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Aims: Renal dysfunction in patients with chronic heart failure predicts a poor prognosis. Tolvaptan has a diuretic effect in patients with chronic kidney disease and heart failure without adverse effects on renal function. We aimed to determine the effects of tolvaptan and predictors of worsening renal function in patients with heart failure., Methods and Results: This post hoc analysis was a sub-analysis of a single-centre prospectively randomized trial on the early and short-term tolvaptan administration. We enrolled 201 participants with decompensated heart failure between January 2014 and March 2019 (early group, n = 104; age: 79.0 ± 12.8 years; late group, n = 97; age: 80.3 ± 10.8 years). Renal ultrasonography was performed before and after the administration of tolvaptan. Urine output and oral water intake significantly increased during tolvaptan administration. The difference between water intake and urine volume increased during tolvaptan administration. Changes in body weight, blood pressure, heart rate, and estimated glomerular filtration rate (eGFR) in both groups were comparable. The changes in peak-systolic velocity (PSV), acceleration time (AT) of the renal arteries, and resistance index were comparable. The changes in PSV and end-diastolic velocity (EDV) of the interlobar arteries increased following tolvaptan administration (Δmax PSV: 0.0 ± 14.8 cm/s before tolvaptan vs. 5.6 ± 15.7 cm/s after tolvaptan, P = 0.002; Δmean PSV: 0.4 ± 12.3 vs. 4.9 ± 12.7 cm/s, P = 0.002; Δmax EDV: -0.2 ± 3.5 vs. 1.4 ± 4.0 cm/s, P = 0.001; Δmean EDV: -0.0 ± 3.1 vs. 1.1 ± 3.4 cm/s, P = 0.003). The renal artery AT was negatively correlated with the eGFR (Δmax AT: beta = -0.2354, P = 0.044; Δmean AT: beta = -0.2477, P = 0.035)., Conclusions: Tolvaptan increased the PSV and EDV of the interlobar artery, which may mean tolvaptan increased renal blood flow. The renal artery AT may be a surrogate for worsening renal function., (© 2024 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Objectives: The authors sought to elucidate the prognostic value of cardiac sympathetic nerve dysfunction as evaluated using iodine-123-labeled metaiodobenzylguanidine ( 123 I-MIBG) single-photon emission computed tomography (SPECT) imaging in patients with heart failure (HF) with preserved left ventricular ejection fraction (HFpEF)., Background: Cardiac sympathetic nerve dysfunction assessed by 123 I-MIBG imaging is associated with poor outcomes in chronic HF patients with reduced left ventricular ejection fraction (HFrEF). However, no information is available on the prognostic vale of cardiac 123 I-MIBG SPECT imaging in patients with HFpEF., Methods: We studied 148 patients admitted for acute decompensated HF (ADHF) with nonischemic HFpEF and who underwent cardiac 123 I-MIBG imaging at discharge. The cardiac 123 I-MIBG heart-to-mediastinum ratio (H/M) was measured on the delayed planar image (late H/M). SPECT analysis of the delayed image was conducted, and the tracer uptake in all 17 regions on the polar map was scored on a 5-point scale by comparison with a sex-matched normal control database. The total defect score (TDS) was calculated by summing the score of each of the 17 segments. The primary endpoint was the association between TDS and cardiac events (the composite of emergent HF hospitalization and cardiac death)., Results: During a mean follow-up period of 2.4 ± 1.6 years, 61 patients experienced cardiac events. TDS was significantly associated with cardiac events after multivariate Cox adjustment (P < 0.0001). Patients with high TDS levels had a significantly greater risk of cardiac events than those with middle or low TDS levels (63% vs 40% vs 20%, respectively; P < 0.0001; HR: 4.69; 95% CI: 2.29 to 9.61; and HR: 2.46; 95% CI: 1.14 to 5.29). C-statistic of TDS was 0.730 (95% CI: 0.651 to 0.799), which was significantly higher than that of late H/M (0.607; 95% CI: 0.524 to 0.686; P = 0.0228)., Conclusions: Cardiac 123 I-MIBG SPECT imaging provided useful prognostic information in nonischemic ADHF patients with HFpEF. (Clinical Trial: Osaka Prefectural Acute Heart Failure Syndrome Registry [OPAR]: UMIN000015246)., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Cardiohepatic interactions have been a focus of attention in heart failure (HF). The model for end-stage liver disease excluding international normalized ratio (MELD-XI) score has been shown to be useful for predicting poor outcomes in patients with acute decompensated HF (ADHF). Furthermore, the fibrosis-4 (FIB-4) index, a simple marker to assess liver fibrosis, predicts adverse prognoses in patients with HF as well. However, there is little information available on the prognostic significance of the combination of the MELD-XI score and FIB-4 index in patients with ADHF and its association with left ventricular ejection fraction (LVEF) subgroup., Methods and Results: We prospectively studied 466 consecutive patients who were admitted for ADHF [HF with reduced LVEF (LVEF < 40%): n = 164, HF with mid-range LVEF (40% ≤ LVEF < 50%): n = 104, and HF with preserved LVEF (LVEF ≥ 50%): n = 198]. We calculated the MELD-XI score and FIB-4 indices at discharge. The primary endpoint was all-cause death (ACD). During the mean follow-up period of 2.8 years, 143 patients had ACD. In the multivariate Cox analysis, the MELD-XI score and FIB-4 index were independently associated with ACD. Patients were stratified into the following three groups according to the median value of MELD-XI score (=11) and FIB-4 index (=2.13): Group 1 had both a low MELD-XI score and a low FIB-4 index; Group 2 had either a high MELD-XI score (MELD-XI score ≥11) or a high FIB-4 index (FIB-4 index ≥2.13); and Group 3 had both a high MELD-XI score and a high FIB-4 index. Kaplan-Meier analysis revealed that Group 2 and Group 3 had a significantly greater risk of ACD than Group 1 [Group 2 vs. Group 1: adjusted hazard ratio, 2.48 (95% confidence interval: 1.75-3.53), P < 0.0001; Group 3 vs. Group 1: adjusted hazard ratio, 7.03 (95% confidence interval: 3.95-13.7), P < 0.0001]. In addition, the patients with both a higher MELD-XI score and FIB-4 index showed a significantly higher risk of ACD also in the patients with HF with reduced LVEF, HF with mid-range LVEF, and HF with preserved LVEF (all P < 0.0001)., Conclusions: The combination of MELD-XI score and FIB-4 index may be useful for stratifying patients at risk for ACD in patients with ADHF, irrespective of LVEF., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Aims: Co-morbidities are associated with poor clinical outcomes in patients with chronic heart failure, while cardiac iodine-123 (I-123) metaiodobenzylguanidine (MIBG) imaging provides prognostic information in such patients. We sought to prospectively investigate the incremental prognostic value of cardiac MIBG imaging over the co-morbid burden, in patients admitted for acute decompensated heart failure (ADHF)., Methods and Results: In 433 consecutive ADHF patients with survival to discharge, we measured the co-morbidity using age-adjusted Charlson co-morbidity index (ACCI), commonly employed to evaluate a weighted and scored co-morbid condition, adding additional points for age. In cardiac MIBG imaging, the cardiac MIBG heart-to-mediastinum ratio (late HMR) was measured on the delayed image. Over a follow-up period of 2.9 ± 1.5 years, 160 patients had a cardiac event (a composite of cardiac death and unplanned hospitalization for worsening heart failure). Patients with high ACCI (≥6: median value) had a significantly greater risk of a cardiac event. In multivariate Cox analysis, the ACCI and late HMR were significantly and independently associated with a cardiac event. In both high and low ACCI subgroups (ACCI ≥ 6 and <6, respectively), patients with low late HMR had a significantly greater risk of a cardiac event (high ACCI: 51% vs. 34% P = 0.0026, adjusted HR 1.74 [1.21-2.51]; low ACCI: 34% vs. 17%, P = 0.0228, adjusted HR 2.19 [1.10-4.37])., Conclusions: Cardiac MIBG imaging could provide additional prognostic information over ACCI, which was also promoted to be a useful risk model, in patients admitted for ADHF., (© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Background: Empagliflozin reduces the risk of hospitalization for heart failure in patients with type 2 diabetes and cardiovascular disease. We sought to elucidate the effect of empagliflozin as an add-on therapy on decongestion and renal function in patients with type 2 diabetes admitted for acute decompensated heart failure., Methods: The study was terminated early due to COVID-19 pandemic. We enrolled 59 consecutive patients with type 2 diabetes admitted for acute decompensated heart failure. Patients were randomly assigned to receive either empagliflozin add-on (n=30) or conventional glucose-lowering therapy (n=29). We performed laboratory tests at baseline and 1, 2, 3, and 7 days after randomization. Percent change in plasma volume between admission and subsequent time points was calculated using the Strauss formula., Results: There were no significant baseline differences in left ventricular ejection fraction and serum NT-proBNP (N-terminal pro-B-type natriuretic peptide), hematocrit, or serum creatinine levels between the 2 groups. Seven days after randomization, NT-proBNP level was significantly lower in the empagliflozin group than in the conventional group ( P =0.040), and hemoconcentration (≥3% absolute increase in hematocrit) was more frequently observed in the empagliflozin group than in the conventional group ( P =0.020). The decrease in percent change in plasma volume between baseline and subsequent time points was significantly larger in the empagliflozin group than in the conventional group 7 days after randomization ( P =0.017). The incidence of worsening renal function (an increase in serum creatinine ≥0.3 mg/dL) did not significantly differ between the 2 groups., Conclusions: In this exploratory analysis, empagliflozin achieved effective decongestion without an increased risk of worsening renal function as an add-on therapy in patients with type 2 diabetes with acute decompensated heart failure. Registration: URL: https://www.umin.ac.jp/ctr/index.htm; Unique identifier: UMIN000026315.

