Impact of home- and community-based services in the long-term care insurance system on outcomes of patients with acute heart failure: Insights from the Kitakawachi Clinical Background and Outcome of Heart Failure Registry.

AIM: In Japan, the long-term care insurance (LTCI) system is important for elderly people living at home; however, no clinical studies have revealed a relationship between home- or community-based services and outcomes in patients with acute heart failure (AHF). METHODS: This was a prospective multicenter cohort study of patients with AHF enrolled between April 2015 and August 2017. Patients aged ≥65 years with LTCI were divided into those receiving home- and community-based services (service users) and without home and community-based services (service non-users). The endpoint was defined as a composite endpoint, which included all-cause mortality and hospitalization for heart failure after discharge. Subgroup analyses were performed for elderly patients (<85 years) or super-elderly patients (≥85 years). RESULTS: The study participants were eligible for LTCI two times more than community-dwelling people were. At the 1-year follow-up period, the rate of the composite endpoint showed no significant difference between service users and service non-users among all patients or super-elderly patients. However, in elderly patients, the rate of the composite endpoint was significantly lower among service users than service non-users. The difference was independently maintained even after adjustments for differences in comorbidities or in social backgrounds (adjusted hazard ratio 0.62; 95% confidence interval 0.38-0.99, and adjusted hazard ratio 0.57; 95% confidence interval 0.35-0.90, respectively). CONCLUSIONS: In this study, adverse events following discharge of patients with AHF who used home- and community-based services were prevented only in elderly patients, not in super-elderly patients. Geriatr Gerontol Int 2020; 20: 967-973.

Clinical Characteristics and Outcomes of Heart Failure Patients With Long-Term Care Insurance　- Insights From the Kitakawachi Clinical Background and Outcome of Heart Failure Registry.

BACKGROUND: In Japan, the long-term care insurance (LTCI) system has an important role in helping elderly people, but there have been no clinical studies that have examined the relationship between the LTCI and prognosis for patients with acute heart failure (HF).Methods and Results:This registry was a prospective multicenter cohort, 1,253 patients were enrolled and 965 patients with acute HF aged ≥65 years were comprised the study group. The composite endpoint included all-cause death and hospitalization for HF after discharge. We divided the patients into 4 groups: (i) patients without LTCI, (ii) patients requiring support level 1 or 2, (iii) patients with care level 1 or 2, and (iv) patients with care levels 3-5. The Kaplan-Meier analysis identified a lower rate of the composite endpoint in group (i) than in the other groups. After adjusting for potentially confounding effects using a Cox proportional regression model, the hazard ratio (HR) of the composite endpoint increased significantly in groups (iii) and (iv) (adjusted HR, 1.62; 95% confidence interval [CI], 1.22-1.98 and adjusted HR, 1.62; 95% CI, 1.23-2.14, respectively) when compared with group (i). However, there was no significant difference between groups (i) and (ii). CONCLUSIONS: The level of LTCI was associated with a higher risk of the composite endpoint after discharge in acute HF patients.

A decline in activities of daily living due to acute heart failure is an independent risk factor of hospitalization for heart failure and mortality.

BACKGROUND: Although activities of daily living (ADL) are recognized as being pertinent in averting relevant readmission of heart failure (HF) and mortality, little research has been conducted to assess a correlation between a decline in ADL and outcomes in HF patients. METHODS: The Kitakawachi Clinical Background and Outcome of Heart Failure Registry is a prospective, multicenter, community-based cohort of HF patients. We categorized the patients into four types of ADL: independent outdoor walking, independent indoor walking, indoor walking with assistance, and abasia. We defined a decline in ADL (decline ADL) as downgrade of ADL and others (non-decline ADL) as preservation of ADL before discharge compared with admission. RESULTS: Among 1253 registered patients, 923 were eligible, comprising 98 (10.6%) with decline ADL and 825 (89.4%) with non-decline ADL. Decline ADL exhibited a higher risk of hospitalization for HF and mortality compared with non-decline ADL. A multivariate analysis revealed that decline ADL emerged as an independent risk factor of hospitalization for HF [hazard ratio (HR), 1.42; 95% confidence interval (CI): 1.01-1.96; p=0.046] and mortality (HR, 1.95; 95% CI: 1.23-2.99; p<0.01). Although 66.3% of patients with decline ADL were registered for long-term care insurance, few received daycare services (32.7%) or home-visit medical services (8.2%). CONCLUSIONS: Decline in ADL is a predictor of hospitalization for HF and mortality in HF patients.

