Association between the health insurance status and clinical outcomes among patients with acute heart failure in Japan.

The relationship between the socioeconomic status, including the health insurance status, and prognosis of heart failure (HF) has been recognized as an important concept for stratifying the risk in HF patients and is gaining increasing attention worldwide even in countries with a universal healthcare system. However, the impact of the Japanese health insurance status on outcomes among patients admitted for acute HF has not been fully clarified. We enrolled 771 patients admitted for acute HF between January 2018 and December 2019 and collected data on the in-hospital mortality, length of the hospital stay, and cardiac events, defined as cardiovascular death and readmission for HF within 1 year after discharge. Patients were divided into two groups according to their insurance status, i.e., public assistance (n = 87) vs. other insurance (n = 684). The public assistance group was significantly younger and had a higher rate of diabetes, smoking, ischemic and hypertensive heart disease, and low estimated glomerular filtration rate (all P < 0.05). Pharmacological/invasive heart failure therapy, in-hospital mortality, and the 90-day cardiac event rate after discharge did not differ between the groups. However, the public assistance group had a significantly higher 1-year cardiac event rate than the other insurance groups (P = 0.025). After adjusting for covariates, public assistance was independently associated with the 1-year cardiac event rate (HR: 2.15, 95% CI: 1.42-3.26, P < 0.001). Acute HF patients covered by public assistance received the same quality of medical care, including invasive therapy. As a result, no health disparities were found in terms of the in-hospital mortality and 90-day cardiac event rate, unlike overseas surveys. Nevertheless, HF patients with public assistance had a higher risk for the long-term prognosis than those with other insurance. Comprehensive HF management is required post-discharge.

Comprehensive assessment of left atrial and ventricular remodeling in paroxysmal atrial fibrillation by the cardiovascular magnetic resonance myocardial extracellular volume fraction and feature tracking strain.

Atrial fibrillation (AF) is a progressive disease that starts with structural or functional changes in the left atrium and left ventricle, and evolves from paroxysmal toward sustained forms. Early detection of structural or functional changes in the left atrium and left ventricle in the paroxysmal stage could be useful for identifying a higher risk of progression to persistent AF and future cardio-cerebrovascular events. The aim of this study was to test the hypothesis that the feature tracking (FT) left atrial (LA) strain and left ventricular (LV) extracellular volume fraction (ECV) derived from cardiovascular magnetic resonance (CMR) could detect early changes in remodeling of the left atrium and ventricle in the paroxysmal AF (PAF) stage. The participants were comprised of 106 PAF patients (age, 66.1 ± 10.7 years; 66% male) who underwent clinical CMR before pulmonary vein isolation and 20 control subjects (age, 68.3 ± 8.6 years; 55% male). The CMR-FT LA strain/phasic function and LV-ECV were compared between the PAF and control groups. The total and passive LA empty fraction (LAEF) and LA strain (corresponding to LA reservoir and conduit function) were decreased in the PAF group as compared to the control group. However, active LAEF (corresponding to the LA booster pump function) did not differ significantly between the PAF group (33.9 ± 10.9%) and control group (37.9 ± 13.3%, p = 0.15), while the active LA strain (corresponding to the LA booster pump function) was significantly decreased in the PAF group (11.4 ± 4.3 vs. 15.2 ± 5.6%, p = 0.002). The LV-ECV was significantly greater in the PAF group (28.7 ± 2.8%) than control group (26.6 ± 2.0%, p = 0.002). In the PAF group, the LV-ECV correlated significantly with the E/e' and LA volume index. Regarding the LA strain, correlations were seen between the LV-ECV and both the reservoir function and conduit function. CMR-FT LA strain in combination with the LV-ECV in a single clinical study offers a potential imaging marker that identifies LA/LV remodeling including subtle LA booster pump dysfunction undetectable by the conventional booster pump LAEF in the PAF stage.

