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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. [ABSTRACT FROM AUTHOR]

Aims: Non‐dilated left ventricular cardiomyopathy (NDLVC) was proposed as a new category of cardiomyopathy that included patients with non‐left ventricular (LV) dilatation, LV wall motion abnormality, or LV scar. However, the clinical background and event rates of NDLVC were unclear. The aim of this study was to examine the characteristics and event rates of patients with NDLVC and reduced LV ejection fraction (NDLVC–REF) in comparison with those with dilated cardiomyopathy (DCM). Methods and results: We retrospectively included 363 patients with newly diagnosed non‐ischaemic cardiomyopathy and reduced LV ejection fraction (<50%) between December 2004 and January 2018. Patients who did not have LV dilatation (LV dimension index of ≦31 mm/m2 in men and ≦34 mm/m2 in women) were categorized as NDLVC–REF (n = 80, 22.2%), and the remaining patients were categorized as DCM. Cardiac events were defined as sudden cardiac death and rehospitalization for heart failure. Patients with NDLVC–REF had a higher prevalence of atrial fibrillation and a higher LV ejection fraction than those with DCM at baseline. LV ejection fraction was higher and LV end‐diastolic diameter was smaller in patients with NDLVC–REF than in those with DCM at all time points after diagnosis. During the median follow‐up period of 68.8 months (interquartile range: 33.0–93.7 months), 44 patients experienced cardiac events. The Kaplan–Meier curves showed no significant differences in the probability of cardiac events among NDLVC–REF and DCM patients (P = 0.349). However, patients with NDLVC–REF and LV dilatation after diagnosis (14%) had a higher risk of cardiac events than those with NDLVC–REF without LV dilatation (P = 0.049). Conclusions: There was no significant difference in the incidence of cardiac events between NDLVC–REF and DCM. Among NDLVC–REF patients, 18% of patients who showed LV dilatation after diagnosis had poor outcomes. Therefore, both NDLVC–REF and DCM patients may require equivalent attention to follow‐up and regular assessment of LV function. [ABSTRACT FROM AUTHOR]

Background: Familial hypercholesterolemia (FH) is associated with atherosclerotic cardiovascular disease (ASCVD). However, the prevalence of FH among a general population remains unknown, and it is unclear if FH is associated with other cardiovascular complications, including heart failure (HF) and atrial fibrillation (AF). Methods: Analyses were conducted on individuals without a prior history of cardiovascular disease using a nationwide health claims database collected in the JMDC Claims Database between 2005 and 2022 (n = 4,126,642; median age, 44 years; 57.5% men). We defined FH as either LDL cholesterol ≥250 mg/dL or LDL cholesterol ≥175 mg/dL under the lipid‐lowering medications under the assumption that lipid‐lowering medications reduced LDL cholesterol by 30%. We assessed the associations between FH and composite outcomes, including, ASCVD (myocardial infarction, angina pectoris, and stroke), HF, and AF using Cox proportional hazard model. Results: We identified 11,983 (.29%) FH patients. In total, 181,150 events were recorded during the mean follow‐up period of 3.5 years. The status FH was significantly associated with composite outcomes after adjustments (hazard ratio [HR]; 1.38, 95% confidence interval [CI]: 1.30–1.47, p <.001). Interestingly, the status FH was significantly associated with HF (HR: 1.48, 95% CI: 1.36–1.61, p <.001) and AF (HR: 1.33, 95% CI: 1.08–1.64, p <.001) in addition to angina pectoris (HR: 1.45, 95% CI: 1.33–1.58, p <.001) and stroke (HR: 1.19, 95% CI: 1.04–1.36, p <.001). Conclusion: We found that the prevalence of FH was.29% in a general population. FH was significantly associated with a higher risk of developing cardiovascular disease, HF and AF. Lay summary: We sought to identify the prevalence of FH among a general population, and to clarify whether FH increases the risk of not only ASCVD but also HF and AF. [ABSTRACT FROM AUTHOR]

Aims: Frailty is highly prevalent and associated with poor prognoses in elderly patients with heart failure (HF). However, the potential effects of physical frailty on the benefits of HF medications in elderly patients with HF are unclear. We aimed to determine the influence of physical frailty on the prognosis of HF medications in elderly patients with HF with reduced and mildly reduced ejection fraction (HFr/mrEF). Methods and results: From the combined HF database of the FRAGILE‐HF and Kitasato cohorts, hospitalized HF patients with a left ventricular ejection fraction < 50% and age ≥ 65 years were analysed. Patients treated with or without renin‐angiotensin‐aldosterone system inhibitors (RAASi) and beta‐blockers at discharge were compared. Physical frailty was defined by the presence of ≥3 items on the Japanese version of the Cardiovascular Health Study criteria. The primary endpoint was all‐cause mortality rate. Among the 1021 enrolled patients, 604 patients (59%) received both RAASi and beta‐blockers, and 604 patients (59%) were diagnosed as physically frail. Patients receiving both RAASi and beta‐blockers showed a significantly lower 1 year mortality than those not receiving either, even after adjusting for covariates (hazard ratio: 0.50, 95% confidence interval: 0.34–0.75). This beneficial effect of both medications on 1 year mortality was comparable between patients with and without physical frailty (hazard ratio: 0.53 and 0.51, respectively; P for interaction = 0.77). Conclusions: The presence of physical frailty did not interact with the beneficial prognostic impact of RAASi and beta‐blocker combination therapy in elderly patients with HFr/mrEF. [ABSTRACT FROM AUTHOR]

