Journal of cardiology最新文献

Background: To prevent sudden cardiac death after acute myocardial infarction (AMI), current guidelines recommend the use of a wearable cardioverter-defibrillator (WCD) as bridging therapy before implantable cardioverter-defibrillator implantation in patients with left ventricular ejection fraction ≤ 35% and New York Heart Association class ≥ II at discharge. However, real-world data regarding the implementation of guideline-based indications for WCD therapy-and the reasons for their underuse-remain limited in Japan.

Purpose: This study aimed to evaluate the gap between guideline-based indications and real-world implementation of WCD therapy after AMI, and to identify physician- and system-related barriers contributing to WCD underuse.

Methods and results: We analyzed data from the SING (Shizuoka Catheter INtervention Group)-AMI registry, a prospective multicenter cohort of patients with AMI who underwent primary percutaneous coronary intervention at seven hospitals in Shizuoka Prefecture, Japan. Among 229 patients (mean age, 70.7 years; 76.3% male), 15 sustained ventricular arrhythmia events (ventricular tachycardia/ventricular fibrillation [VT/VF]) occurred in 15 patients (6.6%) during hospitalization. At discharge, 12 patients (5.2%) met guideline-based WCD eligibility; however, no WCDs were prescribed. Although physicians identified 10 patients as WCD candidates, 8 were misclassified due to misinterpretation of eligibility criteria. Furthermore, WCD use was not discussed with 19 of 20 eligible or potentially eligible patients, primarily due to lack of recognition of eligibility, limited physician familiarity, or patient-related concern.

Conclusions: In this prospective Japanese registry, 5.2% of AMI patients met guideline-based indications for WCD therapy; however, no WCDs were prescribed. While these findings are limited by the small sample size, they suggest a potential gap between clinical guidelines and their implementation in real-world practice.

Background: This study aimed to assess the prevalence of noncardiac comorbidities (NCCs) and their association with hospitalization-associated disability (HAD) and 1-year outcomes in older patients with acute heart failure (HF).

Methods: Ninety-six institutions participated in this prospective, nationwide, multicenter registry of older patients with HF (J-Proof HF). Of the 10,052 eligible patients, 852 were excluded based on the study exclusion criteria, 9200 older patients with HF (mean age 82 ± 8 years; women, 48.8%) were included in the subanalysis. We evaluated 14 predefined NCCs based on the Charlson Comorbidity Index plus anemia, and classified patients by NCCs count (0, 1, 2, ≥3). We examined associations between NCCs category and HAD, 1-year all-cause mortality, HF hospitalization, and noncardiovascular hospitalization.

Results: Among the patients, 1107(12.0%) had no comorbidities (0 NCCs), 2615 (28.4%) had 1 NCC, 2919 (31.7%) had 2 NCCs, and 2559 (27.8%) had ≥3 NCCs. The incidence of HAD increased progressively across NCC categories (28.6%, 32.9%, 34.9%, and 39.8%; p for trend <0.001). Higher NCC category was associated with 1-year all-cause mortality after adjusting for confounders [hazard ratios were 1.099 (95% CI, 0.860-1.403) for 1 NCC, 1.382 (95% CI, 1.092-1.748) for 2 NCCs, and 1.873 (95% CI, 1.482-2.368) for ≥3 NCCs]. Similarly, higher NCC categories was significantly associated with HF hospitalization and noncardiovascular hospitalization.

Conclusions: NCCs are highly prevalent in older patients with HF. A greater NCC burden was associated with a higher incidence of HAD and poorer 1-year outcomes.

Background: Echocardiography is a first-line modality for evaluating type A acute aortic dissection (TAAAD). However, the diagnostic and prognostic implications of echocardiographic findings may differ between acute type A intramural hematoma (ATAIMH) and classic type A aortic dissection (CAAAD). This study aimed to compare echocardiographic characteristics between ATAIMH and CAAAD and to evaluate their prognostic value for in-hospital mortality, stratified by surgical treatment.

