RESUMEN
Objective- Secondary prevention for recurrent myocardial infarction (MI) is one of the most important therapeutic goals in patients with old MI (OMI). Although statins are widely used for this purpose, there remains considerable residual risk even after LDL (low-density lipoprotein cholesterol) is well controlled by statins. Approach and Results- We examined clinical impacts of nHDL (nonhigh-density lipoprotein cholesterol) and its major components triglyceride and LDL as residual risks for acute MI recurrence, using the database of our CHART (Chronic Heart Failure Analysis and Registry in the Tohoku District)-2 Study, the largest-scale cohort study of cardiovascular patients in Japan. We enrolled 1843 consecutive old MI patients treated with statins (mean age 67.3 years, male 19.2%) in the CHART-2 Study. The incidence of recurrent acute MI during the median 8.6-year follow-up was compared among the groups divided by the levels of nHDL (<100, 100-129, and ≥130 mg/dL), LDL (<70, 70-99, and ≥100 mg/dL), triglyceride (<84, 84-149, and ≥150 mg/dL), and combination of LDL and triglyceride. Kaplan-Meier curves and multiple Cox proportional hazards models showed that higher levels of nHDL, but not LDL or triglyceride alone, were associated with higher incidence of recurrent acute MI. Furthermore, higher triglyceride levels were associated with higher incidence of recurrent MI in patients with LDL <100 mg/dL but not in those with LDL ≥100 mg/dL. Conclusions- These results indicate that management of residual risks for acute MI recurrence should include nHDL management considering both LDL and triglyceride in old MI patients under statin treatment. Clinical Trial Registration- URL: http://www.clinicaltrials.gov . Unique identifier: NCT00418041.
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LDL-Colesterol/sangre , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Infarto del Miocardio/sangre , Infarto del Miocardio/mortalidad , Prevención Secundaria/métodos , Triglicéridos/sangre , Anciano , Biomarcadores/sangre , HDL-Colesterol/sangre , Estudios de Cohortes , Femenino , Humanos , Japón , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/tratamiento farmacológico , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Recurrencia , Medición de Riesgo , Índice de Severidad de la Enfermedad , Análisis de SupervivenciaRESUMEN
We aimed to compare the usefulness of plasma levels of B-type natriuretic peptide (BNP) for long-term risk stratification among patients with heart failure (HF) with preserved left ventricular ejection fraction (LVEF) (HFpEF), borderline HFpEF, and HF with reduced LVEF (HFrEF) in the same HF cohort. In the CHART-2 Study (N = 10,219), we categorized 4301 consecutive Stage C/D HF patients (mean age 68.7 years, female 32.4%) into 3 groups: HFpEF (LVEF ≥ 50%, N = 2893), borderline HFpEF (LVEF 40-50%, N = 666), and HFrEF (LVEF ≤ 40%, N = 742). During the median 6.3-year follow-up, all-cause deaths occurred in 887 HFpEF, 330 borderline HFpEF, and 330 HFrEF patients. Although median BNP levels increased from HFpEF, borderline HFpEF to HFrEF (85.3, 126 and 208 pg/ml, respectively, P < 0.001), the relationship between log2 BNP levels and the mortality risk was comparable among the 3 groups. As compared with patients with BNP < 30 pg/ml, those with 30-99, 100-299 and ≥ 300 pg/ml had comparably increasing mortality risk among the 3 groups (hazard ratio 2.5, 4.7 and 7.8 in HFpEF, 2.1, 4.2 and 7.0 in borderline HFpEF, and 3.0, 4.7 and 9.5 in HFrEF, respectively, all P < 0.001). BNP levels have comparable prognostic impact among HFpEF, borderline HFpEF, and HFrEF patients.
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Insuficiencia Cardíaca/sangre , Péptido Natriurético Encefálico/sangre , Medición de Riesgo/métodos , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiología , Anciano , Biomarcadores/sangre , Causas de Muerte/tendencias , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/epidemiología , Insuficiencia Cardíaca/fisiopatología , Humanos , Incidencia , Japón/epidemiología , Masculino , Pronóstico , Estudios Prospectivos , Factores de RiesgoRESUMEN
BACKGROUND: The prognostic impact of atrial fibrillation (AF) among patients at high risk for heart failure (HF) remains unclear. In addition, there is no risk estimation model for AF development in these patients.MethodsâandâResults:The present study included 5,382 consecutive patients at high risk of HF enrolled in the CHART-2 Study (n=10,219). At enrollment, 1,217 (22.6%) had AF, and were characterized, as compared with non-AF patients, by higher age, lower estimated glomerular filtration rate, higher B-type natriuretic peptide (BNP) level and lower left ventricular ejection fraction. A total of 116 non-AF patients (2.8%) newly developed AF (new AF) during the median 3.1-year follow-up. AF at enrollment was associated with worse prognosis for both all-cause death and HF hospitalization (adjusted hazard ratio (aHR) 1.31, P=0.027 and aHR 1.74, P=0.001, for all-cause death and HF hospitalization, respectively) and new AF was associated with HF hospitalization (aHR 4.54, P<0.001). We developed a risk score with higher age, smoking, pulse pressure, lower eGFR, higher BNP, aortic valvular regurgitation, LV hypertrophy, and left atrial and ventricular dilatation on echocardiography, which effectively stratified the risk of AF development with excellent accuracy (AUC 0.76). CONCLUSIONS: These results indicated that AF is associated with worse prognosis in patients at high risk of HF, and our new risk score may be useful to identify patients at high risk for AF onset.
