BackgroundGoreisan, a Japanese herbal medicine, possesses aquaretic properties to regulate body fluid homeostasis and may therefore be effective as a complement to standard therapy in improving outcomes in patients with heart failure (HF). MethodsWe retrospectively identified 431,393 patients (mean age 79.2 ± 12.6 years; male 52.3 %) who were admitted for HF for the first time and were discharged alive with standard HF medications between April 2016 and March 2021, using the Japanese Diagnosis Procedure Combination database. We divided patients into two groups according to the prescription of Goreisan at discharge: patients who received standard HF medications plus Goreisan and those who received standard medications alone. We compared the incidence of HF readmission within 1 year after discharge between the groups using propensity score matching. ResultsOverall, Goreisan was prescribed in 1957 (0.45 %) patients at discharge. Patients who received Goreisan were older and received diuretics more frequently than those who did not. One-to-four propensity score matching created a cohort of 1957 and 7828 patients treated with and without Goreisan, respectively. No significant difference was found in the incidence of 1-year HF readmission between the groups [22.1 % vs. 21.7 %; hazard ratio (HR) = 1.02, 95 % confidence interval (CI) = 0.92–1.13]. This result was consistent with that from competing risk analysis (subdistribution HR = 1.02, 95 % CI = 0.92–1.13) and across clinically relevant subgroups except for renal disease. Goreisan use was associated with a lower incidence of HF readmission among patients with renal disease (HR = 0.77, 95 % CI = 0.60–0.97), but not among those without (HR = 1.09, 95 % CI = 0.97–1.23; p for interaction = 0.009). ConclusionsThis nationwide propensity score-matched analysis did not demonstrate that complementary Goreisan use at discharge was associated with a lower incidence of 1-year HF readmission in patients with HF receiving standard medications. An ongoing randomized trial is awaited to establish the effectiveness of Goreisan use in patients with HF.

BackgroundSodium-glucose cotransporter 2 (SGLT2) inhibitors have revolutionized the therapeutic scenario of heart failure, demonstrating favorable effects on mortality and quality of life. Previous studies have yielded conflicting data regarding the effects on ventricular arrhythmias. MethodsA prospective observational study was conducted to investigate the anti-arrhythmic properties of SGLT2 inhibitors evaluating the intra-patient difference in major adverse arrhythmic cardiac events (MAACE) over a six-month period in patients with chronic heart failure who were undergoing continuous monitoring using a cardiac implantable electronic device. ResultsFrom January 2022 to January 2023, 82 patients [median age 63 years (IQR 15), male 87 %] were enrolled in the study, with a median follow-up of 28 weeks (IQR 5). The rate of MAACE at baseline was 11 %, without relevant differences in the follow up in terms of major and minor arrhythmic events. In patients with an arrhythmic phenotype at baseline, a mild but non statistically significant reduction of MAACE (from 36 % to 28 %, p = 0.727) was observed and a significant decrease of non-sustained ventricular tachycardia (from 68 % to 32 %, p = 0.022). ConclusionsOur findings suggest potential anti-arrhythmic properties of SGLT2 inhibitors, evident in patients with arrhythmic events before the initiation of the drug.

BackgroundThe PARALLEL-HF trial showed that treatment with sacubitril/valsartan resulted in more symptomatic hypotension versus enalapril in Japanese patients with heart failure (HF) and reduced ejection fraction, similar to PARADIGM-HF. Use of sacubitril/valsartan in these patients may be limited by concerns regarding hypotension. MethodsThis post-hoc analysis characterized hypotension-related adverse events (AEs) and their effects on efficacy using data from PARALLEL-HF, in which patients received sacubitril/valsartan 200 mg twice daily or enalapril 10 mg twice daily. ResultsOf 223 patients, 28.2 % experienced hypotension-related AEs and incidence was higher with sacubitril/valsartan versus enalapril (hazard ratio, 2.2; 95 % CI, 1.3–3.8; p = 0.0027). However, reduction in mean systolic blood pressure from baseline to study end did not significantly differ (sacubitril/valsartan: −2.2 mmHg vs enalapril: −1.3 mmHg; p = 0.6895). Patients who experienced hypotension-related AEs had lower mean body mass index, higher median N-terminal pro-brain natriuretic peptide at randomization, and more frequent history of stroke. Hypotension-related AEs leading to treatment discontinuation were not significantly different for sacubitril/valsartan versus enalapril (3.4 % vs 6.9 %, p = 0.5957). Reduction in risk of cardiovascular death or HF hospitalization was similar with sacubitril/valsartan versus enalapril in patients with or without hypotension-related AEs. ConclusionsIncidence of hypotension-related AEs was higher in the sacubitril/valsartan versus enalapril group but did not affect risk of cardiovascular death or HF hospitalization, which was similar between treatment groups.

