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Our Approach to Palliative Care for Heart Failure
The 21st Annual Scientific Meeting prevention after aborted SCD. The 5-year risk of SCD estimated in these patients assuming without aborted SCD using the HCM Risk-SCD model was 1.85 ± 0.84 (SD) % (ranged between 0.85 and 3.07%), none of which was above 4% that is the cutoff point which ICD implantation may be considered as primary prevention. Conclusions: Since none of patients implanted with ICD after aborted SCD was a candidate for ICD implantation as primary prevention, the HCM Risk-SCD model may not be applicable to Japanese patients due to its low negative predictive value.
O28-3 A Case of Amyloid Cardiomyopathy Proved by Myocardial Biopsy but Diagnosed as Isolated Cardiac Sarcoidosis with Clinical Manifestations Makoto Takahashi, Yasuhiro Nakashima, Yuri Ochi, Kazuya Miyagawa, Tatuya Noguchi, Toru Kubo, Naohito Yamasaki, Hiroaki Kitaoka; Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kochi, Japan A 74-year-old man with dyspnea on exertion was referred to our hospital for treatment of heart failure and evaluation of the cause. The symptom was immediately improved by medical therapy including oxygenation and diuretics. Electrocardiography showed frequent premature ventricular contraction with non-sustained ventricular tachycardia. Echocardiography revealed left ventricular (LV) dilatation (LV end-diastolic diameter/ end-systolic diameter = 64/56 mm), thinning of the basal interventricular septum with severe hypokinesis of the region and LV systolic dysfunction (LVEF = 25%). Coronary angiography showed patent coronary artery. Late gadolinium enhancement in cardiac MR imaging was observed in septal to anterior wall. Furthermore, his lysozyme value was high (13.6 µg/mL). Cardiac sarcoidosis was strongly suspected, and 18Ffluorodeoxy glucose-positron emission tomography imaging showed lightly increased uptake in interventricular septum. Although he did not have the clinical findings other than heart, based on current guidelines for diagnosis and treatment of cardiac sarcoidosis (JCS 2016), a diagnosis of isolated cardiac sarcoidosis was finally made and we decided to start corticosteroid therapy with the initial dose of 30 mg/day of prednisolone. However, the specimens of myocardial biopsy revealed significant amount of transthyretin amyloid deposit. In addition 99mTc-pyrophosphate scintigraphy showed increased uptake by interventricular septum. In this case, there are two possibilities: first, all clinical manifestations due to transthyretin cardiac amyloidosis, and second, a chance complication with cardiac sarcoidosis and amyloid cardiomyopathy.
O28-4 Apical Thickening Score Using Quantitative Gated SPECT for the Diagnosis of Cardiac Amyloidosis Shimpei Ito1, Nobuhiro Kodani2, Taiji Okada1, Akihiro Endo1, Hiroyuki Yoshitomi3, Kazuaki Tanabe1; 1The Forth Department of Internal Medicine, Shimane University, Shimane, Japan; 2Department of Emergency and Critical Care Medicine, Shimane University, Shimane, Japan; 3Clinical Laboratory Department, Shimane University Hospital, Shimane, Japan Introduction: Cardiac amyloidosis (CA) is characterized by regional variations from base to apex in longitudinal strain (LS) using echocardiography. A relative apical sparing pattern of LS is reproductive method of differentiating CA from other causes of left ventricular hypertrophy. Methods: 40 consecutive patients suspected CA by echocardiography underwent thallium-201-chloride and 99mTc-PYP SPECT. We evaluated apical sparing on nuclear cardiology using the each percentage of left ventricular thickenings (17 segment) that were accumulated by quantitative gated SPECT. We calculated the relative apical thickening score (average apical thickening/average basal thickening + mid thickening). Results: Mean age of study population was 70 ± 12 years, and 70% were males. Six patients had biopsy proven systemic amyloidosis. The average score in the group of CA was 1.07 ± 0.25 and the other was 0.78 ± 0.44 (P = .034). Cutoff value of the apical thickening score was 0.82 and the sensitivity and specificity for diagnosing CA were 83% and 68%. Conclusions: In CA, the relative apical thickening score accumulated by SPECT expressed in a similar pattern to that of echocardiography. We may predict likelihood of CA by adding the score when we check SPECT image.
