Incidence of Hospitalization-Associated Disability in Older Patients With Heart Failure.

BACKGROUND: This study determined the incidence of hospitalization-associated disability (HAD) and its characteristics in older patients with heart failure in Japan.Methods and Results: Ninety-six institutions participated in this nationwide multicenter registry study (J-Proof HF). From December 2020 to March 2022, consecutive heart failure patients aged ≥65 years who were prescribed physical rehabilitation during hospitalization were enrolled. Of the 9,403 patients enrolled (median age 83.0 years, 50.9% male), 3,488 (37.1%) had HAD. Compared with the non-HAD group, the HAD group was older and had higher rates of hypertension, chronic kidney disease, and cerebrovascular disease comorbidity. The HAD group also had a significantly lower Barthel Index score and a significantly higher Kihon checklist score before admission. Of the 9,403 patients, 2,158 (23.0%) had a preadmission Barthel Index score of <85 points. Binomial logistic analysis revealed that age and preadmission Kihon checklist score were associated with HAD in patients with a preadmission Barthel Index score of ≥85, compared with New York Heart Association functional classification and preadmission cognitive decline in those with a Barthel Index score <85. CONCLUSIONS: This nationwide registry survey found that 37.1% of older patients with HF had HAD and that these patients are indicated for convalescent rehabilitation. Further widespread implementation of rehabilitation for older patients with heart failure is expected in Japan.

Clinical impact of non-lying time on hospital-associated functional decline in older patients undergoing transcatheter aortic valve implantation.

The purposes of the present study were: (1) to investigate the relationship between hospital-associated functional decline (HAFD) and non-lying time and (2) to clarify the optimal cut-off value for non-lying time associated with HAFD in older patients undergoing transcatheter aortic valve implantation (TAVI). From January 2021 to December 2022, patients admitted to a university hospital who underwent trans-femoral TAVI were consecutively recruited. We measured short physical performance battery (SPPB) pre and post-TAVI, and non-lying time from post-operative days 3-5. HAFD was defined as at least 1 point decrease in SPPB during pre and post-TAVI. Among 75 patients (47 female, mean age of 84.5 years) enrolled, 14 patients were classified as having HAFD. Non-lying time was significantly shorter in the HAFD group than in the non-HAFD group (371 min vs. 539 min, P < 0.001). Receiver-operating characteristic analysis determined an optimal cut-off value of 477 min for differentiating the patients more likely to experience HAFD (sensitivity, 75%; specificity, 92%; area under the curve, 0.798). The non-lying time could be one of the associated factors of HAFD in older patients with TAVI. Non-lying time of about 480 min (8 h) during hospitalization may be an initial target for preventing HAFD.

Impact of heart failure severity on bone mineral density among older patients with heart failure.

The study aimed to identify factors related to bone mineral density (BMD) among older patients with heart failure (HF). A total of 70 consecutive patients with HF aged 65 years or older who were admitted to an acute hospital due to worsening condition were enrolled before discharge. BMD of the femoral neck was evaluated using the DEXA method. Physical function, as well as echocardiographic and laboratory findings including biomarker of HF severity were collected. Bivariate and multiple regression analyses were employed to determine the association between BMD and the clinical variables. Bivariate analysis determined that age, grip strength, walking speed, serum albumin, and N-terminal pro B-type natriuretic peptide (NT-proBNP) were significantly correlated with BMD (P < 0.01), whereas other clinical parameters were not. The multiple regression analysis identified NT-proBNP as an independent related factor for BMD after adjusting with confounding clinical variables. NT-proBNP was independently related to BMD among older patients with HF. Our results suggest the inclusion of bone fracture prevention strategies in disease management programs, especially for older patients with HF.

Predictive impact of early mobilization on rehospitalization for elderly Japanese heart failure patients.

The aim of this study was to determine whether early mobilization was associated with rehospitalization among elderly heart failure patients. We measured the time from admission to mobilization and other clinical characteristics for 190 heart failure patients (mean age, 80.7 years). The primary outcome was heart failure rehospitalization. Kaplan-Meier survival curves were plotted and the hazard ratios for rehospitalization were determined using Cox proportional hazards regression models. During a median follow-up period of 750 days, 58 patients underwent rehospitalization. The time from admission to mobilization was significantly longer for these patients than for those who were not rehospitalized. Univariate and multivariate Cox proportional hazards analyses showed that the time from admission to mobilization was an independent predictor of rehospitalization, and receiver-operating characteristic analysis determined an optimal cutoff value of 3 days for differentiating the patients more likely to experience a subsequent cardiac event (sensitivity, 76%; specificity, 69%; area under the curve, 0.667). Kaplan-Meier survival curve analysis showed a significantly lower event rate in the ≤ 3-day group (p = 0.001, log-rank test). In conclusion, the time from admission to mobilization may be one of the strongest predictors of rehospitalization in elderly heart failure patients. Early mobilization within 3 days may be an initial target for the acute phase treatment of heart failure.

