.0 mm), a significant SBI risk was also observed with an increase by each category of bIMT (aOR: 3.96, 95% CI: 1.63-9.52, P=0.002). CONCLUSION: The maximum bIMT was found to be the main determinant of SBI. A significant SBI risk was associated with an increase in each category of the maximum bIMT. Therefore, the maximum bIMT might be a useful predictor of future stroke in Japanese stroke-free medical check-up participants.

Smoking cessation and the odds of developing hypertension in a working-age male population; the impact of body weight changes.

BACKGROUND: Smoking elevates blood pressure (BP) whereas smoking cessation increases body weight (BW), which predisposes new quitters to the development of hypertension. This study aimed to investigate the effect of smoking cessation and subsequent BW change on the odds of developing hypertension. METHODS: A total of 10,354 Japanese male workers without hypertension who underwent a baseline annual medical checkup were followed up for three years to detect the development of hypertension. They were divided into six groups according to their smoking status (non-smokers, new quitters, or continuous smokers) and BW change (≥3 kg or <3 kg) during the follow-up period. Logistic regression analysis was used to calculate odds ratio (OR) for developing hypertension. RESULTS: During the follow-up period, 1,032 participants (mean age, 38.4 ± 8.8 years) developed hypertension. After adjusting for multiple potential confounders, the odds of developing hypertension were significantly higher in new quitters with BW gains ≥3 kg (OR, 2.95, 95% confidence interval [CI], 1.37-6.35) compared to non-smokers with BW gains <3 kg. However, increased odds of developing hypertension were not observed in those with BW gains <3 kg (OR, 0.90, 95% CI, 0.52-1.58). Continuous smokers were at increased odds of developing hypertension regardless of their BW changes (BW gain <3 kg, OR, 1.35, 95% CI, 1.13-1.61 vs BW gain ≥3 kg, OR, 1.90, 95% CI, 1.43-2.52). CONCLUSIONS: The odds of developing hypertension were increased in new quitters only when their BW gain was not controlled after smoking cessation.

Nationwide Analysis of the Relationship Between Low Ambient Temperature and Acute Aortic Dissection-related Hospitalizations.

AIMS: Acute aortic dissection (AAD) is a life-threatening cardiovascular emergency. Therefore, identifying modifiable risk factors for AAD is of great public health significance. An association between ambient temperature (AT) and AAD has been reported; however, not all findings have been elucidated. This study examined the association between AAD-related hospitalization and AT using data from the Japanese Registry of All Cardiac and Vascular Diseases Diagnostic Procedure Combination (JROAD-DPC), which is a nationwide claims-based database. METHODS: This nationwide time-stratified case-crossover study evaluated data of hospitalized patients with AAD from 1,119 certified hospitals between 2012 and 2020 using the JROAD-DPC database. Conditional logistic regression and distributed lag non-linear models were used to investigate the association between average daily temperature and AAD-related hospitalization. RESULTS: Among the 96,812 cases analyzed. The exposure-response curve between AT and AAD-related hospitalization showed an increase in the odds ratio for lower temperatures, with a peak at timed -10°C (odds ratio: 2.28, 95% confidence interval: 1.92-2.71, compared with that at 20°C). The effects of temperature on lag days 0 and 1 were also significant.Stratified analyses showed a greater association between AT and AAD-related hospitalization for the following variables: older age (≥75 years), female sex (44.4%, the mean age ± SD was 76 ± 12 years), low body mass index (<22), winter season, and warmer regions. CONCLUSIONS: Low AT is associated with an increased risk of AAD-related hospitalization. Several susceptible groups are affected by cold temperatures and have a higher risk of hospitalization.

This study examined the association between hospitalization due to acute aortic dissection (AAD) and ambient temperature using data from the Japanese Registry of All Cardiac and Vascular Diseases Diagnostic Procedure Combination, which is a nationwide claims-based database. Key findings:Low ambient temperature is associated with an increased risk of AAD-related hospitalization, with a greater association with older age and female sex.Other predisposing factors for the above association include lower body mass index, winter seasons, and warmer regions.