Hybrid Assessment of Myocardial Ischemia Using Stress-Only Nuclear Myocardial Perfusion Imaging and Rest Computed Tomography Perfusion Imaging.

BACKGROUND: Sequential assessment using CT coronary angiography (coronary CT) and nuclear myocardial perfusion imaging (MPI) is considered an anatomical and functional evaluation of coronary artery disease (CAD). However, there can be unexpected radiation exposure. Hybrid MPI with stress-only nuclear MPI and rest CT-MPI using coronary CT may contribute to reducing the radiation dose in sequential assessment with nuclear MPI after coronary CT. We analyzed the diagnostic performance and total radiation dose of hybrid MPI for detection of significant CAD compared with sequential assessment using nuclear MPI after coronary CT.Methods and Results:The results for 101 patients who underwent coronary CT, nuclear MPI and invasive coronary angiography within 3 months of all imaging were analyzed. We calculated the summed difference score (SDS) from standard nuclear MPI and hybrid SDS from hybrid MPI, which revealed myocardial ischemia. The diagnostic performance of SDS and hybrid SDS for detecting significant CAD was analyzed using receiver-operating characteristic (ROC) curve analysis. We also compared the total radiation dose of both methods. The area under the ROC curve was not different between SDS and hybrid SDS (0.901 and 0.815, P=0.079). Total radiation dose of hybrid MPI was significantly lower than standard nuclear MPI with CT angiography (4.62 mSv vs. 9.72 mSv, P<0.0001). CONCLUSIONS: Hybrid MPI showed a precise diagnostic accuracy for significant CAD detection.

Prognostic impact of reducing myocardial ischemia identified using ECG-gated myocardial perfusion SPECT in Japanese patients with coronary artery disease: J-ACCESS 4 study.

AIM: Whether myocardial ischemia identified using myocardial perfusion imaging (MPI) can be an alternative target of coronary revascularization to reduce the incidence of cardiac events remains unclear. METHODS AND RESULTS: This multicenter, prospective cohort study aimed to clarify the prognostic impact of reducing myocardial ischemia. Among 494 registered patients with possible or definite coronary artery disease (CAD), 298 underwent initial pharmacological stress 99mTc-tetrofosmin MPI before, and eight months after revascularization or medical therapy, and were followed up for at least one year. Among these, 114 with at least 5% ischemia at initial MPI were investigated. The primary endpoints were cardiac death, non-fatal myocardial infarction and hospitalization for heart failure. Ischemia was reduced ≥5% in 92 patients. Coronary revascularization reduced ischemia (n = 89) more effectively than medical therapy (n = 25). Post-stress cardiac function also improved after coronary revascularization. Ejection fraction significantly improved at stress (61.0% ±â€¯10.7% vs. 65.4% ±â€¯11.3%; p < 0.001) but not at rest (67.1% ±â€¯11.3% vs. 68.3% ±â€¯11.6%; p = 0.144), among patients who underwent revascularization. Rates of coronary revascularization and cardiac events among the 114 patients were significantly higher (13.6%, p = 0.035) and lower (1.1% p = 0.0053), respectively, in patients with, than without ≥5% ischemia reduction. Moreover, patients with complete resolution of ischemia at the time of the second MPI had a significantly better prognosis. CONCLUSIONS: Reducing ischemia by ≥5% and the complete resolution of ischemia could improve the prognosis of patients with stable CAD.

Cardiovascular Outcomes in Patients With Previous Myocardial Infarction and Mild Diabetes Mellitus Following Treatment With Pioglitazone: Reports of a Randomised Trial From The Japan Working Group for the Assessment Whether Pioglitazone Protects DM Patients Against Re-Infarction (PPAR Study).

