Oral nutritional supplements in older outpatients with heart failure: rationale and design of the ALIMENT-HF trial.

AIMS: The ALIMENT-HF trial aims to determine whether high-calorie and high-protein oral nutritional supplements (ONS) are safe and beneficial for older adult outpatients with heart failure (HF). METHODS AND RESULTS: This multicentre, single-arm, interventional pilot trial is designed to evaluate the tolerance, efficacy, and safety of ONS in older adult outpatients with chronic HF, malnutrition, and anorexia. In total, 80 outpatients with HF regardless of their left ventricular ejection fraction will be treated with ONS, including high-energy (900 kcal/day) and high protein (36 g/day) supplementation, at eight sites in Japan. Inclusion criteria are as follows: age, ≥65 years; outpatients receiving maximally tolerated guideline-directed medical therapy for HF and without change in their diuretic dosage during the last 3 months; outpatients at risk of malnutrition, defined as a Malnutrition Universal Screening Tool score ≥1 point, and anorexia, defined using a Simplified Nutritional Appetite Questionnaire for the Japanese Elderly (SNAQ-JE) score of ≤14 points. Nutritional intervention will continue for up to 120 days, with an observational period lasting for a further 60 days. The primary outcome is a change in body weight between baseline and day 120. CONCLUSIONS: The ALIMENT-HF trial will evaluate the tolerance, efficacy, and safety of high-calorie and high-protein-rich ONS in older outpatients with HF co-morbid with malnutrition and anorexia and will provide insightful information for future randomized controlled trials.

Association between instrumental activities of daily living with the change in left ventricular function in older patients with cardiovascular disease.

Left ventricular dysfunction is a pathophysiologic characteristic of heart failure. Impaired instrumental activities of daily living are associated with an elevated risk of mortality and heart failure in older adults. Nevertheless, the relationship between these activities and left ventricular function changes remains unclear. We determined whether instrumental activities of daily living are associated with subsequent left ventricular function changes in older cardiovascular disease patients. This retrospective cohort study included 383 outpatients with cardiovascular disease (74.5 ± 5.3 years, 273 males). Patients were divided according to the Frenchay activities index tertile and followed for six months after cardiovascular disease diagnosis. The left ventricular ejection fraction and annular early diastolic velocity (e') were measured for left ventricular systolic and diastolic function, respectively, at baseline and after one year. After adjusting for confounders, changes in the left ventricular ejection fraction were not significantly different. However, changes in the e' in the highest tertile group were significantly greater than in other groups. In the general linear model with multiple regression analysis, Frenchay activities index independently predicted the absolute change in the e'. In older cardiovascular disease patients, higher instrumental activities of daily living were associated with preserved left ventricular relaxation.

Quadriceps Strength and Mortality in Older Patients With Heart Failure.

BACKGROUND: This study was performed to test the hypothesis that low quadriceps isometric strength (QIS) is associated with greater risk of mortality and has the additive prognostic significance to the severity of heart failure (HF) and gait speed in older patients with HF. METHODS: A retrospective cohort study was performed in 1273 patients ≥ 60 years of age with HF (mean age 75 ± 8 years, 59.1% men); all of whom were evaluated during hospitalization for usual gait speed and maximal QIS. The QIS was expressed relative to body mass (% BM). The endpoint was all-cause mortality. RESULTS: Over a median follow-up period of 1.59 years (interquartile range, 0.58 to 3.42 years), 224 patients died. The cutoff value based on the Youden index for the QIS discriminating those at high risk of mortality was 36.2% BM for overall, and we defined less than this cutoff point of QIS as low QIS. After adjustment for the HF risk score, the hazard ratio in low QIS was 1.55 for overall (95% confidence interval [CI], 1.17-2.06). The addition of low QIS to the HF risk score and gait speed was associated with significant increases in both net reclassification improvement (NRI, 0.239 for overall; 95% CI, 0.096-0.381) and integrated discrimination improvement (IDI, 0.004 for overall; 95% CI, 0.001-0.009) for all-cause mortality. CONCLUSION: Low QIS was strongly associated with poor prognosis and showed complementary prognostic predictive capability to the HF risk score and gait speed in older patients with HF.

Changes in Respiratory Muscle Strength Following Cardiac Rehabilitation for Prognosis in Patients with Heart Failure.