Maximum Walking Speed at Discharge Could Be a Prognostic Factor for Vascular Events in Patients With Mild Stroke: A Cohort Study.

OBJECTIVE: To identify the prognostic value of physical activity-related factors as well as known vascular risk factors for vascular events in mild ischemic stroke (MIS). DESIGN: Single-center prospective cohort study. SETTING: University hospital. PARTICIPANTS: Consecutive patients (N=255) (175 men, median age 70.0y) with acute ischemic stroke and transient ischemic attack (TIA) with modified Rankin scale scores ranging from 0 to 2 were enrolled in this study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Enrolled patients were followed up for composite vascular events as primary outcomes up to 3 years postdischarge. Primary outcomes included stroke and cardiovascular death, hospitalization due to stroke or TIA recurrence, cardiovascular disease, and peripheral artery disease. During hospitalization, known vascular risk factors such as previous history of vascular events, stroke subtype, white matter lesions, and ankle-brachial index were assessed. Moreover, at the time of discharge, physical activity-related factors such as maximum walking speed (MWS), handgrip strength, knee extensor isometric muscle strength, anxiety, and depression were assessed as potential predictors. RESULTS: The Kaplan-Meier estimates of cumulative risk of composite vascular events at 1, 2, and 3 years were 9.6%, 14.4%, and 15.2%, respectively. After multivariate analysis, cerebral white matter lesions of periventricular hyperintensity (PVH) (grade=3; hazard ratio: 2.904; 95% confidence interval: 1.160 to 7.266; P=.023) and MWS (<1.45m/s; hazard ratio: 2.232; 95% confidence interval: 1.010 to 4.933; P=.047) were identified as significant independent predictors of composite vascular events. CONCLUSIONS: The results of this study indicate that MWS could be an independent prognostic factor for composite vascular events in MIS.

Estimation of reduced walking speed using simple measurements of physical and psychophysiological function in community-dwelling elderly people: a cross-sectional and longitudinal study.

BACKGROUND: Early detection of reduced mobility function is important in elderly people. Usual walking speed is useful to assess mobility function, but is often not feasible in a community setting. AIMS: This study aimed to explore a simple surrogate indicator of usual walking speed in elderly people. METHODS: The participants were 516 community-dwelling elderly people. As a baseline survey, the usual walking speed and candidates of surrogate indicators including physical function and psychophysiological function were measured. After 2 years, the occurrence of mobility limitation was assessed. RESULTS: In cross-sectional analysis, a linear regression model with maximum step length, age, and sex presented the most favourable adjusted R2 of 0.426 for estimating usual walking speed. Maximum step length (MSL) also showed good predictive accuracy for usual walking speed < 0.8 m/s {area under the curve [AUC] 0.908 [95% confidence interval (CI) 0.811, 1.000]} and < 1.0 m/s [AUC 0.883 (95% CI) 0.832, 0.933)] in receiver-operating characteristic (ROC) analysis. In longitudinal analysis, the predictive accuracy of MSL for mobility limitation [AUC 0.813 (95% CI 0.752, 0.874)] was similar to that of usual walking speed [AUC 0.808 (95% CI 0.747, 0.869)] in ROC analysis. CONCLUSIONS AND DISCUSSION: The results of this study suggest that MSL may serve as a simple surrogate indicator of UWS in elderly people.

Development of a Self-Efficacy Questionnaire for Walking in Patients with Mild Ischemic Stroke.

