Hospital-acquired disability in older heart failure patients decreases independence and increases difficulties in activities of daily living.

AIMS: The aim of this study was to clarify whether worsening of independence in activities of daily living (ADL) and also difficulties in ADL are triggered by hospitalization in older patients with heart failure (HF) and whether difficulties in ADL can predict readmission for HF regardless of independence in ADL in these patients. METHODS AND RESULTS: We enrolled 241 HF patients in the present multi-institutional, prospective, observational study. The patients were divided according to age into the non-older patient group (<75 years, n = 137) and the older patient group (≥75 years, n = 104). The Katz index and the Performance Measure for Activities of Daily Living-8 (PMADL-8) were used to evaluate independence and difficulties in ADL, respectively. The endpoint of this study was rehospitalization for HF. Independence as indicated by the Katz index at discharge was significantly lower than that before admission only in the older patient group, and the value of the PMADL-8 at discharge was significantly higher than that before admission (P < 0.001). In all patients, after adjusting for the Katz index and other variables, PMADL-8 score was a significant predictor of rehospitalization for HF (hazard ratio 1.50; 95% confidence interval 1.07-2.13; P = 0.021). CONCLUSIONS: Worsening of both independence and difficulties in ADL was triggered by hospitalization in older HF patients, and difficulties in ADL were relevant factors for risk of rehospitalization regardless of independence in ADL. These findings indicate the importance of preventing not only decreased independence but also increased difficulties in ADL during and after hospitalization.

Relevant factors of leg strength at hospital discharge in patients hospitalized due to acute decompensated heart failure: multi-institutional prospective observational study.

BACKGROUND: Lower leg strength at hospital discharge is strongly associated with poor prognosis in older patients with acute decompensated heart failure (ADHF). Improving leg strength is important in acute-phase cardiac rehabilitation (CR). AIMS: This study aimed to clarify whether a change in leg strength occurs during hospitalization of older ADHF patients receiving CR and whether it affects leg strength at discharge. METHODS AND RESULTS: We enrolled 247 ADHF patients who underwent CR during hospitalization. They were divided into the non-older patient group (<75 years; n = 142) and older patient group (≥75 years; n = 105). Quadriceps isometric strength (QIS), body mass-corrected QIS (%BM QIS), and change in QIS during hospitalization (QIS ratio) were evaluated in all patients. Physical function in the stable phase was measured by the Performance Measure for Activities of Daily Living-8 (PMADL-8). The QIS value increased during hospitalization in the non-older patient group (30.0 ± 11.1 vs. 31.6 ± 10.9 kgf, P < 0.001) but did not increase in the older patient group (19.1 ± 6.3 vs. 19.5 ± 6.1 kgf, P = 0.275). Multiple regression analysis revealed that PMADL-8 significantly predicted %BM QIS at discharge in the non-older patient group (ß = -0.254, P = 0.004), whereas in the older patient group, QIS ratio and PMADL-8 significantly predicted %BM QIS at discharge (ß = 0.264, P = 0.008 for QIS ratio and ß = -0.307, P = 0.003 for PMADL-8). CONCLUSIONS: Leg strength was not improved in older ADHF patients during hospitalization even if they received CR, and this affected leg strength at discharge, suggesting that careful skeletal muscle intervention should be provided during hospitalization, and patients need to continue exercise after discharge.

The Factors Affecting the Non-dipper Pattern in Japanese Patients with Severe Obstructive Sleep Apnea.

Objective Obstructive sleep apnea (OSA) is assumed to influence the circadian blood pressure (BP) fluctuation, particularly causing nocturnal hypertension and changing the dipping pattern of nocturnal BP. This study aimed to clarify the triggers of the non-dipper pattern in nocturnal BP in Japanese patients with severe OSA (the apnea-hypopnea index ≥30/h). Methods Of 541 patients with OSA diagnosed using polysomnography (PSG) and ambulatory BP monitoring (ABPM), 163 patients <60 years of age (Younger group) and 101 patients ≥60 years of age (Older group) were stratified into the dipper or non-dipper pattern groups. Results A logistic regression analysis was performed using a non-dipper pattern as a dependent variable. A multivariate analysis demonstrated that the cumulative percentage of time at saturation below 90% was the only independent risk factor for the non-dipper and riser patterns in the Younger group (odds ratio, 1.022; 95% confidence interval, 1.001-1.044; p=0.035), whereas slow-wave sleep (odds ratio, 0.941; 95% confidence interval, 0.891-0.990; p=0.019) and the use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (odds ratio, 2.589; 95% confidence interval, 1.051-6.848; p=0.039) were risk factors in the Older group. Conclusion These findings suggested that the degree of desaturation in young OSA patients and sleep quality in old OSA patients might influence the dipping patterns in nocturnal BP.

