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Objectives Upright computed tomography (CT) can detect slight changes particularly in the superior vena cava (SVC) volume in healthy volunteers under the influence of gravity. This study aimed to evaluate whether upright CT-based measurements of the SVC area are useful for assessing mean right atrial pressure (mRAP) in patients with heart failure. Methods We performed CT in both standing and supine positions to evaluate the SVC (directly below the junction of the bilateral brachiocephalic veins) and inferior vena cava (IVC; at the height of the diaphragm) areas and analyzed their relationship with mRAP, measured by right heart catheterization in 23 patients with heart failure. Results The median age of enrolled patients was 60 (51−72) years, and 69.6% were male. The median mRAP was 3 (1−7) mmHg. The correlations between the standing position SVC and IVC areas and mRAP were stronger than those in the supine position (SVC, ρ = 0.68, p < 0.001 and ρ = 0.43, p = 0.040; IVC, ρ = 0.57, p = 0.005 and ρ = 0.46, p = 0.026; respectively). Furthermore, the SVC area in the standing position was most accurate in identifying patients with higher mRAP (> 5 mmHg) (SVC standing, area under the receiver operating characteristic curve [AUC] = 0.91, 95% confidence interval [CI], 0.77–1.00; SVC supine, AUC = 0.78, 95% CI, 0.59–0.98; IVC standing, AUC = 0.77, 95% CI, 0.55–0.98; IVC supine, AUC = 0.72, 95% CI, 0.49–0.94). The inter- and intraobserver agreements (evaluated by intraclass correlation coefficients) for all CT measurements were 0.962–0.991. Conclusions Upright CT-based measurement of the SVC area can be useful for non-invasive estimation of mRAP under the influence of gravity in patients with heart failure. Key Points • This study showed that the superior vena cava (SVC) area in the standing position was most accurate in identifying patients with heart failure with higher mean right atrial pressure. • Upright computed tomography-based measurements of the SVC area can be a promising non-invasive method for estimating mean right atrial pressure under the influence of gravity in patients with heart failure. • Clinical management of patients with heart failure based on this non-invasive modality may lead to early assessment of conditional changes and reduced hospitalization for exacerbation of heart failure.

Background: The prevalence, patient profile, and outcomes of sleep-disordered breathing (SDB) in aortic stenosis (AS) remain unknown, especially in East Asia. Methods and Results: One hundred and eighty-one AS patients undergoing transcatheter aortic valve implantation (TAVI) were enrolled. Sixty-one patients (33.7%) had SDB, and lower stroke volume index was an independent determinant of SDB. Incidence of in-hospital stroke after TAVI was higher in the SDB group. Conclusions: SDB is associated with left ventricular systolic dysfunction in Japanese AS patients referred for TAVI. SDB was highly associated with the incidence of stroke as a procedural complication.

Dual antiplatelet therapy (DAPT) after percutaneous coronary intervention has become the standard of care, particularly in patients with acute coronary syndrome (ACS). Current clinical guidelines recommend novel P2Y12 inhibitors (e.g., prasugrel or ticagrelor) in addition to aspirin based on the results of representative randomized controlled trials conducted predominantly in Western countries. These agents were superior to clopidogrel in reducing the composite ischemic events, with a trade-off of the increased bleeding events. However, multiple differences exist between East Asian and Western patients, especially with respect to their physique, thrombogenicity, hemorrhagic diathesis, and on-treatment platelet reactivity. Recent studies from East Asian countries (e.g., Japan or South Korea) have consistently demonstrated that use of novel P2Y12 inhibitors is associated with a higher risk of bleeding events than use of clopidogrel, despite borderline statistical difference in the incidence of composite ischemic events. Additionally, multiple studies have shown that the optimal duration of DAPT may be shorter in East Asian than Western patients. This review summarizes clinical studies of antithrombotic strategies in East Asian patients with ACS. Understanding these differences in antithrombotic strategies including DAPT and their impacts on clinical outcomes will aid in selection of the optimal tailored antithrombotic therapy for patients with ACS.