Respiratory muscle weakness, frequently observed in patients with heart failure (HF), is reported as a predictor for poor prognosis. Although increased respiratory muscle strength ameliorates exercise tolerance and quality of life in HF patients, the relationship between changes in respiratory muscle strength and patient prognosis remains unclear. A total of 456 patients with HF who continued a 5-month cardiac rehabilitation (CR) were studied. We measured maximal inspiratory pressure (PImax) at hospital discharge as the baseline and five months thereafter to assess the respiratory muscle strength. Changes in PImax during the 5-month observation period (⊿PImax) were examined. We investigated the composite multiple incidence of all-cause death or unplanned readmission after 5-month CR. The relationship between ⊿PImax and the incidence of clinical events was analyzed. Over a median follow-up of 1.8 years, 221 deaths or readmissions occurred, and their rate of incidence was 4.3/100 person-years. The higher ⊿PImax was significantly associated with lower incidence of clinical event. In multivariate Poisson regression model after adjustment for clinical confounding factors, ⊿PImax remained a significant and independent predictor for all-cause death/readmission (adjusted incident rate ratio for ⊿PImax increase of 10 cmH2O: 0.77, 95% confidence interval: 0.70-0.86). In conclusion, the changes in respiratory muscle strength independently predict the incidence of clinical events in patients with HF.

Prevalence and prognosis of respiratory muscle weakness in heart failure patients with preserved ejection fraction.

BACKGROUND: Although respiratory muscle weakness (RMW) is known to predict prognosis in patients with heart failure with reduced ejection fraction (HFrEF), RMW prevalence and its prognosis in those with preserved ejection fraction (HFpEF) remain unknown. We aimed to investigate whether the RMW predicted mortality in HFpEF patients. METHODS: We conducted a single-centre observational study with consecutive 1023 heart failure patients (445 in HFrEF and 578 in HFpEF). Maximal inspiratory pressure (PImax) was measured to assess respiratory muscle strength at hospital discharge, and RMW was defined as PImax <70% of predicted value. Endpoint was all-cause mortality after hospital discharge, and we examined the influence of RMW on the endpoint. RESULTS: Over a median follow-up of 1.8 years, 134 patients (13.1%) died; of these 53 (11.9%) were in HFrEF and 81 (14.0%) in HFpEF. RMW was evident in 190 (42.7%) HFrEF and 226 (39.1%) HFpEF patients and was independently associated with all-cause mortality in both HFrEF (adjusted hazard ratio [HR]: 2.13, 95% confidence interval [CI]: 1.17-3.88) and HFpEF (adjusted HR: 2.85, 95% CI: 1.74-4.67) patients. Adding RMW to the multivariate logistic regression model significantly increased area under the receiver-operating characteristic curve (AUC) for all-cause mortality in HFpEF (AUC including RMW: 0.78, not including RMW: 0.74, P = 0.026) but not in HFrEF (AUC including RMW: 0.84, not including RMW: 0.82, P = 0.132). CONCLUSIONS: RMW was observed in 39% of HFpEF patients, which was independently associated with poor prognosis. The additive effect of RMW on prognosis was detected only in HFpEF but not in HFrEF.

Short-Term Change in Gait Speed and Clinical Outcomes in Older Patients With Acute Heart Failure.

BACKGROUND: Evidence for the prognostic value of gait speed is largely based on a single measure at baseline, so we investigated the prognostic significance of change in gait speed in hospitalized older acute heart failure (AHF) patients.Methods and Results:This retrospective study was performed in a cohort of 388 AHF patients ≥60 years old (mean age: 74.8±7.8 years, 228 men). Routine geriatric assessment included gait speed measurement at baseline and at discharge. The primary outcome of this study was all-cause death. Gait speed increased from 0.74±0.25 m/s to 0.98±0.27 m/s after 13.5±11.0 days. Older age, shorter height and lower hemoglobin level at admission, prior HF admission, and higher baseline gait speed were independently associated with lesser improvement in gait speed. A total of 80 patients died and 137 patients were readmitted for HF over a mean follow-up period of 2.1±1.9 years. In multivariate analyses, change in gait speed showed inverse associations with all-cause death (hazard ratio [HR] per 0.1 m/s increase: 0.83; 95% confidence interval [CI]: 0.73 to 0.95; P=0.006) and with risk of readmission for HF (HR: 0.91; 95% CI: 0.83 to 0.99; P=0.036). CONCLUSIONS: Short-term improvement in gait speed during hospitalization was associated with reduced risks of death and readmission for HF in older patients with AHF.

