Tokyo Cardiovascular Care Unit Network Research Articles

Impact of hypoalbuminemia on in-hospital mortality in patients with takotsubo syndrome: A multicenter registry of the Tokyo Cardiovascular Care Unit Network

BackgroundHypoalbuminemia is common in critically ill patients and is associated with poor outcomes. However, the relationship between serum albumin levels and clinical outcomes in patients with takotsubo syndrome remains unclear. We examined the impact of hypoalbuminemia on in-hospital mortality in patients with takotsubo syndrome. MethodsUsing the multicenter registry of the Tokyo Cardiovascular Care Unit Network between January 2017 and December 2020, we identified 631 eligible patients with takotsubo syndrome (median age, 78 years; male proportion, 22 %) and documented serum albumin levels at admission, which were used to allocate patients to hypoalbuminemia (serum albumin <3.5 g/dL) or normal albumin (serum albumin ≥3.5 g/dL) groups. Patient characteristics and in-hospital mortality were compared between the groups. ResultsHypoalbuminemia was detected in 200 (32 %) patients at admission. The hypoalbuminemia group was older and had a higher proportion of men and preceding physical triggers than the normal albumin group. In-hospital all-cause mortality was greater in the hypoalbuminemia group than in the normal albumin group (9.5 % vs. 1.9 %, p < 0.001). Both cardiac (3.0 % vs. 0.5 %, p = 0.015) and non-cardiac (6.5 % vs. 1.4 %, p = 0.002) mortality was greater in the hypoalbuminemia group. In multivariable logistic regression analysis, hypoalbuminemia was independently associated with increased in-hospital mortality, even after adjusting for confounders, including age, sex, and triggering events (odds ratio, 3.23; 95 % confidence interval, 1.31–7.95; p = 0.011). ConclusionsIn patients with takotsubo syndrome, hypoalbuminemia is a common comorbidity and is associated with a substantial risk of in-hospital death. Close monitoring and comprehensive critical care are required in these patients.

Clinical features and predictors of non-cardiac death in patients hospitalised for acute myocardial infarction: Insights from the Tokyo CCU network multicentre registry

BackgroundPatients with acute myocardial infarction (AMI) commonly have multiple comorbidities, and some die in hospitals due to causes other than cardiac complications. However, limited information is available on noncardiac death in patients hospitalised for AMI. Therefore, the present study was performed to determine the incidence, annual trend, clinical characteristics, and predictors of in-hospital non-cardiac death in patients with AMI using the Tokyo Cardiovascular Care Unit (CCU) network registry. MethodsThe registry included 38,589 consecutive patients with AMI who were admitted to the CCU between 2010 and 2019. The primary endpoint was in-hospital noncardiac death. Further, predictors of cardiac and non-cardiac death were identified. ResultsThe incidence of all-cause in-hospital mortality was 7.0% (n = 2700), and the proportion of mortality was 15.6% (n = 420) and 84.4% (n = 2280) for noncardiac and cardiac causes, respectively. The proportion of noncardiac deaths did not change annually over the last decade (p = 0.66). After adjusting for all variables, age, Killip classification grade, peak creatine kinase, hemoglobin, serum creatinine, and C-reactive protein were common predictors of cardiac and non-cardiac deaths. Indicators of malnutrition, such as lower body mass index (kg/m2) [odds 0.94, 95%CI (0.90–0.97), p < 0.001] and serum low-density lipoprotein cholesterol level (per 10 mg/dl) [odds 0.92, 95%CI (0.89–0.96), p < 0.001] were the specific predictors for non-cardiac deaths. ConclusionsThe incidence of in-hospital noncardiac death was significant in patients with AMI, accounting for 15.6% of all in-hospital mortalities. Thus, prevention and management of non-cardiac complications are vital to improve acute-phase outcomes, especially those with predictors of non-cardiac death.

Impact of the COVID-19 pandemic on incidence and mortality of emergency cardiovascular diseases in Tokyo