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Fibrilación Atrial/complicaciones , Fibrilación Atrial/mortalidad , Medición de Riesgo/métodos , Anciano , Estudios de Casos y Controles , Femenino , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Factores de RiesgoRESUMEN
From August 26th to 30th, the 2017 Annual Congress of the European Society of Cardiology (ESC 2017) was held in Barcelona, Spain. Despite the terrorism tradegy just before the ESC congress, the congress attracted many medical professionals from all over the world to discuss the recent topics in cardiovascular medicine in more than 500 sessions, including COMPASS (Cardiovascular OutcoMes for People using Anticoagulation StrategieS Trial), CANTOS (Canakinumab Anti-Inflammatory Thrombosis Outcomes Study), and ORION (which assessed the effect of a novel siRNA inhibitor to PCSK9 on reductions in low-density lipoprotein cholesterol). Japanese cardiologists and the Japanese Circulation Society greatly contributed to the congress. This report briefly introduces some late-breaking registry results, late-breaking clinical trials, and ESC Guidelines from the ESC 2017 Congress.
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Cardiología , Congresos como Asunto , Humanos , Sociedades Médicas , EspañaRESUMEN
BACKGROUND: It remains to be elucidated whether addition of renin-angiotensin-aldosterone system (RAAS) inhibitors and/or ß-blockers to loop diuretics has a beneficial prognostic impact on chronic heart failure (CHF) patients. METHODSâANDâRESULTS: From the Chronic Heart failure Analysis and Registry in the Tohoku district 2 (CHART-2) Study (n=10,219), we enrolled 4,134 consecutive patients with symptomatic stage C/D CHF (mean age, 69.3 years, 67.7% male). We constructed Cox models for composite of death, myocardial infarction, stroke and HF admission. On multivariate inverse probability of treatment weighted (IPTW) Cox modeling, loop diuretics use was associated with worse prognosis with hazard ratio (HR) 1.28 (P<0001). Furthermore, on IPTW multivariate Cox modeling for multiple treatments, both low-dose (<40 mg/day) and high-dose (≥40 mg/day) loop diuretics were associated with worse prognosis with HR 1.32 and 1.56, respectively (both P<0.001). Triple blockade with RAS inhibitor(s), mineral corticoid (aldosterone) receptor antagonist(s) (MRA), and ß-blocker(s) was significantly associated with better prognosis in those on low-dose but not on high-dose loop diuretics. CONCLUSIONS: Chronic use of loop diuretics is significantly associated with worse prognosis in CHF patients in a dose-dependent manner, whereas the triple combination of RAAS inhibitor(s), MRA, and ß-blocker(s) is associated with better prognosis when combined with low-dose loop diuretics. (Circ J 2016; 80: 1396-1403).
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Antagonistas Adrenérgicos beta/farmacología , Diuréticos/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Antagonistas de Receptores de Mineralocorticoides/farmacología , Sistema Renina-Angiotensina/efectos de los fármacos , Anciano , Relación Dosis-Respuesta a Droga , Femenino , Humanos , Masculino , Pronóstico , Modelos de Riesgos ProporcionalesRESUMEN
BACKGROUND: The prognostic impact of new-onset atrial fibrillation (AF) is not fully elucidated. METHODS AND RESULTS: We examined 4,818 consecutive stage C/D chronic heart failure (CHF) patients in the Chronic Heart Failure Analysis and Registry in the Tohoku District-2 (CHART-2) Study (n=10,219). At enrollment, 1,859 (38.6%) of them had AF. Compared with the 2,953 patients without AF, AF patients were characterized by higher age (71 vs. 68 years), lower estimated glomerular filtration rate (58.9 vs. 61.9 ml/min/1.73 m(2)), higher brain natriuretic peptide (152 vs. 74.5 pg/ml), similar left ventricular ejection fraction (56.8 vs. 56.5%), and a similar prescription rate of ß-blockers (48.1 vs. 50.6%) and renin-angiotensin system (RAS) inhibitors (72.9 vs. 71.6%). Among the patients without AF at enrollment, 106 (3.6%) developed new AF during the median 3.2-year follow-up, which was associated with increased mortality (adjusted hazard ratio, 1.72; P=0.013). In contrast, neither paroxysmal nor chronic AF at enrollment was associated with increased mortality. The mortality rate was significantly high in the first year after the onset of new AF. On inverse probability of treatment weighting analysis using propensity score, RAS inhibitors and statins were associated with reduced incidence of new AF, and diuretics were associated with increase of new AF. CONCLUSIONS: Onset of new AF, but not a history of AF, is associated with increased mortality in CHF patients, especially in the first year.