Background The clinical significance of obstructive sleep apnea (OSA) in pulmonary hypertension (PH) patients remains unclear. We investigated the hemodynamics and serum troponin T concentrations associated with OSA in PH patients. Methods Cross-sectional study was performed on data from 97 clinically stable PH patients. Using overnight sleep study, we evaluated apnea–hypopnea index (AHI) and divided patients into two groups: none-to-mild OSA (AHI N = 81) and moderate-to-severe OSA (AHI ≥ 15/h, N = 16). Clinical, hemodynamic, and laboratory data were compared with OSA severity. Results Moderate-to-severe OSA patients had higher pulmonary vascular resistance (PVR; 6.5 [5.7–12.9] vs 4.4 [2.9–6.4] Wood units, p = 0.001) and mean pulmonary artery pressure (mPAP; 37 [30–49] vs 30 [22–37] mmHg, p = 0.045), and a lower cardiac index (2.2 [1.6–2.6] vs 2.8 [2.3–3.5] L/min/m 2 , p = 0.001) than those without. There was no association between plasma B-type natriuretic peptide (BNP) or serum C-reactive protein levels and OSA. However, high-sensitivity troponin T (hs-TnT) level was significantly higher in moderate-to-severe OSA patients (13 [8–18] vs 6 [4–10] ng/L, p 0.001). The hs-TnT level positively correlated with the plasma BNP level, mPAP, PVR, AHI, obstructive apnea index, and 6-min walking distance. After adjustment for age, estimated glomerular filtration rate, hypertension, smoking, and plasma BNP level, moderate-to-severe OSA was an independent factor for determining the plasma level of log hs-TnT level (β = 0.419, 95% confidence interval 0.119–0.718, p = 0.007). Conclusions Moderate-to-severe OSA is associated with impaired hemodynamics and subclinical myocardial damage in PH patients. Thus, OSA-related myocardial injury may play a role in hemodynamic destabilization with its associated poor prognosis.

Sleep-disordered breathing (SDB) or short sleep duration and coronary artery disease (CAD) are related, yet, the prevalence of SDB and short sleep duration as well as their mechanism remain unknown. Enhanced vascular inflammation is also implicated as one of the pathophysiologic mechanisms in CAD. The aims of this study were to evaluate the prevalence of patients with SDB and short sleep duration, and to examine their relationship with serum C-reactive protein (CRP) level in CAD patients.We evaluated 161 CAD patients who underwent percutaneous coronary intervention, using nocturnal pulse oximetry, a non-invasive screening method for nocturnal intermittent hypoxia. Based on three percent oxygen desaturation index (3% ODI), the patients were divided into nocturnal intermittent hypoxia (3% ODI ≥ 15; n = 45) and control groups (3% ODI 15, n = 116). The nocturnal intermittent hypoxia group had higher body mass index and serum CRP level compared with the control group. Short sleep duration (6 h, n = 45) was also associated with increased CRP level compared with the control group (≥6 h, n = 116). In multiple regression analysis, nocturnal intermittent hypoxia (β = 0.332, 95% confidence interval [CI] 0.102-0.562, P = 0.005) and short sleep duration (β = 0.311, 95% CI 0.097-0.526, P = 0.005) were both independent determinants for log serum CRP level.Nocturnal intermittent hypoxia and short sleep duration were independently associated with elevated serum CRP level in CAD patients, suggesting that both SDB and sleep shortage are associated with enhanced inflammation in CAD patients. SDB and sleep duration may be important modifiable factors in the clinical management of patients with CAD.

