Predictors of Improvement in Exercise Capacity After Cardiac Rehabilitation Differ Between Octogenarian and Young-Old Patients With Acute Myocardial Infarction.

BACKGROUND: Whether the magnitude and predictors of improvement in exercise capacity after cardiac rehabilitation (CR) are the same between young-old (YO) and octogenarian (OCT) patients with acute myocardial infarction (AMI) is unknown.Methods and Results: We studied 284 YO (age range 65-69 years; mean [±SD] 67±1 years) and 65 OCT (age range ≥80 years; mean [±SD] 83±2 years) patients who participated in a post-AMI CR program. After 3 months of CR, peak oxygen uptake (PV̇O2) measured during cardiopulmonary exercise testing improved significantly in both age groups (P<0.01), although the percentage increase in PV̇O2(%∆PV̇O2) was significantly smaller in the OCT than YO group (5.4±13.7% vs. 10.0±12.8%; P<0.01). Multiple regression analysis demonstrated that independent predictors of %∆PV̇O2were the number of outpatient CR (OPCR) sessions attended (P=0.015), left ventricular ejection fraction (P=0.028), and baseline PV̇O2(P=0.0007) in the YO group; and the number of sessions attended (P=0.018), atrial fibrillation (P=0.042), and the presence of nutritional risk (Geriatric Nutritional Risk Index ≤98; P=0.036) in the OCT group. CONCLUSIONS: The predictors of improvement in exercise capacity after CR differed between the YO and OCT patients with AMI. To obtain a greater improvement in PV̇O2in CR, frequent OPCR session attendance may be necessary in both groups; in addition, particularly in OCT patients, better nutritional status may be important.

Exercise-Based Cardiac Rehabilitation Improves Exercise Capacity Regardless of the Response to Cardiac Resynchronization Therapy in Patients With Heart Failure and Reduced Ejection Fraction.

BACKGROUND: In patients with chronic heart failure with reduced ejection fraction (HFrEF), cardiac resynchronization therapy (CRT) improves left ventricular ejection fraction (LVEF) and exercise-based cardiac rehabilitation (ECR) enhances exercise capacity. This study examined the relationship between the 2 responses.Methods and Results:Sixty-four consecutive HFrEF patients who participated in a 3-month ECR program after CRT were investigated. Patients were categorized according to a median improvement in peak oxygen uptake (PV̇O2) after ECR of 7% as either good (n=32; mean percentage change in PV̇O2[%∆PV̇O2]=23.2%) or poor (n=32; mean %∆PV̇O2=2.5%) responders. There was no significant difference in baseline characteristics between the good and poor responders, except for PV̇O2(51% vs. 59%, respectively; P=0.01). The proportion of good CRT responders was similar between the good and poor responders (%∆LVEF ≥10%; 53% vs. 47%, respectively; P=NS). Overall, there was no significant correlation between %∆LVEF after CRT and %∆PV̇O2after ECR. Notably, among poor CRT responders (n=32), the prevalence of atrial fibrillation (0% vs. 29%; P<0.03) and baseline PV̇O2(48% vs. 57%; P<0.05) were significantly lower among those with a good (n=15) than poor (n=17) response to ECR. CONCLUSIONS: In patients with HFrEF, good ECR and CRT responses are unrelated. A good PV̇O2response to ECR can be achieved even in poor CRT responders, particularly in those with a sinus rhythm or low baseline PV̇O2.

Efficacy of Cardiac Rehabilitation in Heart Failure Patients With Low Body Mass Index.