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Fibrilación Atrial/mortalidad , Insuficiencia Cardíaca/mortalidad , Sistema de Registros , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/sangre , Fibrilación Atrial/etiología , Fibrilación Atrial/fisiopatología , Enfermedad Crónica , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/complicaciones , Insuficiencia Cardíaca/fisiopatología , Humanos , Japón , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Tasa de SupervivenciaRESUMEN
BACKGROUND: Temporal trends in clinical characteristics, management and prognosis of patients with symptomatic heart failure (HF) remain to be elucidated in Japan. METHODSâANDâRESULTS: From the Chronic Heart Failure Analysis and Registry in the Tohoku District-1 (CHART-1; 2000-2005, n=1,278) and CHART-2 (2006-present, n=10,219) Studies, we enrolled 1,006 and 3,676 consecutive symptomatic stage C/D HF patients, respectively. As compared with the patients in the CHART-1 Study, those in the CHART-2 Study had similar age and sex prevalence, and were characterized by lower brain natriuretic peptide, higher prevalence of preserved left ventricular ejection fraction (LVEF) and higher prevalence of hypertension, diabetes mellitus and ischemic heart disease (IHD), particularly IHD with LVEF ≥50%. From CHART-1 to CHART-2, use of renin-angiotensin system inhibitors, ß-blockers and aldosterone antagonists was significantly increased, while that of loop diuretics and digitalis was decreased. Three-year incidences of all-cause death (24 vs. 15%; adjusted hazard ratio [adjHR], 0.73; P<0.001), cardiovascular death (17 vs. 7%; adjHR, 0.38; P<0.001) and hospitalization for HF (30 vs. 17%; adjHR, 0.51; P<0.001) were all significantly decreased from CHART-1 to CHART-2. In the CHART-2 Study, use of ß-blockers was associated with improved prognosis in patients with LVEF <50%, while that of statins was associated with improved prognosis in those with LVEF ≥50%. CONCLUSIONS: Along with implementation of evidence-based medications, the prognosis of HF patients has been improved in Japan. ( TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT00418041)
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Fármacos Cardiovasculares/uso terapéutico , Insuficiencia Cardíaca/tratamiento farmacológico , Anciano , Fármacos Cardiovasculares/efectos adversos , Comorbilidad , Femenino , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Humanos , Incidencia , Japón , Estimación de Kaplan-Meier , Masculino , Prevalencia , Modelos de Riesgos Proporcionales , Sistema de Registros , Factores de Riesgo , Volumen Sistólico/efectos de los fármacos , Factores de Tiempo , Resultado del Tratamiento , Función Ventricular Izquierda/efectos de los fármacosRESUMEN
AIMS: Prognostic impacts of serum uric acid (UA) levels in patients with chronic heart failure (CHF) remain inconclusive, especially for the whole range of serum UA levels. METHODS AND RESULTS: In the Chronic Heart Failure Registry and Analysis in the Tohoku District-2 (CHART-2) study, we enrolled 4652 consecutive patients with CHF and classified them into four groups based on baseline serum UA levels by the Classification and Regression Tree: G1 (<3.8 mg/dL, N = 313), G2 (3.8-7.1 mg/dL, N = 3070), G3 (7.2-9.2 mg/dL, N = 1018), and G4 (>9.2 mg/dL, N = 251). Mean age was 71 ± 12, 69 ± 12, 68 ± 13, and 69 ± 15 years in G1, G2, G3, and G4, respectively (P < 0.001). During the median follow-up of 6.3 years, in G1, G2, G3, and G4, 111 (35%), 905 (29%), 370 (36%), and 139 (55%) patients died and 79 (25%), 729 (24%), 300 (29%), and 115 (46%) experienced heart failure hospitalization, respectively (both P < 0.001). G1 was characterized by a significantly high prevalence of women as compared with G2, G3, and G4 (59%, 32%, 24%, and 23%, respectively). Serum creatinine levels (0.8 ± 0.4, 0.9 ± 0.4, 1.2 ± 0.6, and 1.4 ± 0.8 mg/dL, respectively), prevalence of atrial fibrillation (34%, 39%, 45%, and 50%, respectively), and diuretics use (36%, 45%, 67%, and 89%, respectively) increased from G1, G2, G3 to G4 (all P < 0.001), while left ventricular ejection fraction decreased from G1, G2, G3 to G4 (59 ± 15, 58 ± 15, 54 ± 15, and 52 ± 17%, respectively, P < 0.001). Multivariable Cox proportional hazards models showed that, as compared with G2, both G1 and G4 had increased incidence of all-cause death [adjusted hazard ratio (aHR) 1.34, 95% confidence interval (CI) 1.08-1.67, P = 0.009; aHR 1.28, 95% CI 1.02-1.61, P = 0.037, respectively] and heart failure admission (aHR 1.39, 95% CI 1.09-1.78, P = 0.008 and aHR 1.35, 95% CI, 1.06-1.71, P = 0.014, respectively). This U-shaped relationship was evident in the elderly patients. Furthermore, abnormal transitions to either higher or lower levels of serum UA from G2 were associated with increased mortality (aHR 1.29, 95% CI 1.06-1.57, P = 0.012; aHR 1.57, 95% CI 1.12-2.20, P = 0.009). CONCLUSIONS: These results demonstrate that serum UA levels have the U-shaped prognostic effects and abnormal transitions to either higher or lower levels are associated with poor prognosis in the elderly patients with CHF.