O28-5 Usefulness of 99mTc-pyrophosphate Scintigraphy in Screening of Cardiac Transthyretin Amyloidosis in Patients with Heart Failure Over Sixty Years of Age Yoshitomo Tsutsui, Toru Kubota, Masatsugu Nozoe, Nobuhiro Suematsu, Masanori Okabe, Yusuke Yamamoto; The Department of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan Background: Cardiac transthyretin amyloidosis (ATTR) might be one of major causes of heart failure especially in elderly patients. However, it appears underdiagnosed because of a relatively high threshold of performing endomyocardial biopsy in daily practice. The purpose of the present study was to evaluate the usefulness of 99mTc- pyrophosphate (PYP) scintigraphy in screening of ATTR. Methods: Consecutive patients with non-ischemic and non-valvular heart failure over sixty years of age studied with 99mTcPYP scintigraphy were analyzed. Cardiac 99mTc-PYP retention was graded from 0 to 3, where score 0–1 is negative and score 2–3 positive. Results: There were 57 patients who underwent 99mTc-PYP in last two years, of whom nineteen patients underwent endomyocardial biopsy concomitantly. Concordant with high prevalence of ATTR in
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this population, 99mTc-PYP was positive in a quarter of patients (0, n = 17; 1 + , n = 26; 2 + , n = 9; 3 + , n = 5). Since all patients with ATTR positive biopsy (n = 6) were 99mTcPYP positive (2 + , n = 3; 3 + , n = 3), while patients with ATTR negative biopsy (n = 13) were 99mTc-PYP negative except one patient (0, n = 4; 1 + , n = 8; 2 + , n = 1), both positive and negative predictive values of 99mTc-PYP were high (0.857 and 1.000 respectively). Conclusions: 99mTc-PYP appears useful and should be encouraged to screen ATTR non-invasively.
O31-1 Our Approach to Palliative Care for Heart Failure Hideki Saito, Yusuke Mizuno, Hiroko Kato, Takehiro Hata, Yoshinobu Kato, Masayuki Goto, Daichi Isomura, Naoyuki Okada, Ryo Sugiura, Toshiaki Oka; The Department of Cardiology, Seire Hamamatsu General Hospital, Hamamatsu, Japan Japan has been an aging society, and the number of patients with heart failure is dramatically increasing. Furthermore, it is becoming a multi-death society, where palliative care for patients with heart failure is important. We have held the in-hospital study meeting on palliative care for heart failure once a month since April 2016. The participants include cardiologists, palliative care physicians, pharmacists, nurses, clinical engineers, and rehabilitation engineers. The themes of the meeting are heart failure diagnosis and cure, cutting-edge heart failure treatment, medical ethics, advanced-care planning, and others. In December, an opinion-exchange meeting was also held, as a result, our hospital became more informed about the necessity of palliative care for patients with heart failure. The number of patients with heart failure managed with the involvement of the palliative support team in the hospital is also increasing. We report on our approach to palliative care for heart failure from a cardiologist’s perspective.
O31-2 Fatigue in Patients with Heart Failure: Results from a Systematic Review Hiroko Ishida1, Miyuki Makaya2; 1Nippon Medical School Musashi-Kosugi Hospital, Japan; 2School of Nursing, Kitasato University, Japan Introduction: Fatigue is a prevalent symptom burden in heart failure (HF) patients, negatively affecting quality of life (QOL) and prognosis. However, the state of fatigue in HF patients remains unclear. Methods: We conducted a systematic review by entering the following keywords into four search engines (“heart failure” or “ventricular dysfunction”) and (“fatigue” or “tiredness” or “exhaustion” or “lack of energy”). Results: One hundred six studies were selected for analysis, including seven qualitative studies. To describe “fatigue”, 86 studies used the term fatigue, 11 used tiredness, 11 used lack of energy, and five used vital exhaustion. Fatigue was experienced in 30% to 96% of all HF patients, and their symptom burden was more severe than that of the general population. Fatigue was expressed as a subjective experience with decreased physical and mental status. Additionally, fatigue was associated with increase in cardiac readmission and mortality rate, low QOL, poor self-care and consulting behavior. Fatigue was significantly predicted by comorbidities, severity of HF, physical capacity, several symptoms including dyspnea and pain, psychological distress and sense of coherence. Conclusions: Fatigue in HF patients is a multidimensional and complex symptom that is affected by several factors. To reduce symptom burden due to fatigue, further research is needed.
O31-3 Trends in Heart Failure Hospitalization in Cardiology Department of a University Hospital in Osaka between 1990 to 2015 Kanako Akamatsu, Masaaki Hoshiga, Kazushi Sakane, Mishige Ozeki, Tomohiro Fujisaka, Koichi Sohmiya, Nobukazu Ishizaka; Departmnet of Cardiology, Osaka Medical College, Osaka, Japan Japan is presently aging more rapidly than anywhere else in the world. With rapidly aging population, the disease structure in cardiology greatly changes and prevalence of heart failure (HF) is increasing. To clarify this, we retrospectively examined characters of patients admitted to the cardiology department in our hospital every 5 years between1990 and 2015. Elderly patients were defined as aged >65 years and very elderly as aged >75 years. The age of hospitalized patients increased as over time. HF admission increased, in particular, the number of very elderly patients increased rapidly. Since 2010, more than half of very elderly patients admitted due to HF. In conclusion, HF admission has increased rapidly in aging society and it becomes center of medical care in current cardiology.