Second Derivative of the Finger Photoplethysmogram Predicts the Risk of Developing Hypertension in Middle-Aged Men.

AIM: Increased arterial stiffness impairs the functional and structural properties of arteries, which in turn elevates blood pressure (BP). The aim of this study was to test whether indices obtained from the second derivative of the finger photoplethysmogram (SDPTG), a marker of arterial stiffness, predict future development of hypertension in middle-aged men. METHODS: The SDPTG was measured in 902 men without hypertension (mean age 44±6 years) at an annual medical checkup. The development of hypertension was monitored for a maximum of 4 years. Two indices of arterial stiffness were calculated from the SDPTG waveforms: b/a, an index of large elastic arterial stiffness, and d/a, an index of systemic arterial stiffness, including the structural and functional properties of small and muscular arteries and peripheral circulation. A Cox proportional hazards model was used to examine whether the b/a and d/a ratios were independent predictors of future development of hypertension. RESULTS: During the follow-up period, 124 individuals developed hypertension, defined as a systolic/diastolic BP ≥ 140/90 mm Hg or the use of antihypertensive medications. The hazard ratio for the development of hypertension significantly increased in the lowest quartile of the d/a ratio (2.84, 95% confidence interval: 1.58-5.13, p＜0.001) compared with the highest quartile, after adjusting for multiple potential confounders. In contrast, the b/a ratio did not show significant hazard ratios for the development of hypertension. CONCLUSIONS: The d/a ratio, calculated from the SDPTG waveforms, predicted the risk of future development of hypertension in this study population.

Fractional excretion of urea nitrogen can identify true worsening renal function in patients with heart failure.

AIMS: Fractional excretion of urea nitrogen (FEUN), used to differentiate the cause of acute kidney injury, has emerged as a useful fluid index in patients with heart failure (HF). We hypothesized that FEUN could be useful in identifying worsening renal function (WRF) associated with poor outcomes in patients with acute HF (AHF). METHODS AND RESULTS: Overall, 1103 patients with AHF (median age, 78 years; male proportion, 60%) were categorized into six groups according to the presence of WRF and FEUN values (low, ≤32.1%; medium, >32.1% and ≤38.0%; and high, >38.0%) at discharge. WRF was defined as an increase of ≥0.3 mg/dL in the serum creatinine level from admission to discharge. FEUN was calculated by the following formula: (urinary urea × serum creatinine) × 100/(serum urea × urinary creatinine). The cut-off values for low, medium, and high FEUN were based on a previous study. The primary outcome of this study was HF readmission after hospital discharge. During the 1 year follow-up, 170 HF readmissions occurred. Kaplan-Meier analysis revealed significantly higher HF readmission rates in patients with WRF than in those without WRF (log-rank test, P < 0.001). Additionally, among patients with WRF, HF readmission rates were lowest in those with medium FEUN values, followed by those with low FEUN values and those with high FEUN values. On multivariable analysis, the presence of WRF with low or high FEUN values was independently associated with increased HF readmission, as compared with the absence of WRF with medium FEUN values. Notably, no association was noted between WRF with medium FEUN values and HF readmission. CONCLUSIONS: The prognostic impact of WRF was significantly mediated by the FEUN values and was associated with worse outcomes only when the FEUN values were either low or high. Our study suggests that FEUN can identify prognostically relevant WRF in patients with AHF.

Reinforcement of pimobendan with guideline-directed medical therapy may reduce the rehospitalization rates in patients with heart failure: retrospective cohort study.