BackgroundThe impact of the coronavirus disease 2019 (COVID-19) pandemic on the incidence and in-hospital mortality of emergency cardiovascular disease (CVD) has not been clarified in Japan. MethodsWe compared the number of admissions and in-hospital mortality for emergency CVD during the pandemic (from January to December 2020) with those of pre-pandemic periods (from January 2018 to December 2019), using quarterly data from the Tokyo Cardiovascular Care Unit Network. The incidence rate in 2020 is compared with the average incidence rate observed in the same quarter of 2018 and 2019 and is presented as an incidence rate ratio (IRR) with 95 % confidence interval (CI). ResultsThe number of admissions for acute myocardial infarction during the pandemic was significantly lower than before the pandemic, with an IRR of 0.93 (95 % CI; 0.88–0.98). Similarly, the IRR for unstable angina was 0.78 (95 % CI; 0.72–0.83), for acute heart failure was 0.84 (95 % CI; 0.76–0.91), for acute aortic dissection was 0.88 (95 % CI; 0.78–0.98), and for ruptured aortic aneurysm was 0.75 (95 % CI; 0.62–0.88). In quarterly comparisons, the numbers of acute aortic diseases and emergency arrhythmia significantly decreased from July to September 2020, while those of other emergency CVDs significantly declined in the 2020 April–June period, which includes the first wave period in Japan. In-hospital mortality of emergency CVDs was unchanged from the pre-pandemic period, except for acute aortic dissection, which increased in odds ratio of 1.31 (95 % CI 1.10–1.57). ConclusionsThe COVID-19 pandemic significantly reduced the number of admissions for all emergency CVDs in all or part of the year. In-hospital mortality was unchanged from the pre-pandemic period, except for acute aortic dissection, which increased.

A study of takotsubo syndrome over 9 years at the Tokyo Cardiovascular Care Unit Network Registry

BackgroundTakotsubo syndrome (TTS) is an acute cardiovascular disease with clinical manifestations similar to those of acute myocardial infarction (AMI), and TTS sometimes occurs just after catastrophes. Large-scale studies of TTS in Japan are scarce, so we examined data over 9 years from Tokyo metropolitan acute cardiovascular care hospital network registry. MethodsA total of 1626 patients were diagnosed with TTS between 2010 and 2018 at Tokyo Cardiovascular Care Unit Network facilities, and data from all these patients were analyzed. We investigated annual and monthly captured incidence of TTS, temporal trend of the captured incidence proportion of TTS versus AMI, the occurrence of TTS on the day of the great earthquake, and we elucidated the prognostic factors for in-hospital death. ResultsThe annual incidence proportion of TTS versus AMI increased from 2.3 % to 4.5 % (p < 0.001) over 9 years. The mean TTS patient age was 74.4 years: the peak incidence of TTS was at 80 to 84 years of age for both male and female; females accounted for 78.5 % of patients. The monthly variation of the incidence of TTS was found (p = 0.009). In 2011, a total of 137 cases of TTS occurred, with as many as 6 occurring on March 11, the day of the Great East Japan Earthquake. There was a definable trigger for TTS in 64 % (physical: 36 %; emotional: 27 %; others: 2 %). All-cause in-hospital mortality was 5.3 % and was higher in males than in females (10.3 % vs 3.9 %; p < 0.001). Non-cardiac causes accounted for 62 % of in-hospital mortality. Factors at presentation that were associated with in-hospital all-cause mortality were male sex, low body mass index, and a high C-reactive protein level. ConclusionsThis study elucidated the clinical features, in-hospital outcomes, and their attributed factors in patients with TTS in real-world clinical practice in Japan.

10-Year Temporal Trends of In-Hospital Mortality and Emergency Percutaneous Coronary Intervention for Acute Myocardial Infarction.

The mortality rate of acute myocardial infarction (AMI) has improved dramatically because of reperfusion therapy during the last 40 years; however, recent temporal trends for AMI have not been fully clarified in Japan. The purpose of this study was to elucidate the temporary trend in in-hospital mortality and treatment of AMI for the last decade in the Tokyo Metropolitan area. We enrolled 30,553 patients from the Tokyo Cardiovascular Care Unit Network Registry, diagnosed with AMI from 2007 to 2016, as part of an ongoing, multicenter, cohort study. We analyzed the temporal trends in basic characteristics, treatment, and in-hospital mortality of AMI. The overall emergency percutaneous coronary intervention (PCI) rate significantly increased (P< 0.001). In particular, it remarkably increased in patients older than 80 years of age (58.3% to 70.3%, P< 0.001) and patients with Killip III or IV (Killip III, 46.9% to 65.7%; Killip IV, 65.2% to 76.6%, P< 0.001 for both). The crude and age-adjusted in-hospital mortality remained low (5.2% to 8.2% and 3.4% to 5.5%, respectively) and significantly decreased during the decade (P< 0.001). The in-hospital mortality remarkably decreased in patients older than 80 years of age (17.3% to 12.7%, P< 0.001) and in those with cardiogenic shock (38.5% to 27.3%, P< 0.001). This large cohort study from Tokyo revealed that in-hospital mortality of AMI significantly decreased with the increase in emergency percutaneous coronary intervention rate over the decade, particularly for high-risk patients such as older patients and those with cardiogenic shock.