BackgroundCardiogenic shock poses a critical challenge characterized by diminished cardiac output and organ perfusion. Timely recognition and risk stratification are essential for effective intervention. Liver cirrhosis adds complexity due to its diverse systemic manifestations. The effect of liver cirrhosis on in-hospital outcomes in cardiogenic shock remains underexplored. MethodsWe conducted a retrospective cohort study using the National Inpatient Sample database from 2016 to 2020, matching cirrhotic patients with non-cirrhotic counterparts using propensity scores. The Cochran-Mantel-Haenszel method was used to assess the impact of cirrhosis on in-hospital mortality and complications. Simple linear regression models were used to assess differences in length of stay and cost of hospitalization. ResultsThere were a total of 44,288 patients in the cohort, evenly distributed between the group with and without liver cirrhosis. Mean age of the cohort was 64 years (SD 12.5), 69.7 % were males, and 61.3 % were white. The overall in-hospital mortality rate in the cohort was 37.2 % with higher odds of in-hospital mortality in cirrhotic patients [OR = 1.3; 95 % CI (1.25, 1.35)]. Patients with cirrhosis exhibited increased risks of bowel ischemia, acute kidney injury, and sepsis compared to those without cirrhosis. Additionally, they had a heightened overall risk of major bleeding, particularly gastrointestinal bleeding, but a lower risk of intracranial hemorrhage and access site bleeding. Conversely, patients with cirrhosis had lower odds of deep vein thrombosis and pulmonary embolism, as well as arterial access site thrombosis and dissection, leading to reduced odds of peripheral angioplasty, thrombectomy, and amputation. Cirrhotic patients also had increased length of stay and cost of hospitalization. ConclusionLiver cirrhosis exacerbates outcomes in cardiogenic shock, necessitating tailored management strategies. Further research is warranted to optimize patient care and understand the underlying mechanisms.

BackgroundIn patients with persistent atrial fibrillation (AF), extensive ablation for substrate modification, such as linear ablation or complex fractionated atrial electrogram ablation in addition to pulmonary vein isolation (PVI) remains controversial. Previous studies investigating extensive ablation have demonstrated its varying efficacy, suggesting the possible heterogeneity of its efficacy. Aging is a major risk factor for AF and is associated with atrial remodeling. We aimed to compare the efficacy and safety of the extensive ablation strategy compared with PVI alone strategy between young and elderly patients. MethodsThis study is a post-hoc analysis of the multicenter, randomized controlled, noninferiority trial investigating the efficacy and safety of PVI-only (PVI-alone arm) compared with extensive ablation (PVI-plus arm) in patients with persistent AF (EARNEST-PVI trial). We divided the overall population into 2 groups based on age and assessed treatment effects. ResultsIn the young group (age <65 years, N = 206), there was no significant difference in the recurrence rate between the PVI-alone group and PVI-plus group [hazard ratio (HR): 1.00, 95 % CI: 0.57–1.73, p = 0.987], whereas the recurrence rate was significantly lower in the PVI-plus group compared to the PVI-alone group in the elderly group (age ≥65 years, N = 291) (HR: 0.47, 95 % CI: 0.29–0.76, p = 0.0021) (p for interaction = 0.0446). There were no fatal procedural complications. ConclusionIn patients with persistent AF, the extensive ablation strategy was more effective than the PVI-alone strategy in elderly patients, while the effectiveness of both approaches was comparable in young patients. Trial registrationURL: https://clinicaltrials.gov; Unique identifier: NCT03514693.URL: https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000022454Unique ID issued by UMIN: UMIN000019449.