BACKGROUND: Low body mass index (BMI) is a relevant prognostic factor for heart failure (HF), but HF patients with low BMI are reported to be at risk of not receiving optimal drug treatment. We sought to evaluate the efficacy of cardiac rehabilitation (CR) in patients with low vs. normal BMI. Methods and Results: We studied 152 consecutive patients (low BMI, n=32; normal BMI, n=119) who participated in a 3-month CR program. Low BMI was defined as <18.5 kg/m2and normal BMI, as 18.5≤BMI<25 kg/m2. All patients underwent cardiopulmonary exercise testing and muscle strength testing at the beginning and end of the 3-month CR program. After CR, a significantly greater proportion of HF patients with low BMI had a positive change in peak V̇O2than in the normal BMI group (91% vs. 70%; P=0.010). Average percent change in peak V̇O2was significantly greater in patients with low vs. normal BMI (17.1±2.8% vs. 7.8±1.5%; P<0.001). In addition, on multivariable logistic regression, low BMI was an independent predictor of a positive change in peak V̇O2after CR (OR, 3.97; 95% CI: 1.10-14.31; P=0.035). CONCLUSIONS: CR has a greater effect in patients with low than normal BMI, and low BMI is an independent predictor of a positive change in peak V̇O2. Thus, CR should be strongly recommended for HF patients with low BMI.

Improvement in Exercise Capacity by Exercise Training Associated With Favorable Clinical Outcomes in Advanced Heart Failure With High B-Type Natriuretic Peptide Level.

BACKGROUND: The efficacy of exercise training (ET) programs and its relationship with long-term clinical outcomes in advanced heart failure (HF) patients with high levels of B-type natriuretic peptide (BNP) remain uncertain.Methods and Results:We studied 340 consecutive HF patients with ejection fraction (EF) <45% who completed a 3-month ET program. Patients with BNP ≥200 pg/mL (High-BNP, n=170) had more advanced HF characteristics, including lower EF (25.0±8.6% vs. 28.1±8.0%, P=0.0008), than those with BNP <200 pg/mL. In the High-BNP patients, peak oxygen uptake (V̇O2) was significantly increased by 8.3±16.2% during the ET program, and changes in peak V̇O2inversely correlated with changes in BNP (R=-0.453, P<0.0001) and changes in ventilatory efficiency (V̇E/V̇CO2slope) (R=-0.439, P<0.0001). During a median follow-up of 46 months, patients in the upper tertile of changes in peak V̇O2(≥13.0%), compared with those in the lower tertile (<1.0%), had lower rates of the composite of all-cause death or HF hospitalization (37.9% vs. 54.4%, P=0.036) and all-cause death (8.6% vs. 24.6%, P=0.056). In the multivariate analysis, change in peak V̇O2was a significant independent predictor of the composite outcome and all-cause death. CONCLUSIONS: Even among advanced HF patients with high BNP level, an ET program significantly improved exercise capacity, and a greater improvement in exercise capacity was associated with greater decreases in BNP level and V̇E/V̇CO2slope and more favorable long-term clinical outcomes.

Regional Clinical Alliance Path and Cardiac Rehabilitation After Hospital Discharge for Acute Myocardial Infarction Patients in Japan　- A Nationwide Survey.

BACKGROUND: The regional clinical alliance path (RCAP) after discharge from an acute-phase hospital is emerging as a tool for bridging acute-phase treatment and chronic-phase disease management. However, the optimal application of RCAP for acute myocardial infarction (AMI) remains unknown in Japan, and therefore a nationwide survey of hospitals was conducted. METHODS AND RESULTS: In 2009, questionnaires were sent to 1,240 cardiology training hospitals authorized by the Japanese Circulation Society. The response rate was 62.9% (780/1,240). Of the 780 responding hospitals, 708 treated AMI, and in these hospitals the number of AMI patients and percutaneous coronary intervention (PCI) procedures performed were, respectively, 59±52 and 200±206 per year. The implementation rate of emergency PCI was high (91%), but that of outpatient cardiac rehabilitation (OPCR) was very low (18%). The implementation rate of RCAP after AMI was significantly lower (10%) than after stroke (57%). Cardiac rehabilitation (CR) was adopted as part of RCAP in only 19% (13/70) of currently operating RCAP programs. CONCLUSIONS: This first Japanese nationwide survey of RCAP after AMI showed that in contrast to the broad dissemination of acute-phase invasive treatment for AMI, there was infrequent implementation of OPCR, RCAP after AMI, and RCAP including CR. It will be necessary to broaden the use of RCAP after AMI, including OPCR. (Circ J 2016; 80: 1750-1755).