Abstract 9996: Clinical Features and Predictors of Non-Cardiac Death in Patients Hospitalized for Acute Myocardial Infarction

Introduction: Patients with acute myocardial infarction (AMI) commonly have multiple co-morbidities, and some of these patients die in the hospital from causes other than cardiac complication. However, limited information is available on the mode of death in patients with AMI. Therefore, the present study was performed to determine the incidence, clinical characteristics and predictors of in-hospital non-cardiac death in patients with AMI, using Tokyo Cardiovascular Care Unit (CCU) network registry. Methods: Tokyo CCU network registry included 33,780 consecutive patients with AMI admitted to CCU between 2010-2018. The primary endpoint of the present study was in-hospital non-cardiac death. A stepwise regression model was used to identify the predictors of in-hospital non-cardiac death. Results: The incidence of all-cause in-hospital mortality was 7.1% (n = 2382), and the incidence was 16% (n = 381) and 84% (n = 2001) for non-cardiac and cardiac causes, respectively. The primary diseases responsible for non-cardiac deaths are shown in Figure. Old age was associated with in-hospital non-cardiac death, with a 29% increase in the risk per decade [odds 1.29, 95%CI (1.17-1.43), p &lt; 0.001]. AMI onset in hospital [odds 2.78, 95%CI (1.98-3.92), p &lt; 0.001], high grade of Killip class [odds 1.92, 95%CI (1.75-2.11), p &lt; 0.001], no PCI [odds 1.76, 95%CI (1.32-2.34), p &lt; 0.001] and history of maintenance haemodialysis [odds 2.13, 95%CI (1.38-3.30), p = 0.003] were associated with in-hospital non-cardiac death. Conclusions: The incidence of in-hospital non-cardiac death was significant in patients with AMI, accounting for 16% of all in-hospital deaths in the Tokyo CCU network registry. Thus, the prevention and management of non-cardiac complications are vital to reduce acute-phase mortality in patients with AMI, especially those with predictors of in-hospital non-cardiac death.

Combined use of venoarterial extracorporeal membrane oxygenation and intra-aortic balloon pump after cardiac arrest

ObjectivesWe investigated whether intra-aortic balloon pump (IABP) combined with venoarterial extracorporeal membrane oxygenation (VA-ECMO) was associated with favourable neurological outcomes for patients after the return of spontaneous circulation (ROSC). Moreover, we evaluated the aetiology of cardiac arrest on the effectiveness of this therapy in a sub-study. BackgroundThere is insufficient research on the optimal combination of machines for patients after ROSC is not established. MethodsThis is a large-scale, multicentre, 30-day cohort study. Among 80,716 patients who delivered to the emergency room, 935 patients treated with VA-ECMO after ROSC were included using the data from the Tokyo Cardiovascular Care Unit Network Registry between 2010 and 2017. The study patients were stratified according to the use of IABP [the ECMO + IABP group (n = 762) vs. the ECMO-alone group (n = 173)]. We also evaluated the cause of cardiac arrest [acute coronary syndrome (ACS) and non-ACS] in the sub-study. To adjust the patients’ backgrounds, we used the propensity score matching for additional analyses. The endpoint was 30-day favourable neurological outcome. ResultsThe ECMO + IABP group showed significantly better neurological outcomes than the ECMO-alone group (crude; 35% vs. 25%; log-lank P < 0.001). In the ACS subgroup, the ECMO + IABP group showed significantly better neurological outcome (crude; 34% vs. 18%; log-lank P < 0.001), but not in the non-ACS subgroup (crude; 38% vs. 32%; log-lank P = 0.11). These results are similar after adjustments to their backgrounds using propensity matching. ConclusionsCompared to VA-ECMO alone, the combined use of VA-ECMO and IABP is associated with better neurological outcomes after ROSC, especially in complicated ACS.