Impact of Gait Speed on the Obesity Paradox in Older Patients With Cardiovascular Disease.

PURPOSE: The purpose of this study was to determine whether gait speed affects the obesity paradox in older patients with cardiovascular disease. METHODS: The study population consisted of 2224 patients ≥60 years old with cardiovascular disease admitted to hospital between May 1, 2006, and January 31, 2018. Body mass index (BMI) and gait speed before hospital discharge were determined, and patients were divided into two groups: slow and preserved gait speed (≤0.8 and >0.8 m/s, respectively), according to the algorithm for sarcopenia diagnosis. The slow and preserved gait speed groups were also further subdivided according to BMI: <18.5 kg/m2, 18.5-24.9 kg/m2, and BMI ≥25.0 kg/m2. The study endpoint was all-cause mortality. RESULTS: The study population (male: 66.7%) had a mean age of 73.1 ± 7.6 years. Over a median follow-up period of 1.69 years (interquartile range 0.67-3.67 years), 283 patients died. Higher BMI was associated with favorable prognosis in the group with preserved gait speed but not in the group with slow gait speed after adjusting for other prognostic factors. Adding BMI to the clinical model significantly increased the area under the receiver operating characteristic curve in the group with preserved gait speed (0.744 vs 0.726, P = 0.028) but not in the group with slow gait speed (0.716 vs 0.716, P = 0.789). CONCLUSIONS: Higher BMI was consistently associated with favorable prognosis in patients with cardiovascular disease and preserved gait speed but not in those with slow gait speed. These findings indicated that physical frailty influences the obesity paradox in older patients with cardiovascular disease.

Acute Effects of Whole-Body Vibration Training on Endothelial Function and Cardiovascular Response in Elderly Patients with Cardiovascular Disease.

The aim of this single-arm pilot study was to determine the effects of whole-body vibration training (WBVT) on endothelial function in elderly patients with cardiovascular diseases, as well as its safety. A total of 20 elderly patients with stable cardiovascular diseases underwent WBVT, which consisted of five static resistance training exercises (squats, wide stance squats, toe-stands, squats + band, and front lunges). The parameters of WBVT included vertical vibrations, 30 Hz frequency, and a 3-mm peak-to-peak amplitude. Each vibration session lasted 30 seconds, with 120 seconds of rest between sessions. Before and after WBVT, the reactive hyperemia peripheral arterial tonometry index (RH-PAT index) and transcutaneous oxygen pressure (tcPO2) were recorded as a measure of endothelial function and peripheral blood circulation. Systolic blood pressure, diastolic blood pressure, heart rate, and arterial oxygen saturation of pulse oximetry (SpO2) were measured at each rest interval as well as before and after WBVT. All patients completed our WBVT protocol without adverse events. The RH-PAT index significantly increased following WBVT (1.42 to 2.06, P < 0.001). There were no significant changes in heart rate (P = 0.777), systolic blood pressure (P = 0.183), diastolic blood pressure (P = 0.925), or SpO2 (P = 0.248) during WBVT. In conclusion, we demonstrated the acute effects of WBVT on endothelial function, with no reports of adverse events. These findings support the need for further randomized controlled studies to investigate the long-term effects of WBVT.

Respiratory muscle weakness increases dead-space ventilation ratio aggravating ventilation-perfusion mismatch during exercise in patients with chronic heart failure.