BackgroundAlthough diastolic dysfunction is the main pathophysiological feature of hypertrophic cardiomyopathy (HCM), it remains to be clarified whether parameters of diastolic function can reliably determine HCM prognosis. In patients with reduced left ventricular (LV) distensibility, chronic elevation of LV diastolic pressure is seen with a smaller than expected LV size. Accordingly, patients with HCM with severe LV diastolic dysfunction typically demonstrate left atrial (LA) dilation and a disproportionately smaller left ventricle. Therefore, we investigated the relationship between LA/LV diameter ratio, as a potential indicator of disease progression, and outcomes in patients with HCM. MethodsWe included 468 patients in whom LA and LV end-diastolic diameter were successfully evaluated by echocardiography at the initial assessment. We divided the patients into two groups: those with an LA/LV diameter ratio > 1 and those with an LA/LV diameter ratio ≤ 1. We compared the HCM-related death rates between the two groups. ResultsOf the 468 patients, 96 patients (20.5 %) with HCM showed an LA/LV diameter ratio > 1. In the univariate analysis, patients with an LA/LV diameter ratio > 1 had a significantly greater likelihood of HCM-related death than patients with an LA/LV diameter ratio ≤ 1 (log-rank p = 0.002). In the multivariate Cox proportional hazards analysis, when including LA/LV diameter ratio > 1 and imbalanced baseline variables, an LA/LV diameter ratio > 1 was an independent determinant of HCM-related death (adjusted hazard ratio: 1.87, 95 % confidence interval: 1.08–3.24; p = 0.024). ConclusionLA/LV diameter ratio can be easily evaluated and may be useful for risk stratification of HCM-related death in patients with HCM.

An escalation strategy from intra-aortic balloon pump (IABP) to Impella (AbioMed, Danvers, MA, USA) is proposed in patients with cardiogenic shock (CS) refractory to IABP therapy, but its clinical data are lacking. This study aimed to elucidate the clinical characteristics and short-term outcomes in patients undergoing IABP-Impella escalation. From the Japanese nationwide registry of Impella (J-PVAD), a total of 2578 patients with CS receiving Impella support were classified into the IABP-Impella group (n = 189) or the Primary Impella group (n = 2389). We applied 1:3 propensity score (PS) matching, selecting 185 patients and 555 patients, respectively. Before matching, the IABP-Impella group presented longer shock-to-Impella time, worse laboratory data, and more frequent inotropes and pulmonary artery catheter use than the Primary Impella group. After matching, the baseline characteristics were well-balanced. Regarding the 30-day clinical outcomes in the PS-matched cohort, there were no significant differences in the rates of mortality and major complications (a composite of bleeding, hemolysis, infection, stroke, myocardial infarction, limb ischemia, and vascular injury) between the groups. However, The IABP-Impella group showed a significantly higher rate of infection (10.3 % vs. 5.6 %, p = 0.042) and additional mechanical circulatory support use (34.1 % vs. 23.8 %, p = 0.008) than the Primary Impella group. Compared to patients with primary Impella support, those undergoing IABP-Impella escalation showed similar 30-day mortality and major complications despite poorer clinical conditions before Impella support and a more complicated clinical course after Impella insertion.

BackgroundDespite strong recommendations in the latest guidelines for implementing guideline-directed medical therapy (GDMT) before discharge, there is a lack of data on the clinical characteristics and outcomes of older patients with heart failure (HF). Therefore, this study aimed to investigate the clinical characteristics and outcomes of patients with HF in a super-aging society during the GDMT era. Methods and ResultsIn the COMPASS-HF study including 305 consecutive hospitalized patients, 177 with acute HF were identified through a medical record review. The mean age of the enrolled patients was 86.2 years, and 46.3 % were men. The mean simple GDMT score, which is recognized as a useful prognostic tool for Japanese patients with HF, was 5.0. The incidences of all-cause death and HF hospitalization were 46.5 % and 19.4 %, respectively. The incidences of all-cause death and cardiovascular death were significantly lower in the high simple GDMT score group (≥5 points) than in the low simple GDMT score group (≤4 points) (p = 0.049 and p = 0.044, respectively). However, no significant differences were noted in HF hospitalization and composite events (cardiovascular death and HF hospitalization) between the groups (p = 0.564 and p = 0.086, respectively). ConclusionsWhile GDMT was well-implemented in the older community, the mortality rate among hospitalized patients with HF remained high. Although GDMT appears to have reduced the HF hospitalization rate, further validation and development of an optimal predictive model for elderly patients with HF are essential. X (formerly Twitter)In the older community, although the short- and long-term mortality of hospitalized patients with HF is still high even in the GDMT era, the HF hospitalization rate is suppressed, probably due to GDMT. A simple GDMT score may also be useful for stratifying the prognosis of older patients with HF.#HeartFailure#Mortality#GDMT#Fantastic4.