Hospital performance in a large urban acute myocardial infarction emergency care system: Tokyo Cardiovascular Care Unit network

Background: An ideal urban network system for improving regional acute myocardial infarction (AMI) outcomes should be geographically balanced and uniform according to regional population in performance of participating hospitals. The objective of our study is to evaluate whether there is a major difference in risk-adjusted in-hospital mortality between the Tokyo Cardiovascular Care Unit (CCU) network hospitals, which cover the whole population of large cities.Methods: The study subjects were all AMI patients without cardiac arrest on arrival admitted to the Tokyo CCU network hospitals from 2009 to 2017. Risk-adjusted in-hospital mortality rates (RAMRs) were compared between the categories of each hospital-level factor. A hospital-level multivariable linear regression was modeled to analyze the association between RAMRs and hospital-level factors. A funnel plot was constructed by plotting RAMRs against hospital volumes.Results: From 2009 to 2017, there were 42,123 hospitalizations for AMI in Tokyo CCU network hospitals (n=72, as of December, 2017). There were no significant differences in RAMRs in the comparison of hospital backgrounds. Each hospital background was not significantly associated with the RAMR. Considering the 99% CI in funnel plots, only five hospitals (7.2%) were located outside the control limits.Conclusions: There was no major difference in the RAMRs between the participating hospitals within the Tokyo CCU network, despite the different hospital backgrounds.

Diagnostic markers for discriminating between acute aortic dissection and acute myocardial infarction during the pre-hospital phase: analysis of 3,195 cases

Abstract   Both acute aortic dissection (AAD) and acute myocardial infarction (AMI) present with chest pain and are life-threatening diseases that require early diagnosis and treatment for better clinical outcome. However, two critical diseases in the very acute phase are sometimes difficult to differentiate, especially prior to arrival at the hospital for urgent diagnosis and selection of specific treatment. The aim of our study was to clarify the diagnostic markers acquired from the information gathered from medical history taking and physical examination for discriminating AAD from AMI by using data from the Tokyo Cardiovascular Care Unit (CCU) Network database. We examined the clinical features and laboratory data of patients with AAD and AMI who were admitted to the hospital in Tokyo between January 2013 and December 2015 by using the Tokyo CCU Network database. The Tokyo CCU Network consists of &amp;gt;60 hospitals that fulfil certain clinical criteria and receive patients from ambulance units coordinated by the Tokyo Fire Department. Of 15,061 patients diagnosed as having AAD and AMI, 3,195 with chest pain within 2 hours after symptom onset (537 AAD and 2,658 AMI) were examined. The patients with out-of-hospital cardiac arrest were excluded. We compared the clinical data of the patients with chest pain who were diagnosed as having AAD and AMI. The following indicators were more frequent or had higher values among those with AAD: female sex (38% vs. 20%, P&amp;lt;0.001), systolic blood pressures (SBPs) at the time of first contact by the emergency crew (142 mmHg vs. 127 mmHg), back pain in addition to chest pain (54% vs. 5%, P&amp;lt;0.001), history of hypertension (73% vs. 58%, P&amp;lt;0.001), SBP ≥150 mmHg (39% vs. 22%, P&amp;lt;0.001), back pain combined with SBP ≥150 mmHg (23% vs. 0.8%, P&amp;lt;0.001), and back pain with SBP &amp;lt;90 mmHg (4.5% vs. 0.1%, P&amp;lt;0.001). The following data were less frequently observed among those with AAD: diabetes mellitus (7% vs. 28%, P&amp;lt;0.001), dyslipidaemia (17% vs. 42%, P&amp;lt;0.001), and history of smoking (48% vs. 61%, P&amp;lt;0.001). The multivariate regression analysis suggested that back pain with SBP ≥150 mmHg (odds ratio [OR] 47; 95% confidence interval [CI] 28–77; P&amp;lt;0.001), back pain with SBP &amp;lt;90 mmHg (OR 68, 95% CI 16–297, P&amp;lt;0.001), and history of smoking (OR 0.49, 95% CI 0.38–0.63, P&amp;lt;0.001) were the independent markers of AAD. The sensitivity and specificity of back pain with SBPs of ≥150 mmHg and back pain with SBPs &amp;lt;90 mmHg for detecting AAD were 23% and 99%, and 4% and 99%, respectively. In patients with chest pain suspicious of AAD and AMI, “back pain accompanied by chest pain with SBP ≥150 mmHg” or “back pain accompanied by chest pain with SBP &amp;lt;90 mmH” is a reliable diagnostic marker of AAD with high specificity, although the sensitivity was low. The two SBP values with back pain are markers that may be useful for the ambulance crew at their first contact with patients with chest pain. Funding Acknowledgement Type of funding source: None

Predictors of in-hospital mortality in patients with acute myocardial infarction due to unprotected left main trunk lesion: insight from the Tokyo Cardiovascular Care Unit network multicenter registry