BACKGROUND AND OBJECTIVE: Respiratory muscle weakness causes fatigue in these muscles during exercise and thereby increases dead-space ventilation ratio with decreased tidal volume. However, it remains unclear whether respiratory muscle weakness aggravates ventilation-perfusion mismatch through the increased dead-space ventilation ratio. In ventilation-perfusion mismatch during exercise, minute ventilation versus carbon dioxide production (VE/VCO2 ) slope > 34 is an indicator of poor prognosis in patients with chronic heart failure (CHF). We examined the relationship of respiratory muscle weakness with dead-space ventilation ratio and ventilation-perfusion mismatch during exercise and clarified whether respiratory muscle weakness was a clinical predictor of VE/VCO2 slope > 34 in patients with CHF. METHODS: Maximal inspiratory pressure (PImax ) was measured as respiratory muscle strength 2 months after hospital discharge in 256 compensated patients with CHF. During cardiopulmonary exercise test, we assessed minute dead-space ventilation versus VE (VD/VE ratio) as dead-space ventilation ratio and VE/VCO2 slope as ventilation-perfusion mismatch. Patients were divided into low, moderate and high PImax groups based on the PImax tertile. We investigated determinants of VE/VCO2 slope > 34 among these groups. RESULTS: The low PImax group showed significantly higher VD/VE ratios at 50% of peak workload and at peak workload and higher VE/VCO2 slope than the other two groups (P < 0.001, respectively). PImax was a significant independent determinant of VE/VCO2 slope > 34 (odds ratio (OR): 0.67, 95% CI: 0.54-0.82) with area under the receiver operating characteristic curve of 0.812 (95% CI: 0.750-0.874). CONCLUSION: Respiratory muscle weakness was associated with an increased dead-space ventilation ratio aggravating ventilation-perfusion mismatch during exercise in patients with CHF.

Incremental Value of Objective Frailty Assessment to Predict Mortality in Elderly Patients Hospitalized for Heart Failure.

BACKGROUND: The impact of frailty on long-term prognosis in patients with heart failure (HF) remains unclear, and there is no simple and objective assessment for it. This study was performed to examine the association between frailty score and clinical outcome in elderly patients hospitalized for HF. METHODS AND RESULTS: A retrospective cohort study was performed with 603 elderly patients with HF (mean age 75 ± 6 years, 378 [62.7%] men). Frailty was measured by a composite of 4 markers combined into a frailty score (possible range 0-12): gait speed, handgrip strength, serum albumin, and activities of daily living status. The patient population was divided into 2 groups with frailty score <5 (non-frail) or ≥5 (frail). The end point was all-cause mortality. Over a mean follow-up period of 1.7 ± 0.5 years, 89 patients died. After adjustment for several preexisting factors associated with prognosis, the frailty score (hazard ratio [HR] 1.11; P = .014) and frailty (HR 1.75; P = .036) were independently associated with all-cause mortality. The inclusion of frailty score significantly increased both continuous net reclassification improvement (0.341; P = .002) and integrated discrimination improvement (0.016; P = .039) for all-cause mortality. CONCLUSIONS: A simple and objective frailty score was associated with health outcome in elderly patients hospitalized for HF.

Excessive SBP elevation during moderate exercise discriminates patients at high risk of developing left ventricular hypertrophy from hypertensive patients.

OBJECTIVE: Hypertensive patients show an excessive elevation of SBP during exercise, although optimal blood pressure (BP) control is required to prevent development of left ventricular hypertrophy (LVH). This study examined whether excessive SBP elevation during moderate exercise is associated with new-onset LVH in these patients. METHODS: A total of 143 hypertensive patients without LVH whose BP had been maintained below 140/90 mmHg with antihypertensives performed cycle ergometer exercise test at moderate intensity to assess SBP elevation during exercise (ΔSBP). Left ventricular mass index (LVMI) was assessed by echocardiography once a year to identify new-onset LVH. Patients were divided into three groups according to tertiles of ΔSBP. We examined the associations between ΔSBP and new-onset LVH using the Kaplan-Meier method, log-rank test, and Cox regression analysis. RESULTS: The patients (100 men, 65.3 ±â€Š9.1 years) had resting BP of 126 ±â€Š16/75 ±â€Š11 mmHg. New-onset LVH developed in 47 patients (32.9%) within a follow-up period of 2.5 ±â€Š1.6 years. Higher ΔSBP was significantly associated with higher incidence of LVH (P < 0.001): 12.8, 27.1, and 58.3% in the lowest, middle, and highest tertiles, respectively. In multivariate analysis, ΔSBP was a significant independent determinant of new-onset LVH (hazard ratio for 10 mmHg increase in ΔSBP, 1.45; 95% CI 1.22-1.73; P < 0.001). In comparison with the lowest tertile, the hazard ratios of the middle and highest tertiles for incidence of LVH were 3.16 (95% CI 1.07-9.32) and 6.43 (95% CI 2.35-17.62), respectively. CONCLUSION: Excessive SBP elevation during moderate exercise can be used to identify hypertensive patients at high risk of developing LVH.

