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Impact of Sarcopenia on the Prognosis in Heart Failure
S8 Journal of Cardiac Failure Vol. 23 No. 10S October 2017
Symposium SY1-1
SY2-2
Pharmacologic Management of Arrhythmia in Heart Failure Tsuyoshi Shiga, Atsushi Suzuki, Morio Shoda, Nobuhisa Hagiwara; Department of Cardiology, Tokyo Women’s Medical University, Tokyo, Japan
Evaluation and Operative Indication of Functional Tricusid Regurgitation Chisato Izumi; Department of Cardiology, Tenri Hospital, Nara, Japan
Arrhythmia confers a substantial risk of mortality and morbidity in patients with heart failure (HF). The treatment goals of arrhythmia in HF patients are to improve prognosis and quality of life. Sudden cardiac death (SCD), which is primarily caused by ventricular tachycardia (VT)/fibrillation (VF), accounts for approximately onethird of all deaths in HF patients. Implantable cardioverter-defibrillator (ICD) is useful for preventing SCD, but the improvement of outcome is limited in patients with advanced HF. Beta-blockers reduces SCD and improves survival. Amiodarone is potentially effective to prevent VT/VF. Intravenous nifekalant, a pure class III antiarrhythmic drug, or intravenous amiodarone is useful in the emergency treatment of VT/VF. Recently, short-acting intravenous beta-blocker such as landiolol can be tried. Atrial fibrillation (AF) frequently occurs in HF patients and leads to clinical and hemodynamic deterioration. They also increase a risk of HF deterioration. Amiodarone is safely used in HF patients. In AF patients with congestive, landiolol can also be used to control the ventricular rate as an intravenous infusion. In conclusions, standard pharmacologic therapy for HF including beta-blockers should be optimized to prevent arrhythmia as well as mortality. In emergency and acute care settings, short-acting beta-blocker may have an important role in management of arrhythmia and HF.
Operative indication for functional tricuspid regurgitation (TR) remains controversial. According to the guidelines, it is determined based on severity of TR, symptoms, annular diameter, pulmonary hypertension and right ventricular (RV) function. However, there are many problems in the guidelines, such as difficulties in determining symptoms, quantification of TR severity and evaluation of RV function. There are many echocardiographic parameters of RV function, but any of them have not been established. Surgical treatment for functional TR is classified into two patterns; one is tricuspid annuloplasty concomitant with mitral valve surgery and the other is “isolated” tricuspid valve surgery. We should consider them as different disease entities because they show totally different clinical characteristics and prognosis. RV function is critical especially in isolated tricuspid valve surgery. In clinical settings, “isolated” tricuspid valve surgery has not been enough performed. Poor outcomes of “isolated” tricuspid valve surgery has been related to our reluctance to perform tricuspid surgery. There have been controversial issues in operative indication and its optimal timing and selection of operative procedures in patients with “isolated” TR. I would like to discuss these issues based on previous studies and our experience in the real world of our daily practice.
SY3-4 SY1-4 Evidence of Cardiac Rehabilitation Program for Heart Failure Patients With Arrhythmia Hirokazu Shiraishi1,2, Takeshi Shirayama1, Satoaki Matoba1, Yasuo Mikami2, Toshikazu Kubo2; 1The Department of cardiovascular medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan; 2The Rehabilitation Unit, Kyoto-Prefectural University Hospital, Kyoto, Japan Cardiac rehabilitation (CR) program for heart failure (HF) patients has been established. 2016 ESC Guidelines for acute and chronic heart failure recommended CR program for the HF patients with reduced ejection fraction as Class1, evidence level A (Eur J Heart Fail 2016;18:891–975). In recent years, the efficacy of exercise training has also been confirmed in the patients with HF patients with preserved ejection fraction (Circ Heart Fail 2015;8:33–40). Besides, the reports regarding to CR program for the patients with arrhythmia were limited. The efficacy of exercise training for the patients with atrial fibrillation, such as rate control, improvement of exercise tolerance and QOL has been shown in the metaanalysis (Can J Cardiol 2013;29:1721). CR program is also recommended for the patients with implanted device (ICD/CRTD) and the efficacy of CR to decrease ICD shocks in patients with HF remains controversial (Euro J Prev cardiol 2012;19: 804). I will show our representative cases and discuss these points of view based on literature reviews in this symposium.