PURPOSE: This study aimed to develop a self-efficacy questionnaire, which particularly focuses on walking in patients with mild ischemic stroke and transient ischemic attack. METHODS: We enrolled patients with acute ischemic stroke and transient ischemic attack who scored 0-2 on the modified Rankin Scale. The process of development of questionnaire on self-efficacy for walking with 7 items (SEW-7) was composed of 3 steps: (1) item generation; (2) item reduction; and (3) testing the final version. The measurement properties were assessed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. RESULTS: A total of 168 patients (mean age 69.4 ± 10.1 years) were enrolled for testing the questionnaire on SEW-7. The total score of the SEW-7 ranged from 7 to 35 points. Internal consistency was acceptable with the Cronbach's alpha coefficient of .93. Test-retest reliability was good with intraclass correlation coefficient of .83 (95% confidence interval: .67-.91). The smallest detectable changes at individual and group levels were 8.0 and 1.5, respectively. The results of principal component analysis showed a single factor explaining 71.8% of the total variance. The SEW-7 questionnaire showed moderate to strong correlation with physical activity parameters (step counts: r = .596, P < .001; physical activity-related energy expenditure: r = .615, P < .001; low-intensity physical activity: r = .449, P < .001; moderate- to vigorous-intensity physical activity: r = .581, P < .001). CONCLUSIONS: We propose a simple self-report questionnaire for walking, with 7 items. The SEW-7 has adequate measurement properties and may serve as a time-saving tool for promoting physical activity in mild ischemic stroke patients.

Secondary prevention of new vascular events with lifestyle intervention in patients with noncardioembolic mild ischemic stroke: a single-center randomized controlled trial.

BACKGROUND: Lifestyle modification is associated with a substantially decreased risk of cardiovascular events. However, the role of lifestyle intervention for secondary prevention in patients with noncardioembolic ischemic stroke is inadequately defined. We assessed the hypothesis that lifestyle intervention can reduce the onset of new vascular events in patients with noncardioembolic mild ischemic stroke. METHODS: We conducted an observer-blind randomized controlled trial that enrolled 70 patients (48 men, mean age 63.5 years) with acute noncardioembolic mild ischemic stroke. The patients were allocated in equal numbers to a lifestyle intervention group or a control group. We performed lifestyle interventions, which comprised exercise training, salt restriction and nutrition advice for 24 weeks. Then all patients were prospectively followed up for occurrence of the primary endpoints, including hospitalization due to stroke recurrence and the onset of other vascular events. We also evaluated systolic blood pressure (SBP) at the clinic and at home, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), hemoglobin A1c (HbA1c) and high-sensitivity C-reactive protein (hs-CRP) to compare the efficacy of the lifestyle interventions. RESULTS: This trial was terminated earlier than expected because of the prespecified early stopping rule for efficacy. After the 24-week intervention period, the intervention group showed a significant increase in daily physical activity and a significant decrease in salt intake (physical activity, p = 0.012; salt intake, p < 0.001), with a significant difference between the randomized groups (physical activity, p < 0.001; salt intake, p = 0.018). Similarly, blood pressure was decreased and the HDL-C levels were increased in the intervention group (SBP, p < 0.001; HDL-C, p = 0.018), with significant differences between the randomized groups (SBP, p < 0.001; HDL-C, p = 0.022). In contrast, LDL-C, HbA1c and hs-CRP tended to decrease in the intervention group, but this decrease did not achieve significance. After a median follow-up period of 2.9 years, 12 patients allocated to the control group and 1 patient in the lifestyle intervention group experienced at least 1 vascular event. A sequential plans analysis indicated the superiority of the lifestyle intervention in interim analysis. Kaplan-Meier survival curves after the log-rank test showed a significant prognostic difference between the randomized groups (p = 0.005). CONCLUSIONS: Lifestyle intervention with appropriate medication is beneficial for reducing the incidence of new vascular events and improving vascular risk factors in patients with noncardioembolic mild ischemic stroke.

Exploring the factors associated with decreased dynamic balance ability in older patients with heart failure.

BACKGROUND: Older patients with heart failure (HF) have a higher prevalence of frailty and poorer dynamic balance ability than other community-dwelling older adults. However, the association of frailty and other clinical characteristics with dynamic balance ability in these patients remains unclear. OBJECTIVES: We aimed to determine the clinical characteristics associated with decreased dynamic balance ability in older patients with HF. METHODS: This observational study included patients aged ≥65 years who could walk independently and were admitted to our university hospitals to undergo a cardiac rehabilitation. The timed up and go test (TUG) was used to evaluate dynamic balance ability. Pearson's and Spearman's correlation analyses were performed to determine the relationships between TUG scores and clinical characteristics. A multiple regression model based on the forced entry method was used to determine independent predictors of TUG scores. RESULTS: Of the 183 participants in this study (94 women; mean age, 82.5 ± 8.1 years), 116 (61.7%) had frailty. Pearson's and Spearman's correlation analyses revealed that age, frailty, sex, knee extensor muscle strength, maximum calf circumference, and Mini-Mental State Examination-Japanese version (MMSE-J) score were significantly correlated with TUG score (p < 0.001). Further, multiple regression analysis showed that age (p < 0.001), frailty (p = 0.041), knee extensor muscle strength (p = 0.002), and MMSE-J score (p = 0.048) were independent predictors of TUG scores. CONCLUSION: Multiple factors, including age, frailty, knee extensor muscle weakness, and cognitive function impairment are independently associated with decreased dynamic balance ability in older patients with HF.