Background: Data on the potential benefit of acute‐phase rehabilitation initiation in very old (aged ≥90) patients with acute heart failure (AHF) have been scarce. Methods: We retrospectively analyzed data from the Diagnosis Procedure Combination database, which is a nationwide inpatient database. This study included patients hospitalized for heart failure (HF) from January 2010 to March 2018, those aged ≥90 years, who had a length of stay of ≥3 days, New York Heart Association (NYHA) class of ≥II, and had not undergone major procedures under general anesthesia. Propensity score matching and generalized linear models were used to compare in‐hospital mortality, length of stay, 30‐day readmission rate due to HF, all‐cause 30‐day readmission, and improvement in activities of daily living (ADL) between patients with and without an acute‐phase rehabilitation initiation, which is defined as the rehabilitation initiation within 2 days after hospital admission. Results: Acute‐phase rehabilitation was initiated in 8588 of 41,896 eligible patients. Propensity score matching created 8587 pairs. Patients with acute‐phase rehabilitation initiation have lower in‐hospital mortality (9.0% vs. 11.2%, p < 0.001). Acute‐phase rehabilitation initiation was associated with lower in‐hospital mortality (odds ratio, 0.778; 95% confidence interval, 0.704–0.860). Patients with acute‐phase rehabilitation initiation have a shorter median length of stay (17 days vs. 18 days, p < 0.001), lower 30‐day readmission rate due to HF (5.5% vs. 6.4%, p = 0.011) and all‐cause 30‐day readmission (10.2% vs. 11.2%, p = 0.036), and better ADL improvement (49.7% vs. 46.9%, p < 0.001). Subgroup analysis revealed consistent results (sex, body mass index, NYHA class, and Barthel Index). Conclusions: The acute‐phase rehabilitation initiation was associated with improved short‐term clinical outcomes in patients aged ≥90 years with AHF. [ABSTRACT FROM AUTHOR]

Background: Previous studies have identified noninvasive methods for predicting atrial fibrillation (AF) recurrence after catheter ablation (CA). We assessed the association between AF recurrence and atrial late potentials (ALPs), which were measured using P‐wave signal‐averaged electrocardiography (P‐SAECG). Methods: Consecutive patients with paroxysmal AF who underwent their first CA at our institution between August 2015 and August 2019 were enrolled. P‐SAECG was performed before CA. Two ALP parameters were evaluated: the root‐mean‐square voltage during the terminal 20 ms (RMS20) and the P‐wave duration (PWD). Positive ALPs were defined as an RMS20 <2.2 μV and/or a PWD >115 ms. Patients were allocated to either the recurrence or nonrecurrence group based on the presence of AF recurrence at the 1‐year follow‐up post‐CA. Results: Of the 190 patients (age: 65 ± 11 years, 37% women) enrolled in this study, 21 (11%) had AF recurrence. The positive ALP rate was significantly higher in the recurrence group than in the nonrecurrence group (86% vs. 64%, p =.04), despite the absence of differences in other baseline characteristics between the two groups. In the multivariate analysis, positive ALP was an independent predictor of AF recurrence (odds ratio: 3.83, 95% confidence interval: 1.05–14.1, p =.04). Conclusions: Positive ALP on pre‐CA P‐SAECG is associated with AF recurrence after CA. [ABSTRACT FROM AUTHOR]

Aims: The analysis of heart rate (HR) changes, such as the HR variability or HR turbulence, has been reported as a marker of cardiovascular events during sinus rhythm; however, those relationships during atrial fibrillation (AF) remain controversial, and those parameters are not commonly used in AF patients. We sought to investigate the relationship between a simple index focused on the HR and heart failure (HF) events in patients with permanent AF. Methods and results: We enrolled 198 patients with permanent AF and evaluated the HR range, defined as the maximum HR minus the minimum HR on 24‐h Holter electrocardiogram recordings. The patients were divided into two groups, i.e., the larger (n = 101) and smaller (n = 97) HR range (HRR) groups, determined by the median value. The HF events were defined as hospitalizations for HF or urgent hospital visits due to exacerbations of one's HF status. The observation period of this study was set at 5 years from registration. The median age was 73 (68–77) years, and 29% were female. The median HRR was 84 (63–118) beats per minutes (bpm). During the observational period of 1825 days (median), HF events occurred in 37 (0.047 per patient‐year) patients. In a log‐rank test, the larger HRR group had more frequent HF events than the smaller HRR group (P = 0.0078). In the adjusted Cox proportional hazards model using the significantly different factors from the univariate analysis (Model 1) and factors and medications associated with HF (Model 2), the larger HRR group had a higher prevalence of HF events than the smaller HRR group for both models [Model 1, adjusted hazard ratio = 3.21, 95% confidence interval (CI) 1.593–6.708, P = 0.0009; Model 2, adjusted hazard ratio = 3.12, 95% CI 1.522–6.685, P = 0.002]. When analysed using the time‐dependent Cox proportional hazards model, the HRR was associated with HF with a statistically significant difference in both the univariate and multivariate analyses [hazard ratio = 1.01, 95% CI 1.006–1.020, P = 0.0002; Model 1, adjusted hazard ratio = 1.02, 95% CI 1.011–1.027, P < 0.0001; Model 2, adjusted hazard ratio = 1.01, 95% CI 1.008–1.021, P = 0.0003). There was no significant difference in the chronotropic medications between the two groups. Conclusions: In patients with permanent AF, a larger HRR was associated with HF events. [ABSTRACT FROM AUTHOR]