Impact of obstructive sleep apnea and hypertension on left ventricular hypertrophy in Japanese patients.

The incidence of cardiovascular disease and mortality rates are high among patients with left ventricular hypertrophy (LVH). Obstructive sleep apnea (OSA) has been reported to increase left ventricular mass (LVM) and cause LVH. The prevalence of hypertension, a major cause of increased LVM, is high in OSA; however, it is still unknown whether OSA is an independent factor that increases LVM in addition to triggering LVH. This study investigated out-of-office blood pressure (BP) via ambulatory BP monitoring (ABPM) in patients with OSA diagnosed by polysomnography (PSG) and sought to determine the effects of OSA and hypertension on LVM. A total of 432 patients with OSA underwent ABPM and echocardiography. These patients were stratified into four groups according to their left ventricular mass index (LVMI) quartiles, and the component factors influencing LVMI, such as patient background, sleep data and all-day BP data, were analyzed. This study included 356 men and 76 women. The mean age was 54.6±13.2 years, the mean body mass index was 26.7±4.6 kg m-2 and the mean apnea-hypopnea index (AHI) was 37.9±22.5. Multivariate analysis indicated that antihypertensive agent use (ß=0.143, P=0.002), an AHI ⩾15/h (ß=0.100, P=0.045) and 24-h systolic BP (ß=0.252, P<0.001) were significant independent factors for increased LVM. The significant LVMI component factors in OSA patients were an AHI ⩾15/h and 24-h systolic BP. The results of this study demonstrated that both elevated BP and OSA were independently associated with increased LVM.

A daytime normotensive patient with nocturnal hypoxia-induced hypertension and severe obstructive sleep apnea.

This is the case of a 60-year-old male. He had no past medical history at a regular medical check-up. According to findings at the regular medical check-up, he was obese (body mass index, 32.8 kg/m2), and had short neck, small jaw, and low soft palate; therefore, it was suspected that he may have sleep-disordered breathing. Blood pressure (BP) at the medical check-up was 121/80 mmHg, and the results of electrocardiogram and chest radiography were normal. Blood test data at the medical check-up indicated abnormality of lipid metabolism and hyperuricemia. No other abnormalities were found. It became clear that he became sleepy during daytime at an additional medical interview. Accordingly, he was diagnosed as having severe obstructive sleep apnea (OSA) with apnea-hypopnea index 65.3/h and arousal index 64.4/h by polysomnography. The oxygen-triggered nocturnal BP monitoring that was conducted at home around the same time indicated remarkable hypoxia-induced hypertension (Day 1: hypoxia-peak nocturnal BP 181/117 mmHg, Day 2: hypoxia-peak nocturnal BP 204/137 mmHg). The patient recognized the risk of OSA by visualizing the hypoxia-induced hypertension; therefore, introduction of continuous positive airway pressure (CPAP) therapy for severe OSA was smooth. As the results of CPAP therapy, we could confirm disappearance of hypoxia-induced hypertension. .

Effect of oral appliance therapy on blood pressure in Japanese patients with obstructive sleep apnea.

OBJECTIVE: Obstructive sleep apnea (OSA) treatment in patients with OSA and hypertension reduces blood pressure (BP). Oral appliance (OA) therapy is nowadays prescribed for patients with mild to moderate OSA. This study aimed to clarify the effect of OA therapy on BP reduction in Japanese patients with mild to moderate OSA. METHODS: Polysomnography was employed to detect sleep-disordered breathing. Totally, 237 patients without cardiac and/or cerebrovascular diseases and those with apnea-hypopnea index (AHI) ≥ 5/h-< 30/h were enrolled. Office BP change after receiving 8-12 weeks of OA therapy was assessed and the factors related to the degree of BP reduction were analyzed. RESULTS: The study patients consisted of 188 men and 49 women, the mean age was 54.7 ± 13.2 years old, and the body mass index (BMI) was 24.6 ± 3.4 kg/m(2). The antihypertensive effect of OA therapy resulted in systolic BP (SBP) -2.4 ± 14.8 (p = 0.078) and diastolic BP (DBP) -2.0 ± 11.7 mm Hg (p = 0.045) in all patients. SBP before OA therapy played a significant role in the degree of SBP reduction (ß = -0.597, p < 0.001), whereas DBP before OA therapy was a significant factor of the degree of DBP reduction (ß = -0.522, p < 0.001). CONCLUSION: A certain time period of OA therapy effected BP reduction in mild to moderate OSA patients without cardiac and/or cerebrovascular diseases. Its antihypertensive effect was greater in OSA patients whose BP was higher before receiving OA therapy.