Aims: Cardiac 123I-metaiodobenzylguanidine (123I-MIBG) imaging provides prognostic information in patients with chronic heart failure (HF). However, there is little information available on the prognostic role of cardiac 123I-MIBG imaging in patients admitted for acute decompensated heart failure (ADHF), especially relating to reduced ejection fraction [HFrEF; left ventricular ejection fraction (LVEF) < 40%], mid-range ejection fraction (HFmrEF; 40% ≤ LVEF < 50%) and preserved ejection fraction (HFpEF; LVEF ≥ 50%)., Methods and Results: We studied 349 patients admitted for ADHF and discharged with survival. Cardiac 123I-MIBG imaging, echocardiography, and venous blood sampling were performed just before discharge. The cardiac 123I-MIBG heart-to-mediastinum ratio (late H/M) was measured on the chest anterior view images obtained at 200 min after the isotope injection. The endpoint was cardiac events defined as unplanned HF hospitalization and cardiac death. During a follow-up period of 2.1 ± 1.4 years, 128 patients had cardiac events (45/127 in HFrEF, 28/78 in HFmrEF, and 55/144 in HFpEF). On multivariable Cox analysis, late H/M was significantly associated with cardiac events in overall cohort (P = 0.0038), and in subgroup analysis of each LVEF subgroup (P = 0.0235 in HFrEF, P = 0.0119 in HFmEF and P = 0.0311 in HFpEF). Kaplan-Meier analysis showed that patients with low late H/M (defined by median) had significantly greater risk of cardiac events in overall cohort (49% vs. 25% P < 0.0001) and in each LVEF subgroup (HFrEF: 48% vs. 23% P = 0.0061, HFmrEF: 51% vs. 21% P = 0.0068 and HFpEF: 50% vs. 26% P = 0.0026)., Conclusion: Cardiac sympathetic nerve dysfunction was associated with poor outcome in ADHF patients irrespective of HFrEF, HFmrEF, or HFpEF., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: Acute decompensated heart failure (ADHF) is generally treated by decongestion using diuretic therapy. However, the use of loop diuretics is associated with increased cardiac sympathetic nerve activity (CSNA). We aimed to evaluate the effect of adjunctive tolvaptan therapy on CSNA in ADHF patients with preserved left ventricular ejection fraction (LVEF)., Methods and Results: We enrolled 51 consecutive ADHF patients with LVEF ≥45%. Patients were randomly assigned to receive either tolvaptan add-on (n = 25) or conventional diuretic therapy (n = 26). Cardiac iodine-123 metaiodobenzylguanidine (MIBG) imaging was performed after stabilisation of heart failure symptoms, and the cardiac MIBG heart-to-mediastinum ratio (HMR) and washout rate (WR) were calculated. There were no significant differences in the body weight change and total urine volume during 2 days after randomisation or in the HMR on delayed image (HMR(d)) and WR between the tolvaptan and conventional groups. After stratification based on the median change in body weight, the patients with higher weight reduction had a significantly lower HMR(d) (P = 0.0128) and tended to have a higher WR (P = 0.0786) in the conventional group, whereas the cardiac MIBG imaging results were not influenced by body weight reduction in the tolvaptan group., Conclusions: Adjunctive tolvaptan therapy may provide rapid decongestion without a harmful effect on CSNA in ADHF patients with preserved LVEF., (© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

Background: AdreView myocardial imaging for risk evaluation in heart failure (ADMIRE-HF) risk score is a novel risk score to predict serious arrhythmic risk in chronic heart failure patients with reduced ejection fraction (HFrEF). Moreover, early repolarization pattern (ERP) has been shown to be associated with an increased risk of sudden cardiac death (SCD) in HFrEF patients. We sought to investigate the prognostic value of combining ADMIRE-HF risk score and ERP to predict SCD in HFrEF patients., Methods: We studied 90 HFrEF outpatients with LVEF< 40% in our prospective cohort study. In cardiac MIBG imaging, the heart-to-mediastinum (H/M) ratio was measured on the delayed planar image. ADMIRE-HF risk score was derived from the sum of the point values of LVEF, H/M ratio, and systolic blood pressure. We also assessed ERP on the standard electrocardiogram., Results: During a median follow-up of 7.5(4.5-12.0) years, 22 patients had SCD. At multivariate Cox analysis, ADMIRE-HF risk score and ERP were independently associated with SCD. Patients with both intermediate/high ADMIRE-HF score and ERP had a higher SCD risk than those with either and none of them., Conclusion: The combination of ADMIRE-HF risk score and ERP would provide the incremental prognostic information for predicting SCD in HFrEF patients.

