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Review the Guideline of Acute Heart Failure Syndromes in Japan
The 15th Annual Scientific Meeting
JHFS
S131
Symposium 6 S6-1 Revision Points and Remaining Issues to be Solved in the Updated Guidelines for Treatment of Chronic Heart Failure YASUHIRO IKEDA, TOMOKO OHKUSA, MASAFUMI YANO, MASUNORI MATSUZAKI Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine Heart failure (HF) is a leading cause of morbidity and mortality in developed countries and afflicts more than 55 million people in the united states. Patients with chronic HF manifests progressive cardiac dysfunction that is characterized by either reduced systolic and diastolic left ventricular function, or both of it, with ventricular remodeling, arrhythmia, and intracardiac conduction disturbances. A growing body of evidence indicates that combination of pharmacological and non-pharmacological therapies had been significantly contributed to the improved morbidity and mortality of HF in the last decade. Reflecting those advances in HF-therapy, guidelines for treatment of chronic heart failure (JCS2010) has been updated at the end of year 2010. The new version of the guidelines includes updated information for device therapy for cardiac arrhythmia [implantable cardioverter defibllirator (ICD) and ablation therapy], respiratory support therapy for sleep disordered breathing, cardiac resynchronization therapy(CRT) for patients with wide QRS, surgical intervention for severe congestive heart failure, and newly developed left ventricular assist devices. In addition, disease management program and protocols of exercise and Waon therapy for HF patients were revised or newly added into the guideline. In this Symposium, I will review these revision points and remaining issues to be solved for treatment of chronic heart failure.
S6-2 Treatment of Heart Failure with Preserved Ejection Fraction TOHRU MASUYAMA Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
S6-4 The Role of Metabolic Components in Heart Failure in Japan YOSHIHIRO FUKUMOTO1, YUTAKA MIURA1, TOSHIRO MIURA2, KAZUNORI SHIMADA3, HIROYUKI DAIDA3, HIROYUKI TSUTSUI4, MASANORI ASAKURA5, AKIRA YAMADA6, NOBUYUKI SHIBA1, HIROAKI SHIMOKAWA1 1 Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan, 2Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan, 3 Department of Cardiovascular Medicine, Juntendo University School of Medicine, Tokyo, Japan, 4Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan, 5Cardiovascular Division of Internal Medicine, National Cerebral and Cardiovascular Center, Suita, Japan, 6 Division of Cardiovascular Medicine, Aso-Iizuka Hospital, Iizuka, Japan Chronic heart failure (CHF) is a clinical syndrome, where both heart failure with reduced ejection fraction and that with preserved ejection fraction (HFPEF) are involved. Although metabolic syndrome (MetS) is the pathological condition with a clustering of metabolic components and is a well known risk and prognostic factor for ischemic heart disease (IHD), its prevalence and clinical significance remain to be fully elucidated in CHF. In the nationwide large-scale clinical study, we enrolled 3,603 patients with Stage C/D CHF from 6 institutes in Japan. First, we demonstrated that the prevalence of MetS in CHF was in 45% in male and 19% in female patients, which is more than double compared with the general population in Japan. The CHF patients with MetS were characterized by younger age, higher prevalence of current smoking and drinking, IHD, and hypertensive heart disease, while the prevalence of HFPEF and MetS was higher in elderly female patients. Next, we found that the contribution of the metabolic components (waist circumference, hypertension, glucose intolerance/diabetes mellitus and dyslipidemia) was comparable between the ischemic and the non-ischemic CHF patients. These results indicate that the prevalence of MetS in CHF is more than double compared with the general population in Japan and suggest that the metabolic components may have substantial impacts on the development of both ischemic and non-ischemic CHF.
S6-5 Heart failure with preserved ejection fraction (HFpEF) is a common type of heart failure, and not only cardiologists but general physicians want to know the therapeutic strategy of patients with HFpEF. Unfortunately, in terms of the treatment of HFpEF, any of the guidelines of Japan, Europe and USA failed to provide a clear therapeutic direction. This is simply because there have been no mega-trials that are successful to provide an evidence that any medication is useful to improve mortality or morbidity in patients with HFpEF. Thus, any guideline is described on the basis of experience rather than of evidence. Long-term administration of ACE inhibitors, ARBs, beta blockers or aldosterone antagonists improved ventricular function and prognosis in animal models of HFpEF. These data support the idea that myocardial hypertrophy and fibrosis are reversed by these medications, causing an improvement of ventricular diastolic function. It is noted animal model is usually homogenous, and most of the models are based on pressure overload. In contrast, etiology of HFpEF is very heterogeneous in patients. HFpEF is a relatively new concept, and the guidelines need to be updated with more experimental and human findings.