BACKGROUND: Pimobendan reportedly improves the subjective symptoms of heart failure. However, evidence of improved prognosis is lacking. This study aimed to determine whether reinforcing guideline-directed medical therapy (GDMT) improved rehospitalization rates for worsening heart failure in patients administered pimobendan. METHODS: A total of 175 patients with heart failure who were urgently admitted to our hospital for worsening heart failure and who received pimobendan between January 2015 and February 2022 were included. Of the 175 patients, 44 were excluded because of in-hospital death at the time of pimobendan induction. The remaining 131 patients were divided into two groups, the reduced ejection fraction (rEF) (n = 93) and non-rEF (n = 38) groups, and further divided into the GDMT-reinforced and non-reinforced groups. RESULTS: In patients with rEF, the rate of rehospitalization for heart failure was significantly lower in the GDMT-reinforced group than in the non-reinforced group (log-rank test, P = .04). However, the same trend was not observed in the non-rEF group. CONCLUSIONS: Reinforcing GDMT may reduce the heart failure rehospitalization rate in patients with pimobendan administration and rEF. However, multicenter collaborative research is needed. TRIAL REGISTRATION: IRB Approval by the Nippon Medical School Hospital Ethics Committee B-2021-433 (April 10, 2023).

Impact of polypharmacy on 3-year mortality in patients with heart failure: a retrospective study.

BACKGROUND: Guideline-directed medical therapy (GDMT) is important in heart failure management; however, polypharmacy itself may impact heart failure. Although measures against polypharmacy are needed, current discussion on unilateral drug tapering (including the drugs that should be tapered) is insufficient. In this study, we investigated the relationship between the number of prescribed GDMT drugs and prognosis in patients with heart failure. METHODS: In this single-centre retrospective study, 3,146 eligible patients with heart failure were included and divided into four groups based on the median number of prescribed GDMT drugs and the median number of drugs not included in the GDMT (ni-GDMT) at the time of hospital discharge. The definition of GDMT was based on various Japanese guidelines. The primary outcome was all-cause mortality within 3 years of hospital discharge. RESULTS: A total of 252 deaths were observed during the 3-year follow-up period. Kaplan-Meier analysis revealed that groups with GDMT drug count ≥ 5 and ni-GDMT drug count < 4 had the lowest mortality, and those with GDMT drug count < 5 and ni-GDMT drug count ≥ 4 had the highest mortality (log-rank, P < 0.001). Cox regression analysis revealed a significant association between ni-GDMT drug count and all-cause mortality, even after adjustment for number of GDMT medications, age, male, left ventricular ejection function < 40%, hemoglobin, albumin levels, and estimated glomerular filtration rate [HR = 1.06 (95% CI: 1.01-1.11), P = 0.020]. Conversely, the GDMT drug count was not associated with increased mortality rates. CONCLUSIONS: The ni-GDMT drug count was significantly associated with 3-year mortality in patients with heart failure. Conversely, the GDMT drug count did not worsen the prognosis. Polypharmacy measures should consider ni-GDMT drug quantity to improve the prognosis and outcomes in patients with heart failure.

Subjective evaluation of the frequency of salty food intake and its relationship to urinary sodium excretion and blood pressure in a middle-aged population.

OBJECTIVES: The aim of this study was to examine the relationship between subjective evaluations of the frequency of salty food intake and both urinary sodium excretion and blood pressure (BP) in a middle-aged population. METHODS: Urinary sodium and creatinine concentrations in a spot sample and brachial BP were measured in 419 subjects (mean age 37±9 years, 385 men) during a health examination at a company in Kanagawa, Japan, 2011. Twenty-four-hour urinary sodium excretion was estimated from sodium and creatinine concentrations in the spot sample. The subjects were asked about the frequency of salty food intake on a self-reported questionnaire, choosing their answer from 'seldom', 'sometimes', or 'always' based on their own subjective evaluation. The amount of daily salt intake was converted from 24-h urinary sodium excretion. RESULTS: The prevalence of high salt intake, defined as greater than the daily average salt intake of Japanese according to the National Health and Nutrition Survey in 2010, gradually increased from the 'seldom' to the 'sometimes', and then 'always' categories (10.3, 13.4, and 24.0%, respectively; P=0.013 for trend). The 24-h urinary sodium excretion among these groups also tended to be different; however, the differences did not reach a significantly significant level (145±41, 152±34, and 160±40 mEq/day, respectively; P=0.076). Both systolic and diastolic BP were similar among the groups. CONCLUSIONS: Although some of our findings raise the possibility of a relationship between a subjective evaluation of the frequency of salty food intake and urinary sodium excretion, further studies are needed to confirm the relationship. In contrast, no relationship with BP was found.