Background: Cardiac metaiodobenzylguanidine (MIBG) imaging provides prognostic information in patients with heart failure (HF). Recent studies showed that the highest rate of ventricular tachyarrhythmias (VTs) is seen in HF patients with an intermediate decrease in MIBG uptake, rather than in those with the lowest values. However, prolonged QRS duration (QRSd) has been shown to be associated with VTs in HF patients. This study assessed the prognostic value of the combination of an intermediate decrease in MIBG uptake and prolonged QRSd for predicting VTs in patients with implantable cardioverter defibrillators (ICDs) in relation to the presence of heart failure (HF)., Methods and Results: A total of 196 outpatients with ICDs (age: 64 ± 14 years, male: 81%, left ventricular ejection fraction [LVEF]: 49% ± 16%) were prospectively enrolled; 135 had HF (NYHA class: 2.0 ± 0.6). At entry, cardiac MIBG imaging was performed, and QRSd was measured on standard 12‑lead electrocardiography. An intermediate decrease in the heart-to-mediastinum ratio on the delayed planar image (ID-H/M) was defined as 1.40-1.89. During the 3.3 ± 2.2-year follow-up, 59 patients had appropriate ICD discharges (ATx) for VTs. On multivariate Cox analysis, ID-H/M and prolonged QRSd (≥147 ms) were significantly and independently associated with ATx. In both patients with and without HF, ATx were significantly more frequent in patients with ID-H/M and/or prolonged QRSd than in those with neither (with HF: 40% vs. 14%, p = 0.020; without HF: 43% vs. 10%, p = 0.0028)., Conclusions: The combination of ID-H/M and prolonged QRSd provided more prognostic information for predicting VTs in ICD patients, with and without HF., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Nutritional status is associated with poor outcomes in patients with heart failure. Serum cholinesterase (CHE) concentration, a marker of malnutrition, was reported to be a prognostic factor in patients with chronic heart failure. The geriatric nutritional risk index (GNRI), the controlling nutritional status (CONUT) score, and the prognostic nutritional index (PNI) are established objective nutritional indices., Objective: The aim of this study was to clarify the prognostic significance of CHE concentration and to compare it with other well-established objective nutritional indices in patients with acute decompensated heart failure (ADHF)., Methods: We prospectively enrolled 371 consecutive patients admitted for ADHF with survival discharge. Laboratory data including CHE and the objective nutritional indices were obtained at discharge. The primary endpoint of this study was all-cause mortality., Results: During a mean ± SD follow-up period of 2.5 ± 1.4 y, 112 patients died. CHE concentration was significantly associated with all-cause mortality independently of GNRI, CONUT score, or PNI, after adjustment for major confounders including other nutritional indices, such as age, sex, systolic blood pressure, BMI, left ventricular ejection fraction, history of hypertension, diabetes mellitus, dyslipidemia, prior heart failure hospitalization, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, β-blocker use, statin use, hemoglobin, sodium, blood urea nitrogen, albumin, C-reactive protein, and brain natriuretic peptide concentrations via multivariable Cox analysis. Kaplan-Meier analysis revealed that the risk of all-cause mortality significantly increased in accordance with CHE stratum [lowest tertile: 53%, adjusted HR: 6.92; 95% CI: 3.87, 12.36, compared with middle tertile: 28%, adjusted HR: 2.72; 95% CI: 1.45, 5.11, compared with highest tertile: 11%, adjusted HR: 1.0 (reference), P < 0.0001]. CHE showed the best area under the curve value (0.745) for the prediction of all-cause mortality compared with the other objective nutritional indices. Net reclassification improvement afforded by adding CHE to the fully adjusted multivariable model was statistically significant for all-cause mortality (0.330; 95% CI: 0.112, 0.549, P = 0.0030)., Conclusion: CHE is a simple, strong prognostic marker for the prediction of all-cause mortality in patients with ADHF., (© American Society for Nutrition 2019.)

Background: The sympathetic nervous system provides an important trigger for major arrhythmic events through regional heterogeneity of sympathetic activity, which could be evaluated by SPECT imaging as the regional MIBG washout rate (WR). There is little information available on the prognostic value of regional WR in SPECT imaging for the prediction of sudden cardiac death (SCD) in patients with chronic heart failure (CHF)., Methods: We studied 73 CHF outpatients with LVEF < 40%. At study entry, the regional WR was measured in 17 segments on the polar map. We defined abnormal regional WR as both the regional WR range (maximum - minimum regional WR) and maximum regional WR > mean value + 2SD obtained in 15 normal controls., Results: During a mean follow-up of 7.5 ± 4.1 years, 15 of 73 patients had SCD. The abnormal regional WR and abnormal global WR on planar images were significantly and independently associated with SCD. Patients with both the abnormal regional WR and global WR had a significantly higher risk of SCD than those with none of these criteria., Conclusions: The analysis of regional MIBG WR on SPECT imaging provides additional prognostic value to global WR on planar images for SCD prediction in CHF patients.

Background: Although hyponatremia predicts morbidity and mortality in acute decompensated heart failure (ADHF), hypochloremia is also independently associated with poor prognosis in ADHF. Little is known, however, about the prognostic value of serial change in serum chloride during hospitalization in ADHF patients., Methods and results: We prospectively studied 208 ADHF survivors after discharge and divided them into 4 groups according to serum chloride on admission and at discharge: (1) persistent hypochloremia group (n=12), hypochloremia both on admission and at discharge; (2) progressive hypochloremia group (n=42), development of hypochloremia after admission; (3) improved hypochloremia group (n=14), hypochloremia only on admission; and (4) no hypochloremia group, no hypochloremia during hospitalization (n=140). During a mean follow-up period of 1.86±0.76 years, 20 of 208 patients had heart failure death (HFD). In a model adjusted for hyponatremia, hypochloremia both on admission and at discharge was still significantly associated with HFD. Hyponatremia, however, was not significantly associated with HFD after adjustment for hypochloremia. Patients with persistent hypochloremia (HR, 9.13; 95% CI: 2.56-32.55) and with progressive hypochloremia (HR, 4.65; 95% CI: 1.61-13.4) had a significantly greater risk of HFD than those without hypochloremia during hospitalization., Conclusions: Both persistent hypochloremia and progressive hypochloremia during hospitalization are associated with HFD in ADHF patients.

Background: Although the mainstay of treatment for acute decompensated heart failure (ADHF) is decongestion by diuretic therapy, it is often associated with worsening renal function (WRF). The effect of tolvaptan, a selective V2 receptor antagonist, on WRF in ADHF patients with preserved left ventricular ejection fraction (LVEF) is unknown.Methods and Results:We enrolled 50 consecutive ADHF patients whose LVEF on admission was ≥45%. Patients were randomly assigned to either tolvaptan add-on (n=26) or conventional diuretic therapy (n=24). The primary endpoint was the incidence of WRF, defined as an increase in serum creatinine (Cr) ≥0.3 mg/dL or 50% above baseline within 48 h of randomization. There was no significant difference between the 2 groups in the change in body weight or the total urine volume during 48 h. However, the change in Cr (∆Cr) at 24 and 48 h after randomization and the incidence of WRF (12% vs. 42%, P=0.0236) were significantly lower, and the fractional excretion of urea (FEUN) at 24 and 48 h after randomization was significantly higher in the tolvaptan group. There was an inverse correlation between ∆Cr and FEUN at 48 h after randomization., Conclusions: Tolvaptan can alleviate congestion with a significantly lower risk of WRF in ADHF patients with preserved LVEF, presumably through maintenance of renal perfusion.