Clinical Characteristics and Social Frailty of Super-Elderly Patients With Heart Failure　- The Kitakawachi Clinical Background and Outcome of Heart Failure Registry.

BACKGROUND: Social background is important in preventing admission/readmission of heart failure (HF) patients. However, few clinical studies have been conducted to assess the social background of these patients, especially elderly patients.Methods and Results:The Kitakawachi Clinical Background and Outcome of Heart Failure (KICKOFF) Registry is a prospective multicenter community-based cohort of HF patients, established in April 2015. We compared the clinical characteristics and social background of the super-elderly group (≥85 years old) and the non-super-elderly group (<85 years old). This study included 647 patients; 11.8% of the super-elderly patients were living alone, 15.6% were living with only a partner, and of these, only 66.7% had the support of other family members. The super-elderly group had less control over their diet and drug therapies than the non-super-elderly group. Most patients in the super-elderly group were registered for long-term care insurance (77.4%); 73.5% of the super-elderly patients could walk independently before admission, but only 55.5% could walk independently at discharge, whereas 94% of the non-super-elderly patients could walk independently before admission and 89.4% could walk independently at discharge. CONCLUSIONS: The KICKOFF Registry provides unique detailed social background information of Japanese patients with HF. Super-elderly patients are at serious risk of social frailty; they need the support of other people and their ability to perform activities of daily living decline when hospitalized.

Paclitaxel-coated balloon catheter compared with drug-eluting stent for drug-eluting stent restenosis in routine clinical practice.

AIMS: The aim of this study was to compare the efficacy between paclitaxel-coated balloon (PCB) and drug-eluting stent (DES) implantation for the treatment of DES restenosis in complex situations. METHODS AND RESULTS: Data of patients who received revascularisation for DES restenosis between 2004 and 2011 were collected. A total of 683 patients with 777 lesions were analysed in this study (306 lesions treated by PCB, 471 lesions by DES). The use of PCB or DES was at the discretion of the operator. Angiographic outcomes at six to eight months and clinical outcomes at 12-month follow-up were compared between groups. The primary outcome was binary restenosis. Cox regression analysis with propensity score adjustment suggested that there were no significant differences between the two groups with respect to binary restenosis, target lesion revascularisation (TLR), and major adverse cardiac events. As for the angiographic endpoints, subgroup analysis was performed for several parameters. There was a significant trend favouring PCB with respect to binary restenosis and TLR in non-focal type lesions and bifurcation lesions. CONCLUSIONS: Angiographic and clinical outcomes in the PCB group were similar to those in the repeat DES group. PCB seemed to offer more favourable results in non-focal type lesions and bifurcation lesions.

Association between tissue characteristics assessed with optical coherence tomography and mid-term results after percutaneous coronary intervention for in-stent restenosis lesions: a comparison between balloon angioplasty, paclitaxel-coated balloon dilatation, and drug-eluting stent implantation.