Methods: This retrospective single-center study included 434 patients with TAAAD (156 ATAIMH, 278 CAAAD) who underwent admission echocardiography. Findings assessed included direct signs (flap or hematoma), pericardial effusion, tamponade, aortic regurgitation, thoracic aortic enlargement (≥4 cm), and left ventricular wall motion abnormality (LVWMA). Prognostic value was evaluated stratified by surgical treatment (central repair vs. non-operative).

Results: Direct signs were less common in ATAIMH than CAAAD (39.1% vs. 66.6%, p < 0.001). Thoracic aortic enlargement ≥4 cm was similarly frequent (94.2% in both). ATAIMH showed more pericardial effusion but less aortic regurgitation than CAAAD. In multivariable analysis, tamponade predicted in-hospital mortality in the overall cohort, ATAIMH, and CAAAD; however, this lost significance in CAAAD after adjustment for central repair. Pericardial effusion was prognostic in the overall cohort and CAAAD, but not ATAIMH. LVWMA was not predictive in ATAIMH but remained significant in CAAAD, even after adjustment for central repair.

Conclusions: Thoracic aortic enlargement was the most consistent diagnostic marker, suggesting this finding as a diagnostic priority, whereas direct signs were less frequent in ATAIMH, highlighting diagnostic challenges. Although no single echocardiographic parameter consistently predicted outcomes across all disease subtypes, pericardial effusion, tamponade, and LVWMA should be regarded as dynamic indicators readily assessed by echocardiography.

Background: Uric acid (UA) is a routinely measured biomarker linked to cardiovascular and metabolic disorders, but its role in the development of aortic aneurysm (AA) and aortic dissection (AD) remains unclear. This study aimed to evaluate the association between UA levels and incident AA/AD.

Methods: We included 468,223 participants without baseline AA/AD from the UK Biobank prospective cohort. Baseline UA was measured and categorized by quartiles. The primary outcome was incident AA/AD. Cox proportional hazards models and restricted cubic spline (RCS) analyses were employed. Subgroup analyses were performed by age, sex, smoking status, blood pressure status, and history of coronary artery or cerebrovascular disease.

Results: During a median follow-up of 15.1 years, 4,504 AA/AD events were recorded. At baseline, elevated UA levels were significantly associated with decreased estimated glomerular filtration rate and increased C-reactive protein levels. AA/AD incidence increased across UA quartiles. In fully adjusted models, hazard ratios (HRs) for AA/AD were 1.00 (reference), 1.03 (95% CI 0.92-1.15), 1.04 (95% CI 0.92-1.16), and 1.17 (95% CI 1.04-1.31) from lowest to highest UA quartile. RCS analyses indicated a linear association between UA and AA/AD risk. The association was significant for AA (Q4 vs Q1: HR 1.15, 95% CI 1.02-1.31), but not for AD (Q4 vs Q1: HR 1.30, 95% CI 0.90-1.86). Subgroup analyses showed stronger associations in participants younger than 60 years, previous smokers, and those without prior coronary artery or cerebrovascular disease. Notably, the association remained statistically significant even in participants with clinically normal blood pressure.

Conclusions: Elevated UA levels are independently associated with a higher risk of AA/AD, particularly AA. This association persists independently of hypertension and may be linked to inflammatory mechanisms and renal dysfunction. These findings support the role of UA as a potential biomarker for risk assessment and prevention of AA, especially in high-risk populations.