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Insuficiencia Cardíaca , Ácido Úrico , Anciano , Anciano de 80 o más Años , Femenino , Insuficiencia Cardíaca/epidemiología , Humanos , Persona de Mediana Edad , Pronóstico , Volumen Sistólico , Función Ventricular IzquierdaRESUMEN
AIMS: We aimed to examine temporal changes in left ventricular (LV) structures and their prognostic impacts in patients with heart failure (HF) and preserved ejection fraction (HFpEF). METHODS AND RESULTS: In the Chronic Heart Failure Analysis and Registry in the Tohoku District-2 (CHART-2) study (n = 10 219), we divided 2698 consecutive HFpEF patients (68.9 ± 12.2 years, 32.1% female) into three groups by LV hypertrophy (LVH) and enlargement (LVE) at baseline: (-)LVH/(-)LVE (n = 989), (+)LVH/(-)LVE (n = 1448), and (+)LVH/(+)LVE (n = 261). We examined temporal changes in LV structures and their prognostic impacts during a median 8.7-year follow-up. From (-)LVH/(-)LVE, (+)LVH/(-)LVE to (+)LVH/(+)LVE at baseline, the incidence of the primary outcome, a composite of cardiovascular death or HF admission, significantly increased. Among 1808 patients who underwent echocardiography at both baseline and 1 year, we noted substantial group transitions from baseline to 1 year; the transition rates from (-)LVH/(-)LVE to (+)LVH/(-)LVE, from (+)LVH/(-)LVE to (-)LVH/(-)LVE, from (+)LVH/(-)LVE to (+)LVH/(+)LVE, and from (+)LVH/(+)LVE to (+)LVH/(-)LVE were 27% (182/671), 22% (213/967), 6% (59/967), and 26% (44/170), respectively. In the univariable Cox proportional hazard model, patients who transitioned from (+)LVH/(-)LVE to (+)LVH/(+)LVE or remained in (+)LVH/(+)LVE had the worst subsequent prognosis [hazard ratio (HR) 4.65, 95% confidence interval (CI) 3.09-6.99, P < 0.001; HR 4.01, 95% CI 2.85-5.65, P < 0.001, respectively], as compared with those who remained in (-)LVH/(-)LVE. These results were unchanged after adjustment for the covariates including baseline LV ejection fraction (LVEF) and 1-year LVEF change. CONCLUSION: In HFpEF patients, LV structures dynamically change over time with significant prognostic impacts, where patients who develop LVE with LVH have the worst prognosis.
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Cardiomegalia , Insuficiencia Cardíaca , Ventrículos Cardíacos , Anciano , Anciano de 80 o más Años , Cardiomegalia/diagnóstico por imagen , Cardiomegalia/mortalidad , Cardiomegalia/fisiopatología , Enfermedad Crónica , Progresión de la Enfermedad , Ecocardiografía , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Ventrículos Cardíacos/diagnóstico por imagen , Ventrículos Cardíacos/fisiopatología , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Sistema de Registros , Volumen Sistólico/fisiología , Factores de TiempoRESUMEN
BACKGROUND: The benefits of antithrombotic therapy (ATT) for atrial fibrillation (AF) are occasionally offset by major bleeding complications. However, the clinical benefits and risks of ATT in AF patients, with special references to comorbidities, such as heart failure (HF), coronary artery disease (CAD), and the patterns of AF, remain to be fully elucidated. METHODS: A total of 3221 consecutive AF patients from our Chronic Heart Failure Analysis and Registry in the Tohoku District-2 (CHART-2) Study (Nâ¯=â¯10,219) were divided into 4 groups based on ATT at enrollment; no-ATT, anticoagulant alone, antiplatelet alone, and both of them (AC&AP). Then, efficacy and safety outcomes including thromboembolic events, major bleeding, and mortality were evaluated among the 4 groups. RESULTS: Anticoagulant monotherapy was associated with reduced risk of ischemic stroke in patients with but not in those without HF, CAD, or non-paroxysmal AF. Although there was no significant difference in major bleeding among the 4 groups, a composite of thromboembolism and major bleeding occurred more frequently in the AC&AP group, even in combination with anticoagulants and single antiplatelet therapy, indicating that the combination therapy is more harmful than anticoagulant monotherapy for AF patients, especially for those with HF or CAD. Lastly, no-ATT group was associated with worse prognosis compared with other 3 groups. CONCLUSIONS: These results indicate that ATT is beneficial for AF patients particularly for those with HF, CAD, or non-paroxysmal AF and that among ATT, anticoagulant monotherapy may be most profitable for both clinical benefits and risks for AF patients.
