BACKGROUND:Heart failure with preserved ejection fraction (HFpEF) is more prevalent in aging societies and remains challenging to diagnose in primary care. The BREATH2 score is a screening tool for diagnosing HFpEF in Japanese primary care settings. However, its broader utility and association with cardiac outcomes are unclear. OBJECTIVES:This study aimed to evaluate the diagnostic utility of the BREATH2 score for HFpEF and its prognostic value for cardiac event. METHODS:This retrospective, single-center study examined 234 patients (median age 73 years; 25.6% female) with a left ventricular ejection fraction ≥ 50%. HFpEF was diagnosed using the HFA-PEFF algorithm. The BREATH2 scores were categorized as low (≤ 3), intermediate (4-5), or high (≥ 6) risk. Defined cardiac event was either cardiac death or HF hospitalization. RESULTS:HFpEF prevalence rose progressively with the BREATH2 score, with 10.5% of participants in the low-, 38.6% in the intermediate-, and 70.3% in the high-risk groups. The BREATH2 score discriminated HFpEF from non-HFpEF better than the H₂FPEF score (AUC 0.81 vs. 0.69, P < 0.001). During the median follow-up period of 287 days, 17 (7.3%) patients experienced first cardiac event. Each 1-point increase in the BREATH2 score was associated with increased risk of a cardiac event (Hazard ratio 1.94, P < 0.001), independent of H₂FPEF or HFA-PEFF scores. Kaplan-Meier analysis demonstrated increasing cardiac event as the BREATH2 score increased. CONCLUSIONS:The BREATH2 score was associated with HFpEF and more cardiac event, suggesting possible utility as a screening tool in primary care.

Objective Frailty is common in patients with heart failure (HF). Given that gardening demands regular physical activity and offers therapeutic relaxation benefits, this activity may reduce frailty. We investigated the association between gardening activities and frailty in patients with HF. Methods Between August 2022 and March 2023, we surveyed patients at risk of HF and those with HF who regularly attended a cardiology outpatient clinic. Gardening activities were defined as the ongoing cultivation of flowers, vegetables, or fruits for more than a year. The questionnaire assessed the presence or absence of gardening activities as well as the frequency, duration per session, years of experience, and scale of such activities. We calculated the frailty index. Frailty was defined as a frailty index of 0.25 or greater. Results Of the 1,277 respondents, 69% engaged in gardening and 35% were frail. After adjusting for multiple confounding factors, gardening activities showed an inverse association with frailty [odds ratio=0.723, 95% confidence interval (0.533-0.981)]. Moreover, frailty and the frailty index showed an inverse association with more extended and large-scale gardening activities. Conclusion Gardening activities were thus found to be associated with a low prevalence of frailty in patients with HF.

PURPOSE:Exercise-induced pulmonary hypertension (EIPH), assessed using exercise stress echocardiography (ESE), is important in diagnosing early stage of heart failure (HF) with preserved ejection fraction (EF) and affects exercise tolerance and prognosis. Left atrial (LA) reservoir strain, which reflects the left ventricular filling pressure, is an associated factor with HF. This study aimed to investigate the association between the LA reservoir strain at rest and EIPH. METHODS:This retrospective analysis included 188 participants with a left ventricular EF ≥ 50% who underwent ESE. EIPH was defined as a peak tricuspid regurgitation (TR) pressure gradient >50 mm Hg. HF events (HF hospitalization or diuretic use with brain natriuretic peptide ≥100 pg/mL) were evaluated in patients with ≥3 months follow-up. RESULTS:Thirty-four (18.1%) patients were diagnosed with EIPH. LA reservoir strain at rest with an optimal cutoff value of 21% identified patients, with 73% sensitivity and 59% specificity. The multivariate logistic regression analysis indicated that LA reservoir strain was independently associated with EIPH. Furthermore, adding LA reservoir strain to the TR-velocity significantly improved EIPH discrimination. During a median follow-up period of 336 days, 29 patients (21.6%) experienced HF events. The hazard ratio for HF events in patients with LA reservoir strain ≤21% was 4.04 after adjusting for age and HFA-PEFF score (95% confidence interval, 1.29-12.7). CONCLUSION:LA reservoir strain at rest was associated with EIPH and HF events in patients with preserved EF, suggesting that impaired LA reservoir strain could increase the risk of HF.