Aims Heart failure (HF) is associated with an increased risk of sudden cardiac death (SCD). This study sought to demonstrate the incidence of SCD within a multicentre Japanese registry of HF patients hospitalized for acute decompensation, and externally validate the Seattle Proportional Risk Model (SPRM). Methods and results We consecutively registered 2240 acute HF patients from academic institutions in Tokyo, Japan. The discrimination and calibration of the SPRM were assessed by the c-statistic, Hosmer–Lemeshow statistic, and visual plotting among non-survivors. Patient-level SPRM predictions and implantable cardioverter-defibrillator (ICD) benefit [ICD estimated hazard ratio (HR), derived from the Cox proportional hazards model in the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT)] was calculated. During the 2-year follow-up, 356 deaths (15.9%) occurred, which included 76 adjudicated SCDs (3.4%) and 280 non-SCDs (12.5%). The SPRM showed acceptable discrimination [c-index = 0.63; 95% confidence interval (CI) 0.56–0.70], similar to that of original SPRM-derivation cohort. The calibration plot showed reasonable conformance. Among HF patients with reduced ejection fraction (EF; < 40%), SPRM showed improved discrimination compared with the ICD eligibility criteria (e.g. New York Heart Association functional Class II–III with EF ≤ 35%): c-index = 0.53 (95% CI 0.42–0.63) vs. 0.65 (95% CI 0.55–0.75) for SPRM. Finally, in the subgroup of 246 patients with both EF ≤ 35% and SPRM-predicted risk of ≥ 42.0% (SCD-HeFT defined ICD benefit threshold), mean ICD estimated HR was 0.70 (30% reduction of all-cause mortality by ICD). Conclusion The cumulative incidence of SCD was 3.4% in Japanese HF registry. The SPRM performed reasonably well in Japanese patients and may aid in improving SCD prediction.

Some patients with hypertrophic cardiomyopathy (HCM) develop systolic dysfunction, called the dilated phase of HCM (d-HCM), which is associated with increased morbidity and mortality. We conducted a retrospective study using an HCM database to clarify the incidence, clinical characteristics, and long-term outcomes of d-HCM. We analyzed an HCM cohort consisting of 434 patients (273 with apical HCM and 161 with non-apical HCM; 18 had obstructive HCM, 16 had dilated HCM, and 127 had other HCM) diagnosed by echocardiography in our hospital between 1991 and 2010. The follow-up period was 8.4 ± 6.7 years. The mean age at final follow-up was 67 ± 14 years, and 304 patients (70%) were men. The mean age of the 16 d-HCM patients at the initial visit was 45 ± 17 years, the age at final follow-up was 59 ± 18 years, and 13 were men. Thirteen d-HCM patients developed atrial fibrillation and six patients developed ischemic stroke. Twelve d-HCM patients were implanted with cardiac devices: one pacemaker, nine implantable cardioverter-defibrillators, and two cardiac resynchronization therapy with defibrillator. Five patients died of progressive heart failure at the age of 61 ± 23 years. The age at the initial visit and final follow-up were lower and the NYHA class, brain natriuretic peptide levels, and left ventricular function at initial evaluation were worse in the d-HCM group. Univariate analysis demonstrated that a lower age at the initial visit was associated with d-HCM (hazard ratio 0.955/1 year increase; 95% CI 0.920-0.991, P = 0.015). In our HCM cohort, the incidence of d-HCM was 4%. A high prevalence of atrial fibrillation and cerebral infarction and poor prognosis were noted in this group, despite patients undergoing medication and device implantation.