Management of Patients with Heart Failure Complicated with Sleep Disordered Breathing SHIN-ICHI MOMOMURA Cardiovascular Medicine, Saitama Medical Center Jichi Medical University Sleep disordered breathing including sleep apnea is very often associated with heart failure. Not only that, SDB plays an important role in the onset and progression of heart failure. Therefore, early recognition and treatment of SDB may lead to improvement of the outcome of heart failure. Thus, revised Japanese guidelines for treatment of chronic heart failure (JSH2010) included management of SDB in patients with chronic heart failure. First, the guidelines recommended routine screening of SDB in all patients with heart failure. Secondly, treatment of heart failure itself should be optimized. Thirdly, then aggressive treatment to moderate to severe SDB centering on positive pressure ventilation device is recommended. The outline on the management of SDB in chronic heart failure will be presented.
S6-6 S6-3 Review the Guideline of Acute Heart Failure Syndromes in Japan NAOKI SATO1, KYOICHI MIZUNO2 1 Internal Medicine, Cardiology, and Intensive Care Unit, Nippon Medical School Musashi Kosugi Hospital, 2Department of Medicine, Divisions of Cardiology, Hepatology, Geriatirics, and Integrated Medicine The guideline for acute heart failure syndromes (AHFS) was issued in 2006 from the Japanese Circulation Society committee and is now updating. The most important issue is to review periodically whether or not the guideline is truly available for realworld management. It has, however, not been well performed because we do not have the data of real-world. From this viewpoint, we are performing the multicenter prospective observational cohort study of AHFS in Japan. As of May 31, 2011, 3676 AHFS patients were enrolled Using the data from the registry, comparison between the recommended therapies by the guideline and the real-world management for AHFS in Japan will be analyzed and the gaps between them will be presented. On the basis of these data, we would like to suggest what a better guideline is for AHFS in Japan is.
Management of Heart Failure in Patinets with Reduced Renal Function YOSHIHIKO SAITO The First Department of Internal Medicine, Nara Medical University Earlier works demonstrated that chronic heart failure (CHF) is usually associated with chronic kidney diseases (CKD), and that estimated glomerular filtration rate (eGFR) is a strong predictor of cardiovascular events and prognosis in patients with CHF. Thus cardiologists should pay attention to patients’ renal function in CHF management. Guidelines say that the first line drugs for the treatment of CHF are blockers for renin-angiotensin-aldosterone system and; b adrenergic blockers. Of course diuretic is good indication for acute decompensated heart failure. It should be noted, however, that a large body of evidence is provided by many large scale prospective randomized clinical trials, many of which excludes CHF patients with severely reduced renal function. Usually patients with serum creatinine level higher than 2.0-2.5 mg/dl were excluded. Thus, we have not had enough evidence for the treatment of CHF accompanied by renal dysfunction.Here we introduce some subanalyses which analyze the relationship between renal function and effect of angiotensin converting enzyme or; b blocker. In addition, we also show you some information about management of anemia in patients with CHF.
JHFS
S131
Symposium 6 S6-1 Revision Points and Remaining Issues to be Solved in the Updated Guidelines for Treatment of Chronic Heart Failure YASUHIRO IKEDA, TOMOKO OHKUSA, MASAFUMI YANO, MASUNORI MATSUZAKI Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine Heart failure (HF) is a leading cause of morbidity and mortality in developed countries and afflicts more than 55 million people in the united states. Patients with chronic HF manifests progressive cardiac dysfunction that is characterized by either reduced systolic and diastolic left ventricular function, or both of it, with ventricular remodeling, arrhythmia, and intracardiac conduction disturbances. A growing body of evidence indicates that combination of pharmacological and non-pharmacological therapies had been significantly contributed to the improved morbidity and mortality of HF in the last decade. Reflecting those advances in HF-therapy, guidelines for treatment of chronic heart failure (JCS2010) has been updated at the end of year 2010. The new version of the guidelines includes updated information for device therapy for cardiac arrhythmia [implantable cardioverter defibllirator (ICD) and ablation therapy], respiratory support therapy for sleep disordered breathing, cardiac resynchronization therapy(CRT) for patients with wide QRS, surgical intervention for severe congestive heart failure, and newly developed left ventricular assist devices. In addition, disease management program and protocols of exercise and Waon therapy for HF patients were revised or newly added into the guideline. In this Symposium, I will review these revision points and remaining issues to be solved for treatment of chronic heart failure.