Abstract Background Acute myocardial infarction (AMI) due to unprotected left main trunk (LMT) lesion remains a clinical challenge because it requires prompt and efficient revascularization in catastrophic clinical presentation. However, predictors of in-hospital prognosis in patients with LMT-AMI are still not fully understood. Purpose To examine the predictors of in-hospital mortality in patients with LMT-AMI. Methods From 20,257 AMI patients in the Tokyo Cardiovascular Care Unit network registry (comprising 72 hospitals) from 2013 to 2017, we identified 371 (1.8%) eligible LMT-AMI patients without a history of coronary artery bypass grafting (CABG) and divided them into two groups: 254 survivors and 117 non-survivors. Measured variables included patient demographics, vital signs, laboratory data on admission, and in-hospital treatment. The outcome was in-hospital mortality. We performed a multivariable logistic regression analysis for in-hospital mortality with adjustment for the following 9 potential confounders, based on previous studies: (1) age, (2) sex, (3) Killip class, (4) ST elevation, (5) wide QRS (&amp;gt;120 msec), (6) the Thrombolysis in Myocardial Infarction (TIMI) grade on initial coronary angiography, (7) number of vessels with significant stenosis other than LMT, (8) renal dysfunction on admission, and (9) plasma glucose on admission. Results Overall, mean age was 70.6±11.8 years and 81.9% were male. ST-elevation myocardial infarction accounted for 61.8%. Cardiac arrest was observed in 102 (33.6%) patients. Percutaneous coronary intervention and CABG were performed in 302 (81.8%) and 63 (17.0%) patients, respectively. Intra-aortic balloon pumping and veno-arterial extracorporeal membranous oxygenation were used in 288 (77.8%) and 81 (21.9%) patients, respectively. In-hospital mortality was 31.5%. Multivariable logistic regression analysis showed that higher in-hospital mortality was significantly associated with Killip class IV (adjusted odds ratio 3.41 [95% confidence interval 1.36–8.56]; reference: Killip I), TIMI grade 0 (3.51 [1.22–10.14]; reference: TIMI grade 3), renal dysfunction (estimated glomerular filtration &amp;lt;60 mL/min/1.73m2; 6.48 [2.53–16.57]), and high plasma glucose on admission (&amp;gt;150 mg/dl; 3.64 [1.33–9.97]). Age, sex, ST-elevation, wide QRS, and multi-vessel disease were not significantly associated with in-hospital mortality. Conclusions LMT-AMI remains life-threatening in the current era of widely available revascularization. Our results showed that haemodynamic compromise, no coronary flow, renal dysfunction, and high plasma glucose on admission were strong predictors of in-hospital mortality after LMT-AMI. Given the high cardiac arrest rate, more aggressive therapeutic measures including mechanical circulatory support may be required to improve the prognosis of LMT-AMI. Funding Acknowledgement Type of funding source: None

Impact of body temperature at admission on inhospital outcomes in patients with takotsubo syndrome: insights from the Tokyo Cardiovascular Care Unit Network Registry.

Takotsubo syndrome occasionally occurs in patients with fever due to underlying diseases. However, the impact of body temperature on inhospital prognosis of patients with takotsubo syndrome remains unknown. Using the patient cohort in the Tokyo Cardiovascular Care Unit Network Registry from 2013 to 2015, we identified 421 eligible patients whose data on body temperature at admission were available and classified them into three groups: high body temperature group (≥37.5°C; n=27), normal body temperature group (36.0-37.4°C; n=319), and low body temperature group (≤35.9°C; n=75). We compared the patient characteristics and inhospital outcomes among the three groups. On admission, the high body temperature group showed a higher proportion of men and preceding physical triggers, higher heart and respiratory rates, and higher C-reactive protein level than the other groups. Inhospital all-cause mortality was significantly higher in the high body temperature group than in the normal or low body temperature group (18.5% vs. 2.2% vs. 4.0%, respectively, P<0.001). Both cardiac mortality (11.1% vs. 1.3% vs. 1.3%, P=0.001) and non-cardiac mortality (7.4% vs. 0.9% vs. 2.7%, P=0.031) were also significantly higher in the high body temperature group. Multivariable logistic regression analysis showed that high body temperature (reference: normal body temperature) was significantly associated with higher inhospital mortality (adjusted odds ratio 4.22; 95% confidence interval 1.15-15.51; P=0.030). Our findings suggest that high body temperature at admission is a strong predictor of inhospital mortality in patients with takotsubo syndrome. Febrile takotsubo syndrome patients may need to be managed with recognition of life-threatening conditions from the time of diagnosis, no matter what the causes of fever are.

Permanent pacemaker implantation and its predictors in patients admitted for complete atrioventricular block: a report from the Tokyo Cardiovascular Care Unit Network multi-center registry.