The CHADS 2 score is useful in stratifying the risk of ischemic stroke or transient ischemic attack (TIA) in patients with non-valvular atrial fibrillation (AF). However, it remains unclear whether the CHADS 2 score could predict stroke or TIA in chronic heart failure (CHF) patients without AF. Recently, the new stroke risk score was proposed from 2 contemporary heart failure trials. We evaluated the prognostic power of the CHADS 2 score for stroke or TIA in CHF patients without AF in comparison to the "stroke risk score". We retrospectively studied 127 CHF patients [left ventricular ejection fraction (LVEF) <40 %] without AF, who had been enrolled in our previous prospective cohort study. The primary endpoint was the incidence of stroke or TIA. The mean baseline CHADS 2 score was 2.1 ± 1.0. During the follow-up period of 8.4 ± 5.1 years, stroke or TIA occurred in 21 of 127 patients. At multivariate Cox analysis, CHADS 2 score (C-index 0.794), but not "stroke risk score" (C-index 0.625), was significantly and independently associated with stroke or TIA. The incidence of stroke or TIA appeared to increase in relation to the CHADS 2 score [low (=1), 0 per 100 person-years; intermediate (=2), 1.6 per 100 person-years; high (≥3), 4.7 per 100 person-years; p = 0.04]. CHADS 2 score could stratify the risk of ischemic stroke in CHF patients with the absence of AF, with greater prognostic power than the "stroke risk score".

Liver dysfunction has a prognostic impact on the outcomes of patients with advanced heart failure (HF). The model for end-stage liver disease (MELD) score is a robust system for rating liver dysfunction, and a high score has been shown to be associated with a poor prognosis in ambulatory patients with HF. In addition, cardiac metaiodobenzylguanidine (MIBG) imaging provides prognostic information in patients with chronic HF (CHF). However, the long-term predictive value of combining the MELD score and cardiac MIBG imaging in patients with CHF has not been elucidated. To prospectively investigate whether cardiac MIBG imaging provides additional prognostic value to the MELD score in patients with mild-to-moderate CHF, we studied 109 CHF outpatients (New York Heart Association: 2.0 ± 0.6) with left ventricular ejection fraction <40%. At enrollment, an MELD score was obtained, and the heart-to-mediastinal ratio on delayed imaging and MIBG washout rate (WR) were measured using cardiac MIBG scintigraphy. During a follow-up period of 7.5 ± 4.2 years, 36 of 109 patients experienced cardiac death (CD). On multivariate Cox analysis, MELD score and WR were significantly independently associated with CD, although heart-to-mediastinal ratio showed an association with CD only on univariate Cox analysis. Patients with abnormal WR (>27%) had a significantly greater risk of CD than those with normal WR in both those with high MELD scores (≥10; hazard ratio 4.0 [1.2 to 13.6]) and with low MELD scores (<10; hazard ratio 6.4 [1.7 to 23.2]). In conclusion, cardiac MIBG imaging would provide additional prognostic information to the MELD score in patients with mild-to-moderate CHF., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Patients with chronic heart failure (CHF) at risk of sudden cardiac death (SCD) are often treated with implantable cardiac defibrillators (ICDs). However, current criteria for device use that is based largely on left ventricular ejection fraction (LVEF) lead to many patients receiving ICDs that never deliver therapy. It is of clinical significance to identify patients who do not require ICDs. Although cardiac I-123 meta-iodobenzylguanidine (MIBG) imaging provides prognostic information about CHF, whether it can identify patients with CHF who do not require an ICD remains unclear. We studied 81 patients with CHF and LVEF <35%, assessed by cardiac MIBG imaging at enrollment. The heart-to-mediastinal ratio (H/M) in delayed images and washout rates were divided into 6 grades from 0 to 5, according to the degree of deviation from control values. The study patients were classified into 3 groups: low (1 to 4), intermediate (5 to 7), and high (8 to 10), according to the MIBG scores defined as the sum of the H/M and washout rate scores. Sixteen patients died of SCD during a follow-up period. Patients with low MIBG score had a significantly lower risk of SCD than those with intermediate and high scores (low [n = 19], 0%; intermediate [n = 37], 19%; high [n = 25], 36%; p = 0.001). The positive predictive value of low MIBG score for identifying patients without SCD was 100%. In conclusion, the MIBG score can identify patients with CHF and LVEF <35% who have low risk of developing SCD., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Identification of patients with chronic heart failure (CHF) at a risk for sudden cardiac death (SCD) is an important objective. Early repolarization pattern (ERP) is associated with ventricular fibrillation in patients without structural heart diseases. Moreover, ERP was reported to be associated with SCD in patients with old myocardial infarction in a case-control study. However, little information is available on the prognostic significance of ERP in CHF patients. Thus, we aimed to investigate whether ERP is associated with SCD in CHF patients., Methods and Results: The study population consisted of 132 consecutive outpatients with NYHA class I, II and III congestive heart failure and radionuclide left ventricular ejection fraction less than 40%. All patients underwent the standard 12-lead electrocardiogram at enrollment, where we assessed the presence of ERP using the criteria of J-point elevation ≥ 0.1 mV in at least 2 inferior or lateral leads. The primary endpoint of this study was SCD. At enrollment, 16 patients had ERP. During the follow-up period of 6.7 ± 3.5 years, 26 patients had SCD. Kaplan-Meier analysis showed that SCD was observed significantly more frequently in patients with ERP than in those without ERP (63% [10/16] vs 14% [16/116], P < 0.0001]. A multivariate Cox analysis revealed that ERP was significantly and independently associated with SCD (hazard ratio, 3.7; 95% confidence interval, 1.6-8.6; P = 0.002)., Conclusion: ERP in inferior leads would be associated with an increased risk of SCD in CHF patients., (© 2013 Wiley Periodicals, Inc.)

The Seattle Heart Failure Model (SHFM) is a validated prediction model that estimates the mortality in patients with chronic heart failure (CHF) using commonly obtained information, including clinical data, laboratory test results, medication use, and device implantation. In addition, cardiac iodine-123 meta-iodobenzylguanidine (MIBG) imaging provides prognostic information for patients with CHF. However, the long-term predictive value of combining the SHFM and cardiac MIBG imaging in patients with CHF has not been elucidated. To prospectively investigate whether cardiac iodine-123 MIBG imaging provides additional prognostic value to the SHFM in patients with CHF, we studied 106 outpatients with CHF who had radionuclide left ventricular ejection fraction < 40% (30 ± 8%). The SHFM score was obtained at enrollment, and the cardiac MIBG washout rate (WR) was calculated from anterior chest images obtained at 20 and 200 minutes after isotope injection. During a mean follow-up of 6.8 ± 3.5 years (range 0 to 13), 32 of 106 patients died from cardiac causes. A multivariate Cox analysis revealed that the WR (p = 0.0002) and SHFM score (p = 0.0091) were independent predictors of cardiac death. Kaplan-Meier analysis showed that patients with an abnormal WR (> 27%) had a significantly greater risk of cardiac death than did those with a normal WR for both those with a SHFM score of ≥ 1 (relative risk 3.3, 95% confidence interval 1.2 to 9.7, p = 0.01) and a SHFM score of ≤ 0 (relative risk 3.4, 95% confidence interval 1.2 to 9.6, p = 0.004). In conclusion, the cardiac MIBG WR provided additional prognostic information to the SHFM score for patients with CHF., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Aims Cardiac 123I-metaiodobenzylguanidine (123I-MIBG) imaging provides prognostic information in patients with chronic heart failure (HF). However, there is little information available on the prognostic role of cardiac 123I-MIBG imaging in patients admitted for acute decompensated heart failure (ADHF), especially relating to reduced ejection fraction [HFrEF; left ventricular ejection fraction (LVEF) < 40%], mid-range ejection fraction (HFmrEF; 40% ≤ LVEF < 50%) and preserved ejection fraction (HFpEF; LVEF ≥ 50%). Methods and results We studied 349 patients admitted for ADHF and discharged with survival. Cardiac 123I-MIBG imaging, echocardiography, and venous blood sampling were performed just before discharge. The cardiac 123I-MIBG heart-to-mediastinum ratio (late H/M) was measured on the chest anterior view images obtained at 200 min after the isotope injection. The endpoint was cardiac events defined as unplanned HF hospitalization and cardiac death. During a follow-up period of 2.1 ± 1.4 years, 128 patients had cardiac events (45/127 in HFrEF, 28/78 in HFmrEF, and 55/144 in HFpEF). On multivariable Cox analysis, late H/M was significantly associated with cardiac events in overall cohort (P = 0.0038), and in subgroup analysis of each LVEF subgroup (P = 0.0235 in HFrEF, P = 0.0119 in HFmEF and P = 0.0311 in HFpEF). Kaplan–Meier analysis showed that patients with low late H/M (defined by median) had significantly greater risk of cardiac events in overall cohort (49% vs. 25% P < 0.0001) and in each LVEF subgroup (HFrEF: 48% vs. 23% P = 0.0061, HFmrEF: 51% vs. 21% P = 0.0068 and HFpEF: 50% vs. 26% P = 0.0026). Conclusion Cardiac sympathetic nerve dysfunction was associated with poor outcome in ADHF patients irrespective of HFrEF, HFmrEF, or HFpEF. [ABSTRACT FROM AUTHOR]