The Relation of Respiratory Muscle Strength to Disease Severity and Abnormal Ventilation During Exercise in Chronic Heart Failure Patients.

BACKGROUND: Breathlessness is a common problem in chronic heart failure (CHF) patients, and respiratory muscle strength has been proposed to play an important role in causing breathlessness in these patients. OBJECTIVES: The aim of this study was to investigate the relation between respiratory muscle strength and the severity of CHF, and the influence of respiratory muscle strength on abnormal ventilation during exercise in CHF patients. PATIENTS AND METHODS: In this case series study, we assessed clinically stable CHF outpatients (N = 66, age: 57.7 ± 14.6 years). The peak oxygen consumption (peak VO2), the slope relating minute ventilation to carbon dioxide production (VE/VCO2 slope), and the slope relating tidal volume to respiratory rate (TV/RR slope) were measured during cardiopulmonary exercise testing. Respiratory muscle strength was assessed by measuring the maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). RESULTS: The MIP and MEP decreased significantly as the New York Heart Association functional class increased (MIP, P = 0.021; MEP, P < 0.01). The MIP correlated with the TV/RR slope (r = 0.57, P < 0.001) and the VE/VCO2 slope (r = -0.44, P < 0.001), and the MEP also correlated with the TV/RR slope (r = 0.53, P < 0.001) and the VE/VCO2 slope (r = -0.25, P < 0.040). Stepwise multiple regression analysis revealed that age and MIP were statistically significant predictors of the TV/RR and VE/VCO2 slopes (both P < 0.05). CONCLUSIONS: Respiratory muscle strength is related to the severity of CHF, and associated with rapid and shallow ventilation or excessive ventilation during exercise.

Gender-related differences in maximum gait speed and daily physical activity in elderly hospitalized cardiac inpatients: a preliminary study.

Maximum gait speed and physical activity (PA) relate to mortality and morbidity, but little is known about gender-related differences in these factors in elderly hospitalized cardiac inpatients. This study aimed to determine differences in maximum gait speed and daily measured PA based on sex and the relationship between these measures in elderly cardiac inpatients.A consecutive 268 elderly Japanese cardiac inpatients (mean age, 73.3 years) were enrolled and divided by sex into female (n = 75, 28%) and male (n = 193, 72%) groups. Patient characteristics and maximum gait speed, average step count, and PA energy expenditure (PAEE) in kilocalorie per day for 2 days assessed by accelerometer were compared between groups.Gait speed correlated positively with in-hospital PA measured by average daily step count (r = 0.46, P < 0.001) and average daily PAEE (r = 0.47, P < 0.001) in all patients. After adjustment for left ventricular ejection fraction, step counts and PAEE were significantly lower in females than males (2651.35 ± 1889.92 vs 4037.33 ± 1866.81 steps, P < 0.001; 52.74 ± 51.98 vs 99.33 ± 51.40 kcal, P < 0.001), respectively.Maximum gait speed was slower and PA lower in elderly female versus male inpatients. Minimum gait speed and step count values in this study might be minimum target values for elderly male and female Japanese cardiac inpatients.

Differences in physical performance based on the Geriatric Nutritional Risk Index in elderly female cardiac patients.

BACKGROUND AND AIMS: Little is known about differences in the risk of poor nutritional status as assessed by the Geriatric Nutritional Risk Index (GNRI) in relation to physical performance in elderly female cardiac inpatients. The present study aimed to determine both differences in physical performance based on the GNRI and physical performance cut-off values according to the GNRI in elderly female cardiac inpatients. METHODS: We enrolled 105 consecutive female Japanese inpatients aged ≥65 years (mean age, 74.6 years) with cardiac disease in this cross-sectional study. We divided the patients into two groups according to GNRI: high-GNRI group (≥92 points) (n = 71) and low-GNRI group (<92 points) (n = 34). Handgrip strength (HG), knee extensor muscle strength (KEMS), gait speed (GS), and one-leg standing time (OLST) were assessed as indices of hospital physical performance and compared between the two groups to determine cut-off values of physical performance. RESULTS: After adjustment for age and left ventricular ejection fraction, HG, KEMS, GS, and OLST were significantly lower in the low-GNRI versus high-GNRI group. Cut-off values by ROC curve analysis were 16.2 kgf (AUC = 0.66; p < 0.001) for HG, 34.3 % of body weight (AUC = 0.62; p = 0.04) for KEMS, 1.24 m/s (AUC = 0.72; p < 0.01) for GS, and 8.28 s (AUC = 0.62; p = 0.04) for OLST. CONCLUSION: The risk of poor nutrition, as indicated by a low GNRI, might be a predictor of lower physical performance. Cut-off values determined in this study might be minimum target goals for physical performance that can be attained by elderly female cardiac inpatients.