In repaired tetralogy of Fallot (TOF), chronic pulmonary regurgitation drives right ventricular (RV) dilation, ventricular arrhythmias, and heart failure. Surgical pulmonary valve replacement improves outcomes but requires redo sternotomy. Transcatheter pulmonary valve implantation (TPVI) has emerged as a less invasive alternative. This review summarizes contemporary evidence and the Japanese context for TPVI. International registries report high procedural success and favorable mid-term outcomes with both balloon-expandable and self-expanding platforms. In Japan, two platforms are approved-SAPIEN 3 transcatheter heart valve (THV) (Edwards Lifesciences, Irvine, CA, USA) and Harmony transcatheter pulmonary valve (TPV) (Medtronic Inc., Minneapolis, MN, USA)-reflecting distinct anatomic targets. SAPIEN 3 THV is indicated for degenerated conduits or surgical bioprostheses in high-risk candidates, whereas Harmony TPV targets native, often dilated RV outflow tracts mainly after transannular patch repair. Although indications remain relatively restricted in Japan, early outcomes are expected to be favorable as experience grows. Key unresolved issues include long-term valve durability, post-TPVI antithrombotic strategy, arrhythmia surveillance, coronary compression risk, and timely referral before irreversible RV remodeling. Overall, TPVI has transformed the management of pulmonary valve dysfunction after TOF repair and is increasingly recognized as first-line therapy in appropriate anatomies. In Japan, accumulating TPVI experience-combined with optimized patient selection and refinements in treatment strategy-is expected to further improve procedural safety and clinical outcomes. National registries and high-quality domestic studies are needed to guide indications, optimize lifetime strategies, and extend the benefits of TPVI.

Background: The readmission rate in patients with heart failure (HF) has risen worldwide. One reason for the lack of reduction in readmission rates may be the absence of standardized evaluation methods tailored to the readmission period. Therefore, this study aimed to examine the influence of nutritional status and physical functions on readmission after discharge in patients with HF according to the readmission period.

Methods: This study was a scoping review. We conducted a comprehensive search for observational studies using the electronic databases PubMed, MEDLINE, CINAHL, and NPO Japan Medical Abstracts Society.

Results: The search resulted in a total of 452 selected articles, we finally selected 12 articles. The results of this scoping review showed that patients with HF who were readmitted from 3 months to 1 year after discharge exhibited significantly worse nutritional status and muscle strength compared with patients who were not readmitted. Patients with HF readmitted from 6 months to 1 year after discharge showed significantly worse postural balance function compared with patients who were not readmitted. Exercise tolerance was significantly worse in patients with HF readmitted from 6 months to 1 year and more than 1 year after discharge as compared with patients who were not readmitted. Malnutrition influenced readmissions from 3 to 6 months, 6 months to 1 year, and more than 1 year after discharge. Muscle weakness influenced readmissions from 3 months to 1 year after discharge. Low exercise tolerance influenced readmissions from 6 months to more than 1 year after discharge.

Conclusion: Malnutrition may influence readmissions over a wide range of periods, from 3 months to more than 1 year after discharge. Muscle weakness may influence short- to mid-term readmissions within 1 year after discharge, whereas low exercise tolerance may influence mid- to long-term readmissions occurring after 6 months.

Heart failure with preserved ejection fraction (HFpEF) is one of the most common forms of heart failure, and its prevalence is rising. As disease-modifying therapies become available, the accurate identification of early-stage HFpEF has become a major clinical priority. However, many patients with HFpEF are often managed for comorbidities such as hypertension, obesity, or diabetes, without recognizing the presence of HFpEF and targeted heart failure evaluation. In primary care, clinicians should keep HFpEF on the differential diagnosis for patients with unexplained exertional dyspnea, especially in older adults and in those with comorbidities such as obesity and atrial fibrillation. Simple clinical scores have been developed for this setting, including the HFpEF-ABA and BREATH₂ scores. These scoring systems can help clinicians estimate pre-test probabilities, enabling them to identify patients who should be referred to secondary or tertiary specialist centers. Close collaboration between primary care and secondary or tertiary centers is essential for timely diagnosis, treatment, and follow-up. In secondary and tertiary care settings, more detailed multimodality scores, such as H₂FPEF and HFA-PEFF which utilize natriuretic peptide levels and comprehensive echocardiography, are useful to rule in HFpEF. However, these scores have limited sensitivity to rule out HFpEF, particularly in obese patients, in whom natriuretic peptides and diastolic indices may underestimate the severity of left ventricular filling pressure. Patients with an intermediate probability should be evaluated by exercise stress echocardiography, but a substantial proportion of patients with negative or indeterminate test results still meets invasive hemodynamic criteria for HFpEF. This review summarizes current diagnostic strategies for suspected HFpEF and proposes a practical framework that combines validated noninvasive tools with selective use of invasive hemodynamic exercise testing and careful longitudinal follow-up.