Tricuspid annular enlargement in patients with atrial fibrillation (AF) can induce tricuspid regurgitation (TR). However, risk factors associated with TR progression in patients with AF have not been defined. This study aimed to clarify an association between tricuspid annular diameter (TAD) and TR progression in patients with longstanding persistent AF. We retrospectively analyzed data from 228 patients who had longstanding persistent AF for > 1 year and mild or less TR on baseline echocardiograms. We defined significant TR as moderate or greater TR, graded according to the jet area and vena contracta. The optimal cut-off value of the TAD index (TADI), based on body surface area for predicting progression to significant TR, was estimated using receiver operating characteristic (ROC) curves. The independence and incremental value of the TADI were evaluated using multivariate Cox proportional hazard regression analysis and likelihood ratio tests. Over a median follow-up of 3.7 years, 55 (24.1

Background: Exercise intolerance in patients with heart failure (HF) increases HF-associated readmission, and right ventricular (RV) contractile reserve assessed by low-load exercise stress echocardiography (ESE) is associ-ated with exercise intolerance. This study investigated the impact of RV contractile reserve evaluated by low-load ESE on HF readmission.Methods: We prospectively examined 81 consecutive patients hospitalized for HF who underwent low-load ESE under a stabilized HF condition between May 2018 and September 2020. We performed a 25-W low-load ESE and defined RV contractile reserve as the increment in RV systolic velocity (RV s '). The primary outcome was hos -pital readmission. Incremental values of the change in RV s ' over a readmission risk (RR) score were analyzed using the receiver operating characteristic (ROC) area under the curve; internal validation using bootstrapping was performed. The association between RV contractile reserve and HF readmission was illustrated with the Kaplan-Meier curve.Results: Eighteen (22 %) patients were readmitted due to worsening HF during the observation period (median 15.6 months). The cut-off value of 0.68 cm/s for the change in RV s ' to predict HF readmission with the ROC curve analysis indicated good sensitivity (100 %) and specificity (76.2 %). The discriminatory ability for HF read-mission was significantly improved by adding the change in RV s ' to the RR score (p = 0.006), and the c-statistic using the bootstrap method was 0.92. The cumulative survival rate free of HF readmission was significantly lower in patients with reduced-RV contractile reserve (log-rank test, p < 0.001).Conclusions: The change in RV s ' during low-load exercise had an incremental prognostic value for predicting HF readmission. The results demonstrated the loss of RV contractile reserve assessed by low-load ESE was associated with HF readmission.(c) 2023 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

The slow flow phenomenon is a critical complication during percutaneous coronary intervention (PCI) that leads to poor outcomes. We aimed to evaluate the mechanisms underlying the slow flow phenomenon using intravascular ultrasound (IVUS). We retrospectively analyzed IVUS data from 62 lesions in 58 consecutive patients who experienced the slow flow phenomenon during PCI. IVUS was performed immediately after the development of the slow flow phenomenon to assess its cause. No IVUS-based evidence of mechanical obstruction was categorized as distal embolization. Distal embolization was observed in 46 lesions (74%). The slow flow phenomenon occurred in all these lesions after stent implantation. In addition to distal embolization, three different mechanisms underlying the induction of the slow flow phenomenon due to mechanical obstructions (16 lesions, 26%) were detected on IVUS, namely, medial dissection/hematoma (6 lesions), intimal flap (6 lesions), and thrombus obstruction (4 lesions). Most mechanical obstructions (13 lesions, 81%) could not be identified by angiography alone. In 15/16 lesions (94%) with mechanical obstruction, deteriorated flow improved immediately after balloon dilatation or bail-out stent implantation, although intracoronary vasodilator administration could not reestablish coronary flow. The frequency of mechanical obstruction as the cause of the slow flow phenomenon was relatively high. Given the difficulty in angiographical differentiation, IVUS-guided management of slow flow may be a useful strategy.