An Approach for Super-Elderly Patients With Heart Failure and Frailty in Community Hospital: DOPPO Rehabilitation Hiroaki Obata1,2, Satoru Abe2, Akihumi Uehara2, Hiroshi Watanabe2, Yuki Izumi1, Yorio Suzuki3, Tohru Izumi1,2; 1Division of Rehabilitation, Niigataminami Hospital, Niigata, Japan; 2Division of Medicine, Niigataminami Hospital, Niigata, Japan; 3Division of Orthopedic surgery, Niigataminami Hospital, Niigata, Japan As referred to as the 2025 problem, the reduction of caregiver burden for elderly people is an urgent task. Our hospital is located in central part of Niigata City, and one of regional hospitals that provide several supports of caregiving for elderlies to return home after medical treatment. In the last year, 1343 medical patients were admitted to our hospital. Their mean age was 78 years. Aspiration pneumonia (15%) and congestive heart failure (10%) caused the majority of hospitalization. Over 80% of heart failure patients were octogenarians. Compared to patients aged under 80, these super-elderly patients had a lower ADL score, had a higher prevalence of cognitive disorder and malnutrition, regardless of cardiac function and BNP level. Except in-hospital death, only 25% cases could walk independently when discharged even if rehabilitation was performed. In other words, although management of heart failure is essential, how to improve ADL is key to return home. Meanwhile, since super-elderlies have risky comorbidities in silent, it is critical to manage the rehabilitation safely. From these points of view, we are proposing, an advance form derived from cardiac rehabilitation is the best way to improve the frailty of low ADL elderly in the presence or absence of heart failure. Now we are promoting DOPPO rehabilitation. As we have experienced 161 cases since 2013, here will report on the results and outcomes.
SY2-1
SY4-3
Assessment and Treatment for Secondary Mitral Regurgitation Yukio Abe; Department of Cardiology, Osaka City General Hospital, Osaka, Japan
Impact of Sarcopenia on the Prognosis in Heart Failure Tetsu Watanabe, Taro Narumi, Isao Kubota; Department of Cardiology, Pulmonology and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
The assessment and treatment for secondary mitral regurgitation (MR) are based on the concepts different from those for primary MR. The main etiology of traditional secondary MR is mitral leaflet tethering-tenting occurring from left ventricular dilatation and systolic dysfunction. The origin of secondary MR usually takes a transverse direction along the mitral leaflets’ coaptation. Consequently, the Doppler-derived volumetric method should be selected for the echocardiographic quantitative analysis of the secondary MR rather than the proximal isovelocity surface area method. In general, the strong medical therapies are required in heart failure patients with significant secondary MR. Mitral valve surgery may be also considered for patients with severe secondary MR with heart failure symptoms despite the optimal medical therapies. Concomitant mitral valve surgery is more reasonable in patients with coronary artery disease and severe secondary MR at the time of coronary artery bypass grafting (CABG). It is still controversial whether concomitant mitral valve surgery should be performed in patients with coronary artery disease and moderate secondary MR at the time of CABG. Low-dose dobutamine stress echocardiography or exercise stress echocardiography may be helpful to address this issue. For secondary MR seen in patients with atrial fibrillation and left atrial dilatation despite havinf preserved left ventricular ejection fraction, mitral annuloplasty would be the primary treatment.
Chronic heart failure (CHF) is an important health issue with high mortality. CHF occurs in 10% or more in the elderly population in developed countries. Since the pathophysiology of CHF involves detrimental levels of catabolism, over 60% of patients with CHF are reported to have muscle weakness and fatigue caused by muscle atrophy. Although obese patients with CHF reportedly have better prognoses compared with lean patients, “obesity paradox” is not observed in case of having insulin resistance. Anker et al reported that prevalence of cardiac cachexia based on body weight loss increases with advancing CHF and is associated with poor prognosis. However, body weight is affected by fluid status. Sarcopenia is defined as skeletal muscle loss and dysfunction during aging and affliction with a chronic disease. Therefore, we evaluated sarcopenia using fat-free mass index (FFMI), which reflects the masses of skeletal muscle, organs, bone, and connective tissue and which is an indicator of resting energy expenditure. Although FFMI is usually measured by bioelectrical impedance analysis or dual-energy X-ray absorptiometry, we estimated FFMI according to the Forbes formula, which simply uses urinary creatinine. Prevalence of sarcopenia was 25% in patients with CHF. Sarcopenia was an independent prognostic factor in patients with CHF. Future research is needed to assess whether therapeutic intervention to ameliorate sarcopenia can improve cardiac prognosis.