Gait speed has comparable prognostic capability to six-minute walk distance in older patients with cardiovascular disease.

Background Although gait speed and six-minute walk distance are used to assess functional capacity in older patients with cardiovascular disease, their prognostic capabilities have not been directly compared. Methods The study population was identified from the Kitasato University Cardiac Rehabilitation Database and consisted of 1474 patients ≥60 years old with a mean age of 72.2 ± 7.1 years that underwent evaluation of both usual gait speed and six-minute walk distance in routine geriatric assessment between 1 June 2008-30 September 2015. Both gait speed and six-minute walk distance were determined on the same day at hospital discharge. Results Mean gait speed and six-minute walk distance in the whole population were 1.04 m/s and 381 m, respectively, and were strongly positively correlated ( r = 0.80, p < 0.001). A total of 180 deaths occurred during a follow-up of 2.3 ± 1.9 years. After adjusting for confounding factors, both gait speed (adjusted hazard ratio per 0.1 m/s increase: 0.87, 95% confidence interval: 0.81-0.93, p < 0.001) and six-minute walk distance (adjusted hazard ratio per 10-metre increase: 0.96, 95% confidence interval: 0.94-0.97, p < 0.001) were independent predictors of all-cause mortality. There was no significant difference in prognostic capability between gait speed and six-minute walk distance (c-index: 0.64 (95% confidence interval: 0.60-0.69) and 0.66 (95% confidence interval: 0.61-0.70), respectively, p = 0.357). Conclusions Gait speed and six-minute walk distance showed similar prognostic predictive ability for all-cause mortality in older cardiovascular disease patients, indicating the potential utility of gait speed as a simple risk stratification tool in older cardiovascular disease patients.

Clinical features and predictors of patients with critical limb ischemia who responded to autologous mononuclear cell transplantation for therapeutic angiogenesis.

The clinical features of patients with critical limb ischemia (CLI) who responded to angiogenesis using autologous peripheral blood mononuclear cell transplantation (PB-MNC) have not yet been fully characterized, and there are no useful predictors to judge the curative effect in the early period after PB-MNC. This study sought to clarify the clinical features and predictors in patients with CLI who were successfully treated using PB-MNC. 30 consecutive patients [arteriosclerosis obliterans: 24 patients, thromboangiitis obliterans: 6 patients] who were diagnosed with major amputation despite maximal medical therapy were enrolled in this study. The study endpoint was major amputation within 3 months after PB-MNC. The collected data were evaluated for correlation between patients with and without major amputation within 3 months after PB-MNC. Six patients underwent major amputation and 1 patient underwent minor amputation. In the patients with major amputation, transcutaneous oxygen tension before PB-MNC and transplanted CD34-positive cells were lower than those of patients without major amputation. In the patients with amputation, interleukin-6 (IL-6) continued to increase after the first PB-MNC, and basic fibroblast growth factor (bFGF) decreased within 3 days after the first PB-MNC. PB-MNC was useful for the patients who were managed for inflammation and who had revascularization of the upper-popliteal arteries and two of the infra-popliteal arteries by endovascular and/or surgical revascularization. Variation in IL-6 and bFGF in the early period after PB-MNC could be useful predictors for the requirement of amputation within 3 months after PB-MNC.

Utility of SARC-F for Assessing Physical Function in Elderly Patients With Cardiovascular Disease.

OBJECTIVES: A simple and inexpensive tool for screening of sarcopenia would be helpful for clinicians. The present study was performed to determine whether the SARC-F questionnaire is useful in screening of patients with cardiovascular disease (CVD) for impaired physical function. DESIGN: Cross-sectional study. SETTING: Single university hospital. PARTICIPANTS: A total of 235 Japanese patients ≥65 years old admitted to our hospital for CVD. MEASUREMENTS: SARC-F, handgrip strength, leg strength, respiratory muscle strength, standing balance, usual gait speed, Short Physical Performance Battery (SPPB) score, and 6-minute walking distance were measured before discharge from hospital. The patients were divided into 2 groups according to SARC-F score: SARC-F < 4 (nonsarcopenia group) and SARC-F ≥ 4 (sarcopenia group). RESULTS: The sarcopenia prevalence rate was 25.5% and increased with age (P trend < .001). The sarcopenia group (SARC-F score ≥ 4) had significantly lower handgrip strength, leg strength, and respiratory muscle strength, poorer standing balance, slower usual gait speed, lower SPPB score, and shorter 6-minute walking distance compared to the nonsarcopenia group (SARC-F score < 4). Patients in the sarcopenia group had consistently poorer physical function even after adjusting for covariates. CONCLUSION: The SARC-F questionnaire is a useful screening tool for impaired physical function in elderly CVD patients. These findings support the use of the SARC-F for screening in hospital settings.