Background Balloon pulmonary angioplasty (BPA) improves pulmonary hemodynamics in chronic thromboembolic pulmonary hypertension (CTEPH) patients. However, whether it affects the severity of sleep apnea (SA) remains unknown. We investigated the effect of BPA on the severity of SA in CTEPH patients. Methods We studied 13 patients with CTEPH who had an apnea hypopnea index (AHI) > 10 before BPA and underwent a second polygraph test 6 months after the last BPA session. Results BPA decreased pulmonary vascular resistance, mean pulmonary artery pressure (PAP), and plasma B-type natriuretic peptide levels, and increased the 6-minute walking distance. BPA decreased the AHI (from 20.9 [13.9–35.7] to 16.3 [7.7–21.8] times/hour, P = 0.023) and hypopnea index (from 13.2 [8.4–22.5] to 6.4 [3.8–10.9] times/hour, P = 0.013), but not the obstructive, central, or mixed apnea index. The change in AHI correlated with that in mean PAP, but not with the change in body mass index or other parameters of hemodynamics. Conclusions BPA-induced improvement in hemodynamics was associated with the attenuation of SA in patients with CTEPH and SA. Therefore, close attention should be paid to SA in CTEPH patients, and SA should be re-evaluated after BPA to avoid overestimating its severity.

Heart failure (HF) is characterized by frequent rehospitalization and prolonged hospital stay. Although length of stay has been used as a surrogate marker for hospital performance, its association with early rehospitalization remains unknown. We investigated their precise association using contemporary Japanese HF registry. We analyzed the 2785 acute HF patients who were registered in the West Tokyo Heart Failure registry and discharged or transferred to the recuperation facilities (mean age, 73.8 ± 13.5 years; 60.8% were men). Median length of stay was 15 days (interquartile range, 10–23 days). One-hundred and fourteen patients (4.1%) were readmitted for worsening HF within 30 days after discharge. Thirty-day risk-adjusted HF readmission after a shorter length of stay (1–12 days; the lower tertile within the cohort) was higher than those after intermediate (13–19 days; the middle tertile) [HR 1.71, 95% confidence interval (CI) 1.05–2.77]. Even after a longer length of stay, there tended to be a higher risk of 30-day HF readmission (HR 1.59, 95% CI 0.96–2.65). In conclusion, the Japanese acute HF patients had low rates of early-HF readmission after quite a long length of stay at urban tertiary care centers. Shorter length of stay was associated with increased rates of 30-day HF readmission, while longer length of stay also the same trended. Clinical Trial Registration: https://www.umin.ac.jp/icdr/index-j.html . Unique identifier: UMIN000001171.

BACKGROUND Excessive daytime sleepiness (EDS) is a significant public health concern, with sleep-disordered breathing (SDB) being a common cause. However, their precise relationship in patients with cardiovascular disease (CVD) is unclear. Furthermore, whether comorbid psychological disorders could contribute to EDS remains unknown. We aimed to assess the prevalence of EDS and its related factors, including SDB and depression, in patients with CVD.Methods and Results:We analyzed data from 1,571 patients admitted for various CVDs in a single university hospital (median age, 67 [56-76] years; 29.6% women). We assessed EDS using the Japanese version of the Epworth Sleepiness Scale (ESS; median 6.0 [4.0-9.0]). The presence of EDS (ESS >10, n=297 [18.9%]) did not differ between patients with and without SDB, which was screened with nocturnal pulse oximetry. In contrast, the patients with EDS had higher depression scores (Hospital Anxiety and Depression Scale subscore for depression [HADS-D] and Patient Healthcare Questionnaire [PHQ]-9). The depression scores, measured by HADS-D (odds ratio [OR] 1.14; 95% confidence interval [CI], 1.07-1.22) and PHQ-9 (OR, 1.14; 95% CI, 1.07-1.20) were independent determinants of EDS. These relationships among EDS, SDB, and depression were consistent among the subgroups with cardiovascular comorbidities. CONCLUSIONS The presence of EDS is associated with depressive symptoms, but not with SDB, in patients with CVD, suggesting that these patients should be thoroughly assessed for psychological disturbances.