AIMS: Morphological assessment of neointimal tissue using optical coherence tomography (OCT) is important for clarifying the pathophysiology of in-stent restenosis (ISR) lesions. The aim of this study was to determine the impact of OCT findings on recurrence of ISR after various types of percutaneous coronary intervention (PCI) including plain old balloon angioplasty (POBA), paclitaxel-coated balloon (PCB) dilatation, and drug-eluting stent (DES) implantation. METHODS AND RESULTS: Between June 2008 and August 2013, we performed PCI for 428 ISR lesions in 379 patients using POBA (78 lesions, POBA group), PCB dilatation (202 lesions, PCB group), and DES implantation (148 lesions, DES group). Morphological assessment of neointimal tissue at the minimum lumen area site to determine restenotic tissue structure (homogeneous, heterogeneous, or layered type) using OCT was performed. We examined the association between tissue structure and midterm results including ISR and target lesion revascularization (TLR) rates. The patients were 308 men and 71 women with a mean age of 68.9 ± 9.4 years. The mean follow-up period was 211 ± 40 days. ISR and TLR rates of lesions with a homogeneous structure were significantly higher in the POBA group than in the PCB group (ISR: 54.8 vs. 19.1%, P < 0.001; TLR: 38.7 vs. 10.6%, P < 0.001) and DES group (ISR: 54.8 vs. 19.6%, P = 0.002; TLR: 38.7 vs. 10.7%, P = 0.005), whereas there were no differences in ISR and TLR rates between the three groups in lesions with a heterogeneous structure. CONCLUSION: Morphological assessment of ISR tissue using OCT might suggest favourable types of PCI for ISR lesions.

Comparison of long-term outcome after percutaneous coronary intervention for stent thrombosis between early, late, and very late stent thrombosis.

BACKGROUND: Differences in long-term outcome between early stent thrombosis (EST), late stent thrombosis (LST), and very late stent thrombosis (VLST) are unknown. METHODS AND RESULTS: A total of 152 patients who had undergone percutaneous coronary intervention for stent thrombosis between January 2001 and October 2011 were enrolled, and the clinical outcome compared between EST (55 patients), LST (34 patients), and VLST (63 patients) after drug-eluting stent (DES) and bare-metal stent (BMS) implantation. Major adverse cardiac events (MACE), including cardiac death, recurrent stent thrombosis, non-fatal myocardial infarction, and target lesion revascularization (TLR), were evaluated at 5 years. The in-hospital mortality was similar between EST, LST, and VLST (P=0.37). The incidence of MACE was significantly lower in VLST (21.9%) than in EST (66.9%, P<0.001) and LST (66.6%, P<0.001), mainly because of a lower TLR rate after VLST (11.1%) than after EST (50.8%, P<0.001) and LST (52.2%, P<0.001). The 5-year mortality rate was also significantly lower in VLST (14.7%) than in EST (29.3%, P=0.049) and LST (41.6%, P=0.025). The incidence of MACE was similar between DES and BMS (46.2% vs. 50.0%, P=0.82), and this finding was observed in EST (P=0.83), LST (P=0.77), and VLST (P=0.57). CONCLUSIONS: Compared with EST and LST, long-term outcome was markedly better in VLST, mainly because of a lower TLR rate, whether after DES or BMS implantation.

Association between tissue characteristics evaluated with optical coherence tomography and mid-term results after paclitaxel-coated balloon dilatation for in-stent restenosis lesions: a comparison with plain old balloon angioplasty.

AIMS: Morphological assessment of neointimal tissue using optical coherence tomography (OCT) is important for clarifying the pathophysiology of in-stent restenosis (ISR) lesions. The aim of this study was to determine the impact of OCT findings on recurrence of ISR after paclitaxel-coated balloon (PCB) dilatation compared with plain old balloon angioplasty (POBA). METHODS AND RESULTS: Between July 2008 and May 2012, we performed percutaneous coronary intervention for 214 ISR lesions using POBA + PCB (146 lesions, PCB group) or POBA only (68 lesions, POBA group). Morphological assessment of neointimal tissue using OCT, including assessment of restenotic tissue structure and restenotic tissue backscatter, was performed. We examined the association between lesion morphologies and mid-term (6-8 months) results including ISR and target lesion revascularization (TLR) rates. Both ISR and TLR rates of lesions with a homogeneous structure were significantly lower in the PCB group than those in the POBA group (ISR: 20.0 vs. 55.6%, P = 0.002, TLR: 12.7 vs. 37.0%, P = 0.019), but there was no difference between the two groups in ISR and TLR rates of lesions with a heterogeneous or layered structure. Both ISR and TLR rates of lesions with high backscatter were significantly lower in the PCB group than those in the POBA group (ISR: 19.8 vs. 52.5%, P < 0.001, TLR: 13.6 vs. 42.5%, P = 0.001), but there was no difference between the two groups in ISR and TLR rates of lesions with low backscatter. CONCLUSION: Morphological assessment of ISR tissue using OCT might be useful for identifying ISR lesions favourable for PCB dilatation.