Utility of fractional excretion of urea nitrogen in heart failure patients with chronic kidney disease.

AIMS: Maintenance of euvolaemia with diuretics is critical in heart failure (HF) patients with chronic kidney disease (CKD); however, it is challenging because no reliable marker of volume status exists. Fractional excretion of urea nitrogen (FEUN) is a useful index of volume status in patients with renal failure. We aimed to examine whether FEUN is a surrogate marker of volume status for risk stratification in HF patients with CKD. METHODS AND RESULTS: We examined 516 HF patients with CKD (defined as discharge estimated glomerular filtration rate < 60 mL/min/1.73 m2 ) whose FEUN was measured at discharge (median age, 80 years; 58% male). The patients were divided into four groups according to quartile FEUN value at discharge: low-FEUN, FEUN ≤ 32.1; medium-FEUN, 32.1 < FEUN ≤ 38.0; high-FEUN, 38.0 < FEUN ≤ 43.7; and extremely-high-FEUN, FEUN > 43.7. FEUN was calculated by the following formula: (urinary urea × serum creatinine) × 100/(serum urea × urinary creatinine). During the 3 year follow-up, 131 HF readmissions occurred. Kaplan-Meier analysis showed that the HF readmission rate was significantly lower in the medium-FEUN group than in the other three groups (log-rank test, P = 0.029). Multivariate Cox regression analysis identified the low-FEUN, high-FEUN, and extremely-high-FEUN values as independent factors associated with post-discharge HF readmission. In the analysis of 130 patients who underwent right heart catheterization during hospitalization, a significant correlation between FEUN value and right atrial pressure was observed (R = 0.243, P = 0.005). Multivariate linear regression analysis revealed that FEUN value at discharge decreased in a dose-dependent manner with loop diuretics. CONCLUSIONS: In HF patients with CKD, FEUN is a potential marker of volume status for risk stratification of post-discharge HF readmission. Low FEUN value (FEUN ≤ 32.1) may represent intravascular dehydration, whereas high FEUN value (FEUN > 38.0) may represent residual congestion; both of them were independent risk factors for HF readmission. FEUN may be useful to determine euvolaemia and guide fluid management in HF patients with CKD.

Effect of long-term nitrate treatment on cardiac events in patients with vasospastic angina.

BACKGROUND: Nitrates have been widely used as anti-ischemic drugs in patients with vasospastic angina (VSA). However, the effect of long-term nitrate treatment on cardiac events in VSA patients remains unclear. METHODS AND RESULTS: Two-hundred and thirty-one patients with VSA who had not been receiving any antiischemic drugs, including calcium channel blockers (CCBs), nitrates, nicorandil, or any combination of these medications were prospectively enrolled in the present study. All patients had a positive acetylcholine provocation test with normal coronary angiograms, and they received CCBs after enrollment. They were divided into 2 groups based on whether nitrates were included in the treatment: a nitrate group (n=86) and a without nitrate group (n=145). The baseline clinical characteristics and frequency of anginal attacks within 48h before enrollment were similar between the 2 groups. With a median follow-up period of 70.5 months, 29 patients developed cardiac events, including 7 sudden cardiac deaths and 22 re-admissions for acute coronary syndrome. Cardiac events occurred in 19.8% of the nitrate group and in only 8.3% of the patients who were not taking nitrates (P=0.015). In a multivariate analysis, long-term nitrate treatment (hazard ratio 5.18, 95% confidence interval: 1.69-15.89, P=0.004) was an independent predictor of cardiac events. CONCLUSIONS: These data indicate that long-term nitrate treatment in addition to CCBs might not reduce cardiac events in VSA patients.

Effect of holiday admission for acute aortic dissection on in-hospital mortality in Japan: A nationwide study.