Abstract Background In Japan, ivabradine is indicated in patients with heart failure (HF) with sinus rhythm and a resting heart rate (HR) ≥75/min under standard treatment. Particularly, it is effective for HF with reduced left ventricular ejection fraction (LVEF). However, elderly people have a higher incidence of atrial fibrillation than young people, and their sinus node function is further deteriorated, resulting in a lower intrinsic HR. In addition, Japan is an ultra-aging society, especially in the countryside; therefore, the target patients for ivabradine may be limited in these regions. Purpose We sought to estimate the possible candidates for ivabradine and investigate their clinical characteristics in our hospital located in rural Japan. Method and results We retrospectively studied 14733 consecutive patients who were suspected heart disease who underwent echocardiography between January 2006 and October 2018 in Kitaishikai Hospital located in Ozu city (Proportion of the population aged ≥65 years: 34%, in 2015) and did not take ivabradine treatment. Of these, 187 patients with hemodynamically stable condition whose E/A ratio was measured and met the criteria of LVEF <40% and HR ≥75 /min were confirmed. Of these, 153 patients reached HR <75 /min with additional intensive medication within one year after the index echocardiography (Controlled group; mean HR: 82 to 62/min). The remaining 34 patients with uncontrolled HR (Uncontrolled group; mean HR: 84 to 82/min) were considered possible candidates for ivabradine (34/14733: 0.23%, 2.6 patients per year; median age, 74 years; male, 56%; median LVEF, 32%; ischemic cardiomyopathy, 53%). In the comparison of clinical and echocardiographic parameters in these two groups, Uncontrolled group had a significantly smaller left ventricular diastolic volume index (71 [59–85] vs 82 [66–109] /ml/m2, p=0.02), left ventricular systolic volume index (50 [39–59] vs 59 [42–80] / ml/m2, p=0.04), stroke volume index (22 [18–26] vs 26 [20–32] /ml/m2, p=0.02), left atrial volume index (47 [40–64] vs 59 [45–71] /ml/m2, p=0.02), and more hemodialysis (12 vs 3%, p=0.04) than Controlled group. However, the discrimination ability of these parameters for identifying Uncontrolled group was modest (Figure). Conclusion In rural Japan, possible candidates for ivabradine may be rare, so daily attention should be paid. Patients with reduced ejection fraction, small left ventricle, and hemodialysis may be the possible targets for this therapy. Funding Acknowledgement Type of funding sources: None.

A 66-year-old man was referred to our hospital due to effort angina. His electrocardiogram (ECG) showed broad ST-segment depression, and high-sensitivity cardiac troponin I level was significantly increased, indicating non–ST-segment elevation acute coronary syndrome (ACS). Emergent coronary

BACKGROUNDS:The relative apical sparing pattern (RASP) of left ventricular (LV) longitudinal strain (LS) is frequently associated with cardiac amyloidosis (CA). However, the visual assessment of RASP is inconsistent, and the quantitative assessment of RASP is time-consuming. This study aimed to compare assessments of RASP for the identification of CA with conventional assessments and investigate their reproducibility and relevance on the assessments.METHODS:Forty patients with biopsy-proven CA were compared with 80 hypertrophied patients matched for mean LV wall thickness. We compared the discriminative abilities of three assessments of RASP to identify CA (visual, quantitative, and semiquantitative). Nine patterns of semiquantitative RASP were investigated; finally, it was defined as "reduction of LS" (≥ -10%) in ≥5 (of 6) basal segments, relative to "preserved LS" (< -15%) in at least one apical segment.RESULTS:The concordance between the two observers for visual RASP was modest (κ = 0.65). On the other hand, the consistency for semiquantitative RASP was perfect (κ = 1.00). The discriminative ability of semiquantitative RASP (area under the curve [AUC]  = 0.74) was significantly better than that of visual RASP (AUC = 0.65) and equivalent to that of binary quantitative RASP.CONCLUSION:Semiquantitative RASP assessment is reproducible and accurately discriminates CA. This simple assessment may help readily refine the risk stratification of patients with diffuse LV hypertrophy.

BackgroundsThe relative apical sparing pattern (RASP) of left ventricular (LV) longitudinal strain (LS) is frequently associated with cardiac amyloidosis. Elderly patients with aortic valve stenosis (AS) complicated by transthyretin amyloid cardiomyopathy have poor prognosis. Furthermore, deteriorated basal LS in AS patients has been reported to be associated with adverse outcome. We investigated the association between RASP and outcomes in patients with severe AS.MethodsWe retrospectively studied 156 consecutive patients with severe AS and preserved LV ejection fraction. RASP was assessed by both of semi-quantitative (sRASP) and quantitative (qRASP) methods. sRASP was defined as a deterioration of LS (≥-10%) in ≥ 5 (of 6) basal segments, relative to preserved LS (<-15%) in at least 1 apical segment. qRASP was calculated using the following formula: average apical LS/(average basal LS + average mid-ventricle LS); qRASP ≥ 1 was defined as positive. Patients were followed up to determine outcomes, which included sudden cardiac death or unexpected admission due to heart failure, over a median of 1.9 years.ResultssRASP and qRASP were assessed in all patients, but 24 and 42 patients fulfilled the criteria for sRASP and qRASP, respectively. Both assessments were significantly associated with outcomes (n = 44; 28%). Furthermore, sRASP was significantly associated with outcome after adjusting for EuroSCORE, NYHA ≥ II, or global longitudinal strain. A model based on these covariates for predicting outcomes significantly improved by adding sRASP.ConclusionRASP is observed in some patients with severe AS and provides additive prognostic information over conventional parameters.