Little is known about the permanent pacemaker implantation rate and predictors of permanent pacemaker implantation in patients admitted for complete atrioventricular block (cAVB). The present study was a retrospective analysis based on a multicenter cohort of 797 patients with cAVB (mean age: 79.6 ± 10.7 years; males: 48.4%) registered with the Tokyo Cardiovascular Care Unit Network multicenter registry between 2013 and 2016. Secondary cAVB due to acute coronary syndrome was excluded. The permanent pacemaker implantation rate was 82.9%. Multivariable logistic regression analysis revealed that systolic blood pressure (SBP) > 140 mmHg [odds ratio (OR) 2.10; 95% confidence interval (CI) 1.38-3.22; P < 0.001], male gender (OR 1.63; 95% CI 1.07-2.49; P = 0.023), and left ventricular ejection fraction (LVEF) ≥ 50% (OR 2.19; 95% CI 1.16-2.06; P = 0.016) were predictors of permanent pacemaker implantation while pre-admission β-blocker use (OR 0.28; 95% CI 0.17-0.47; P < 0.001) was associated with a lower risk of permanent pacemaker implantation. Reversible cAVB was not rare in patients admitted for cAVB. Data on SBP on admission, gender, LVEF, and pre-admission β-blocker use may be important for assessing the requirement for permanent pacemaker implantation in the emergency care setting.

Impact of Trigger on Outcome of Takotsubo Syndrome　- Multi-Center Registry From Tokyo Cardiovascular Care Unit Network.

Background: The relationship between outcome and trigger in takotsubo syndrome (TTS) has been recently discussed, but the data are still limited.Methods and Results: We enrolled 745 consecutive patients with TTS from the Tokyo Cardiovascular Care Unit Network registry. The patients were divided into 4 groups based on trigger: (1) medical illness, 202 (27%); (2) physical activity, trauma and injury, 54 (7%); (3) emotional trigger, 199 (27%); and (4) unidentifiable trigger, 290 (39%). Compared with other groups, the medical illness group had the lowest percentage of female patients (68%, 85%, 89%, and 79%, respectively; P<0.001) and the highest mean patient age (75±11 years, 72±11, 73±12, and 75±11 years, respectively; P=0.02). In-hospital all-cause mortality was higher (11%) in this group (0%, 2%, and 2%, respectively; P<0.001). On multivariate logistic regression analysis, the medical illness group independently predicted all-cause death (OR, 4.73; 95% CI: 1.33–16.87); although there was no significant difference in cardiac deaths between the 4 groups.Conclusions: TTS has a wide spectrum of outcome depending on the trigger. The medical illness trigger was a powerful predictor of outcome but the main cause of death is not cardiac complication.

P2622Use of intravenous vasodilators in patients hospitalized with acute heart failure: insights from Tokyo cardiovascular care unit network database

Abstract Background Despite recommendations from clinical practice guidelines, there is scant evidence confirming the effects of vasodilators on clinical outcomes in patients with acute heart failure (AHF). Purpose We sought to investigate the effects of intravenous vasodilators on clinical outcomes and to identify the potential patient populations that would benefit from its use. Methods Data of 26 212 consecutive patients urgently hospitalized for AHF between 2009 and 2015 were extracted from a multicenter data registration system (Tokyo Cardiovascular Care Unit Network Database, including 72 institutions within the Tokyo metropolitan area in Japan). Patients who did not present with typical AHF episodes, including those without pulmonary congestion on physical and/or chest X-ray and serum B-type natriuretic peptide level &lt;500 pg/ml, as well as those who had hypotension and/or hypoperfusion (systolic blood pressure [SBP] &lt;100 mmHg) as dominant presentation, were excluded. Propensity scores were calculated with multiple imputation and 1:1 matching performed between patients with and without vasodilators. The primary endpoint was in-hospital mortality and the secondary endpoints were length of intensive/cardiovascular care unit (ICU/CCU) stay and hospital stay. Results Overall, 8 863 patients were included in the present analysis; they were predominantly male (57%) with a median age of 79 (interquartile range: 70–86) years. Compared with the group without vasodilator use, the vasodilator group had higher SBPs and heart rates and higher frequency of assisted ventilation use, but lower frequency of intravenous diuretics use. After propensity score matching, there were no significant differences in in-hospital mortality rates (7.8% vs. 8.9% in patients without vasodilators, p=0.16) or in length of ICU/CCU stay (5.8 days vs. 5.4 days, p=0.44) and hospital stay (22.7 days vs. 23.8 days, p=0.22) between the groups. However, in subgroup analyses, favorable impacts of vasodilator use on in-hospital mortality were observed among patients who had higher SBPs and among those who had no atrial fibrillation upon admission (Figure). In addition, vasodilators were likely to be more effective in AHF patients with SBP increasing; while levels below 140 mmHg of SBP appeared to be associated with an increased risk for mortality among patients treated with vasodilators compared with those without vasodilators. Figure 1 Conclusions In patients with AHF, vasodilator use was not universally associated with improved in-hospital outcomes; however, its effect was dependent of individual clinical presentation. Detailed phenotyping might aid tailoring of treatment strategies for patients with AHF. Acknowledgement/Funding the Tokyo Metropolitan Government