BACKGROUND: Patients admitted on weekends have higher mortality than those admitted on weekdays. However, whether the "weekend effect" results in a higher mortality after admission for acute aortic dissection (AAD),-classified according to Stanford types-remains unclear. This study aimed to examine the association between admission day and in-hospital mortality in AAD Type A and B. METHODS: We used data from the Japanese registry of all Cardiac and Vascular Diseases Diagnostic Procedure Combination, a nationwide claim-based database with data from 953 certified hospitals, and enrolled in-patients with AAD admitted between April 1, 2012, and March 31, 2016. Based on the admission day, we stratified patients into groups (Weekdays, Saturdays, and Sundays/holidays). The influence of the admission day on in-hospital mortality was assessed via multi-level logistic regression analysis. We also performed a Stanford type-based stratified analysis. RESULTS: Among the included 25,641 patients, in-hospital mortality was 16.0%. The prevalence of patients admitted with AAD was relatively higher on weekdays. After adjustment for covariates, patients admitted on a Sunday/holiday showed an increased risk of in-hospital mortality (odds ratio [OR] 1.20; 95% confidence interval [CI] 1.07-1.33, p<0.001) than patients admitted on weekdays. Among patients admitted on a Sunday/holiday, only the subgroup of Stanford Type A showed a significantly increased risk of in-hospital mortality. (Stanford Type A, non-surgery vs. surgery groups: 95% CI 1.06-1.48 vs. 1.17-1.68, p<0.001 for both groups, OR 1.25 vs. 1.41, respectively, Stanford Type B, non-surgery vs. surgery groups: 95% CI 0.64-1.09 vs. 0.40-2.10; p = 0.182 vs. 0.846; OR 0.84 vs. 0.92). CONCLUSIONS: In conclusion, patients with AAD Type A admitted on a Sunday/holiday may have an increased in-hospital mortality risk.

Elevated C-reactive Protein Levels Independently Predict the Development of Prediabetes Markers in Subjects with Normal Glucose Regulation.

AIMS: Prediabetes is a precursor of diabetes and increases the risk of cardiovascular disease. Individuals with prediabetes reportedly have higher C-reactive protein levels, which is a risk factor for diabetes, relative to individuals with normal glucose regulation. Inflammation may play a role in the very early-phase deterioration of glucose metabolism, although there is insufficient knowledge regarding this relationship. Thus, we examined the association between serum C-reactive protein level and the development of three prediabetes markers. METHODS: This study included 743 subjects with normal glucose regulation at baseline who completed oral glucose tolerance tests at baseline and after approximately 5 years. Subjects with a history of cardiovascular disease were excluded. RESULTS: During the 5-year follow-up, 55 subjects developed isolated impaired glucose tolerance (IGT; 2h-plasma glucose levels of 7.8-11.0 mmol/L), 24 subjects developed isolated impaired fasting glucose (IFG; fasting plasma glucose levels of 6.1-7.0 mmol/L), 3 subjects developed IFG plus IGT, and 53 subjects developed isolated elevated glycated hemoglobin levels (HbA1c; level of 41-47 mmol/mol). The multivariate analysis revealed that, relative to the lowest quartile, the highest serum C-reactive protein quartile was independently associated with an increased risk of developing isolated elevated HbA1c levels (odds ratio: 2.95, 95% confidence interval: 1.16-7.51, P=0.024) and marginally associated with an increased risk of developing impaired glucose tolerance plus diabetes. However, C-reactive protein levels were not associated with an increased risk of developing IFG. CONCLUSIONS: Elevated serum C-reactive protein levels independently predicted elevated HbA1c levels, but not IFG.

Association between time of out-of-hospital cardiac arrest and survival: Examination of the all-Japan Utstein registry and comparison with the 2005 and 2010 international resuscitation guidelines.