Impaired ß-cell function attenuates training effects by reducing the increase in heart rate reserve in patients with myocardial infarction.

BACKGROUND: Insulin resistance (IR) is characterized as a metabolic disorder syndrome that is upstream of hypertension, dyslipidemia, and diabetes mellitus (DM). This study investigated exercise training effects on the exercise tolerance and heart rate dynamics in patients with IR or pancreatic ß-cell dysfunction. METHODS: Seventy patients (mean age, 60.1 years) with myocardial infarction (MI) participating in a phase II cardiac rehabilitation program were studied. Patients diagnosed with DM were excluded. Homeostasis model-assessment indices were used to divide patients into three groups - A: IR; B: normal; and C: ß-cell dysfunction. A cardiopulmonary exercise test (CPX) was performed and peak oxygen uptake (V˙O2) was measured. After baseline testing, subjects participated in a supervised, combined aerobic and resistance exercise program. RESULTS: Peak V˙O2 at baseline was comparable among the three groups, and it improved after training in all groups (p<0.05). However, both the increase and percentage increase in peak V˙O2 were smaller in Group C than in Group A (p<0.05). Heart rate (HR) reserve (peak HR-rest HR), and HR recovery immediately 1min after exercise during CPX were calculated in 45 patients who were not taking negative chronotropic agents. Group C alone did not show any significant increase in HR reserve. HR reserve at both baseline and after training had significant positive correlations with peak V˙O2. HR recovery was 1.9 beats/min lower in group C than group A, but this was not significant. HR recovery in group C did not increase after cardiac rehabilitation. CONCLUSION: Impaired HR reserve increase after training in patients with pancreatic ß-cell dysfunction attenuates exercise training effects on functional capacity. Comprehensive treatment including vigorous exercise training will be needed in such prediabetic patients.

Relation between VE/VCO2 slope and maximum phonation time in chronic heart failure patients.

This study aimed to determine the relation between the regression slope relating minute ventilation to carbon dioxide output (VE/VCO2 slope) and maximum phonation time (MPT), and the MPT required to attain a threshold value for VE/VCO2 slope of ≤ 34 in chronic heart failure (CHF) patients. This cross-sectional study enrolled 115 CHF patients (mean age, 54.5 years; men, 84.9%). VE/VCO2 slope was assessed during cardiopulmonary exercise testing (CPX). Thereafter, patients were divided into 2 groups according to exercise capacity: VE/VCO2 slope ≤ 34 (VE/VCO2 ≤ 34 group, n = 81) and VE/VCO2 slope > 34 (VE/VCO2 > 34 group, n = 34). For MPT measurements, all patients produced a sustained vowel/a:/ for as long as possible during respiratory effort from the seated position. All subjects showed significant negative correlation between VE/VCO2 slope and MPT (r = -0.51, P < 0.001). After adjustment for clinical characteristics, MPT was significantly higher in the VE/VCO2 ≤ 34 group vs VE/VCO2 > 34 group (21.4 ± 6.4 vs 17.4 ± 4.3 s, F = 7.4, P = 0.007). The appropriate MPT cut-off value for identifying a VE/VCO2 slope ≤ 34 was 18.12 seconds. An MPT value of 18.12 seconds may be a useful target value for identifying CHF patients with a VE/VCO2 slope ≤ 34 and for risk management in these patients.

[Sleep apnea syndrome: SAS].

Obstructive sleep apnea (OSA) is an independent risk factor for hypertension and cardiovascular disease. OSA is the frequent underlying disease of secondary hypertension and resistant hypertension. In 2003, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure recognized sleep apnea as a common and identifiable cause of hypertension and suggested blood pressure screening among patients with OSA. OSA increases both daytime and nocturnal ambulatory blood pressures through the activation of various neurohumoral factors including the sympathetic nervous system and the renin-angiotensin-aldosterone system. Randomized, controlled trials have evaluated the use of continuous positive airway pressure (CPAP) to reduce BP among persons with OSA. The benefits of OSA treatment are related to implications for hypertension management.