Prognostic Usefulness of Arm and Calf Circumference in Patients ≥65 Years of Age With Cardiovascular Disease.

Current diagnostic criteria for sarcopenia require measurement of muscle function (MF) and muscle mass. Mid upper arm circumference (AC) and calf circumference (CC) are currently used as metrics of muscle mass. This study was performed to compare the prognostic predictive capabilities of AC and CC in older patients with cardiovascular disease (CVD). The study population consisted of 599 admitted patients aged ≥65 years (74.8 ± 6.3 years, 392 men) with CVD. We measured MF (gait speed and grip strength), AC, and CC before hospital discharge. The end point was all-cause mortality. During follow-up (median 1.63 years, interquartile range 2.09 years), 72 deaths occurred. Both high AC and high CC were associated with better outcome; however, only AC (adjusted hazard ratio per SD increase 0.56, p = 0.023), but not CC (adjusted hazard ratio per SD increase 0.91, p = 0.696), showed significant independent prognostic capability after adjusting for other prognostic factors. Moreover, adding AC to MF (0.71 vs 0.62, p = 0.005) but not CC to MF (0.67 vs 0.62, p = 0.188) significantly increased the area under the curve on receiver operating characteristic curve. In conclusion, a high AC, but not CC, was an independent predictor of survival and could be a readily available and simple metric for risk stratification in older patients with CVD.

A Single Session of Neuromuscular Electrical Stimulation Enhances Vascular Endothelial Function and Peripheral Blood Circulation in Patients With Acute Myocardial Infarction.

This study aimed to investigate whether a single session of neuromuscular electrical stimulation (NMES) can enhance vascular endothelial function and peripheral blood circulation in patients with acute myocardial infarction (AMI). Thirty-four male patients with AMI were alternately assigned to 2 groups, and received NMES with muscle contraction (NMES group, n = 17) or without muscle contraction (control group, n = 17) after admission. NMES was performed for quadriceps and gastrocnemius muscles of both legs for 30 minutes. We measured systolic blood pressure as a parameter of cardiovascular responses and the low-frequency component of blood pressure variability as an index of sympathetic activity. Reactive hyperemia peripheral arterial tonometry (RH-PAT) index and transcutaneous oxygen pressure in foot (Foot-tcPO2) were also measured as parameters of vascular endothelial function and peripheral blood circulation, respectively. All patients completed the study without severe adverse events. Systolic blood pressure and the low-frequency component increased significantly during the NMES session in both groups (P < 0.01 and P < 0.05, respectively). However, elevation from systolic blood pressure at rest was < 10 mmHg in both groups. In the NMES group, the RH-PAT index and Foot-tcPO2 increased significantly after NMES (P < 0.05 and P < 0.001, respectively). No significant changes were observed in these parameters throughout the session in the control group. In conclusion, a single session of NMES with muscle contraction enhanced vascular endothelial function, leading to improvement in peripheral blood circulation without inducing excessive cardiovascular and autonomic responses in patients with AMI (UMIN000014196).

Low ankle brachial index is associated with the magnitude of impaired walking endurance in patients with heart failure.