Background: Clinical predictors for successful weaning of patients from Impella heart pump have not been clarified. We aimed to elucidate the relationship between pulmonary artery catheter (PAC) parameters at the time of Impella weaning and subsequent outcomes. Methods: We enrolled consecutive patients who had received Impella for cardiogenic shock. PAC data were collected immediately before Impella weaning. Patients were classified as non‐survivors if they died or required any mechanical circulatory support reintroduction within 30 days of weaning. Results: Of 81 patients enrolled, 61 underwent Impella weaning. Of these, 16 were non‐survivors. Predictive indicators of non‐survival were high pulmonary artery wedge pressure (PAWP; hazard ratio [HR] per 5 mm Hg 1.97, 95% CI 1.35–2.80; p < 0.001), high mean pulmonary artery pressure (MPAP; HR per 5 mm Hg 1.90, 1.38–2.58; p < 0.001), and low cardiac power output (CPO; HR per 0.1 Watts 0.71, 0.52–0.92; p = 0.006). Cutoff values of PAWP 20 mm Hg, MPAP 22 mm Hg, and CPO 0.59 Watts showed strong associations with 30‐day non‐survival risk (low risk 8% in patients with low PAWP and high CPO or 4% in patients with low MPAP and high CPO; high risk 100% in patients with high PAWP and low CPO or 82% in patients with high MPAP and low CPO). Conclusions: PAWP or MPAP higher than the cutoff with CPO below the cutoff at Impella weaning were associated with worse outcomes. We proposed a risk classification model for successful Impella weaning using PAC. [ABSTRACT FROM AUTHOR]

Background: Each direct oral anticoagulant (DOAC) has different dose reduction criteria. Here, we evaluated the differences in the doses of three anti‐Xa DOACs and clinical events based on the dose reduction criteria in patients with atrial fibrillation (AF). Methods: Consecutive AF patients prescribed with anti‐Xa DOACs [rivaroxaban (Riva), apixaban (Apix), and edoxaban (Edox)] between April 2011 and May 2016 were retrospectively evaluated. The incidences of thromboembolic and bleeding events were evaluated by the end of December 2020, focusing on the dose proportion. Results: A total of 786 patients (72 ± 10 years old, 66.9% male) were enrolled in this study [Riva (n = 337), Apix (n = 239), and Edox (n = 210)]. The proportion of reduced dose prescriptions was significantly greater for Edox (79.2%) than Riva (38.7%) or Apix (31.9%). A Kaplan–Meier analysis showed that the incidence of minor bleeding was significantly higher in the Apix than other groups (p <.001), even after propensity score matching. The standard dose of Apix had significantly higher bleeding events than the other DOACs (p <.001). Moreover, 23.2% and 51.6% of the patients with a standard dose of Apix were fulfilled with the dose reduction criteria for Riva and Edox and had more minor bleeding events than the unfulfilled ones (p =.046). Conclusions: The patients with a standard dose of Apix had a higher incidence of minor bleeding events than the other dosages. A reduced dose of apixaban was not prone to being chosen because of the dose reduction criteria, which may have been associated with a higher minor bleeding rate in patients with Apix. [ABSTRACT FROM AUTHOR]

Introduction: Direct comparison studies about the incidence of esophagogastric complications between radiofrequency (RF) and cryoballoon (CB) catheter ablation (CA) for atrial fibrillation (AF) have been scarce. We sought to elucidate the relationship between the pulmonary vein isolation (PVI) modalities and esophagogastric complications. Methods: The study population consisted of 254 patients who underwent CA for AF from November 2017 to October 2018. Finally, 160 patients were enrolled and divided into the RF and CB groups. Esophageal ulcers, gastric hypomotility, and exfoliative esophagitis detected by esophagogastroduodenoscopy were defined as esophagogastric complications in this study. Results: The median age was 68 years old, with 34% being females. Esophagogastric complications were observed in 42.5% of patients who underwent CA. According to the detailed esophagogastric complications, the RF group had a higher prevalence of esophageal ulcers than the CB group (19% vs. 0%, p <.0001). There was no significant difference between the two groups regarding gastric hypomotility and exfoliative esophagitis (18% vs. 28%; p =.15 and 16% vs. 21%; p =.42, respectively). Conclusion: Asymptomatic esophagogastric complications were common in CA for AF. The incidence of esophageal ulcers was higher in the RF group than in the CB group, whereas the other esophagogastric complications did not significantly differ. [ABSTRACT FROM AUTHOR]