BACKGROUND: Secondary prevention in patients with myocardial infarction (MI) is critically important to prevent ischaemic heart failure and reduce social burden. Pioglitazone improves vascular dysfunction and prevents coronary atherosclerosis, mainly via anti-inflammatory and antiatherogenic effects by enhancing adiponectin production in addition to antihyperglycemic effects, thus suggesting that pioglitazone attenuates cardiovascular events in patients with mild (HbA1c levels < 6·5%) diabetes mellitus (DM). Therefore, we evaluated the effects of pioglitazone on cardiovascular events in patients with both previous MI and mild DM. METHODS: In this multicentre, prospective, randomised, open, blinded-endpoint trial, we randomly assigned 630 patients with mild DM with a history of MI to undergo either DM therapy with (pioglitazone group) or without (control group) pioglitazone. DM was diagnosed using the 75-g oral glucose tolerance test, and mild DM was defined if HbA1c level was < 6·5%. The primary endpoint was the composite of cardiovascular death and hospitalisation caused by acute MI, unstable angina, coronary revascularisation (including percutaneous coronary intervention and cardiac bypass surgery), and stroke. FINDINGS: HbA1C levels were 5·9 and 5·8% (p = 0·71) at baseline and 6·0 and 5·8% (p < 0·01) at 2 years for the control and pioglitazone groups, respectively.The primary endpoint was observed in 14·2% and 14·1% patients in the control and pioglitazone groups during two years (95% confidential interval (CI):0.662-1·526, p = 0·98), respectively; the incidence of MI and cerebral infarction was 0·3% and 2·2% (95%CI: 0·786-32·415, p = 0·09) and 1·0% and 0·3% (95%CI: 0·051-3·662, p = 0·44), respectively. Post-hoc analyses of the 7-year observation period showed that these trends were comparable (21·9% and 19·2% in the control and pioglitazone groups, 95%CI: 0.618-1·237, p = 0·45). INTERPRETATION: Pioglitazone could not reduce the occurrence of cardiovascular events in patients with mild DM and previous MI.

Usefulness of automated assessment of nuclear cardiology for prediction of major cardiac events in Japanese patients with known or suspected coronary artery disease: comparison with conventional visual assessment in a large-scale prognostic study.

BACKGROUND: There are no reports indicating that automated quantification with a total perfusion deficit (TPD) is used to predict future cardiac events in Japanese patients. We, therefore, aimed to determine the prognostic value of the automated assessment with the TPD for risk stratification of major cardiac events (MCEs) in Japanese patients with known or suspected coronary artery disease (CAD). METHODS: We retrospectively investigated 2848 patients who underwent rest (201)Tl and stress (99m)Tc-tetrofosmin myocardial perfusion single photon emission computed tomography (SPECT) between October 2004 and March 2008. The follow-up period was 25.8 ± 11.0 months. The TPD was automatically derived from the SPECT image through the QPS software with the Japanese normal database. Twenty segments of SPECT images were analyzed with the 5-point visual scoring model to estimate summed scores. The endpoint of the follow-up was the occurrence of MCEs within 1 year after the SPECT, which were identified with medical records or responses to a posted questionnaire. RESULTS: During the first year of the follow-up, 62 patients had MCEs, which comprised cardiac death (n = 30), non-fatal myocardial infarction (n = 13), and unstable angina pectoris (n = 19). The MCE rates positively correlated with the stress TPD and the summed stress score. Sensitivity of the automated quantification with the TPD for detection of the MCEs was high and similar to that of the visual semi-quantification. Multivariate Cox regression analysis indicated that significant independent predictors for the MCEs were an estimated glomerular filtration rate and the ischemic variables both in the automated quantification and visual semi-quantification. CONCLUSION: The automated quantification with the TPD is useful for prognostic risk stratification of MCEs in Japanese patients with known or suspected CAD. Its predictive power is similar to that of the visual semi-quantification by expert interpreters.

Validation of automated quantification of nuclear cardiology in Japanese patients using total perfusion deficits: Comparison with visual assessment.