Symposium SY1-1
SY2-2
Pharmacologic Management of Arrhythmia in Heart Failure Tsuyoshi Shiga, Atsushi Suzuki, Morio Shoda, Nobuhisa Hagiwara; Department of Cardiology, Tokyo Women’s Medical University, Tokyo, Japan
Evaluation and Operative Indication of Functional Tricusid Regurgitation Chisato Izumi; Department of Cardiology, Tenri Hospital, Nara, Japan
Arrhythmia confers a substantial risk of mortality and morbidity in patients with heart failure (HF). The treatment goals of arrhythmia in HF patients are to improve prognosis and quality of life. Sudden cardiac death (SCD), which is primarily caused by ventricular tachycardia (VT)/fibrillation (VF), accounts for approximately onethird of all deaths in HF patients. Implantable cardioverter-defibrillator (ICD) is useful for preventing SCD, but the improvement of outcome is limited in patients with advanced HF. Beta-blockers reduces SCD and improves survival. Amiodarone is potentially effective to prevent VT/VF. Intravenous nifekalant, a pure class III antiarrhythmic drug, or intravenous amiodarone is useful in the emergency treatment of VT/VF. Recently, short-acting intravenous beta-blocker such as landiolol can be tried. Atrial fibrillation (AF) frequently occurs in HF patients and leads to clinical and hemodynamic deterioration. They also increase a risk of HF deterioration. Amiodarone is safely used in HF patients. In AF patients with congestive, landiolol can also be used to control the ventricular rate as an intravenous infusion. In conclusions, standard pharmacologic therapy for HF including beta-blockers should be optimized to prevent arrhythmia as well as mortality. In emergency and acute care settings, short-acting beta-blocker may have an important role in management of arrhythmia and HF.
Operative indication for functional tricuspid regurgitation (TR) remains controversial. According to the guidelines, it is determined based on severity of TR, symptoms, annular diameter, pulmonary hypertension and right ventricular (RV) function. However, there are many problems in the guidelines, such as difficulties in determining symptoms, quantification of TR severity and evaluation of RV function. There are many echocardiographic parameters of RV function, but any of them have not been established. Surgical treatment for functional TR is classified into two patterns; one is tricuspid annuloplasty concomitant with mitral valve surgery and the other is “isolated” tricuspid valve surgery. We should consider them as different disease entities because they show totally different clinical characteristics and prognosis. RV function is critical especially in isolated tricuspid valve surgery. In clinical settings, “isolated” tricuspid valve surgery has not been enough performed. Poor outcomes of “isolated” tricuspid valve surgery has been related to our reluctance to perform tricuspid surgery. There have been controversial issues in operative indication and its optimal timing and selection of operative procedures in patients with “isolated” TR. I would like to discuss these issues based on previous studies and our experience in the real world of our daily practice.
SY3-4 SY1-4 Evidence of Cardiac Rehabilitation Program for Heart Failure Patients With Arrhythmia Hirokazu Shiraishi1,2, Takeshi Shirayama1, Satoaki Matoba1, Yasuo Mikami2, Toshikazu Kubo2; 1The Department of cardiovascular medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan; 2The Rehabilitation Unit, Kyoto-Prefectural University Hospital, Kyoto, Japan Cardiac rehabilitation (CR) program for heart failure (HF) patients has been established. 2016 ESC Guidelines for acute and chronic heart failure recommended CR program for the HF patients with reduced ejection fraction as Class1, evidence level A (Eur J Heart Fail 2016;18:891–975). In recent years, the efficacy of exercise training has also been confirmed in the patients with HF patients with preserved ejection fraction (Circ Heart Fail 2015;8:33–40). Besides, the reports regarding to CR program for the patients with arrhythmia were limited. The efficacy of exercise training for the patients with atrial fibrillation, such as rate control, improvement of exercise tolerance and QOL has been shown in the metaanalysis (Can J Cardiol 2013;29:1721). CR program is also recommended for the patients with implanted device (ICD/CRTD) and the efficacy of CR to decrease ICD shocks in patients with HF remains controversial (Euro J Prev cardiol 2012;19: 804). I will show our representative cases and discuss these points of view based on literature reviews in this symposium.