Patients with generalized left ventricular hypertrophy (LVH) frequently have overlapping conditions which could complicate diagnosis and prognosis. The relative apical sparing pattern (RASP) of left ventricular longitudinal strain (LS) is determined on the strain polar map while measuring global

Patients with generalized left ventricular hypertrophy (LVH) frequently have overlapping conditions which could complicate diagnosis and prognosis. The relative apical sparing pattern (RASP) of left ventricular longitudinal strain (LS) is determined on the strain polar map while measuring global

Abstract Background The relative apical sparing pattern (RASP) of left ventricular longitudinal strain (LS) is determined on the strain polar map, while global longitudinal strain (GLS) is measured using speckle-tracking echocardiography and is frequently associated with cardiac amyloidosis (CA). According to recent reports, some elderly patients with aortic stenosis (AS) suffer from transthyretin CA and have a poor prognosis. Accordingly, we aimed to investigate the association of RASP and outcome of patients with severe AS. Methods We retrospectively studied 157 consecutive patients (age: 81±10 years, 33% men) with severe AS (mean transaortic pressure gradient: 49 mmHg) and preserved ejection fraction (>50%). After measuring GLS, RASP was semi-quantitatively and quantitatively assessed. Semi-quantitative RASP (sRASP) was defined as reduction of LS (more than −10%), showing light red or blue in ≥5 segments out of the basal six segments, relative to apical LS (less than −15%) showing red. This analysis was independently performed in a blinded manner by two observers. Quantitative RASP (qRASP) was calculated using the following formula: average apical LS/(average basal LS + average mid-ventricle LS), then qRASP ≥1 was determined as positive according to the previous paper. Patients were followed up to determine their outcomes, i.e., sudden cardiac death or unexpected admission due to heart failure over a median duration of 1.9 years. Concordance of sRASP was assessed using the kappa statistic, and a Cox proportional hazards model was used to assess the association between the parameters and primary outcome. Results The consistency in the observations of the two sonographers in identifying sRASP was found to be excellent (κ = 1.00). sRASP and qRASP were observed in 24 (15%) and 42 (27%) patients, respectively, and were significantly associated with the primary outcome (n=44; 28%). The representative case is shown in figure (left panel). Further, positive sRASP was associated with the outcome after adjusting for the Euro score, NYHA ≥II, and GLS (hazard ratio = 2.69, p=0.01). The model based on these covariates significantly improved following the addition of sRASP (Figure; right panel). In addition, sRASP was observed in four patients out of 50 patients who underwent aortic valve replacement. Of these, one patient had the primary outcome (25%). On the other hand, in the remaining 46 patients without sRASP, four patients had the outcome (9%). Figure 1 Conclusions RASP was observed in some patients with severe AS and has been shown to have increasing importance in predicting adverse cardiac events in such patients.

Introduction: Slow/no-reflow phenomenon is a critical complication during PCI that leads to poor outcomes. Distal embolization is a known major contributing factor of slow/no-reflow phenomenon. Fur...

