Anthracyclines have cardiotoxic side effects. Cardioprotective drugs such as angiotensin-converting enzyme inhibitors and beta-blockers are therefore recommended for patients with anthracycline-induced cardiomyopathy. We herein present a 54-year-old woman with recurrent metastatic breast cancer who developed heart failure (HF) with a left ventricular ejection fraction (LVEF) of 22% after undergoing epirubicin chemotherapy. However, her HF symptoms and low LVEF persisted despite 5 months of cardioprotective therapy and additional oral pimobendan. Pimobendan was discontinued because of ventricular arrhythmia and hypotension. After the start of low-dose (0.125 mg daily) digoxin, her LVEF increased to 42%, and her HF symptoms improved with no adverse events.
Introduction: Urine osmolality (U-OSM) is determined by the balance of water and solutes, antidiuretic hormone, and renal function. U-OSM can be altered in heart failure (HF) patients, and is influenced by multiple factors, including volume status, diuretics, and so on. However, it is not known whether U-OSM is a predictive factor of prognosis among symptomatic HF patients. Hypothesis: The aim of the study is to clarify the impact of U-OSM at discharge according to baseline renal dysfunction on prognosis among symptomatic HF patients. Methods: This study is a sub-analysis from HIJ-HF-III, which is a single center registry that collected prospectively consecutive 1,408 HF patients hospitalized at Tokyo Women’s Medical University from 2015 to 2019. 745 HF patients who were discharged alive and had available data of U-OSM at discharge were included in this study. The primary endpoint is all cause death after discharge. Results: Mean age was 69 +/- 14.8 years old, 60.1 % of the patients were male. 36.3 % of the patients had renal dysfunction. Median U-OSM at discharge was 465 mOsm/l. During the median follow-up period of 20.1 months after discharge, 108 (14.5 %) patients were died. Kaplan-Meier survival analysis showed that low U-OSM at discharge was associated with high mortality among HF patients with renal dysfunction (p=0.049). On the other hand, there was not associated between U-OSM and mortality after discharge among HF patients without renal dysfunction (p=0.944). Multivariate logistic regression showed that low U-OSM at discharge was independently associated with increased the risk of death (hazard ratio [per 1 mOSM/l]: 1003, 95%CI 1.000-1.005, p=0.041) among HF patients with renal dysfunction. Conclusion: Among HF patients with renal dysfunction, low U-OSM at discharge was significantly associated with poor outcome after discharge.
Abstract Background The development of right ventricular (RV)-pulmonary arterial (PA) coupling has resulted in a novel and comprehensive index for evaluating RV function in relation to the underlying RV afterload. In patients with heart failure (HF), it is acknowledged that RV-PA uncoupling are features that are associated with poor outcome. The RV-PA coupling index can be readily assessed non-invasively using the ratio of two standard echocardiographic measurements: tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP). However, few studies have defined the prognostic impact of the TAPSE/PASP ratio in patients with HF and mildly reduced EF (HFmrEF). Methods From the prospective cohort study of 1,410 hospitalized HF patients (age 68+/-15, men 62%) between August 2015 and September 2019, this study enrolled 191 HFmrEF (i.e., left ventricular ejection fraction (LVEF) 41–49%) patients whose TAPSE and PASP were measured during hospitalization and discharged alive. We studied the prognostic impact of TAPSE/PASP ratio on HFmrEF patients using by cut-off value obtained from receiver operating characteristic (ROC) analysis. The primary and secondary endpoints was defined as the all-cause death and HF re-hospitalization after discharge, respectively. Results During median follow-up of 38 [23–52] months, 48 patients (25%) died. The deceased patients had a significantly older (median 75 vs. 71 years, p<0.05), higher rate of ischemic heart disease (50% vs. 23%, p<0.05), elevated brain natriuretic peptide levels (325 vs. 159 pg/ml, p<0.05) and lower rate of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (65% vs. 80%, p<0.05) at discharge. In the ROC analysis, the cut-off value of TAPSE/PASP ratio for mortality was 0.46. Patients with TAPSE/PASP ≤0.46 had a significantly higher all-cause mortality (log-rank p<0.05) and had a tendency of higher rate of HF re-hospitalization than patients with TAPSE/PASP >0.46 (log-rank p=0.06) (Figure). Using multivariate analysis, the lower TAPSE/PASP ratio had an independent predictive value of prognosis in patients with HFmrEF (hazard ratio 2.16, 95% confidence interval; 1.08–3.92, p<0.05) (Table). Conclusion The TAPSE/PASP ratio has a significant prognostic value in patients with HFmrEF. The RV-PA uncoupling assessed by TAPSE/PASP ratio might be useful for risk assessment in patients with HFmrEF.