A 92-year-old woman with a history of patent ductus arteriosus (PDA) was referred to our hospital because of worsening dyspnea, with New York Heart Association classification IV. She had 3 admissions because of congestive heart failure within a year. A 12-lead ECG showed atrial fibrillation, and a chest radiograph showed severe pulmonary congestion and cardiomegaly (Figure [A]). The plasma B-type natriuretic peptide level was 4527.9 pg/mL. The echocardiogram showed a reduced ejection fraction of 39% and moderate to severe aortic valve stenosis (peak velocity=3.9 m/s; mean pressure gradient=29 mm Hg; aortic valve area=0.83 cm2). The reconstructed 3-dimensional computed tomography (CT; Ziostation2; Ziosoft Inc, Tokyo, Japan) revealed a 50-mm thoracic aortic aneurysm and a large PDA (Krichenko type A, 4.7 mm of the pulmonary artery side) with severe calcifications surrounding it (Figure B–D; Movies I and II in the Data Supplement). Because of her refractory heart failure despite treatment with intravenous furosemide and dobutamine, we decided to perform a transcatheter occlusion of PDA 8 days after her admission to the hospital. For the transcatheter occlusion procedure, we …

Precise risk stratification in heart failure (HF) patients enables clinicians to tailor the intensity of their management. The Seattle Heart Failure Model (SHFM), which uses conventional clinical variables for its prediction, is widely used. We aimed to externally validate SHFM in Japanese HF patients with a recent episode of acute decompensation requiring hospital admission.SHFM was applied to 2470 HF patients registered in the West Tokyo Heart Failure and National Cerebral And Cardiovascular Center Acute Decompensated Heart Failure databases from 2006 to 2016. Discrimination and calibration were assessed with the use of the c-statistic and calibration plots, respectively, in HF patients with reduced ejection fraction (HFrEF;40%) and preserved ejection fraction (HFpEF; ≥40%). In a perfectly calibrated model, the slope and intercept would be 1.0 and 0.0, respectively. The method of intercept recalibration was used to update the model. The registered patients (mean age 74 ± 13 y) were predominantly men (62%). Overall, 572 patients (23.2%) died during a mean follow-up of 2.1 years. Among HFrEF patients, SHFM showed good discrimination (c-statistic = 0.75) but miscalibration, tending to overestimate 1-year survival (slope = 0.78; intercept = -0.22). Among HFpEF patients, SHFM showed modest discrimination (c-statistic = 0.69) and calibration, tending to underestimate 1-year survival (slope = 1.18; intercept = 0.16). Intercept recalibration (replacing the baseline survival function) successfully updated the model for HFrEF (slope = 1.03; intercept = -0.04) but not for HFpEF patients.In Japanese acute HF patients, SHFM showed adequate performance after recalibration among HFrEF patients. Using prediction models to tailor the care for HF patients may improve the allocation of medical resources.

Introduction We aimed to study the prevalence and types of sleep apnea (SA) as well as their clinical characteristics in atrial fibrillation (AF) ablation candidates in Japan. Methods Before catheter ablation, 197 consecutive AF patients (age: 60 ± 9 years, body mass index; 25.0 ± 3.0) were evaluated with portable polygraphy. We compared the clinical characteristics, according to the severity of SA as well as its types, as defined by the presence of obstruction and the mixed vs. central apnea indices. Results The mean apnea–hypopnea index (AHI) was 17.7 ± 11.9, with 135 AF patients having an AHI ≥10 (68.5%). Patients with an AHI ≥10 had a significantly higher body mass index, plasma brain natriuretic peptide (BNP) level, prevalence of hypertension, and larger left atrial size. Among patients with an AHI ≥10, the incidence of obstructive-dominant SA was 60.9% and that of central-dominant SA was 7.6%. The prevalence of hypertension was significantly higher in obstructive-dominant SA patients (obstructive vs. central: 48.3% vs. 20.0%, P = 0.038). The obstructive apnea index correlated with plasma BNP level and age, but the central and mixed apnea indices did not. Conclusions The prevalence of SA was common in AF ablation candidates, even without an obesity epidemic, and the SA type was predominantly obstructive. Portable polygraphy was useful for detecting undiagnosed SA patients in AF ablation candidates.