O28-3 A Case of Amyloid Cardiomyopathy Proved by Myocardial Biopsy but Diagnosed as Isolated Cardiac Sarcoidosis with Clinical Manifestations Makoto Takahashi, Yasuhiro Nakashima, Yuri Ochi, Kazuya Miyagawa, Tatuya Noguchi, Toru Kubo, Naohito Yamasaki, Hiroaki Kitaoka; Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kochi, Japan A 74-year-old man with dyspnea on exertion was referred to our hospital for treatment of heart failure and evaluation of the cause. The symptom was immediately improved by medical therapy including oxygenation and diuretics. Electrocardiography showed frequent premature ventricular contraction with non-sustained ventricular tachycardia. Echocardiography revealed left ventricular (LV) dilatation (LV end-diastolic diameter/ end-systolic diameter = 64/56 mm), thinning of the basal interventricular septum with severe hypokinesis of the region and LV systolic dysfunction (LVEF = 25%). Coronary angiography showed patent coronary artery. Late gadolinium enhancement in cardiac MR imaging was observed in septal to anterior wall. Furthermore, his lysozyme value was high (13.6 µg/mL). Cardiac sarcoidosis was strongly suspected, and 18Ffluorodeoxy glucose-positron emission tomography imaging showed lightly increased uptake in interventricular septum. Although he did not have the clinical findings other than heart, based on current guidelines for diagnosis and treatment of cardiac sarcoidosis (JCS 2016), a diagnosis of isolated cardiac sarcoidosis was finally made and we decided to start corticosteroid therapy with the initial dose of 30 mg/day of prednisolone. However, the specimens of myocardial biopsy revealed significant amount of transthyretin amyloid deposit. In addition 99mTc-pyrophosphate scintigraphy showed increased uptake by interventricular septum. In this case, there are two possibilities: first, all clinical manifestations due to transthyretin cardiac amyloidosis, and second, a chance complication with cardiac sarcoidosis and amyloid cardiomyopathy.
O28-4 Apical Thickening Score Using Quantitative Gated SPECT for the Diagnosis of Cardiac Amyloidosis Shimpei Ito1, Nobuhiro Kodani2, Taiji Okada1, Akihiro Endo1, Hiroyuki Yoshitomi3, Kazuaki Tanabe1; 1The Forth Department of Internal Medicine, Shimane University, Shimane, Japan; 2Department of Emergency and Critical Care Medicine, Shimane University, Shimane, Japan; 3Clinical Laboratory Department, Shimane University Hospital, Shimane, Japan Introduction: Cardiac amyloidosis (CA) is characterized by regional variations from base to apex in longitudinal strain (LS) using echocardiography. A relative apical sparing pattern of LS is reproductive method of differentiating CA from other causes of left ventricular hypertrophy. Methods: 40 consecutive patients suspected CA by echocardiography underwent thallium-201-chloride and 99mTc-PYP SPECT. We evaluated apical sparing on nuclear cardiology using the each percentage of left ventricular thickenings (17 segment) that were accumulated by quantitative gated SPECT. We calculated the relative apical thickening score (average apical thickening/average basal thickening + mid thickening). Results: Mean age of study population was 70 ± 12 years, and 70% were males. Six patients had biopsy proven systemic amyloidosis. The average score in the group of CA was 1.07 ± 0.25 and the other was 0.78 ± 0.44 (P = .034). Cutoff value of the apical thickening score was 0.82 and the sensitivity and specificity for diagnosing CA were 83% and 68%. Conclusions: In CA, the relative apical thickening score accumulated by SPECT expressed in a similar pattern to that of echocardiography. We may predict likelihood of CA by adding the score when we check SPECT image.