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Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/epidemiología , Fibrinolíticos/uso terapéutico , Informe de Investigación , Anciano , Anciano de 80 o más Años , Fibrilación Atrial/diagnóstico , Comorbilidad , Femenino , Fibrinolíticos/efectos adversos , Hemorragia/inducido químicamente , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Tromboembolia/inducido químicamente , Resultado del TratamientoRESUMEN
BACKGROUND: We have recently demonstrated that left ventricular ejection fraction (LVEF) dynamically changes over time with prognostic impacts in Stage C/D patients, namely, those who have a current or past history of heart failure (HF). However, it is unknown whether this is also the case in asymptomatic Stage B patients, namely, those who have a risk of HF, but do not have a history of HF. METHODS: In our CHART-2 Study (N = 10,219), we enrolled 4005 Stage B patients and divided them into 3 groups by LVEF; preserved EF (pEF, LVEF ≥50%, N = 3526), mid-range EF (mrEF, LVEF 41-49%, N = 302), and reduced EF (rEF, LVEF ≤40%, N = 177). We examined the prognostic impacts of LVEF transitions among the 3 groups in comparison with 4477 patients with Stage C/D HF. RESULTS: Stage B were characterized by less severe clinical status and better prognosis compared with Stage C/D. Stage B in mrEF and rEF at baseline dynamically transitioned to other groups at 1-year, whereas those in pEF unchanged; at 1-year, mrEF transitioned to pEF/rEF by 50/16%, and rEF transitioned to pEF/mrEF by 25/31%, respectively, whereas pEF transitioned to mrEF/rEF by only 3.6/0.7%, respectively, which were consistent with findings in findings with Stage C/D. Although LVEF decrease was directly associated with all-cause mortality in both the Stage B and Stage C/D with pEF, factors related to LVEF changes were different between the 2 groups. CONCLUSIONS: In Stage B, LVEF dynamically changes with prognostic impacts as in Stage C/D, whereas different determination factors may be involved in the 2 stages. CLINICAL TRIAL REGISTRATION: Chronic Heart Failure Analysis and Registry in the Tohoku District (CHART)-2 (NCT00418041).
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Insuficiencia Cardíaca , Función Ventricular Izquierda , Insuficiencia Cardíaca/diagnóstico por imagen , Humanos , Pronóstico , Sistema de Registros , Volumen SistólicoRESUMEN
AIMS: Asymptomatic patients with structural heart diseases are classified as a population at high risk for heart failure (HF) in Stage B. However, limited data are available regarding incidence and related factors of de-novo HF (DNHF) considering competing risk in this population. METHODS AND RESULTS: In 3362 Stage B patients (mean age 68 yrs, male 76%) from the CHART-2 Study (N = 10,219), we examined incidence of death and DNHF, defined as the first episode of either HF hospitalization or HF death, and factors related to DNHF. RESULTS: During the median 6.0-year follow-up, 627 deaths (31/1000 person-years) and 293 DNHF (15/1000 person-years) occurred. Among the 627 deaths, 212 (34%) and 325 (52%) were specified as cardiovascular and non-cardiovascular deaths, respectively. During the follow-up of 271 DNHF hospitalizations, we observed 124 deaths, including 65 (52%) cardiovascular and 47 (40%) non-cardiovascular deaths. The competing risk model showed that age, diabetes mellitus, stroke, atrial fibrillation, diastolic blood pressure, hemoglobin levels, estimated glomerular filtration ratio and left ventricular ejection fraction was significantly associated with DNHF. Bayesian structural equation modeling showed that many of these cardiac and non-cardiac variables contribute to DNHF by affecting each other, while diabetes mellitus was independently associated with DNHF. CONCLUSIONS: Stage B patients had a high incidence of DNHF as well as that of death due to both cardiovascular and non-cardiovascular causes. Thus, management of Stage B patients should include multidisciplinary approaches considering both cardiac and non-cardiac factors, in order to prevent DNHF as well as non-HF death as a competing risk. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT00418041.
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Insuficiencia Cardíaca , Función Ventricular Izquierda , Anciano , Teorema de Bayes , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/epidemiología , Hospitalización , Humanos , Masculino , Factores de Riesgo , Volumen SistólicoRESUMEN
BACKGROUND: Since most of the randomized clinical trials for heart failure (HF) were designed to exclude elderly patients, limited data are available on their clinical characteristics, prognosis, and prognostic factors. METHODS: We compared clinical characteristics, prognosis, and prognostic factors among Stage C/D HF patients in our CHART-2 Study (N = 4876, mean 69 years, women 32%, 6.3-year follow-up) by age (G1, ≤64 years, N = 1521; G2, 65-74 years, N = 1510; and G3, ≥75 years, N = 1845). RESULTS: From G1 to G3, the prevalence of women, left ventricular ejection fraction (LVEF) and plasma levels of B-type natriuretic peptide (BNP) increased (all P < 0.001). Similarly, 5-year mortality increased (9.9, 17.3 to 39.9%, P < 0.001) along with a decrease in proportion of cardiovascular death and an increase in non-cardiovascular death in both sexes. While all-cause and cardiovascular mortality was comparable between the sexes, women had significantly lower incidence of non-cardiovascular death than men in G2 and G3, which was attributable to the higher incidence of cancer death and pneumonia death in men than in women. Although NYHA functional class III-IV, chronic kidney disease, cancer, LVEF, and BNP had significant impacts on all-cause death in all groups, their impacts were less evident in G3 as compared with G1. CONCLUSIONS: The elderly HF patients, as compared with younger HF patients, were characterized by more severe clinical background, increased proportion of non-cardiovascular death and worse prognosis with different impacts of prognostic factors across the age groups.