Differences in Initial Electrocardiographic Findings of Apical Takotsubo Syndrome According to the Time from Symptom Onset

No previous study has examined the differences in patient characteristics and initial electrocardiographic findings of Takotsubo syndrome (TTS) according to the time from onset to electrocardiography. Using the Tokyo Cardiovascular Care Unit network registry 2011-2012, we retrospectively identified 106 apical TTS patients in whom symptom onset time was specified, and classified the patients into 5 groups according to the time from onset to the initial electrocardiography: <3 hours (n = 45), 3 to 6 hours (n = 20), 6 to 12 hours (n = 12), 12 to 24 hours (n = 13), and ≥24 hours (n = 16). There was no significant difference across the groups in age, gender, symptoms, triggers, vital signs, blood tests, or in-hospital outcomes. In the electrocardiographic findings, ST-elevation was more frequent in leads V2-V4 than in the other leads, especially in the <24 hour groups, but did not differ significantly across groups. T-wave inversion was more frequent in leads V3-V6, especially in the ≥24 hour group, and differed significantly across groups. The total number of leads with T-wave inversion was significantly larger in the ≥24 hour group than in the <24 hour groups (mean, 5.9 leads vs 1.5 to 2.9 leads; p < 0.001). Isolated ST-elevation was the most frequent pattern of ST-T change in precordial leads (42% to 56%) in the <24 hour groups, while isolated T-wave inversion was the most frequent (44%) in the ≥24 hour group (p = 0.018). Neither ST-elevation nor T-wave inversion was observed in precordial leads in 10 (9%) patients. In conclusion, our results suggest that the initial electrocardiographic findings of apical TTS are affected by the time from onset to electrocardiography and display a wide variation in ST-T changes.

Gender Differences Among Patients With Acute Pulmonary Embolism

Gender differences in patients with acute pulmonary embolism (APE) remain unclear and controversial. We aimed to understand the gender differences in patients with APE treated in the cardiovascular care units. The registry database of 1,428 patients with APE treated at the Tokyo cardiovascular care unit Network institutions from 2010 to 2014 was retrieved for analysis. In all, 795 women (55.7%) and 633 men (44.3%) were included in this study. The women were older than men (68.0 ± 16.1 vs 60.9 ± 15.6 years, p < 0.0001). Compared with men, women had more complaints of dyspnea and disturbed consciousness, lesser complaints of leg symptoms, and chest pain. Pulmonary arterial systolic pressure (51.5 ± 22.2 mm Hg vs 47.4 ± 22.4 mm Hg, p = 0.012) and the serum B-type natriuretic peptide level (180.4 [50.7 to 526.1] pg/ml vs 107.0 [25.0 to 306.8] pg/ml, p < 0.0001) on admission, was higher in women than in men. Severe cases with massive embolism were seen more in women compared with men (14.6% vs 9.2%, p = 0.0002). The use of inferior vena cava filters were lower in women than in men (31.9% vs 37.3%, p = 0.029). Furthermore, 30-day PE-related mortality was higher in women than in men significantly (5.0% vs 2.8%, p = 0.043). In conclusion, women APE patients were older with higher severity than men APE patients, resulting in poor prognosis.

Apical Takotsubo syndrome versus anterior acute myocardial infarction: findings from the Tokyo Cardiovascular Care Unit network registry.