BACKGROUND: Measurement of the ankle brachial index (ABI) is a simple, noninvasive means of diagnosing peripheral arterial disease, and has been shown to be associated with mortality rate. Here, we examined the association between ABI and physical function in patients with heart failure (HF). METHODS: The study population consisted of 524 admitted patients (67.2±13.9years, 343 males) with HF. Blood pressure and the ABI were determined by oscillometry. Prior to hospital discharge, ABI, 6-minute walking distance, walking velocity, handgrip strength, quadriceps isometric strength, and standing balance were determined. The 524 patients were divided according to ABI as follows: ABI≤0.90 (low ABI), ABI 0.91 to 0.99 (borderline ABI), and ABI 1.00 to 1.40 (normal ABI). RESULTS: Lower ABI values were associated with shorter 6-minute walking distance (p trend=0.001), slower walking velocity (p trend=0.023), and poorer standing balance (p trend=0.048). There were no significant associations between ABI and handgrip strength or quadriceps isometric strength. After adjusting for potential confounders, patients with ABI≤0.90 had shorter 6-minute walking distance compared to those with ABI 1.00 to 1.40 (adjusted mean value: 344m vs. 395m, respectively, p<0.001). There were no significant differences in any of the other physical function parameters examined. CONCLUSIONS: In patients with HF, low ABI is associated with the magnitude of impairment in walking endurance.

Complementary Role of Arm Circumference to Body Mass Index in Risk Stratification in Heart Failure.

OBJECTIVES: This study was performed to investigate the complementary role of arm circumference to body mass index (BMI) in risk stratification of patients with heart failure (HF). BACKGROUND: High BMI is associated with improved survival in patients with HF. However, it does not discriminate between fat and lean muscle as a predominant factor. METHODS: BMI, waist circumference (WC), and mid-upper arm circumference (MUAC) were evaluated in 570 consecutive Japanese patients with HF (mean age 67.4 ± 14.0 years). Patients were stratified into low and high groups according to BMI, WC, and MUAC and combined into low- or high-BMI and low- or high-WC groups or low- or high-BMI and low- or high-MUAC groups. The endpoint was all-cause mortality. RESULTS: Seventy deaths occurred over a median follow-up period of 1.5 years (interquartile range: 0.7 to 2.8 years). After adjusting for several pre-existing prognostic factors, including Seattle Heart Failure Score and exercise capacity, BMI (hazard ratio [HR]: 0.68; p = 0.016), WC (HR: 0.76; p = 0.044), and MUAC (HR: 0.52; p < 0.001) were all inversely associated with prognosis. Compared with the high-BMI/high-WC group, both the low-BMI/high-WC and low-BMI/low-WC groups showed comparably poorer prognosis. However, the low-BMI/low-MUAC group but not the low-BMI/high-MUAC group showed poorer prognosis than the high-BMI/high-MUAC group. Adding MUAC to BMI (0.70 vs. 0.63, p = 0.012) but not WC to BMI (0.64 vs. 0.63, p = 0.763) significantly increased the area under the curve on receiver-operating characteristic curve analysis. CONCLUSIONS: MUAC, but not WC, plays a complementary role to BMI in predicting prognosis in patients with HF.

Low Stroke Rate of Carotid Stenosis Under the Guideline-Oriented Medical Treatment Compared With Surgical Treatment.

Medical treatment for asymptomatic carotid artery stenosis (ACAS) has advanced recently. The outcomes of medical treatment and surgical treatment were evaluated to clarify the optimal treatment for ACAS.Patients with ACAS of ≥ 50% luminal narrowing underwent serial follow-up carotid artery ultrasonography for one year or more at the Center for Cardiovascular Disease Prevention between November 2006 and October 2013. The incidence of cardiovascular events (stroke, myocardial infarction, cardiovascular death) was examined in 64 patients (medical treatment group), and in 47 patients (surgical group) who underwent surgical treatment (carotid endarterectomy or carotid artery stenting) during this same period at the Department of Neurosurgery.Annual cardiovascular event rate was 0.91% (2/219 person-year) in the group of guideline-oriented medical treatment with an annual check-up for disease management and 5.6% (6/107 person-year) in the surgical group (log-rank P = 0.027; HR in the medical treatment group, 0.19 [medical treatment/surgical]; 95% confidence interval [CI], 0.028 to 0.87). Annual stroke event rate was 0.46% (1/219 person-year) in the medical treatment group and 4.7% (5/107 personyear) in the surgical group (log-rank P = 0.016; HR in the medical treatment group, 0.11 [medical treatment/surgical]; 95% CI, 0.0057 to 0.70). Multivariate logistic analysis showed that the surgical group was an independent variable associated with cardiovascular events (P = 0.049).Annual cardiovascular and stroke event rates were low in patients receiving medical treatment for ACAS and better than surgical treatment. The present study shows that medical treatment is an important option for ACAS.