RESUMEN
BACKGROUND: Several studies have reported that C-reactive protein (CRP), an inflammatory biomarker, predicts cardiovascular events independently of low-density lipoprotein cholesterol levels. However, no study examined whether temporal changes in CRP levels are associated with clinical events in patients with previous myocardial infarction (MI). METHODS AND RESULTS: We examined 2184 consecutive patients with previous MI and CRP data at baseline in the Chronic Heart Failure Registry and Analysis in the Tohoku district-2 (CHART-2) Study. During the median 6.4â¯years follow-up, 592 all-cause, 245 cardiovascular, and 273 non-cardiovascular deaths occurred. Patients with CRPâ¯≥â¯2.0â¯mg/L at baseline had significantly increased incidence of all-cause (hazard ratio (HR) 1.68, Pâ¯<â¯0.001) and non-cardiovascular death (HR 1.86, Pâ¯<â¯0.001), compared with those with CRPâ¯<â¯2.0â¯mg/L. Temporal changes in CRP levels were associated with prognosis; among patients with CRPâ¯≥â¯2.0â¯mg/L at baseline, those with CRPâ¯≥â¯2.0â¯mg/L at 1-year had significantly increased incidence of all-cause (HR 2.12, Pâ¯<â¯0.001), cardiovascular (HR 2.31, Pâ¯<â¯0.001), and non-cardiovascular death (HR 2.29, Pâ¯<â¯0.001). Among patients with CRPâ¯<â¯2.0â¯mg/L at baseline, those with CRPâ¯≥â¯2.0â¯mg/L at 1-year had significantly increased incidence of all-cause (HR 1.76, Pâ¯<â¯0.001) and cardiovascular death (HR 2.10, Pâ¯=â¯0.001). These results remained significant after adjusted with the inverse probability of treatment weighted models using propensity sore. Furthermore, as compared with patients with CRPâ¯<â¯2.0â¯mg/L at both baseline and 1-year, those with CRPâ¯≥â¯2.0â¯mg/L at both baseline and 1-year had increased incidence of all-cause, cardiovascular, and non-cardiovascular death. CONCLUSIONS: These results provide the evidence that temporal increases in CRP levels are associated with increased clinical events in patients with previous MI.
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Proteína C-Reactiva/metabolismo , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/diagnóstico , Infarto del Miocardio/sangre , Infarto del Miocardio/diagnóstico , Sistema de Registros , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Estudios de Cohortes , Femenino , Insuficiencia Cardíaca/epidemiología , Humanos , Japón/epidemiología , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Pronóstico , Estudios Prospectivos , Informe de Investigación , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: Although several factors, including heart failure (HF) and inflammation, are known to increase the incidence of cancer, it remains unknown whether HF may increase cancer mortality, especially with a reference to inflammation. METHODS AND RESULTS: We examined 8843 consecutive cardiovascular patients without a prior history of cancer in our CHART-2 Study (mean 68â¯yrs., female 30.9%). As compared with patients without HF (Stage A/B, Nâ¯=â¯4622), those with HF (Stage C/D, Nâ¯=â¯4221) were characterized by higher prevalence of diabetes, previous myocardial infarction, atrial fibrillation, and stroke. During the median 6.5-year follow-up (52,675 person-years), 282 cancer deaths occurred. HF patients had significantly higher cancer mortality than those without HF in both the overall (3.7 vs, 2.8%, hazard ratio (HR) 1.42, 95% confidence interval (CI) 1.12-1.79, Pâ¯=â¯0.004) and the propensity score-matched cohorts (HR 1.46, 95%CI 1.10-1.93, Pâ¯=â¯0.008), which was confirmed in the competing risk models. The multivariable Cox proportional hazard model in the matched cohort showed that HF was associated with increased cancer mortality in patients with C-reactive protein (CRP)â¯≥â¯2.0â¯mg/L (HR 1.87, 95%CI 1.18-2.96, Pâ¯=â¯0.008) at baseline, but not in those with CRPâ¯<â¯2.0â¯mg/L (HR 0.89, 95%CI 0.54-1.45, Pâ¯=â¯0.64) (P for interactionâ¯=â¯0.03). Furthermore, temporal changes in CRP levels were associated with cancer death in the overall cohort; HF patients with CRPâ¯≥â¯2.0â¯mg/L at both baseline and 1-year had significantly increased cancer death, while those with CRPâ¯≥â¯2.0â¯mg/L at baseline and <â¯2.0â¯mg/L at 1-year not. CONCLUSIONS: These results provide the first evidence that HF is associated with increased cancer death, especially when associated with prolonged inflammation.