Although the typical apical form of Takotsubo syndrome and anterior acute myocardial infarction have similar electrocardiographic and echocardiographic presentations, data on the clinical differences between the two disorders are limited. Using the Tokyo Cardiovascular Care Unit network registry, we identified patients hospitalised with apical Takotsubo syndrome ( n=540; 2010-2014) or anterior acute myocardial infarction ( n=2,806; 2013-2014) and created 522 age and sex-matched pairs (mean age 74.1 years; women 78.5%). We compared the clinical characteristics and inhospital outcomes between the two groups. On admission, patients with apical Takotsubo syndrome showed a lower body mass index, less frequent chest pain/tightness, lower systolic blood pressure, higher heart rate, lower creatine kinase, higher C-reactive protein and brain natriuretic peptide, and less frequent ST-elevation than patients with anterior acute myocardial infarction. Patients with apical Takotsubo syndrome received catecholamine (12.8% vs. 24.5%, P<0.001) and intra-aortic balloon pumping (5.9% vs. 15.1%, P<0.001) less frequently. Despite similar all-cause mortality (5.4% vs. 7.9%, P=0.134), patients with apical Takotsubo syndrome showed lower cardiac mortality (2.1% vs. 6.7%, P<0.001; risk difference -4.6% (95% confidence interval -7.1% to -2.1%)) but higher non-cardiac mortality (3.3% vs. 1.1%, P=0.033; 2.1% (0.3%-3.9%)). In subgroup comparisons, patients with physically triggered Takotsubo syndrome had higher non-cardiac mortality (7.0%) than those with non-physically triggered Takotsubo syndrome (1.2%, P=0.001) or anterior acute myocardial infarction (1.1%, P<0.001). This study found that cardiac and non-cardiac mortality risks differed significantly between apical Takotsubo syndrome and anterior acute myocardial infarction. Our findings underscore the importance of differentiating between the two disorders for appropriate management.

In-hospital mortality analysis of Japanese patients with acute coronary syndrome using the Tokyo CCU Network database: Applicability of the GRACE risk score

BackgroundThe GRACE risk score was developed to predict in-hospital mortality for acute coronary syndrome (ACS) using multinational registries, but did not include Japanese data. Therefore, GRACE risk scores are not extensively used in Japan. The present study aimed to evaluate the relationship between the GRACE risk score and in-hospital mortality among Japanese patients with ACS using the Tokyo CCU (cardiovascular care unit) Network Database. Methods and resultsA total of 9460 patients with ACS hospitalized at 67 Tokyo CCUs between January 2011 and December 2013 were retrospectively reviewed and GRACE risk scores were calculated. Patients in the Tokyo CCU Network database had more severe conditions compared to those of the original GRACE study. There was a strong correlation between the GRACE risk score and in-hospital mortality for patients with ST-segment elevation myocardial infarction (STEMI) or non ST-segment elevation myocardial infarction (NSTEMI) (r=0.99, p<0.001); however, the correlation was not significant for patients with unstable angina (r=0.35, p=0.126). For STEMI+NSTEMI patients, the discrimination ability of the GRACE risk score was excellent, with a c statistic of 0.87 (95% confidence interval, 0.86–0.89). ConclusionsThe GRACE risk score is a good predictor of in-hospital mortality for Japanese patients with STEMI or NSTEMI, and can help clinicians stratify patients by risk for optimal patient triage and early treatment management.

P3663Influence of weather condition on the occurrence of unstable angina pectoris in Japan (from the Tokyo cardiovascular care unit network)

P3663Influence of weather condition on the occurrence of unstable angina pectoris in Japan (from the Tokyo cardiovascular care unit network)

Seasonal Changes in Hospital Admissions for Pulmonary Embolism in Metropolitan Areas of Tokyo (from the Tokyo Cardiovascular Care Unit Network)

Although several studies have shown the relation between temperature/atmospheric pressure and pulmonary embolism (PE), their results are inconsistent. Furthermore, diurnal temperature range (DTR) and diurnal pressure range (DPR) were not fully evaluated for their associations with hospital admissions for PE. Study subjects comprised cases of 1,148 PE treated at institutions belonging to the Tokyo Cardiovascular Care Unit Network from January 2005 to December 2012. Patient data were combined with a variety of daily local climate parameters obtained from the Japan Meteorological Agency. Every 1°C increase in the DTR at lag0 corresponded to an increased relative risk of hospital admission for PE (odds ratio [OR] 1.036, 95% confidence interval [CI] 1.003 to 1.070). In the cooler season (November to April), an increase of 1 hPa (barometric pressure) in the DPR at lag4 and lag5 was associated with an increased relative risk of hospital admission for PE (OR 1.042, 95% CI 1.007 to 1.077 and OR 0.952, 95% CI 0.914 to 0.992, respectively). An increase in the PE hospitalization rate was seen only in the cool season. Using a metropolitan database, we showed that DTR and DPR have different impacts on hospital admissions for PE. In conclusion, we found that an increase in the DTR increases the PE hospitalization rate, especially during the cooler season. The impact of DTR and DPR on PE incidence and related hospitalizations needs to be further evaluated.