An Approach for Super-Elderly Patients With Heart Failure and Frailty in Community Hospital: DOPPO Rehabilitation Hiroaki Obata1,2, Satoru Abe2, Akihumi Uehara2, Hiroshi Watanabe2, Yuki Izumi1, Yorio Suzuki3, Tohru Izumi1,2; 1Division of Rehabilitation, Niigataminami Hospital, Niigata, Japan; 2Division of Medicine, Niigataminami Hospital, Niigata, Japan; 3Division of Orthopedic surgery, Niigataminami Hospital, Niigata, Japan As referred to as the 2025 problem, the reduction of caregiver burden for elderly people is an urgent task. Our hospital is located in central part of Niigata City, and one of regional hospitals that provide several supports of caregiving for elderlies to return home after medical treatment. In the last year, 1343 medical patients were admitted to our hospital. Their mean age was 78 years. Aspiration pneumonia (15%) and congestive heart failure (10%) caused the majority of hospitalization. Over 80% of heart failure patients were octogenarians. Compared to patients aged under 80, these super-elderly patients had a lower ADL score, had a higher prevalence of cognitive disorder and malnutrition, regardless of cardiac function and BNP level. Except in-hospital death, only 25% cases could walk independently when discharged even if rehabilitation was performed. In other words, although management of heart failure is essential, how to improve ADL is key to return home. Meanwhile, since super-elderlies have risky comorbidities in silent, it is critical to manage the rehabilitation safely. From these points of view, we are proposing, an advance form derived from cardiac rehabilitation is the best way to improve the frailty of low ADL elderly in the presence or absence of heart failure. Now we are promoting DOPPO rehabilitation. As we have experienced 161 cases since 2013, here will report on the results and outcomes.
SY2-1
SY4-3
Assessment and Treatment for Secondary Mitral Regurgitation Yukio Abe; Department of Cardiology, Osaka City General Hospital, Osaka, Japan
Impact of Sarcopenia on the Prognosis in Heart Failure Tetsu Watanabe, Taro Narumi, Isao Kubota; Department of Cardiology, Pulmonology and Nephrology, Yamagata University School of Medicine, Yamagata, Japan
The assessment and treatment for secondary mitral regurgitation (MR) are based on the concepts different from those for primary MR. The main etiology of traditional secondary MR is mitral leaflet tethering-tenting occurring from left ventricular dilatation and systolic dysfunction. The origin of secondary MR usually takes a transverse direction along the mitral leaflets’ coaptation. Consequently, the Doppler-derived volumetric method should be selected for the echocardiographic quantitative analysis of the secondary MR rather than the proximal isovelocity surface area method. In general, the strong medical therapies are required in heart failure patients with significant secondary MR. Mitral valve surgery may be also considered for patients with severe secondary MR with heart failure symptoms despite the optimal medical therapies. Concomitant mitral valve surgery is more reasonable in patients with coronary artery disease and severe secondary MR at the time of coronary artery bypass grafting (CABG). It is still controversial whether concomitant mitral valve surgery should be performed in patients with coronary artery disease and moderate secondary MR at the time of CABG. Low-dose dobutamine stress echocardiography or exercise stress echocardiography may be helpful to address this issue. For secondary MR seen in patients with atrial fibrillation and left atrial dilatation despite havinf preserved left ventricular ejection fraction, mitral annuloplasty would be the primary treatment.
Chronic heart failure (CHF) is an important health issue with high mortality. CHF occurs in 10% or more in the elderly population in developed countries. Since the pathophysiology of CHF involves detrimental levels of catabolism, over 60% of patients with CHF are reported to have muscle weakness and fatigue caused by muscle atrophy. Although obese patients with CHF reportedly have better prognoses compared with lean patients, “obesity paradox” is not observed in case of having insulin resistance. Anker et al reported that prevalence of cardiac cachexia based on body weight loss increases with advancing CHF and is associated with poor prognosis. However, body weight is affected by fluid status. Sarcopenia is defined as skeletal muscle loss and dysfunction during aging and affliction with a chronic disease. Therefore, we evaluated sarcopenia using fat-free mass index (FFMI), which reflects the masses of skeletal muscle, organs, bone, and connective tissue and which is an indicator of resting energy expenditure. Although FFMI is usually measured by bioelectrical impedance analysis or dual-energy X-ray absorptiometry, we estimated FFMI according to the Forbes formula, which simply uses urinary creatinine. Prevalence of sarcopenia was 25% in patients with CHF. Sarcopenia was an independent prognostic factor in patients with CHF. Future research is needed to assess whether therapeutic intervention to ameliorate sarcopenia can improve cardiac prognosis.