BACKGROUND: Automated quantitative assessment based on a total perfusion deficit (TPD) has been recognized to be useful for detection of coronary artery disease (CAD). We, therefore, aimed to validate reproducibility of the automated quantification with the TPD on myocardial perfusion single photon emission computed tomography (SPECT) images in Japanese patients with history of stable CAD. METHODS: Patients (n=47, age 67 ± 10) underwent rest (201)Tl and stress (99m)Tc-tetrofosmin myocardial perfusion SPECT on two separate occasions with the same protocol within 3-26 months. They had abnormal findings on the first SPECT imaging by visual analysis and had no changes in symptoms, cardiac medications, coronary risk factors, and electrocardiogram findings at the time of the second imaging. They had no intervening coronary revascularization and myocardial infarction between the first and second imaging. The TPD was automatically derived from SPECT images through quantitative perfusion SPECT software with the Japanese normal database. A visual summed stress score (SSS) was estimated with the 5-point visual scoring model for 20 segments of SPECT images by independent expert interpreters. Abnormal criteria for the stress TPD and SSS were defined as ≥5% and ≥4, respectively. RESULTS: The stress TPD determined by the quantitative analysis well correlated between the first and second imaging (r=0.985) as well as the SSS by the visual analysis showed good correlation (r=0.978). The correlation coefficients were similar between the visual and quantitative analyses. Bland-Altman analyses indicated extremely good reproducibility in both assessments. CONCLUSION: The TPD is evidently a quantitative index having high reproducibility and the automated quantification with it provides comparable results to the visual assessment by experienced interpreters. The automated quantification with the TPD is highly significant for clinical assessment of CAD, and allows easily performing myocardial perfusion SPECT imaging without expert interpreters.

Combined assessment of myocardial perfusion and function by ECG-gated myocardial perfusion single-photon emission computed tomography for the prediction of future cardiac events in patients with type 2 diabetes mellitus.

BACKGROUND: The mid-term prognostic significance of ECG-gated single-photon emission computed tomography (SPECT) remains unclear in Japanese patients with type 2 diabetes mellitus (DM). In the present study rates of future cardiac events (nonfatal acute myocardial infarction (AMI), cardiac death (CD) and severe heart failure (HF) requiring hospitalization) were compared in patients with and without DM. METHODS AND RESULTS: 1,810 patients (563 DM and 1,247 non-DM) we followed for a mean of 26.3±15.5 months. Summed stress score (SSS), summed difference score (SDS), poststress ejection fraction (EF) and resting end-diastolic volume (EDV) were calculated. In total, 20 cases of AMI (9 in DM (1.59%) and 11 in non-DM (0.88%)), 20 of CD (7 in DM patients (1.24%) and 13 in non-DM (1.04%)) and 54 of severe HF (31 in DM (5.5%) and 23 in non-DM (1.84%)) occurred. Univariate Cox analysis showed that, in DM patients, predictors of total cardiac events were poststress EF (Wald 60.4; P<0.001), resting EDV (Wald 53.8; P<0.001), SSS (Wald 39.6; P<0.001), SDS (Wald 26.1; P<0.001), history of prior MI (Wald 4.32; P<0.05) and hemoglobin A(1c) value (Wald 4.30; P<0.05). Multivariate Cox analysis showed that poststress EF (Wald 9.85; P<0.01) and SDS (Wald 6.19; P<0.01) were independent predictors of total cardiac events. CONCLUSIONS: Combined assessment of perfusion and function by ECG-gated SPECT may predict future cardiac events in type 2 DM patients.

Computed tomography assessment of the regression of an atherosclerotic coronary artery plaque.

Multislice spiral computed tomography (MSCT) permits the noninvasive visualization of coronary artery stenoses and occlusions, as well as atherosclerotic plaques, in patients with coronary artery disease. This report describes a patient with stable angina pectoris in whom the regression of the plaque and coronary artery remodeling was documented by serial MSCT.