Background: Local impedance (LI) can indirectly measure catheter contact and tissue temperature during radiofrequency catheter ablation (RFCA). However, data on the effects of catheter contact angle on LI parameters are scarce. This study aimed to evaluate the influence of catheter contact angle on LI changes and lesion size with two different LI‐sensing catheters in a porcine experimental study. Methods: Lesions were created by the INTELLANAV MiFi™ OI (MiFi) and the INTELLANAV STABLEPOINT™ (STABLEPOINT). RFCA was performed with 30 W and a duration of 30 s. The contact force (CF) (0, 5, 10, 20, and 30 g) and catheter contact angle (30°, 45°, and 90°) were changed in each set (n = 8 each). The LI rise, LI drop, and lesion size were evaluated. Results: The LI rise increased as CF increased. There was no angular dependence with the LI rise under all CFs in the MiFi. On the other hand, the LI rise at 90° was lower than at 30° under 5 and 10 g of CF in STABLEPOINT. The LI drop increased as CF increased. Regarding the difference in catheter contact angles, the LI drop at 90° was lower than that at 30° for both catheters. The maximum lesion widths and surface widths were smaller at 90° than at 30°, whereas there were no differences in lesion depths. Conclusion: The LI drop and lesion widths at 90° were significantly smaller than those at 30°, although the lesion depths were not different among the 3 angles for the MiFi and STABLEPOINT. [ABSTRACT FROM AUTHOR]

Aims: High‐sensitivity cardiac troponin T (hs‐cTnT) and B‐type natriuretic peptide (BNP) are associated with prognosis and severity in patients with heart failure (HF); however, their association with physical function is unclear. This study aimed to investigate whether hs‐cTnT and BNP levels are associated with physical function in patients with HF. Methods and results: Hs‐cTnT, BNP, and physical function (maximal quadriceps isometric strength [QIS], usual gait speed, and 6‐min walk distance [6MWD]) were evaluated in 363 consecutive patients with HF (median age, 70 [60–78] years). Patients were divided into four groups according to their median hs‐cTnT and BNP levels. After adjusting for demographic characteristics, laboratory levels, and HF severity, higher hs‐cTnT and BNP levels were significantly associated with lower physical function (log hs‐cTnT, β = −0.162, P = 0.001, for maximal QIS; β = −0.175, P = 0.002, for usual gait speed, and β = −0.129, P = 0.004, for 6MWD; log BNP, β = −0.090, P = 0.092, for maximal QIS, β = 0.038, P = 0.516, for usual gait speed, and β = −0.108, P = 0.023, for 6MWD). In addition, the high hs‐cTnT and high BNP group had significantly lower physical function (all P < 0.05) than the low hs‐cTnT and low BNP group. Conclusions: Higher hs‐cTnT and BNP levels are both associated with lower physical function in patients with HF, but hs‐cTnT levels showed a more consistent association. The combination of hs‐cTnT and BNP may be effective for the stratification of physical function in patients with HF. [ABSTRACT FROM AUTHOR]

Background: Prediction of atrioventricular block (AVB) resolution after steroid therapy in patients with cardiac sarcoidosis (CS) is difficult. Methods: We identified 24 patients with CS and complete or advanced AVB receiving steroid therapy. AVB resolution was assessed by reviewing surface electrocardiogram and the percentage of ventricular pacing required on subsequent device interrogation reports. Results: AVB resolution was noted in eight (33%) patients 1 year after receiving steroid therapy. Univariate Cox regression analysis demonstrated that left ventricular ejection fraction (LVEF) (hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.01‐1.14, P =.016), interval from recognized AVB to start of steroid therapy (HR 0.98, 95% CI 0.95‐0.99, P <.001), and lysozyme (HR 1.51, 95% CI 1.12‐2.19, P =.013) were significantly associated with resolution of AVB. Combination of area under the curve (AUC) of each variable that was significantly related to resolution of AVB (AUC, 0.969; 95% CI 0.921‐1.000, P <.001) was tended to be higher compared with each variable alone. Conclusions: A shorter interval from recognition of AVB to start of steroid therapy, higher LVEF, and higher lysozyme levels were significantly associated with resolution of AVB after steroid therapy in patients with CS. The combination of each variable could be able to distinguish patients with resolution of AVB from those without. [ABSTRACT FROM AUTHOR]

Background: Although the lesion size index (LSI) has been well established, it is sometimes difficult to achieve first‐pass pulmonary vein isolation (PVI) and to avoid acute pulmonary vein reconnections, even with LSI‐guided procedures. The purpose of this study was to assess the predictive accuracy of a novel parameter, the optimized lesion size index (o‐LSI), to perform PVI. Methods: The voltage maps created by the Advisor™ high‐density (HD) grid catheter before PVI in 35 atrial fibrillation (AF) patients were examined for an association between the voltage amplitude and insufficient ablation sites (IAS), which were defined as either (i) spontaneous reconnection sites, (ii) dormant PV conduction sites unmasked with 20 mg of adenosine triphosphate disodium hydrate (ATP) injection, or (iii) PV‐LA gap sites after the initial PVI. Results: IAS was observed in 25/1417 of the total ablation sites. IAS was significantly associated with higher bipolar voltage areas (4.20 ± 2.68 vs 2.43 ± 1.93 mV, P <.0001) but not with LSI. A novel index, o‐LSI (defined as LSI/bipolar voltage), was significantly lower in IAS than in others (1.14 [0.82, 1.81] vs 2.35 [1.31, 4.80] LSI/mV). By receiver operating characteristic analysis, an o‐LSI of 2.04 was the best cutoff value for the prediction of IAS (88% sensitivity and 55% specificity, P <.0001, areas under the curve: 0.742). Conclusion: Low o‐LSI was strongly associated with IAS, potentially providing a novel index to improve first‐pass PV isolation. [ABSTRACT FROM AUTHOR]