Admission hyperglycemia is an independent predictor of acute kidney injury in patients with acute myocardial infarction.

BACKGROUND: Acute kidney injury (AKI) and acute hyperglycemia are associated with unfavorable outcomes. The impact of acute hyperglycemia on the development of AKI after acute myocardial infarction (AMI), however, remains unclear. This study was undertaken to assess the relationship between admission glucose and incidence of AKI after AMI. METHODS AND RESULTS: This study consisted of 760 patients with AMI admitted to the National Cerebral and Cardiovascular Center within 48h after symptom onset. Blood sample was obtained on admission and repeated sampling was done at least every 1 or 2 days during the first week. AKI was diagnosed as increase in serum creatinine ≥0.3mg/dl or ≥50% within any 48h. Ninety-six patients (13%) had AKI during hospitalization for AMI, and these patients had higher in-hospital mortality than those without AKI (25% vs. 3%, P<0.001). Patients with AKI had higher plasma glucose (PG) on admission than those without (222±105mg/dl vs. 166±69mg/dl, P<0.001). The incidence of AKI increased as admission PG rose: 7% with PG <120mg/dl; 9% with PG 120-160mg/dl; 11% with PG 160-200mg/dl; and 28% with PG >200mg/dl (P<0.01). On multivariate analysis admission PG was an independent predictor of AKI (odds ratio, 1.10; 95% confidence interval: 1.03-1.18, P=0.02). CONCLUSIONS: Admission hyperglycemia might have contributed to the development of AKI in patients with AMI.

Early development of acute kidney injury is an independent predictor of in-hospital mortality in patients with acute myocardial infarction.

BACKGROUND: Acute kidney injury (AKI) often occurs in patients with acute myocardial infarction (AMI), and is associated with adverse outcomes. However, it remains unclear how timing of AKI affects it. This study assessed impact of timing of AKI on prognosis after AMI. METHODS: This study consisted of 760 patients with AMI who were admitted within 48h after symptom onset. AKI was diagnosed as increase in creatinine ≥0.3mg/dl or ≥50% within any 48h after admission. Patients were classified into 3 groups according to the occurrence and timing of AKI: no-AKI, early-AKI (within 48h after admission) and late-AKI (>48h). Early-AKI was classified into transient early-AKI, defined as creatinine returning to the level below the criteria of AKI, and persistent early-AKI. RESULTS: Early-AKI occurred in 64 patients (9%) and late-AKI in 32 patients (4%). Patients with early-AKI had significantly higher mortality (35%) than those with late-AKI (7%, p<0.001) and no-AKI (3%, p<0.001). Multivariate analysis showed early-AKI was an independent predictor of in-hospital mortality (OR: 3.38, 95% CI: 1.30-8.76, p=0.013), but late-AKI was not. Among patients with early-AKI, mortality was significantly higher even if AKI was transient (23%, p<0.001). Patients with persistent early-AKI had the highest mortality (66%, p<0.001). CONCLUSIONS: Early-AKI was associated with worse outcome. Even if renal function once returned to baseline level, patients with early-AKI tended to be at high risk of mortality.

Impact of acute and chronic hyperglycemia on in-hospital outcomes of patients with acute myocardial infarction.

This study was undertaken to assess the impact of acute hyperglycemia (acute-HG) and chronic hyperglycemia (chronic-HG) on short-term outcomes in patients with acute myocardial infarction (AMI). This study consisted of 696 patients with AMI. Acute-HG was defined as admission plasma glucose ≥200 mg/dl and chronic-HG as hemoglobin A1c ≥6.5%. Acute-HG was associated with higher peak serum creatine kinase (4,094 ± 4,594 vs 2,526 ± 2,227 IU/L, p <0.001) and in-hospital mortality (9.8% vs 1.6%, p <0.001). On the contrary, there was no significant difference in peak creatine kinase (2,803 ± 2,661 vs 2,940 ± 3,181 IU/L, p = 0.59) and mortality (3.3 vs 3.7%, p = 0.79) between patients with chronic-HG and those without. Multivariate analysis showed that admission plasma glucose was an independent predictor of in-hospital mortality (odds ratio 1.15, 95% confidence interval 1.05 to 1.27, p <0.001), but hemoglobin A1c was not. When only patients with acute-HG were analyzed, chronic-HG was associated with a significantly smaller infarct size (3,221 ± 3,001 vs 5,904 ± 6,473 IU/L, p <0.001) and lower in-hospital mortality (5.5 vs 18.9%, p = 0.01). In conclusion, these results suggested that acute-HG, but not chronic-HG, was associated with adverse short-term outcomes after AMI. Paradoxically, in patients with acute-HG, chronic-HG might abate the adverse effects of acute-HG.