Abstract Background Patients with heart failure (HF) and low left ventricular ejection fraction (LVEF) are at high risk of sudden cardiac death (SCD). Optimal HF treatment can improve LVEF and reduce the risk of SCD. The aim of this study was to evaluate the incidence and predictors of SCD in Japanese patients with new‐onset systolic HF and to investigate factors that affect LVEF improvement. Methods We retrospectively studied 174 consecutive hospitalized patients with new‐onset HF and LVEF ≤35% (median age, 66 years; men, 71%). The primary outcome was a composite of SCD, sustained ventricular arrhythmias, and appropriate implantable cardioverter‐defibrillator therapy. Results The cumulative rates of meeting of the primary outcome at 3, 12, and 36 months after discharge were 3.9%, 8.1%, and 10.5%, respectively. Atrial fibrillation was a significant predictor of the primary outcome within 12 months after discharge (odds ratio, 5.87; 95% confidence interval [CI], 1.60–21.57). Among 104 patients who completed follow‐up echocardiography within 12 months after discharge, changes in LVEF were inversely associated with SCD (odds ratio/1% increase, 0.78; 95% CI, 0.65–0.93). A QRS duration <130 ms and a B‐type natriuretic peptide level <170 pg/mL were predictors of LVEF improvement to >35% (odds ratio, 3.69; 95% CI, 1.15–11.77; odds ratio, 3.19; 95% CI, 1.33–7.69, respectively). Conclusions Our results showed a high incidence of meeting of the primary outcome within 12 months after discharge in hospitalized patients with new‐onset systolic HF. An improved LVEF may reduce the risk of late SCD.
Abstract Background For patients with severe heart failure (HF) who are not eligible for transplantation, there is destination therapy (DT) that uses a continuous flow left ventricular assist device (LVAD). Implantation of LVAD improves HF and can be expected to improve the prognosis of life. Elderly refractory HF patients with non-responders for cardiac resynchronization therapy (CRT) may benefit from LVAD as DT. In considering indications of LVAD as DT for the elderly in Japan, conditions such as a low risk of Heart Mate Risk Score (HMRS) have been raised. HMRS has been shown to correlate with mortality in the cohort of LVAD patients enrolled in the Heartmate II trials. Purpose Because elderly CRT non-responder refractory HF patients are not indicated for transplantation and may benefit from LVAD as DT in Japan, we aimed to investigate the HMRS and prognosis among elderly CRT non-responders. Methods Of 467 patients underwent CRT implantation between 2000 and 2015, 157 were aged 65–75 years old. Of which 59 patients who could be determined to be non-responders based on echocardiographic data were included in this study. The primary endpoint was all-cause mortality, the secondary was readmission for HF and appropriate implantable cardioverter defibrillator (ICD) therapy. Results The patients' mean age was 68 years, males were 71%. The mean serum creatinine value was 1.1 mg/dl, albumin was 3.8 mg/dl, and BNP was 383 pg/ml. The mean left ventricular ejection fraction (LVEF) was 26%. The subjects were divided into 3 groups according to HMRS. The average of HMRS was 2.2, the low-risk group included 17 (29%) patients, the medium was 22 (37%), and the high was 20 (34%). There was no significant difference in age, LVEF, BNP, and NYHA functional classification at the time of CRT implantation between three groups. In the low-risk group, creatinine and INR were significantly lower, and albumin was significantly higher compared to the high-risk group. BNP tended to be lower in the low-risk group, but there was no significant difference. The mortality rate by HMRS was 12% in the low-risk group, 36% in the medium-risk group, and 50% in the high-risk group. On the Kaplan-Meier analysis, the low-risk group had a significantly lower mortality rate than the high-risk group (Figure). Furthermore, focusing on HF readmission, the rate of readmission was 59% in the low-risk group, 86% in the medium -risk group, and 65% in the high-risk group, and there was no significant difference between three groups. There was also no significant difference in appropriate ICD therapy between three groups. Conclusion Approximately 30% of elderly non-responders of CRT are in the low-risk group by HMRS and their mortality was lower than that of the other two groups. These elderly CRT non-responder patients might be considered a candidate for DT in Japan. Funding Acknowledgement Type of funding sources: None.