Background: Right ventricular (RV) pacing causes left ventricular (LV) dyssynchrony sometimes resulting in pacing‐induced cardiomyopathy. However, RV pacing for hypertrophic obstructive cardiomyopathy is one of the treatment options. LV flow energy loss (EL) using vector flow mapping (VFM) is a novel hemodynamic index for assessing cardiac function. Our study aimed to elucidate the impact of RV pacing on EL in normal LV function and hypertrophic cardiomyopathy (HCM) patients. Methods: A total of 36 patients with dual‐chamber pacemakers for sick sinus syndrome or implantable cardioverter defibrillators for fatal ventricular tachyarrhythmias were enrolled. All patients were divided into two groups: 16 patients with HCM (HCM group) and others (non‐HCM group). The absolute changes in EL under AAI (without RV pacing) and DDD (with RV pacing) modes were assessed using VFM on color Doppler echocardiography. Results: In the non‐HCM group, the mean systolic EL significantly increased from the AAI to DDD modes (14.0 ± 7.7 to 17.0 ± 8.6 mW/m, P =.003), whereas the mean diastolic EL did not change (19.0 ± 12.3 to 17.0 ± 14.8 mW/m, P =.231). In the HCM group, the mean systolic EL significantly decreased from the AAI to DDD modes (26.7 ± 14.2 to 21.6 ± 11.9 mW/m, P <.001), whereas the mean diastolic EL did not change (28.7 ± 16.4 to 23.9 ± 19.7 mW/m, P =.130). Conclusions: RV pacing increased the mean systolic EL in patients without HCM. Conversely, RV pacing decreased the mean systolic EL in patients with HCM. [ABSTRACT FROM AUTHOR]

Aims: This study aimed to evaluate the clinical parameters including late gadolinium enhancement (LGE) of cardiovascular magnetic resonance to predict re‐worsening of left ventricular ejection fraction (LVEF) in patients with dilated cardiomyopathy (DCM). Methods and results: We included 138 patients with recent‐onset DCM who had an LVEF <45% and underwent LGE of cardiovascular magnetic resonance imaging at diagnosis and echocardiography at the yearly follow‐up [median 6 (4–8.3) years]. Initial LVEF recovery was defined as LVEF increase >10% from baseline, resulting in LVEF ≧45% after treatment. The patients were divided into three groups: (i) improved (n = 83, 60%), defined as those with sustained LVEF ≧45%; (ii) re‐worsening (n = 39, 28%), those with >5% decrease and LVEF <45% after the initial LVEF recovery; and (iii) not‐improved (n = 16, 12%), those without initial LVEF recovery. The primary endpoint was a composite of hospitalization for heart failure or sudden cardiac death. In baseline, LGE was observed in 70 patients. The LGE area was significantly larger in the re‐worsening and not‐improved groups than that in the improved group (P < 0.001). Loess curves of long‐term LVEF trajectories showed that LVEF in the re‐worsening group increased in the first 2 years and slowly declined thereafter. Multivariate logistic regression analysis demonstrated that LGE area [odds ratio (OR) 1.09, 95% confidence interval (CI) 1.03–1.16, P = 0.004], B‐type natriuretic peptide (OR 1.49, 95% CI 1.05–2.21, P = 0.030) level at the initial recovery, and LVEF (OR 0.91, 95% CI 0.86–0.97, P = 0.004) at the initial LVEF recovery were independent predictors of re‐worsening of LVEF. During a median follow‐up of 2273 (interquartile range: 1634–3191) days, the primary endpoint was observed in 31 (22%) patients. Univariate Cox proportional hazards analysis demonstrated that the risk of experiencing the primary event in the re‐worsening group was significantly higher (hazard ratio: 4.30, 95% CI 1.63–11.31, P = 0.003) than that in the improved group and was lower than that in the not‐improved group (hazard ratio: 0.33, 95% CI 0.15–0.72, P = 0.006). Conclusions: Re‐worsening of LVEF was observed in 28% of patients with recent‐onset DCM who showed an initial improvement in LVEF. High LGE burden, higher B‐type natriuretic peptide level, and lower LVEF at the initial LVEF recovery were independent predictors of re‐worsening of LVEF in patients with DCM. Careful observation is recommended for patients with a high risk for re‐worsening of LVEF, even in those with an initial LVEF recovery. [ABSTRACT FROM AUTHOR]