Backgrounds: Systemic inflammation plays a critical role in the outcomes of heart failure. Malnutrition is also associated with poor outcome in heart failure patients. It has recently been reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index х serum albumin / neutrophil to lymphocyte ratio (NLR), is an independent prognostic marker in several types of cancer. However, there is no information available on the prognostic impact of ALI in patients admitted with acute decompensated heart failure (ADHF), especially in comparison with NLR. Methods and Results: We studied 263 ADHF patients discharged with survival. At the discharge, we measured NLR and obtained ALI. During a follow up period of 5.1±4.3 yrs, 67 patients had cardiovascular death (CVD). ALI was significantly smaller in patients with than without CVD (32.5±18.2 vs 52.2±30.2, p<0.0001). At multivariate Cox analysis, ALI (hazard ratio 0.975[0.961-0.990], p=0.001) was significantly associated with CVD, independently of systolic blood pressure, serum sodium and creatinine levels. By receiver-operator curve analysis, AUC of ALI (0.733 [0.664-0.803]) was significantly (p=0.0175) greater than that of NLR (0.695[0.620-0.769]). Patients with lowest tertile of ALI (<32.0) had a increased risk of mortality than middle tertile (ALI=32.0-53.6; HR 2.06 [1.15-3.71]) and highest tertile (ALI>53.6: HR 5.80 [2.60-12.94]) (48% vs 21% vs 9%, p<0.0001, respectively). Conclusion: ALI, a systemic nutrition-inflammation index, is a more useful prognostic marker than NLR in patients admitted with ADHF. [ABSTRACT FROM AUTHOR]

Backgrounds: Increased heart rate (HR) and low systolic blood pressure (SBP) are associated with adverse clinical outcomes in patients admitted for acute decompensated heart failure (ADHF), and simple risk index (SRI) based on easily assessed clinical characteristics (age, HR, and SBP) provides prognostic information. On the other hand, malnutrition is associated with increased mortality risk in ADHF patients. However, there is no information available on the prognostic value of the combination of SRI and malnutrition in ADHF patients, relating to reduced or preserved left ventricular ejection fraction (HFrEF or HFpEF). Methods and Results: We studied 298 patients admitted for ADHF and discharged alive (HFrEF(LVEF<50%);n=159, HFpEF(LVEF≥50%);n=139)., and obtained clinical characteristics, conventional hemodynamic parameters and laboratory data at the discharge. SRI was calculated as (HRх[age/10]2)/SBP. Nutritional status was assessed by geriatric nutritional risk index (GNRI) calculated as follows: 14.89 · serum albumin (g/dl) + 41.7 · BMI/22, and malnutrition was defined as GNRI<92. During a follow up period of 4.3±3.2 yrs, 93 patients died. At multivariate Cox analysis, SRI and GNRI were significantly independently associated with total mortality, independently of anemia, serum sodium level, renal function and prior heart failure hospitalization, in both HFrEF and HFpEF groups. The patients with both greater SRI (>median value) and malnutrition had a significantly increased risk of total mortality than those with either and none of them, in both HFrEF (60% vs 30% vs 26%, p<0.0001) and HFpEF (34% vs 26% vs 14%, p=0.0004). Conclusion: The combination of SRI and GNRI might be useful for stratifying patients at risk for all-cause death in patients with ADHF, regardless of HFrEF or HFpEF. [ABSTRACT FROM AUTHOR]

Backgrounds: Ventricular-arterial (VA) coupling has been shown to have physiologic importance in heart failure. It has recently been shown that systemic arterial pulsatility index (SAPi = [systemic systolic pressure-systemic diastolic pressure]/pulmonary capillary wedge pressure), a novel index of VA coupling, is associated with adverse clinical outcomes in patients with advanced heart failure. However, there is little information available on the long-term prognostic value of SAPi in patients with acute decompensated heart failure (ADHF), relating to reduced or preserved left ventricular ejection fraction (LVEF). Methods and Results: We studied 240 patients admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival (HFrEF(LVEF≤40%);n=111, HFpEF(LVEF>40%);n=129). SAPi was significantly lower in patients with HFrEF than HFpEF (2.442±1.470 vs 3.706±2.214, p<0.0001). During a mean follow-up period of 5.4±4.4 yrs, 59 patients had cardiovascular death (CVD). Multivariate Cox regression analysis revealed that SAPi was significantly associated with CVD, independently of prior heart failure hospitalization, body mass index, glomerular filtration rate, and serum sodium level. HFrEF patients with low SAPi (<2.321 by ROC analysis: AUC 0.655[0.545-0.768]) had a significantly higher CVD risk than those with high SAPi (≥2.321) (37%[24/65] vs 13%[6/46], p=0.034). Furthermore, HFpEF patients with low SAPi (<3.324 by ROC analysis: AUC 0.654[0.533-0.775]) also had a significantly higher CVD risk than those with high SAPi (≥3.324) (31%[20/65] vs 15%[9/64], p=0.026). Conclusions: SAPi could provide the long-term prognostic information in patients admitted with ADHF, regardless of HFrEF or HFpEF. [ABSTRACT FROM AUTHOR]

Backgrounds: Cardiohepatic interactions have been a focus of attention among heart failure (HF). A model of end-stage liver disease excluding INR (MELD-XI) provides prognostic information in HF patients (pts). Furthermore, the albumin-bilirubin (ALBI) score has recently been proposed as a validated index of liver dysfunction. We sought to compare the prognostic values of MELD-XI and ALBI scores in pts admitted for acute decompensated heart failure (ADHF), relating to reduced and preserved left ventricular ejection fraction (LVEF). Methods: We studied 303 ADHF pts with survival discharge (HFrEF[LVEF<50%] n=163, HFpEF[LVEF≥50%] n=140). MELD-XI score was calculated by the formula: 5.11х ln(total bilirubin)+11.79х ln(creatinine)+9.44. The ALBI was calculated using the formula: log10(total bilirubin) х 0.66 + albuminх-0.085. The study endpoints were cardiovascular-renal poor outcome (CVR) defined as cardiovascular death and the development of end-stage renal disease requiring renal replacement therapy, and all-cause death (ACD). Results: During a follow-up period of 4.3±3.3 yrs, 81 pts had CVR and 96 pts had ACD. By ROC curve analysis for the identification of CVR, AUC of MELD-XI score (0.731 [0.665-0.797]) was significantly (p=0.0149) greater than that of ALBI score (0.579[0.597-0.651]). AUC of MELD-XI score (0.643 [0.576-0.710]) for ACD was also greater than that of ALBI score (0.568[0.499-0.637]). At multivariate Cox analysis, MELD-XI score was significantly associated with CVR and ACD after the adjustment with age, prior HF hospitalization, BMI and systolic blood pressure, although ALBI score showed the association with the events at the univariate analysis. Pts with higher MELD-XI score (≥14) had a significantly higher risk of CVR and ACD than those with lower MELD-XI score, in both groups with HFrEF and HFpEF. Conclusion: MELD-XI score could provide more prognostic information than ABLI score in ADHF pts, regardless of HFrEF or HFpEF. [ABSTRACT FROM AUTHOR]