Introduction: There is increasing evidence that sleep disturbance significantly contribute to the development of heart disease. However, sleep disturbance often remains unrecognized and untreated because of barrier to its assessment. The aims of this study were to assess the prevalence of sleep disturbance in cardiovascular patients, and examine its related factors including mental status. Methods and Results: A total of 1087 patients (mean age, 65±15 years; 29% female) hospitalized for a spectrum of cardiovascular diseases in Keio University Hospital were enrolled (coronary artery disease n=348, arrhythmia n=459, heart failure n=81, valvular heart disease n=119, and other n=80). We assessed sleep disturbance using the Pittsburgh Sleep Quality Index (PSQI; mean 5.6±3.3). The sleep disturbance was defined as PSQI>7 (n=256 [24%]). We screened sleep-disordered breathing (SDB) using nocturnal pulse oximetry, a non-invasive method for detecting nocturnal intermittent hypoxia. The prevalence of SDB (3% oxygenation desaturation index>15/hour) was higher in patients with sleep disturbance (33% vs 26%, p=0.02). Sleep disturbance was associated with older age, higher BNP and CRP level, and lower eGFR and albumin level (all p Conclusions: Given the high prevalence of sleep disturbances and their strong impact on psychological disturbance, increased efforts should be undertaken for their identification and treatment in patients with cardiovascular diseases, especially in the field of heart failure.

Introduction: There is growing evidence of a relationship between sleep disorders and cardiovascular diseases including coronary artery disease (CAD). However, the mechanism of these association is not well established. Enhanced vascular inflammation is implicated as a pathophysiologic mechanism in CAD. The aim of this study was to evaluate the relationship among sleep-disordered breathing (SDB), sleep duration, and serum C-reactive protein (CRP) level in patients with CAD. Methods and Results: Consecutive 225 patients with CAD who underwent percutaneous coronary intervention were evaluated. We used a nocturnal pulse oximetry as a non-invasive screening method for nocturnal intermittent hypoxia, a surrogate marker of SDB. Nocturnal intermittent hypoxia was evaluated using 3% oxygen desaturation index (3% ODI) which was the number of oxygen desaturation measurement ≤ 3% per hour, and we divided the patients into nocturnal intermittent hypoxia group (3% ODI≥15; n=64) and control group (3% ODI Conclusions: Nocturnal intermittent hypoxia and short sleep duration were independently associated with elevated serum CRP level in CAD patients, suggesting that SDB and sleep duration could be important modifiable factors for the clinical management of patients with CAD.

“Reverse curve” hypertrophic cardiomyopathy (HCM), diffuse cardiac hypertrophy with significant obstruction in left ventricle, is highly frequent in patients with myofilament gene. The association between septal morphologies and cardiac fibrosis in HCM patients remains unclear. We investigated

ObjectiveTo assess patient perspectives on secondary lifestyle modification and knowledge of ‘heart attack’ after percutaneous coronary intervention (PCI) for coronary artery disease (CAD).DesignObservational cross-sectional study.SettingA single university-based hospital centre in Japan.ParticipantsIn total, 236 consecutive patients with CAD who underwent PCI completed a questionnaire (age, 67.4±10.1 years; women, 14.8%; elective PCI, 75.4%). The survey questionnaire included questions related to confidence levels about (1) lifestyle modification at the time of discharge and (2) appropriate recognition of heart attack symptoms and reactions to these symptoms on a four-point Likert scale (1=not confident to 4=completely confident).Primary outcome measureThe primary outcome assessed was the patients’ confidence level regarding lifestyle modification and the recognition of heart attack symptoms.ResultsOverall, patients had a high level of confidence (confident or completely confident,>75%) about smoking cessation, alcohol restriction and medication adherence. However, they had a relatively low level of confidence (ConclusionsThere were substantial disparities in the confidence levels associated with lifestyle modification and recognition/response to heart attack. These gaps need to be studied further and disseminated to improve cardiovascular care.