Seven-year clinical outcomes of unprotected left main coronary artery stenting with drug-eluting stent and bare-metal stent.

BACKGROUND: The superiority of drug-eluting stents (DES) over bare-metal stents (BMS) 7 years after unprotected left main coronary artery (LMCA) stenting has not been investigated. METHODS AND RESULTS: From 2003 to 2005, 182 patients underwent stent implantation for unprotected LMCA disease (DES, 96 patients; BMS, 86 patients; acute coronary syndrome cases excluded), and the 7-year clinical outcomes between the DES and BMS groups were compared. The incidence of cardiac death or non-fatal myocardial infarction was similar between the DES and BMS groups (11.0% vs. 13.5%, P=0.78). The incidence of target lesion revascularization (TLR) at 7 years was significantly lower in the DES group than in the BMS group (26.4% vs. 40.5%, P=0.009); the incidence from 1 to 4 years and that beyond 4 years were similar between the DES and BMS groups (8.9% vs. 7.9%, P=0.97; 10.0% vs. 8.7%, P=0.74, respectively). Among patients with bifurcation lesions, whereas the incidence of 7-year TLR was significantly lower in the DES group than the BMS group in patients undergoing single-stent procedures (15.9% vs. 48.6%, P=0.002), it was similar between the 2 groups in patients undergoing 2-stent procedures (38.5% vs. 39.3%, P=0.49). CONCLUSIONS: With the exception of the 2-stent procedure, the 7-year outcomes after DES implantation for LMCA disease were superior to those after BMS implantation because of the lower TLR rate, when considering TLR during the late phase.

Difference in clinical and angiographic characteristics of very late stent thrombosis between drug-eluting and bare-metal stent implantations.

BACKGROUND: Limited data are available with which to compare the clinical characteristics of patients with very late stent thrombosis (VLST) after drug-eluting stent (DES) or bare-metal stent (BMS) implantation. The purpose of this study was to investigate the differences in the characteristics of VLST after DES and BMS implantation by reviewing the clinical and angiographic data. METHODS AND RESULTS: A total of 28 patients (30 lesions) with VLST after DES implantation and 33 patients (33 lesions) with VLST after BMS implantation were identified. The occurrence of VLST after BMS implantation (2,647±996 days) was much later than that after DES implantation (1,194±558 days, P<0.001). The number of VLST after DES implantation increased gradually each year; however VLST after BMS implantation started to occur >50 months later, and its number increased subsequently. The prevalence of VLST related to surgical procedures involving discontinuation of antiplatelet therapy in VLST patients was higher after DES implantation (14.3%) than after BMS implantation (0%, P=0.039). Angiographic stent fracture was seen in 36.7% of VLST lesions after DES implantation at different times (464-2,102 days after procedure), while none was seen in VLST lesions after BMS implantation (P<0.001). CONCLUSIONS: The timing of VLST was different after DES and BMS implantation. Stent fracture was a specific finding of VLST after DES implantation.

Giant-cell myocarditis complicated by heparin-induced thrombocytopenia.

Giant-cell myocarditis is a fatal autoimmune disorder that is often associated with other autoimmune diseases. We herein describe a case of giant-cell myocarditis complicated by heparin-induced thrombocytopenia (HIT). A 71-year-old woman was admitted to our hospital due to palpitations and ptosis. Echocardiography revealed hypokinesis in the left basal ventricular walls. Heart failure gradually developed, and the condition was complicated by HIT. The patient died of cardiogenic and septic shock caused by agranulocytosis. An autopsy showed giant-cell myocarditis. When severe left ventricular dysfunction due to an unknown cause is complicated by HIT, potential diagnoses of giant-cell and other types of autoimmune myocarditis should thus be investigated.