Prediction of stroke patients' bedroom-stay duration: machine-learning approach using wearable sensor data.

Background: The importance of being physically active and avoiding staying in bed has been recognized in stroke rehabilitation. However, studies have pointed out that stroke patients admitted to rehabilitation units often spend most of their day immobile and inactive, with limited opportunities for activity outside their bedrooms. To address this issue, it is necessary to record the duration of stroke patients staying in their bedrooms, but it is impractical for medical providers to do this manually during their daily work of providing care. Although an automated approach using wearable devices and access points is more practical, implementing these access points into medical facilities is costly. However, when combined with machine learning, predicting the duration of stroke patients staying in their bedrooms is possible with reduced cost. We assessed using machine learning to estimate bedroom-stay duration using activity data recorded with wearable devices. Method: We recruited 99 stroke hemiparesis inpatients and conducted 343 measurements. Data on electrocardiograms and chest acceleration were measured using a wearable device, and the location name of the access point that detected the signal of the device was recorded. We first investigated the correlation between bedroom-stay duration measured from the access point as the objective variable and activity data measured with a wearable device and demographic information as explanatory variables. To evaluate the duration predictability, we then compared machine-learning models commonly used in medical studies. Results: We conducted 228 measurements that surpassed a 90% data-acquisition rate using Bluetooth Low Energy. Among the explanatory variables, the period spent reclining and sitting/standing were correlated with bedroom-stay duration (Spearman's rank correlation coefficient (R) of 0.56 and -0.52, p < 0.001). Interestingly, the sum of the motor and cognitive categories of the functional independence measure, clinical indicators of the abilities of stroke patients, lacked correlation. The correlation between the actual bedroom-stay duration and predicted one using machine-learning models resulted in an R of 0.72 and p < 0.001, suggesting the possibility of predicting bedroom-stay duration from activity data and demographics. Conclusion: Wearable devices, coupled with machine learning, can predict the duration of patients staying in their bedrooms. Once trained, the machine-learning model can predict without continuously tracking the actual location, enabling more cost-effective and privacy-centric future measurements.

Predictive value of heart rate recovery after exercise testing in addition to brain natriuretic peptide levels in ambulatory patients with nonischemic dilated cardiomyopathy.

BACKGROUND: Heart rate recovery (HRR) is related to autonomic function and is a prognostic marker in cardiovascular disease. We sought to investigate the clinical utility of HRR in addition to BNP levels in ambulatory outpatients with nonischemic dilated cardiomyopathy (NICM). METHODS: Seventy-nine NICM outpatients were followed for a mean of 19 months. HRR was defined as the difference in heart rate between peak exercise and 1 minute later. On the basis of the lower tertile value, we allocated the patients to two groups: with HRR >12 bpm (n = 48; normal) and with HRR ≤12 bpm (n = 31, abnormal). RESULTS: The probability of cardiac event-free survival was significantly lower in the abnormal HRR group than in the normal HRR group (P = 0.002). Stepwise multivariate analysis revealed that plasma BNP and HRR were independent predictors of cardiac events. Patients with both HRR ≤12 bpm and BNP ≥200 pg/mL had significantly higher rates of cardiac events than those in whom only one, or neither, of these variables was abnormal. CONCLUSIONS: HRR after exercise testing, in addition to plasma BNP level, might be a useful indicator as a predictor for admission due to worsening heart failure and its combination is able to provide additive prognostic information in ambulatory outpatients with NICM.