Endothelial dysfunction in paroxysmal atrial fibrillation as a prothrombotic state. Comparison with permanent/persistent atrial fibrillation.

AIM: Atrial fibrillation (AF), regardless of subtype, is associated with a prothrombotic state, which is related to endothelial dysfunction (ED).We hypothesized that paroxysmal atrial fibrillation (PAF) patients have endothelial dysfunction, and this may partially explain the high thromboembolic risk and poorer outcome in this category of patients. METHODS: The study population consisted of 100 consecutive outpatients with AF (mean age 65.9±7.9 years; 68 (68%) male) and 21 characteristics and comorbidity matched control subjects (mean age 64.8±7.0 years; 13 (61.9%) male). AF patients were divided into the PAF group (n=50) and permanent/persistent AF (PeAF) group (n=50).Reactive hyperemia pulse amplitude tonometry index (RHI) was measured to evaluate endothelial function. RESULTS: RHI was significantly lower in the PAF (1.67±0.30) and PeAF (1.63±0.28) groups in comparison with control subjects (2.12±0.40, both p< 0.001). There was no significant difference in RHI between the PAF and PeAF groups (p= 0.88). On linear regression analysis, both PeAF and PAF are significant independent predictors of RHI. CONCLUSIONS: In conclusion, ED in PAF patients was comparable to PeAF patients, and the presence of PAF itself is a contributing factor for ED independent of other coexisting comorbidities. This may provide a mechanism explaining why the risk of thromboembolism in PAF is comparable with PeAF patients.

A case of fulminant myocarditis with three recurrences and recoveries.

Fulminant myocarditis is characterised by acute onset with severe haemodynamic deterioration. With intensive and appropriate bridging management, the prognosis is better than classic forms of myocarditis. Here, we report a patient who suffered from fulminant myocarditis 3 times over the last 8 years with recovery each time.

Effectiveness of risk stratification according to CHADS2 score in Japanese patients with nonvalvular atrial fibrillation.

Cerebrovascular events increase with additional risk factors in patients with nonvalvular atrial fibrillation (NVAF). The relative risk proportional to the number of risk factors in Japanese patients has not been reported. The prevalence of risk factors was investigated for over 2 years in a prospective cohort study of 265 patients with NVAF. The CHADS2 score is a widely used risk stratification scheme that includes age, hypertension, diabetes mellitus, previous stroke, and heart failure. Cerebral infarction occurred in 23 patients. This group was significantly older and had a significantly higher prevalence of hypertension. The ratio of a CHADS2 score of 0 - 2 was 77% among patients without stroke, but 44% in the cerebral infarction group. Univariate logistic regression analysis showed that the predictive factors of cerebral infarction were: age (odds ratio (OR) 1.087 (confidence interval (CI) 1.032 - 1.145, P = 0.002), hypertension (OR 3.288 (CI 1.086 - 9.962, P = 0.03) and CHADS2 score (OR 1.762 (CI 1.222 - 2.543, P = 0.002). Furthermore, a CHADS2 score of 3 - 6 was associated with a greater risk of cerebral infarction (OR 4.420 (CI 1.838 - 10.631, P < 0.001). The CHADS2 score was a useful marker of stroke risk in this Japanese population. An increased CHADS2 score was associated with an approximate 1.8-fold increase in risk.