Aims: The area of the pupil can be used as an indicator of autonomic function. However, the relation between pupil area and prognosis in heart failure (HF) patients remains unclear. This study was performed to examine whether pupil area can be used as a prognostic indicator in patients with HF. Methods and results: This retrospective review was performed in 870 consecutive patients (mean age: 67.0 ± 14.1 years, 37.0% women) hospitalized for acute HF. Pupil area was measured with a pupilometer at least 7 days after hospitalization for HF. The primary endpoint was all‐cause mortality, and the secondary endpoint was readmission due to HF. A total of 131 patients died, and 328 patients were readmitted because of HF over a median follow‐up of 1.9 (interquartile range: 1.0–3.7 years) years. After adjustment for several pre‐existing prognostic factors, including Seattle Heart Failure Score (SHFS), pupil area was shown to be independently associated with all‐cause mortality (hazard ratio: 0.72; 95% confidence interval: 0.59–0.88; P = 0.001) and readmission due to HF (hazard ratio: 0.82; 95% confidence interval: 0.73–0.93; P = 0.003). Addition of pupil area to SHFS significantly increased the area under the receiver‐operating characteristic curve for all‐cause mortality (0.69 vs. 0.72, respectively; P = 0.034). Conclusions: Pupil area is an independent predictor of all‐cause mortality and readmission due to HF and adds prognostic information to SHFS in patients with HF. The results presented here suggest that pupil area may be useful as a prognostic marker in patients with HF. [ABSTRACT FROM AUTHOR]

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. Respiratory muscle weakness is often detected in patients with chronic heart failure (CHF). During exercise, we demonstrate that respiratory muscle weakness is associated with increased dead‐space ventilation ratio and higher ventilation–perfusion mismatch. Our findings indicate that respiratory muscle weakness complicates CHF; possibly causing abnormal ventilation during exercise. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Esophageal injury is a major concern during catheter ablation of atrial fibrillation. Operators avoid radiofrequency applications on the esophagus by changing ablation line; however, it is unavoidable in patients with a dilated esophagus, such as esophageal achalasia. Steerable esophageal thermometer is useful for evaluating precise temperatures to prevent esophageal injury. [ABSTRACT FROM AUTHOR]

Background Cardiac troponin T (cTnT) has been reported to be associated with cardiac mortality. In the present study, we evaluated the role of routine assessment of cTnT as a predictor of future cardiac death in patients with left ventricular (LV) dysfunction. Methods Patients who were eligible for prophylactic implantable cardioverter defibrillator (ICD) were included from cardiac catheterization database. Inclusion criteria were patients with LV ejection fraction of ≤ 35% and with New York Heart Association (NYHA) ≥class II. Exclusion criteria were patients with acute coronary syndrome, ICD for secondary prevention, NYHA class IV, and lack of data. The final study patients were divided into the following three groups in accordance with two quartile points of serum cTnT levels: low cTnT, intermediate cTnT, and high cTnT groups. The primary endpoint of this study was cardiac death. Results A total of 70 patients were included (mean age, 62±13 years; male individuals, 56; ischemic, 36; and non-ischemic, 34). During the observation period of 2.2 years, cardiac death was observed in 17 patients (fatal arrhythmic event, 9; heart failure, 7; myocardial infarction, 1). In the Kaplan–Meier analysis, the high cTnT group showed the highest risk among all the groups ( p <0.001). Even in sub-analyses for ischemic and non-ischemic patients, the results were the same, and the high cTnT group showed the highest event rate ( p <0.05). In contrast, no cardiac death was observed in the low cTnT group. Conclusion The cTnT levels in a stable state were associated with cardiac death in patients with LV dysfunction, even in those with non-ischemic diseases. [ABSTRACT FROM AUTHOR]

A seventy year-old male was referred to our hospital to undergo radiofrequency catheter ablation (RFCA) for drug-refractory paroxysmal atrial fibrillation (AF). Pre-operative three-dimensional computed tomography revealed a unique left atrial (LA) roof vein. Electrophysiological findings showed expansion of the myocardial sleeve and local firing in the LA roof vein. We performed isolation of this arrhythmogenic abnormal vein concomitant with general pulmonary vein isolation in this case, and AF did not recur after the procedure. [ABSTRACT FROM AUTHOR]

Key Clinical Message Major aortopulmonary collateral arteries branching from coronary arteries may cause coronary steal. The careful follow-up is needed irrespective of symptoms because increasing physical activities and oxygen demand along with the age may induce myocardial ischemia. Transcatheter intervention by well-trained physician would be a treatment option in patients with myocardial ischemia. [ABSTRACT FROM AUTHOR]

A 57‐year‐old man was admitted to our hospital due to syncopal attack. He was diagnosed with Brugada syndrome due to which a subcutaneous implantable cardiac defibrillator (S‐ICD) was inserted using the standard technique. Two hours after the implantation, he experienced inappropriate shock while conscious. Device interrogation revealed a contentious baseline shift and frequent oversensing of low‐amplitude signals, which was followed by a shock. Lateral chest X‐ray revealed subcutaneous air surrounding the proximal electrode. Another inappropriate shock could be avoided by changing the sensing vector. The subcutaneous air was completely resolved 7 days after implantation. [ABSTRACT FROM AUTHOR]

Ventricular capture management is an automatic pacing threshold adjustment algorithm that automatically measures pacing threshold through detection of the evoked response after a pacing stimulus. Although it is principally designed to save device battery under the maintenance of the patient׳s safety, we experienced a rare case with serious pacing failure due to a weakness of this algorithm. This pacing failure might be explained by a large variation in the ventricular pacing threshold depending on the atrioventricular interval and daily variation of pacing threshold and concomitant steroid use in this patient. [ABSTRACT FROM AUTHOR]