Backgrounds: Ventricular-arterial (VA) coupling has been shown to have physiologic importance in heart failure. It has recently been shown that systemic arterial pulsatility index (SAPi=[systemic systolic pressure - diastolic pressure]/pulmonary capillary wedge pressure), a novel index of VA coupling, is associated with adverse clinical outcomes in patients with advanced heart failure. On the other hand, cardiohepatic interactions have been a focus of attention in heart failure, and the model of end-stage liver disease excluding INR (MELD-XI), a robust scoring system of liver dysfunction, has been shown to be useful for prediction of poor outcome in patients with acute decompensated heart failure (ADHF). However, there is no information available on the prognostic value of the combination of SAPi and MELD-XI score in ADHF patients. Methods and Results: We studied 240 patiens admitted for ADHF, who underwent right heart catheterization and were discharged with survival. SAPi was obtained at the admission. MELD-XI score was calculated by the formula: 5.11хln(bilirubin)+11.79хln(creatinine)+9.44. During a follow up period of 5.2±4.4 yrs, 59 patients had cardiovascular death (CVD). At multivariate Cox analysis, SAPi (p=0.014) and MELD-XI score (p=0.0025) were significantly associated with CVD, independently of serum sodium level, prior heart failure hospitalization and body mass index. The patients with both lower SAPi (≤0240: AUC 0.655[0.584-0.746]) and greater MELD-XI score (≥12: AUC 0.689[0.612-0.765]) had a significantly increased risk of CVD than those with either lower SAPi or greater MELD-XI score and none of them (49% vs 25% vs 9%, p<0.0001, respectively). Conclusion: The combination of SAPi and MELD-XI score might be useful for stratifying ADHF patients at higher risk for CVD. [ABSTRACT FROM AUTHOR]

Background: Controlled heart rate (HR) and increased pulse pressure (PP) are related to better outcomes in stable chronic heart failure. Hemodynamic response to stress evaluated by an acute hemodynamics index (AHI), the product of HR and PP, has been reported to be associated with in-hospital mortality in patients admitted for acute decompensated heart failure (ADHF). However, there is no information available on the long-term prognostic significance of AHI in ADHF patients. Methods and Results: We studied 303 ADHF patients discharged with survival. AHI (HR x PP/1000) was calculated at the admission. During a follow-up period of 5.1±4.3 years, 121 patients died. Deceased patients showed a lower AHI (6.4±2.8 vs 7.4±3.0 bpm·mmHg, p<0.001). At multivariate Cox analysis, AHI (adjusted hazard ratio 0.919[0.851-0.991], p=0.028) was significantly associated with the total mortality, independently of age, prior heart failure hospitalization, eGFR and serum sodium level after the adjustment with gender, the use of beta-blocker, BMI, anemia, serum albumin and BUN levels, left ventricular end-diastolic and left atrial dimension indexes. Patients with lowest AHI quartile (<4.9 bpm·mmHg) had a significantly increased risk of the total mortality than those with middle AHI quartiles (4.9-8.4 bpm·mmHg) and highest AHI quartile (>8.4 bpm·mmHg) (56% vs 38% vs 30%, p=0.001, respectively). Conclusion: AHI could provide long-term prognostic information after the discharge, in patients admitted for ADHF. [ABSTRACT FROM AUTHOR]

Background: The Get With the Guidelines-Heart Failure (GWTG-HF) risk score was recently developed to predict in-hospital mortality in patients admitted with acute decompensated heart failure (ADHF). However, little is known about the ability of the risk score to predict poor prognosis after hospital discharge in ADHF patients, and it remains unclear which measure of GWTG-HF risk score (admission, discharge, or the change from admission to discharge) is the most important predictor of poor prognosis after hospital discharge. Methods: We prospectively studied 372 consecutive patients who were admitted for ADHF and survived to discharge. Venous blood sampling and echocardiography were performed on admission and just before discharge. Variables required for the GWTG-HF risk score were race, age, systolic blood pressure, heart rate, blood urea nitrogen and sodium levels, and the presence of chronic obstructive pulmonary disease. The study endpoint was all-cause death. Results: During the follow-up period of 2.5±1.4 years, 108 patients had all-cause death. Multivariate Cox regression analysis that included clinical, hemodynamic, biochemical, and echocardiographic parameters and the GWTG-HF risk score (admission, discharge, or the change from admission to discharge) showed that only the GWTG-HF risk score measured at discharge was an independent predictor of all-cause mortality (p=0.0233) among the three measures of the risk score. Although the GWTG-HF risk score on admission was one of the univariate predictors of all-cause death, receiver operating characteristic curve analysis confirmed the higher accuracy of GWTG-HF risk score at discharge (AUC=0.726, 95% CI: 0.678-0.771) over on admission (AUC=0.666, 95% CI: 0.615-0.714) in predicting the endpoint (p=0.0461). The change of GWTG-HF risk score from admission to discharge was not a significant predictor of all-cause death even in univariate analysis. Kaplan-Meier analysis showed that patients with GWTG-HF risk score >40 (median value) at discharge had a significantly higher risk of all-cause death (p<0.0001, HR 2.99 [95% CI: 2.04-4.40]). Conclusions: The GWTG-HF risk score predicts poor prognosis after hospital discharge, and the score measured at discharge best predicts all-cause mortality in ADHF patients. [ABSTRACT FROM AUTHOR]

Introduction: Plasma volume (PV) expansion plays an essential role in heart failure (HF). Recently, it has been reported that PV can be estimated by a simple formula based on hematocrit and body weight, and PV status (PVS) provides prognostic information in patients with chronic HF. In addition, malnutrition has been associated with increased mortality in HF patients, and the controlling nutritional status (CONUT) score is a previously established objective nutritional index. Hypothesis: We assessed the hypothesis that PVS and CONUT score have incremental prognostic value even in patients who are admitted for acute decompensated heart failure (ADHF). Methods: We prospectively studied 362 consecutive patients who were admitted for ADHF and survived to discharge. Body weight measurement and venous blood sampling were performed just before discharge. PVS was defined as follows: actual PV = (1 - hematocrit) х [a + (b х body weight)] (a=1530 in males and a=864 in females, b=41.0 in males and b=47.9 in females); ideal PV = c х body weight (c=39 in males and c=40 in females); and PVS = [(actual PV - ideal PV)/ideal PV] х 100 (%). The CONUT score was calculated by serum albumin and total cholesterol levels, and total lymphocyte counts as previously reported. The study endpoint was all-cause death. Results: During a follow-up period of 2.5±1.4 years, 108 patients had all-cause death. Multivariate Cox analysis showed that both PVS and CONUT score were independent predictors of all-cause death (p=0.0005 and p=0.0013, respectively). Kaplan-Meier analysis showed that there was a significant difference in the risk of the endpoint when patients were stratified into 3 groups based on the median values of PVS (12.1%) and CONUT score (3 points) (Figure). Conclusions: PVS and CONUT score had incremental prognostic value in even in ADHF patients. [ABSTRACT FROM AUTHOR]