BACKGROUND: Existing studies have yielded conflicting results regarding the relationship between the time of occurrence of out-of-hospital cardiac arrests and the associated outcomes. We examined whether the one-month survival rate for out-of-hospital cardiac arrests differed depending on whether the cardiac arrest occurred during the day or night. Further, we examined whether this rate differed when comparing the period succeeding the 2005 International Resuscitation Guidelines (2006-2010) with that following the 2010 guidelines (2011-2015). METHOD: Using data from the All-Japan Utstein Registry for 2006-2015, adult out-of-hospital cardiac arrest patients whose collapse was witnessed and for whom the collapse-to-hospital-arrival interval was shorter than 120 min were included in this study. Patients were categorized in terms of whether their arrest occurred during the post-2005- or post-2010-guideline period. The primary measure was the one-month survival with a favorable neurological outcome. RESULTS: Of 481,624 cases analyzed, 20% occurred at night. For both guideline periods, nighttime out-of-hospital cardiac arrests were associated with significantly lower one-month survival rates than daytime incidents (used as a reference; adjusted odds ratio: 0.69 and 0.63, 95% confidence interval: 0.65-0.73 and 0.60-0.65, and P < 0.001 and <0.001 for the 2005 and 2010 guideline periods, respectively). CONCLUSIONS: One-month survival with a favorable neurological outcome was significantly lower for patients who experienced nighttime out-of-hospital cardiac arrests, compared to daytime out-of-hospital cardiac arrests. This could be addressed by improving cardiopulmonary resuscitation training for bystanders and expanding and improving nighttime emergency medical services.

Non-cardiovascular disorders in a contemporary cardiovascular intensive care unit in Japan.

BACKGROUND: In the modern US cardiovascular intensive care unit (CICU), the incidence of non-cardiovascular disorders has increased and non-cardiovascular disorders are associated with an increase in morbidity and mortality. In Japan, however, data regarding the association between non-cardiovascular disorders and outcomes in the CICU are limited. METHODS: This study examined 490 consecutive admissions to a closed CICU at the Nippon Medical School Hospital from January to December 2017. Characteristics, diagnoses, treatments, and outcomes of admitted patients were identified. RESULTS: The most common primary diagnosis was acute coronary syndrome (50.4%), followed by acute heart failure (20.0%), arrhythmia (6.7%), and non-cardiovascular diseases (3.7%). The mortality rate and median length of stay (LOS) in the CICU were 4.7% and 4 (interquartile range, 2-8) days, respectively. Of all patients, 42.2% (n = 207) developed non-cardiovascular complications such as acute respiratory failure, acute kidney injury, or sepsis during CICU stay. Multivariate logistic regression analysis revealed that acute respiratory failure and sepsis were significantly associated with mortality in the CICU (odds ratio, 11.014 and 25.678, respectively; both p<0.05). The multiple linear regression analysis showed that acute kidney injury was significantly associated with LOS in the CICU (ß=0.144, p = 0.002). CONCLUSIONS: Approximately half of patients admitted to the CICU had non-cardiovascular disorders including non-cardiovascular disease and non-cardiovascular complications, which were significantly associated with mortality and LOS in the CICU.

Elevated cardio-ankle vascular index may be related to future stroke risk in Japanese subjects.

BACKGROUND: The cardio-ankle vascular index (CAVI) has been proposed as a useful parameter for arteriosclerotic diseases. However, whether it is associated with stroke risk in Japanese subjects remains unclear. METHODS: In total, 280 Japanese subjects (92 females, 52.6 ± 5 years old) underwent a medical check-up. CAVI value and risk factors for arterial dysfunction were evaluated; the predicted 10-year stroke risk was measured by the Japan Public Health Center study. RESULTS: Age, sex, body mass index, and systolic blood pressure were significant independent predictors of CAVI. CAVI values were significantly elevated in the high, compared with the medium-low and low predicted risk groups. A significant odds ratio (OR) for the high-risk group was noted in the highest quartile of CAVI values (OR, 14.67; 95% confidence interval [CI], 3.17-68.0), compared with the lowest quartile, after adjusting for potential confounders. A significant OR for very high predicted stroke risk was also found for each quartile increase (OR, 3.04; 95% CI, 1.87-4.94) and 1-standard deviation increase (OR, 2.24; 95% CI, 1.52-3.30) in CAVI value. CONCLUSION: Elevated CAVI values were related to an elevated predicted stroke risk, suggesting that CAVI could be a suitable surrogate marker for finding subjects at an increased risk of first-ever stroke.