Pneumothorax contralateral to the venous access site due to the right atrial lead is an uncommon complication. Concomitant steroid use is known as a risk factor of pacemaker lead perforation. We report a rare case of subacute contralateral pneumothorax due to a screw-in atrial lead perforation that occurred after dual-chamber pacemaker implantation in a patient who was receiving steroid therapy. The pneumothorax disappeared, and no recurrence was observed during follow-up with close observation alone. [ABSTRACT FROM AUTHOR]

Aim: To evaluate long-term, multiple risk factor intervention on physical, psychological and mental prognosis, and development of complications and cardiovascular disease in elderly type 2 diabetes patients. Methods: Our randomized, controlled, multicenter, prospective intervention trial included 1173 elderly type 2 diabetes patients who were enrolled from 39 Japanese institutions and randomized to an intensive or conservative treatment group. Glycemic control, dyslipidemia, hypertension, obesity, diabetic complications and atherosclerotic disease were measured annually. Instrumental activity of daily living, cognitive impairment, depressive symptoms and diabetes burden were assessed at baseline and 3 years. Results: There was no significant difference in clinical or cognitive parameters at baseline between the two groups. The prevalence of low activities of daily living, depressive symptoms and cognitive impairment was 13%, 28% and 4%, respectively, and was similar in the two groups. A small, but significant difference in HbA1c between the two groups was observed at 1 year after the start of intervention (7.9% vs 8.1%, P < 0.05), although this significant difference was not observed after the second year. With the exception of coronary revascularization, there was no significant difference in fatal or non-fatal events between the two groups. Composite events were also similar in the two groups. Conclusions: This study showed no significant differences in fatal or non-fatal events between intensive and conventional treatment. The present study might clarify whether treatment of risk factors influences function and quality of life in elderly diabetic patients. Geriatr Gerontol Int 2012; 12 (Suppl. 1): 7-17. [ABSTRACT FROM AUTHOR]

Aims: To evaluate the association of low-density lipoprotein, high-density lipoprotein and non-high-density lipoprotein cholesterol with the risk of stroke, diabetes-related vascular events and mortality in elderly diabetes patients. Methods: This study was carried out as a post-hoc landmark analysis of a randomized, controlled, multicenter, prospective intervention trial. We included 1173 elderly type 2 diabetes patients (aged ≥65 years) from 39 Japanese institutions who were enrolled in the Japanese elderly diabetes intervention trial study and who could be followed up for 1 year. A landmark survival analysis was carried out in which follow up was set to start 1 year after the initial time of entry. Results: During 6 years of follow up, there were 38 cardiovascular events, 50 strokes, 21 diabetes-related deaths and 113 diabetes-related events. High low-density lipoprotein cholesterol was associated with incident cardiovascular events, and high glycated hemoglobin was associated with strokes. After adjustment for possible covariables, non-high-density lipoprotein cholesterol showed a significant association with increased risk of stroke, diabetes-related mortality and total events. The adjusted hazard ratios (95% confidence intervals) of non-high-density lipoprotein cholesterol were 1.010 (1.001-1.018, P = 0.029) for stroke, 1.019 (1.007-1.031, P < 0.001) for diabetes-related death and 1.008 (1.002-1.014; P < 0.001) for total diabetes-related events. Conclusions: Higher non-high-density lipoprotein cholesterol was associated with an increased risk of stroke, diabetes-related mortality and total events in elderly diabetes patients. Geriatr Gerontol Int 2012; 12 (Suppl. 1): 18-28. [ABSTRACT FROM AUTHOR]

The wearable cardioverter-defibrillator (WCD) represents an alternative clinical approach to prevent sudden cardiac death as a bridge to therapy when making a final decision regarding the need for an implantable cardioverter defibrillator (ICD), especially in patients who are in the so-called gray zone according to ICD guidelines. Although the WCD system was introduced in Japan in April 2014, data regarding its usage and experience are limited. We report the first case of appropriate shock therapy using the WCD in an outpatient setting in Japan. We describe the case of a 22-year-old-woman who received the first case of successful appropriate WCD shock therapy in an outpatient setting in Japan. [ABSTRACT FROM AUTHOR]

An emotionally-distressed, elderly Caucasian woman presented with chest pain and hypertension. Electrocardiogram showed inferior ST-segment elevation, and an urgent cardiac catheterization was performed. Coronary angiography revealed normal appearing coronary arteries; however, left ventriculography showed extensive left ventricular apical akinesis. The patient had a mild rise in cardiac enzyme levels indicative of myocardial injury. She was discharged after an uncomplicated in-hospital course. One month later, the left ventricular wall motion abnormality had improved. In this report, the authors discuss this compilation of findings known as tako-tsubo-like left ventricular dysfunction. [ABSTRACT FROM AUTHOR]