Poor walking ability outcome and activities of daily living improvement in patients undergoing cardiac rehabilitation during COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has had wide-ranging impacts across international healthcare systems and direct impacts on rehabilitation professionals. Few outcome data for cardiac patients undergoing rehabilitation programs during the COVID-19 pandemic are available. AIM: We conducted a study to compare the effect of modified rehabilitation therapies mainly performed in wards versus conventional therapies mainly performed in rehabilitation units in which exercise on a treadmill and cardiopulmonary exercise testing were available. DESIGN: Observational study. SETTING: University hospital. POPULATION: Fifty-five consecutive inpatients admitted to a university hospital and underwent a cardiac rehabilitation program from August 2019 to June 2020. METHODS: The patients were divided into two groups: those admitted during the COVID-19 outbreak (Group A, N.=28) and those admitted before the COVID-19 outbreak (Group B, N.=27). The evaluation included age, sex, duration of the rehabilitation intervention program, days before initiation of the rehabilitation program, functional status, and Functional Independence Measure (FIM) Score. RESULTS: A higher proportion of patients in Group A than B underwent a cardiac rehabilitation program provided in wards (88.5% vs. 48.8%, respectively). Group A showed a significantly lower 6-minute walking distance and walking speed than Group B at discharge (P=0.031 and 0.014, respectively). Group A showed a significantly shorter exercise time using an ergometer than Group B (P=0.028). CONCLUSIONS: The difference in the cardiac rehabilitation location during the COVID-19 pandemic may affect the rehabilitation contents and lead to less improvement in physical function. CLINICAL REHABILITATION IMPACT: A cardiac rehabilitation program was performed mainly in wards instead of in rehabilitation units during the COVID-19 pandemic. Walking abilities were adversely affected by the modified cardiac rehabilitation program.

The Acute-Phase Ambulation Program Improves Clinical Outcome for Acute Heart Failure.

It remains unclear whether the acute-phase ambulation program (AAP) improves the prognosis of heart failure (HF) patients. We examined the association between the initiation of AAP and the prognosis of patients with worsening HF. We enrolled 560 consecutive patients admitted due to worsening HF from March 2019 to April 2021. Our hospital introduced AAP in May 2020, but we did not perform AAP until April 2020. We retrospectively compared cardiac events within 180 days after discharge between patients admitted before April 2020 (conventional group) and after May 2020 (AAP group). Primary endpoints were all-cause mortality and readmission for worsening HF. The Kaplan-Meier survival curves showed a significantly lower event rate in the AAP group in HF readmission or the primary endpoint (p = 0.020 and p = 0.014). The occurrence of the primary endpoint was associated with age, history of HF, systolic blood pressure, medications including renin-angiotensin system inhibitors or angiotensin receptor blocker, hemoglobin, NT-proBNP, and AAP participation. After adjusting for these parameters and sex, participation in AAP was an independent factor associated with a reduced risk of primary endpoint occurrence (hazard ratio of 0.62 (0.41-0.95), p = 0.028). The AAP for patients with acute HF might lead to improved short-term prognosis and should be considered for implementation.

Second Nationwide Survey of Japanese Cardiac Rehabilitation Training Facilities During the Coronavirus Disease 2019 (COVID-19) Outbreak.

Background: We previously reported the results of a questionnaire survey of 37 cardiac rehabilitation (CR) training facilities conducted during April 2020, in Japan. Methods and Results: We conducted a second questionnaire survey in 38 CR training facilities to explore the preventive measures against Coronavirus Disease 2019 (COVID-19) after a nationwide state of emergency was declared and to investigate differences between the 2 surveys. No significant differences were observed, except for the requirement for patients to wear surgical masks during CR (P=0.01) in the second survey. Thirty-four facilities (89%) continued CR with innovations, 61% revised their instruction manuals (vs. 46% in the first survey), and, in 39%, patients requested resumption of ambulatory CR and training videos. Conclusions: In the second survey, 74% of facilities were unable to continue conventional group ambulatory CR; however, patients maintained their physical activity and exercise regimens and managed their illnesses with the aid of telephones and mobile devices.

Study Design of the Japanese Association of Cardiac Rehabilitation Registry (J-CARRY)　- Protocol for a Prospective, Multicenter, Open Registry.

Background: Guidelines for the prevention and management of cardiovascular disease (CVD) highly recommend cardiac rehabilitation (CR) on the basis of abundant evidence of its effectiveness. However, the current understanding and dissemination of CR in Japan are far from sufficient. Methods and Results: The Japanese Association of Cardiac Rehabilitation Registry (J-CARRY) is an academic society-led prospective multicenter observational registry conducted by the Registration and Facility Accreditation System Committee of the Japanese Association of Cardiac Rehabilitation. Data are collected prospectively using an electronic data capture system. Items related to patients' clinical background and CR, as well as mortality and major adverse cardiac and cerebrovascular events, will be collected in all cases. This Registry started in May 2014, and the number of participating medical institutions is expected to increase to >30; the targeted number of cases exceeded 3,000 per year as of April 30, 2022. Focusing on late Phase II data collection is a novel and significantly different approach compared with previous studies. The results of this study are currently under investigation. Conclusions: J-CARRY will provide real-world data regarding the current status and prognosis of CVD in patients who undergo Phase II CR in Japan.