Backgrounds: The Get with The Guidelines heart failure (GWTG-HF) risk score was developed in the GWTG inpatient HF registry to predict in-hospital mortality and has been reported to be associated with post-discharge long-term outcomes. We previously reported that serum cholinesterase (CHE) level, which reflect various factors such as hepatic function, inflammation and nutritional status, was a robust independent prognostic indicator in acute decompensated heart failure (ADHF) patients. However, there is no information available on the incremental prognostic value of serum CHE level to GWTG-HF risk score in ADHF patients. Methods and Results: We studied 377 patients admitted for ADHF in our prospective cohort study. Echocardiography and venous blood sampling were obtained just before discharge. We evaluated GWTG-HF score from variables as follows; race, age, systolic blood pressure, heart rate, serum levels of blood urea nitrogen and sodium, and the presence of chronic obstructive pulmonary disease. The endpoint of this study is the cardiac death. During a follow up period of 2.5±1.4 years, 48 patients had cardiac death. At multivariate Cox analysis, GWTG-HF risk score (p=0.0070) and serum CHE levels (p=0.0012) were significantly associated with cardiac death, independently of NYHA class, serum chloride and plasma BNP levels after the adjustment with other major confounders. Cut-off values of serum CHE level and GWTG-HF risk score were determined by ROC analysis (serum CHE levels; 194 U/L AUC 0.762, GWTG-HF risk score; 42, AUC 0.707). In the subgroup of high GWTG-HF risk score (≥42), cardiac death was significantly frequently observed in patients with than without low serum CHE level (≤194 U/L: 32% vs 8%, p=0.0001, adjusted HR 5.16 [2.11-12.6]). Furthermore, in the subgroup of low GWTG-HF risk score (<42), patients with low serum CHE level had a significantly higher risk of cardiac death than those without low serum CHE level (17% vs 5%, p=0.0014, adjusted HR 3.98 [1.59-9.94]) Conclusion: Serum cholinesterase level provides the additional long-term prognostic information to GWTG-HF risk score in patients with acute decompensated heart failure. [ABSTRACT FROM AUTHOR]

Backgrounds: In heart failure patients, comorbidities are reported as robust prognostic marker. AHEAD (A: atrial fibrillation; H: hemoglobin; E: elderly; A: abnormal renal parameters; D: diabetes mellitus) risk score has been reported as a useful long-term risk stratification comorbidity score in acute decompensated heart failure (ADHF) patients. On the other hand, cardiac MIBG imaging provides prognostic information in ADHF patients. Recently, a new group of heart failure patients with mid-range ejection fraction (HFmrEF) has been defined, separated from reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). However, there is no information available on the comparison of prognostic value of AHEAD risk score and cardiac MIBG imaging in patients admitted for ADHF, relating to HFrEF, HFmrEF and HFpEF. Methods and Results: We studied 350 patients (HFrEF:n=126, HFmrEF:n=84, HFpEF:n=140) admitted for ADHF in our prospective cohort study. Echocardiography, venous blood sampling and cardiac MIBG imaging were obtained just before discharge. We evaluated AHEAD risk score (range 0-5, atrial fibrillation, hemoglobin <13 mg/dL for men and 12 mg/dL for women, age >70 years, creatinine >130 μmol/L, and diabetes mellitus). In MIBG imaging, the cardiac MIBG heart-to-mediastinum ratio (late H/M) was measured from the chest anterior view images obtained at 200 min after isotope injection. The endpoint of this study is the composite of worsening heart failure readmission and cardiac death (cardiac event). During a follow up period of 2.1±1.4 years, 145 patients had cardiac events. At multivariate Cox analysis, AHEAD risk score and late H/M were significantly and independently associated with cardiac event in HFrEF, HFmrEF, and HFpEF patients. Kaplan-Meier survival curve analysis demonstrated a significantly increased risk of cardiac event stratified by the combination of higher AHEAD risk score (≥3 by ROC analysis: AUC 0.686 in HFrEF, 0.649 in HFmrEF and 0.697 in HFpEF) and low late H/M (by ROC analysis in each subgroup) in patients with HFrEF, HFmrEF and HFpEF. Conclusion: The combination of AHEAD risk score and cardiac MIBG imaging could provide more powerful prognostic information in ADHF patients irrespective of HFrEF, HFmrEF and HFpEF. [ABSTRACT FROM AUTHOR]

Background: Cardiac MIBG imaging provides prognostic information in patients (pts) with chronic heart failure (HF). Recent studies showed that the highest occurrence of severe arrhythmic events (SAE) was seen in CHF pts with an intermediate reduction in MIBG uptake rather than the lowest values. On the other hand, wide QRS duration has been shown to be associated with SAE in HF pts. However, there is little information available on prognostic value of intermediate decrease of HMR and wide QRS duration for the prediction of ventricular tachyarrhythmias in implantable cardioverter defibrillator (ICD) pts, relating to with and without HF. Methods and Results: We prospectively enrolled 171 consecutive outpatients with ICD (age: 64±14 years, male: 80%, NYHA class: 1.7±0.7, LVEF: 49±16%). One hundred fifteen pts had a past history of hospitalization for worsening heart failure, symptom due to HF, or left ventricular dysfunction (LVEF<50%). At entry, cardiac MIBG imaging was performed and QRS duration was measured in standard 12-lead electrocardiography. An intermediate decrease in heart-to-mediastinum ratio on delayed planar image (HMR) was defined as 1.4-2.1. During a follow-up period of 3.5±1.9 years, 55 pts had appropriate ICD discharge for ventricular tachyarrhythmias. At multivariate Cox analysis, intermediate decrease in HMR and QRS duration were significantly and independently associated with appropriate ICD discharge. ROC curve analysis revealed that QRS duration of 147 ms was a fair discriminator for appropriate ICD discharge (AUC 0.605, 95%CI 0.509-0.693). In both pts with and without HF, appropriate ICD discharge was significantly more frequently observed in pts with intermediate decrease in HMR and/or wide QRS duration (≥ 147ms) than with none of them (with HF: 40 % vs 7%, p=0.036, without HF: 39% vs 8%, p=0.019). Conclusions: The combination of intermediate decrease in HMR and QRS duration would provide more prognostic information to predict ventricular tachyarrhythmias in ICD pts, regardless of the presence of HF. [ABSTRACT FROM AUTHOR]