Abstract It is known that autonomic nervous activities change in correspondence with sleep stages. However, the characteristics of continuous fluctuations in nocturnal autonomic nerve tone have not been clarified in detail. The study aimed to determine the possible correlation between the electroencephalogram (EEG) and autonomic nervous activities, and to clarify in detail the nocturnal fluctuations in autonomic nerve activities. Overnight EEGs and electrocardiograms of seven healthy males were obtained. These EEGs were analyzed by fast Fourier transformation algorithm to extract delta, sigma and beta power. Heart rate and heart rate variability (HRV) were calculated in consecutive 5-min epochs. The HRV indices of low frequency (LF), high frequency (HF) and LF/HF ratio were calculated from the spectral analysis of R-R intervals. The sleep stages were manually scored according to Rechtschaffen and Kales’ criteria. Low frequency and LF/HF were significantly lower during non-rapid eye movement (NREM) than REM, and were lower in stages 3 and 4 than in stages 1 and 2. Furthermore, delta EEG showed inverse correlations with LF (r = - 0.44, P < 0.001) and LF/HF ( r = - 0.41, P < 0.001). In contrast, HF differed neither between REM and NREM nor among NREM sleep stages. Detailed analysis revealed that correlation was evident from the first to third NREM, but not in the fourth and fifth NREM. Delta EEG power showed negative correlations with LF and LF/HF, suggesting that sympathetic nervous activities continuously fluctuate in accordance with sleep deepening and lightening. [ABSTRACT FROM AUTHOR]

A case of yellow nail syndrome is described. Yellow nail syndrome is an uncommon disorder, which is characterized by the triad of slow-growing yellow nails, peripheral edema, and pleural effusions. An 80-year-old man was admitted to University of Tokyo Hospital for the evaluation of pretibial edema lasting over 35 years. Marked bilateral pretibial edema, discoloration of the nails, and onycholysis were noted on physical examination. Chest X-ray showed pleural effusions. The biopsy of the skin revealed ectatic lymph vessels with peripheral interstitial edema. Thorough examination should be emphasized in treating patients with unexplained peripheral edema or pleural effusions. [ABSTRACT FROM AUTHOR]

A case of senile cardiac amyloidosis with recurrent episodes of congestive heart failure is reported here. An 83-year-old woman with a history of hypertension was admitted for the treatment of worsening dyspnea. The echocardiography revealed diffuse mild hypokinesis of the left ventricle with an ejection fraction of 46%. An elevated E wave and shortened deceleration time in the left ventricular inflow waveform was demonstrated with Doppler echocardiography, which suggested that the nature of the heart failure was restrictive. The patient required hospitalization for the treatment of congestive heart failure four times in 2 years. An autopsy revealed deposition of prealbumin-positive amyloid substance in the atrial myocardium and the intramyocardial arterioles of the left ventricle. Recurrent congestive heart failure was presumed to be a result of diastolic dysfunction due to senile cardiac amyloidosis. [ABSTRACT FROM AUTHOR]

The article presents a 87-year-old male, who had undergone cavotricuspid isthmus linear ablation for common atrial flutter (AFL), and was referred to hospital for the treatment of sustained AFL., and mentions that tachycardia was terminated by a single application of radiofrequency ablation.

Background and Objectives: Second‐generation drug‐eluting stents (G2‐DES) are associated with a lower rate of acute and subacute stent thrombosis compared with bare‐metal stent (BMS) in the setting of ST‐segment elevation myocardial infarction (STEMI). In this study, our aim was to compare the vascular response and thrombus burden between G2‐DES and BMS in early‐phase STEMI. Methods: Between May 2010 and August 2014, a total of 41 STEMI patients treated by either G2‐DES (n = 26; everolimus‐eluting stent [EES]: n = 15, zotarolimus‐eluting stent [ZES]: n = 11) or BMS (n = 15) and, with multivessel disease requiring additional percutaneous coronary intervention (PCI), were prospectively enrolled. Optical coherence tomography (OCT) imaging was performed at 1 month after stent implantation. Results: Baseline clinical characteristics, except for age (61.5 ± 9.3 vs 69.3 ± 9.8, P = 0.01, t test), were comparable between patients with drug‐eluting stent (DES) and BMS. The incidence of residual thrombus after the stent implantation for STEMI was comparable between DES and BMS (7.7% vs 6.7%, P = 0.88, χ2 test). At 1 month, thrombus burden, defined as the mean thrombus area divided by the mean lumen area, was significantly smaller with DES than with BMS (median interquartile range (IQR), 1.2 (0.0, 1.0) vs 1.2 (0.0, 2.2), P = 0.04, Mann‐Whitney U test), despite a similar percentage of malapposed (median (IQR), 6.2 (2.4, 9.0) vs 2.6 (0.0, 5.8)%, P = 0.07, Mann‐Whitney U test) or uncovered struts (median (IQR), 6.8 (1.8, 13.1) vs 6.14 (2.8, 18.5)%, P = 0.45, Mann‐Whitney U test). No significant difference in thrombus burden was observed between EES and ZES. Conclusions: Thrombus burden was significantly smaller with DES than with BMS at 1‐month follow‐up in STEMI cases, although the percentage of malapposed or uncovered struts was similar between the groups. This may partly explain the lower rate of acute and subacute stent thrombosis in G2‐DES that has previously been reported in the literature. [ABSTRACT FROM AUTHOR]

A 77-year-old woman, who had suffered from osteoporosis with compression fractures of vertebrae, was admitted to our hospital because of increasing bone pain. She had anemia and monocytosis, and was diagnosed as chronic myelomonocytic leukemia (CMML). Although chemotherapy was initiated, she died from pneumonia. Autopsy revealed multiple tumors composed of megakaryoblastic cells in her bone marrow and extramedullary organs and, therefore, the pathological diagnosis was made as megakaryoblastic transformation of CMML. Severe bone pain was considered to be a symptom of megakaryoblastic transformation of CMML. [ABSTRACT FROM AUTHOR]