Asunto(s)
Proteína C-Reactiva/metabolismo , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/mortalidad , Neoplasias/sangre , Neoplasias/mortalidad , Informe de Investigación , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Enfermedad Crónica , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Inflamación/sangre , Inflamación/mortalidad , Mediadores de Inflamación/sangre , Japón/epidemiología , Masculino , Persona de Mediana Edad , Mortalidad/tendencias , Estudios Prospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Complete revascularization with PCI is not always achieved in patients with ischemic HF. Therefore, this study aimed to elucidate the prognostic impact of residual coronary stenosis (RS) after percutaneous coronary intervention (PCI) in patients with ischemic heart failure (HF). METHODS: We analyzed a total of 1307 patients with symptomatic HF and a history of PCI registered in our Chronic Heart Failure Analysis and Registry in the Tohoku District-2 (CHART-2) Study. RS that was defined as the presence of ≥70% luminal stenosis in major coronary arteries at the last coronary angiography. RESULTS: Among the study population, 851 patients (65.1%) had RS. During a median follow-up period of 3.2â¯years, patients with RS had higher all-cause mortality than those without it even after propensity score matching (21.9 vs. 11.6%, log-rank Pâ¯=â¯0.027). Multivariable Cox hazard analysis also showed the negative impact of RS on all-cause death in ischemic HF patients [hazard ratio (HR):1.62, 95% confidence interval (CI): 1.07-2.46, Pâ¯=â¯0.024]. Importantly, when divided all subjects into three subgroups by left ventricular ejection fraction (LVEF) [LVEFâ¯<â¯40% (HFrEF), LVEF 40-49% (HFmrEF), and LVEFâ¯≥â¯50% (HFpEF)], inverse probability of treatment weighted method provided a similar result that RS after PCI was an independent risk factor for death in the HFpEF [HR(95%CI); 1.94(1.22-3.09), Pâ¯<â¯0.01] and HFmrEF [4.47(1.13-14.98), Pâ¯<â¯0.01] groups, but not in the HFrEF group [1.20(0.59-2.43), Pâ¯=â¯0.62]. CONCLUSIONS: These results indicate that RS after PCI could aggravate long-term prognosis of ischemic HF patients with moderate- to well-preserved EF, but not those with reduced EF.
Asunto(s)
Estenosis Coronaria/diagnóstico por imagen , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/cirugía , Isquemia Miocárdica/diagnóstico por imagen , Isquemia Miocárdica/cirugía , Intervención Coronaria Percutánea/tendencias , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Estenosis Coronaria/epidemiología , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/epidemiología , Pronóstico , Estudios Prospectivos , Informe de InvestigaciónRESUMEN
BACKGROUND: Although B-type natriuretic peptide (BNP) and N-terminal prohormone B-type natriuretic peptide (NT-proBNP) are released in equimolar proportions, their values differ depending on clinical conditions. A useful conversion formula between BNP and NT-proBNP remains to be developed for the clinical use. AIM: To develop a conversion formula from BNP to NT-proBNP. METHODS: In the derivation cohort, 923 patients with chronic heart failure, in whom both BNP and NT-proBNP values were available, were enrolled from our SUPPORT (Supplemental Benefit of ARB in Hypertensive Patients with Stable Heart Failure using Olmesartan) trial. The validation cohort included 1154 consecutive patients with or at risk of cardiovascular diseases, in whom both BNP and NT-proBNP values were measured simultaneously at Tohoku University Hospital. We regressed log10 NT-proBNP onto log10 BNP and factors influencing BNP and NT-proBNP values. RESULTS: We adopted the model with the smallest Akaike information criterion consisting of log10 BNP, age, sex, BMI, creatinine clearance (CCr), hemoglobin, and atrial fibrillation (AF). As compared with the previously reported conversion formulas, the present conversion formula utilized non-linear transformation by spline function, and exhibited the strongest correlation between actual and calculated values of NT-proBNP (râ¯=â¯0.928). The root mean squared error (RMSE) of the present conversion formula was smallest compared with the previously reported conversion formulas, indicating that this formula most effectively converts BNP values to NT-proBNP values. CONCLUSIONS: We have developed a useful conversion formula from BNP to NT-proBNP values, using age, sex, BMI, CCr, hemoglobin, and AF, which could be widely used in daily clinical practice.