The relative apical sparing pattern (RASP) of left ventricular longitudinal strain (LS) is determined using a strain polar map, while global longitudinal strain is measured using speckle-tracking echocardiography, and it is frequently associated with cardiac amyloidosis (CA). However, the definition of visual RASP is ambiguous, and this leads to insufficient reproducibility, whereas quantitative RASP takes time and leads to difficulty in the clinical application. Generally, amyloid predominantly accumulates in the endo-myocardial layer. As such, layer-specific analysis of RASP may more accurately identify CA. Therefore, the aims of this study were to explore the reproducible and easy definition of RASP for identifying CA and investigate the effect of layer-specific analysis on the assessment. A total of 40 patients with CA diagnosed by biopsy and technetium pyrophosphate scintigraphy were compared with 120 control patients matched for mean left ventricular wall thickness (40 aortic stenosis, 40 hypertrophic cardiomyopathy, and 40 hypertensive heart disease). We compared the discriminative abilities of three definitions of RASP (visual, quantitative, and semi-quantitative). According to a previous paper, visual RASP was defined as visual reduction of LS in the basal and middle LS segments (light red or blue) relative to the apical LS (red). Quantitative RASP was calculated using the following formula: average apical LS/(average basal LS + average mid-ventricle LS), then binarized by the optimal cut-off value for predicting CA. Semi-quantitative RASP was defined as reduction of LS (≥-10%) in five or more segments out of the basal six segments, relative to apical LS (≤-15%). Sample cases are shown in Figure (left). Visual and semi-quantitative RASP were independently assessed by two blinded sonographers. The RASP at the endo-myocardial and all layers was evaluated using customized software. The concordance was assessed using the kappa statistic, whereas the discriminative ability was assessed using receiver operating characteristic curve analysis. The concordance of visual RASP was modest but its semi-quantitative RASP was perfect (Table right). The discriminative ability of semi-quantitative RASP at each layer was significantly better than that of visual RASP and close to that of the binary quantitative RASP. Additionally, the discriminative abilities of visual (p=0.10) and semi-quantitative (p=0.11) RASP at the endo-myocardial layer appeared to be better than those at all layers. The assessment method of semi-quantitative RASP is easy and highly reproducible. Furthermore, it accurately discriminates CA. In addition, assessment at the endo-myocardial layer potentially improves the discriminative ability.

Background: Lesions in the proximal left coronary artery (LCA) are associated with a poor prognosis compared with other lesional sites. Transthoracic Doppler echocardiography (TTDE) can help to detect proximal LCA flow, and an accelerated coronary flow velocity (CFV) indicates the presence of proximal LCA lesions. This study aimed to investigate the prognostic value of CFV in the proximal LCA measured by TTDE. Methods: We enrolled 1472 consecutive hemodynamically stable patients with known or suspected heart disease whose CFV was successfully detected using TTDE accompanied by routine echocardiography between 2008 and 2011. The primary outcome was cardiac death (acute myocardial infarction, heart failure, or sudden cardiac death) and patients were followed up over a median of 6.3 years. Results: Overall, 42 cardiac deaths (3%) were observed. An increased CFV was significantly associated with the outcome in several models based on potential confounders (age, rate pressure product, Framingham Risk Score, diabetes, coronary artery disease, hemoglobin, brain natriuretic peptide, estimated glomerular filtration rate, left ventricular mass, left ventricular ejection fraction, and E/e'). Using a receiver operating characteristic curve analysis, the optimal cut-off value for the CFV to the association of the outcome was 37 cm/s (area under the curve, 0.70; sensitivity, 82%; specificity, 62%). In sequential Cox proportional hazards models, the CFV added incremental prognostic information to the clinical and basic echocardiographic parameters (chi-squared: 110.7 to 146.6, P < 0.01). Conclusions: An increased CFV in the proximal LCA was associated with cardiac death, incremental to the clinical and basic echocardiographic parameters. (C) 2018 The Authors. Published by Elsevier B.V.

Objective Mountain districts normally have tougher geographic conditions than plain districts, which might worsen heart failure (HF) conditions in patients. Also, those places frequently are associated with social problems of ageing, underpopulation and fewer medical services, which might cause delay in detection of disease progression and require more admissions. We investigated the association of residence altitude with readmission in patients with HF. Methods We followed 452 patients with HF to determine all-cause readmissions over a median of 1.1 years. The altitude of patient residences, population, proportion of the elderly and number of hospitals or clinics in a minor administrative district (Cho-Aza district) located at the residences were examined using data from the 2010 census and Google Maps. Results All-cause readmissions were observed in 269 (60%) patients. The altitude of ≥200  m was significantly associated with readmissions (HR, 1.49; 95 % CI 1.12 to 1.96; p=0.006) after adjustment for physical and haemodynamic parameters, left ventricular ejection fraction, brain natriuretic peptide and components of the established score for predicting readmission for HF. Altitude was significantly associated with ageing, underpopulation, fewer hospitals or clinics and lower temperature (all p<0.01), with an increased tendency for readmission during the winter season; however, it was not associated with patient clinical parameters. Conclusions High altitude residence may be an important predictor for readmission in patients with HF. This relationship may be confounded by unfavourable sociogeographic conditions at higher altitudes.