S6-2 Treatment of Heart Failure with Preserved Ejection Fraction TOHRU MASUYAMA Cardiovascular Division, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
S6-4 The Role of Metabolic Components in Heart Failure in Japan YOSHIHIRO FUKUMOTO1, YUTAKA MIURA1, TOSHIRO MIURA2, KAZUNORI SHIMADA3, HIROYUKI DAIDA3, HIROYUKI TSUTSUI4, MASANORI ASAKURA5, AKIRA YAMADA6, NOBUYUKI SHIBA1, HIROAKI SHIMOKAWA1 1 Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan, 2Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan, 3 Department of Cardiovascular Medicine, Juntendo University School of Medicine, Tokyo, Japan, 4Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine, Sapporo, Japan, 5Cardiovascular Division of Internal Medicine, National Cerebral and Cardiovascular Center, Suita, Japan, 6 Division of Cardiovascular Medicine, Aso-Iizuka Hospital, Iizuka, Japan Chronic heart failure (CHF) is a clinical syndrome, where both heart failure with reduced ejection fraction and that with preserved ejection fraction (HFPEF) are involved. Although metabolic syndrome (MetS) is the pathological condition with a clustering of metabolic components and is a well known risk and prognostic factor for ischemic heart disease (IHD), its prevalence and clinical significance remain to be fully elucidated in CHF. In the nationwide large-scale clinical study, we enrolled 3,603 patients with Stage C/D CHF from 6 institutes in Japan. First, we demonstrated that the prevalence of MetS in CHF was in 45% in male and 19% in female patients, which is more than double compared with the general population in Japan. The CHF patients with MetS were characterized by younger age, higher prevalence of current smoking and drinking, IHD, and hypertensive heart disease, while the prevalence of HFPEF and MetS was higher in elderly female patients. Next, we found that the contribution of the metabolic components (waist circumference, hypertension, glucose intolerance/diabetes mellitus and dyslipidemia) was comparable between the ischemic and the non-ischemic CHF patients. These results indicate that the prevalence of MetS in CHF is more than double compared with the general population in Japan and suggest that the metabolic components may have substantial impacts on the development of both ischemic and non-ischemic CHF.
S6-5 Heart failure with preserved ejection fraction (HFpEF) is a common type of heart failure, and not only cardiologists but general physicians want to know the therapeutic strategy of patients with HFpEF. Unfortunately, in terms of the treatment of HFpEF, any of the guidelines of Japan, Europe and USA failed to provide a clear therapeutic direction. This is simply because there have been no mega-trials that are successful to provide an evidence that any medication is useful to improve mortality or morbidity in patients with HFpEF. Thus, any guideline is described on the basis of experience rather than of evidence. Long-term administration of ACE inhibitors, ARBs, beta blockers or aldosterone antagonists improved ventricular function and prognosis in animal models of HFpEF. These data support the idea that myocardial hypertrophy and fibrosis are reversed by these medications, causing an improvement of ventricular diastolic function. It is noted animal model is usually homogenous, and most of the models are based on pressure overload. In contrast, etiology of HFpEF is very heterogeneous in patients. HFpEF is a relatively new concept, and the guidelines need to be updated with more experimental and human findings.
Management of Patients with Heart Failure Complicated with Sleep Disordered Breathing SHIN-ICHI MOMOMURA Cardiovascular Medicine, Saitama Medical Center Jichi Medical University Sleep disordered breathing including sleep apnea is very often associated with heart failure. Not only that, SDB plays an important role in the onset and progression of heart failure. Therefore, early recognition and treatment of SDB may lead to improvement of the outcome of heart failure. Thus, revised Japanese guidelines for treatment of chronic heart failure (JSH2010) included management of SDB in patients with chronic heart failure. First, the guidelines recommended routine screening of SDB in all patients with heart failure. Secondly, treatment of heart failure itself should be optimized. Thirdly, then aggressive treatment to moderate to severe SDB centering on positive pressure ventilation device is recommended. The outline on the management of SDB in chronic heart failure will be presented.
S6-6 S6-3 Review the Guideline of Acute Heart Failure Syndromes in Japan NAOKI SATO1, KYOICHI MIZUNO2 1 Internal Medicine, Cardiology, and Intensive Care Unit, Nippon Medical School Musashi Kosugi Hospital, 2Department of Medicine, Divisions of Cardiology, Hepatology, Geriatirics, and Integrated Medicine The guideline for acute heart failure syndromes (AHFS) was issued in 2006 from the Japanese Circulation Society committee and is now updating. The most important issue is to review periodically whether or not the guideline is truly available for realworld management. It has, however, not been well performed because we do not have the data of real-world. From this viewpoint, we are performing the multicenter prospective observational cohort study of AHFS in Japan. As of May 31, 2011, 3676 AHFS patients were enrolled Using the data from the registry, comparison between the recommended therapies by the guideline and the real-world management for AHFS in Japan will be analyzed and the gaps between them will be presented. On the basis of these data, we would like to suggest what a better guideline is for AHFS in Japan is.
Management of Heart Failure in Patinets with Reduced Renal Function YOSHIHIKO SAITO The First Department of Internal Medicine, Nara Medical University Earlier works demonstrated that chronic heart failure (CHF) is usually associated with chronic kidney diseases (CKD), and that estimated glomerular filtration rate (eGFR) is a strong predictor of cardiovascular events and prognosis in patients with CHF. Thus cardiologists should pay attention to patients’ renal function in CHF management. Guidelines say that the first line drugs for the treatment of CHF are blockers for renin-angiotensin-aldosterone system and; b adrenergic blockers. Of course diuretic is good indication for acute decompensated heart failure. It should be noted, however, that a large body of evidence is provided by many large scale prospective randomized clinical trials, many of which excludes CHF patients with severely reduced renal function. Usually patients with serum creatinine level higher than 2.0-2.5 mg/dl were excluded. Thus, we have not had enough evidence for the treatment of CHF accompanied by renal dysfunction.Here we introduce some subanalyses which analyze the relationship between renal function and effect of angiotensin converting enzyme or; b blocker. In addition, we also show you some information about management of anemia in patients with CHF.