Backgrounds: We previously reported that serum cholinesterase (CHE) level, which reflect various factors such as hepatic function, inflammation and nutritional status, was a robust independent prognostic indicator in acute decompensated heart failure (ADHF) patients. Recently, a new group of heart failure patients with mid-range ejection fraction (HFmrEF) has been defined, separated from reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). However, there is no information available on the prognostic role of serum CHE level in the patients admitted for acute decompensated heart failure (ADHF), relating to HFrEF, HFmrEF and HFpEF. Methods and Results: We studied 385 patients admitted for ADHF in our prospective cohort study. There were 135 patients with HFrEF (LVEF<40%), 90 patients with HFmrEF (40%≤LVEF<50%) and 160 patients with HFpEF (LVEF≥50%). Echocardiography and venous blood sampling including CHE were obtained just before discharge. The endpoint of this study is all-cause death. During a follow up period of 2.5±1.4 years, 114 patients had all-cause death. Serum CHE level at discharge were not significantly different in patients with HFrEF, HFmrEF and HFpEF (232±81 vs. 224±81 vs. 216±64, p=0.200, respectively). At multivariate Cox analysis, serum CHE level was significantly associated with all-cause death in HFrEF (p<0.0001), HFmrEF (p=0.012), HFpEF (p=0.0041) patients after the adjustment with major confounders. Kaplan-Meier survival curve analysis demonstrated a significantly increased risk of all-cause death stratified by lower serum CHE level stratified by lower serum CHE level (≤224U/L determined by ROC analysis [AUC 0.822] in HFrEF, ≤185U/L [AUC 0.740] in HFmrEF and ≤173U/L [AUC 0.687] in HFpEF) in patients with HFrEF (52% vs 8%, p<0.0001, adjusted HR 9.48 [95% CI 3.70-24.3]), HFmrEF (57% vs 17%, p<0.0001, adjusted HR 5.05 [95% CI 2.27-11.23]) and HFpEF (53% vs 21%, p<0.0001, adjusted HR 3.25 [95% CI 1.82-5.82]). Conclusion: Serum cholinesterase level was associated with the total mortality in ADHF patients irrespective of HFrEF, HFmrEF and HFpEF. [ABSTRACT FROM AUTHOR]

Introduction: Heart failure and cognitive impairment are associated with hospitalization and increased mortality. However, few studies addressed acute decompensated heart failure(ADHF) outcomes. Hypothesis: The Mini-Mental State Examination (MMSE) score is useful for assessing cognitive status. We sought to elucidate whether the MMSE score have predictive value in ADHF patients. The aim of this study is to estimate the risk of unplanned hospitalization for worsening heart failure (WHF) and all cause death in patients admitted for ADHF. Methods: We studied 260 consecutive patients admitted for ADHF and discharged with survival (age 77±12 years, male 56%). Trained clinical research assistants got the MMSE score just before discharge. The endpoints were unplanned hospitalization for WHF and all cause death. Results: During a follow up period of 2.2±1.5 years, 84 patients had WHF and 134 patients had all cause death. At multivariate Cox analysis, out of the variables including clinical, hemodynamic, biochemical, echocardiographic parameters and MMSE score, MMSE score was significantly independently associated with WHF (p<0.0001) and all cause death (p=0.0004). Receiver-operator curve analysis revealed that the MMSE score of 21 and 24 were fair discriminators for all cause death (AUC 0.706 [95% CI 0.647-0.761], p<0.0001 sensitivity 57% and specificity 80%) and WHF (AUC 0.592 , 95% CI 0.529-0.652, p=0.0013 sensitivity 66% and specificity 53%), respectively. Kaplan-Meier analysis showed that patients with the MMSE score >21 and >24 had a significantly higher risk of all cause death (p<0.0001) and WHF (p=0.0011), respectively. Conclusions: The MMSE score might be useful for the prediction of WHF and all cause death, in patients admitted for ADHF. [ABSTRACT FROM AUTHOR]

Background: Cardiohepatic interactions have been a focus of attention in heart failure, and the model of end-stage liver disease (MELD), a robust scoring system of liver dysfunction, has been shown to be useful for prediction of poor outcome in patients (pts) with acute decompensated heart failure (ADHF). Furthermore, it has recently been reported that liver stiffness assessed by transient elastography predicts adverse prognosis in pts with heart failure (HF). Liver fibrosis is assessed by non-invasive fibrosis markers such as such as Fibrosi-4 (FIB4) index, non-alcoholic fatty liver disease fibrosis score (NFS) and aminotransferase to platelet ratio index(APRI). However, there is little information available on the comparison of prognostic significance of MELD score and liver fibrosis scores in ADHF pts. Methods: We prospectively studied 343 consecutive pts who were admitted for ADHF and survived with discharge. At the admission, MELD score was obtained by 11.2 х ln(INR) + 9.57 х ln(creatinine[mg/dL]) + 3.78 х ln(bilirubin[mg/dL]) + 6.43, and we calculated FIB4 index by the formula: age(yrs) х AST[U/L]/(platelets [103/μL] х (ALT[U/L])1/2), NFS by the formula: -1.675 + 0.037 х age + 0.094 х BMI + 1.13 х hyperglycemia or diabetes (yes = 1, no = 0) + 0.99 х AST/ALT - 0.013 х platelet [ х 103/μL] - 0.66 х albumin, and APRI by the formula:100 х(AST[U/L]/upper limit of normal)/platelets[109/L]. The endpoint was all cause death (ACD). Results: During a follow-up period of 2.5±1.4 years, 96 pts had ACD. At multivariate Cox analysis, NFS and MELD was independently associated with ACD, although FIB4 index showed the significant association with ACD at univariate analysis. The pts with both greater NFS (≥0.928 by ROC analysis: AUC 0.650 [0.597-0.700]) and greater MELD score (≥14 by ROC analysis: AUC 0.681 [0.629-0.730]) had a significantly increased risk of ACD than those with either and none of them (50% vs 29% vs 15%, p<0.0001 respectively). The adjusted hazard ratio in pts with both greater NFS and MELD score was 4.7(2.7-8.2), which was double of that in those with either of them (2.2[1.4-3.4]). Conclusions: The combination of NFS and MELD score might be useful for stratifying patients at risk for all-cause death in ts with ADHF. [ABSTRACT FROM AUTHOR]

Backgrounds: Cardio-renal anemia syndrome (CRAS) has the prognostic significance in patients with heart failure. We previously reported that the product of creatinine (Cr) and blood urea nitrogen (BUN) divided by hemoglobin (Hb), CrхBUN/Hb as an index of CRAS, was associated with poor outcome in the analysis of the retrospective cohort of patients with acute decompensated heart failure (ADHF). On the other hand, a new group of heart failure patients with mid-range ejection fraction (HFmrEF) has recently been defined, separated from heart failure patients with reduced and preserved ejection fraction (HFrEF and HFpEF). The aim of this study was to prospectively validate the prognostic value of the CRAS index in ADHF patients, relating to HFrEF, HFmrEF and HFpEF. Methods and Results: We studied 368 patients (HFrEF: n=129, HFmrEF: n=86, HFpEF: n=153) admitted for ADHF with survival discharge in our prospective cohort study. Echocardiography and venous blood sampling were performed just before discharge, and we obtained CrхBUN/Hb at the discharge. The endpoint of this study was all-cause death (ACD). During a follow-up period of 2.5±1.4 years, 109 pts had ACD. At multivariate Cox analysis, CrхBUN/Hb was significantly and independently associated with ACD after the adjustment with age, NYHA class, systolic blood pressure and plasma BNP level, in all of the three groups. Patients with high CrхBUN/Hb (>2.248 determined from the retrospective cohort) had a significantly greater risk of ACD than low CrхBUN/Hb, in HFrEF(hazard ratio 5.52[2.80-11.89], p<0.0001), HFmrEF (hazard ratio 5.05[1.90-17.41], p=0.0011) and HFpEF (hazard ratio 3.50[1.79-7.53], p=0.0002) groups. Conclusion: CrхBUN/Hb as an index of CRAS, which is easily obtained in the usual clinical setting, would be useful to stratify the risk of all-cause death in ADHF patients, irrespective of HFrEF, HFmrEF and HFpEF. [ABSTRACT FROM AUTHOR]