Asunto(s)
Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/diagnóstico , Péptido Natriurético Encefálico/sangre , Fragmentos de Péptidos/sangre , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estándares de ReferenciaRESUMEN
BACKGROUND: Self-care behaviors (ScB) are associated with symptoms and outcomes in patients with heart failure (HF). However, little is known about gender differences in the prognostic relevance of ScB in HF patients. METHODS: We examined gender differences in ScB of HF patients regarding its prognostic associations with mortality and HF hospitalization with a reference to ScB dimensions. The European Heart Failure Self-Care Behavior Scale (EHFScBS) was used to evaluate ScB in 2233 patients with Stage C/D HF in the CHART-2 Study. RESULTS: Male patients (n=1583) were younger (71 vs. 73 yrs) and had lower ScB (median 33 vs. 31) (all p<0.001) than females (n=650). During the median follow-up of 2.57 years, patients with high ScB (score 12-32, n=1090), as compared with low ScB patients (score 33-60, n=1143), had significantly increased all-cause mortality in males [adjusted hazard ratio (aHR) 1.44, p=0.02] but not in females (aHR 0.80, p=0.40) (p for interaction 0.02), while ScB was not significantly associated with incidence of HF hospitalization in both genders. Among the 3 dimensions in EHFScBS, complying with regimen was associated with decreased mortality in females, but not in males (p for interaction 0.003), while asking for help was related with increased incidence of HF hospitalization in males (aHR 1.34, p=0.072) but not in females (aHR 0.98, p=0.931) (p for interaction 0.048). CONCLUSIONS: There were gender differences in the prognostic relevance of self-care with mortality and incidence of HF hospitalization, suggesting that self-care should be implemented considering gender differences to improve prognosis.
Asunto(s)
Conductas Relacionadas con la Salud , Insuficiencia Cardíaca/epidemiología , Autocuidado , Anciano , Anciano de 80 o más Años , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Pronóstico , Modelos de Riesgos Proporcionales , Factores SexualesRESUMEN
BACKGROUND: Few simple risk models, without echocardiography have been developed for patients with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) (HFpEF). METHODS: To develop a risk score to predict all-cause death for HFpEF patients, we examined 1277 HF patients with LVEF ≥50% and BNP ≥100â¯pg/ml in the CHART-2 Study, a large-scale prospective cohort study for HF in Japan. We selected the optimal subset of covariates for the score with Cox proportional hazard models and random survival forests (RSF). RESULTS: During the median 5.7-year follow-up, 576 deaths occurred. Cox models and RSF analyses consistently indicated age ≥75â¯years, albumin <3.7â¯g/dl, anemia, BMI <22â¯kg/m2, BNP ≥300â¯pg/ml (or NT-proBNP ≥1400â¯pg/ml), and BUN ≥25â¯mg/dl, as the important 6 prognostic variables. Incorporating these 6 variables, we developed a scoring system (3A3B score, with 2 points given to age ≥75â¯years and 1 point to the others based on the hazard ratios. The discrimination ability of the risk score was excellent (c-index 0.708). Regarding model goodness-of-fit, the overall gradient in 5-year risk was well captured by the score. The predictive accuracy of the 3A3B score was confirmed in the external validation cohorts from the TOPCAT trial (Nâ¯=â¯835, c-index 0.652) and the ASIAN-HF registry (Nâ¯=â¯170, c-index 0.741). CONCLUSIONS: We developed a simple risk score to predict long-term prognosis of HFpEF patients. The 3A3B score, comprising 6 commonly available parameters in daily practice, has potential utility in the risk stratification and management of HFpEF patients.
Asunto(s)
Insuficiencia Cardíaca/epidemiología , Medición de Riesgo/métodos , Volumen Sistólico/fisiología , Función Ventricular Izquierda/fisiología , Anciano , Causas de Muerte/tendencias , Femenino , Estudios de Seguimiento , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/fisiopatología , Humanos , Incidencia , Japón/epidemiología , Masculino , Prevalencia , Pronóstico , Estudios Prospectivos , Factores de Riesgo , Tasa de Supervivencia/tendencias , Factores de TiempoRESUMEN
BACKGROUND: The beneficial prognostic impact of statins has been established in patients with ischemic heart disease but not in those with heart failure (HF). In addition, it is still unclear whether patients benefit from statins regardless of low-density lipoprotein cholesterol levels. METHODS AND RESULTS: We examined 2444 consecutive stage C or D HF patients with ischemic heart disease registered in CHART-2 (Chronic Heart Failure Registry and Analysis in the Tohoku District 2), a multicenter, prospective, observational cohort study in Japan. Patients were divided into 3 groups according to the Japanese standard doses of statins and statin-intensity categories defined by the 2013 American College of Cardiology and American Heart Association guidelines: higher (moderate-high)-intensity (n=868), lower (low)-intensity (n=526), and no statin (n=1050). The median follow-up period was 6.4 years (13929 person-years). Analysis with the inverse probability of treatment weighted using a propensity score for multiple treatment revealed that both the higher-intesity group (hazard ratio [HR]: 0.68; P<0.001) and the lower-intensity group (HR: 0.82; P<0.001) had significantly lower incidence of the primary end point-a composite of all-cause death and HF admission-compared with the no statin group. The higher-intensity statin group had significantly lower incidence of the primary end point (HR: 0.82; P<0.001), all-cause death (HR: 0.83; P<0.001), and HF admission (HR: 0.78; P<0.001) than the lower-intensity statin group. Moreover, the use of statins, either higher- or lower-intensity, was associated with reduced incidence of the primary end point, regardless of low-density lipoprotein cholesterol levels. CONCLUSIONS: These results suggest that statin use, particularly the use of higher-intensity statins, has a beneficial prognostic impact in HF patients with ischemic heart disease, regardless of low-density lipoprotein cholesterol levels. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00418041.