O28-5 Usefulness of 99mTc-pyrophosphate Scintigraphy in Screening of Cardiac Transthyretin Amyloidosis in Patients with Heart Failure Over Sixty Years of Age Yoshitomo Tsutsui, Toru Kubota, Masatsugu Nozoe, Nobuhiro Suematsu, Masanori Okabe, Yusuke Yamamoto; The Department of Cardiology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan Background: Cardiac transthyretin amyloidosis (ATTR) might be one of major causes of heart failure especially in elderly patients. However, it appears underdiagnosed because of a relatively high threshold of performing endomyocardial biopsy in daily practice. The purpose of the present study was to evaluate the usefulness of 99mTc- pyrophosphate (PYP) scintigraphy in screening of ATTR. Methods: Consecutive patients with non-ischemic and non-valvular heart failure over sixty years of age studied with 99mTcPYP scintigraphy were analyzed. Cardiac 99mTc-PYP retention was graded from 0 to 3, where score 0–1 is negative and score 2–3 positive. Results: There were 57 patients who underwent 99mTc-PYP in last two years, of whom nineteen patients underwent endomyocardial biopsy concomitantly. Concordant with high prevalence of ATTR in
•
JHFS
S47
this population, 99mTc-PYP was positive in a quarter of patients (0, n = 17; 1 + , n = 26; 2 + , n = 9; 3 + , n = 5). Since all patients with ATTR positive biopsy (n = 6) were 99mTcPYP positive (2 + , n = 3; 3 + , n = 3), while patients with ATTR negative biopsy (n = 13) were 99mTc-PYP negative except one patient (0, n = 4; 1 + , n = 8; 2 + , n = 1), both positive and negative predictive values of 99mTc-PYP were high (0.857 and 1.000 respectively). Conclusions: 99mTc-PYP appears useful and should be encouraged to screen ATTR non-invasively.
O31-1 Our Approach to Palliative Care for Heart Failure Hideki Saito, Yusuke Mizuno, Hiroko Kato, Takehiro Hata, Yoshinobu Kato, Masayuki Goto, Daichi Isomura, Naoyuki Okada, Ryo Sugiura, Toshiaki Oka; The Department of Cardiology, Seire Hamamatsu General Hospital, Hamamatsu, Japan Japan has been an aging society, and the number of patients with heart failure is dramatically increasing. Furthermore, it is becoming a multi-death society, where palliative care for patients with heart failure is important. We have held the in-hospital study meeting on palliative care for heart failure once a month since April 2016. The participants include cardiologists, palliative care physicians, pharmacists, nurses, clinical engineers, and rehabilitation engineers. The themes of the meeting are heart failure diagnosis and cure, cutting-edge heart failure treatment, medical ethics, advanced-care planning, and others. In December, an opinion-exchange meeting was also held, as a result, our hospital became more informed about the necessity of palliative care for patients with heart failure. The number of patients with heart failure managed with the involvement of the palliative support team in the hospital is also increasing. We report on our approach to palliative care for heart failure from a cardiologist’s perspective.
O31-2 Fatigue in Patients with Heart Failure: Results from a Systematic Review Hiroko Ishida1, Miyuki Makaya2; 1Nippon Medical School Musashi-Kosugi Hospital, Japan; 2School of Nursing, Kitasato University, Japan Introduction: Fatigue is a prevalent symptom burden in heart failure (HF) patients, negatively affecting quality of life (QOL) and prognosis. However, the state of fatigue in HF patients remains unclear. Methods: We conducted a systematic review by entering the following keywords into four search engines (“heart failure” or “ventricular dysfunction”) and (“fatigue” or “tiredness” or “exhaustion” or “lack of energy”). Results: One hundred six studies were selected for analysis, including seven qualitative studies. To describe “fatigue”, 86 studies used the term fatigue, 11 used tiredness, 11 used lack of energy, and five used vital exhaustion. Fatigue was experienced in 30% to 96% of all HF patients, and their symptom burden was more severe than that of the general population. Fatigue was expressed as a subjective experience with decreased physical and mental status. Additionally, fatigue was associated with increase in cardiac readmission and mortality rate, low QOL, poor self-care and consulting behavior. Fatigue was significantly predicted by comorbidities, severity of HF, physical capacity, several symptoms including dyspnea and pain, psychological distress and sense of coherence. Conclusions: Fatigue in HF patients is a multidimensional and complex symptom that is affected by several factors. To reduce symptom burden due to fatigue, further research is needed.
O31-3 Trends in Heart Failure Hospitalization in Cardiology Department of a University Hospital in Osaka between 1990 to 2015 Kanako Akamatsu, Masaaki Hoshiga, Kazushi Sakane, Mishige Ozeki, Tomohiro Fujisaka, Koichi Sohmiya, Nobukazu Ishizaka; Departmnet of Cardiology, Osaka Medical College, Osaka, Japan Japan is presently aging more rapidly than anywhere else in the world. With rapidly aging population, the disease structure in cardiology greatly changes and prevalence of heart failure (HF) is increasing. To clarify this, we retrospectively examined characters of patients admitted to the cardiology department in our hospital every 5 years between1990 and 2015. Elderly patients were defined as aged >65 years and very elderly as aged >75 years. The age of hospitalized patients increased as over time. HF admission increased, in particular, the number of very elderly patients increased rapidly. Since 2010, more than half of very elderly patients admitted due to HF. In conclusion, HF admission has increased rapidly in aging society and it becomes center of medical care in current cardiology.