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Prognostic Impact of Living in Temporary Housing in Fukushima After the Great East Japan Earthquake
Journal of Cardiac Failure Vol. 23 No. 1 2017
Research Letter Prognostic Impact of Living in Temporary Housing in Fukushima After the Great East Japan Earthquake
temporary housing and those discharged home. Blood sample data revealed that hemoglobin (11.6 ± 2.3 vs 12.5 ± 2.3 g/ dL; P = .012), estimated glomerular filtration rate (45.8 ± 26.9 vs 55.7 ± 24.7 mL • min−1 • 1.73 m−2; P = .030), and highdensity lipoprotein cholesterol level (40.8 ± 12.0 vs. 50.8 ± 21.1 mg/dL; P = .011) were significantly lower and serum albumin level tended to be lower (3.46 ± 0.69 vs 3.70 ± 0.61 g/dL; P = .075) in patients who moved into temporary housing than in those who did not. These results suggested that evacuees in temporary housing may have been in poorer overall health. The incidence of subsequent cardiac events was significantly higher in patients that moved into temporary housing (6 cardiac deaths and 18 rehospitalizations) than in those who were not evacuees (77 cardiac deaths and 123 rehospitalizations; 47.0% vs 28.9%; P = .036). Although there was no significant difference regarding the incidence of cardiac death (Fig. 1B), the incidence of rehospitalization with worsening heart failure was significantly higher in the temporary housing group than in the nonevacuation group (35.3% vs 17.7%; P = .007; Fig. 1C). Multivariate Cox proportional hazard regression analysis revealed that moving into temporary housing was one of the independent predictors of rehospitalization due to worsening heart failure (hazard ratio 1.846, 95% confidence interval 1.120–3.041; P = .016) in addition to NYHA functional class and presence of diabetes mellitus, chronic kidney disease, or anemia (Table 1). There are several limitations in the present study. First, it is not based on a population-based cohort, but rather it is a prospective observational analysis of data derived from a single institution which is located inland, ~45 km from the coast and ~60 km from the power plant. Second, actual nutritional intake could not be assessed in temporary housing, although it may explain the increase in hospitalization. Additional research is required to assess if there are long-term effects on HF prognosis among evacuees. In conclusion, patients with heart failure who moved into temporary housing after the Great East Japan Earthquake had higher rates of rehospitalization due to worsening heart failure. These results suggest that such patients should be monitored carefully regarding nutrition following a large-scale natural disaster.
To the Editor: On March 11, 2011, the Great East Japan Earthquake hit the northeast area of Japan and, along with its subsequent tsunami, caused great damage, including more than 15,000 deaths directly related to the disaster and 3000 related deaths.1 Previous studies have reported that the disaster increased the risk of several cardiovascular diseases,2–4 and we reported that the incidence of heart failure increased.5 Many residents were forced to evacuate to temporary housing due to the earthquake and the associated Fukushima Daiichi Nuclear Power Plant accident. Therefore, we examined the impact of displacement into temporary housing after the earthquake and tsunami in patients with heart failure. We enrolled 743 consecutive patients with heart failure who were hospitalized at Fukushima Medical University Hospital from March 11, 2011, to September 30, 2014 (mean age 68.0 ± 13.6 y, 450 male). Symptomatic heart failure diagnosis was defined by well trained cardiologists with the use of the Framingham criteria.6 Written informed consents were obtained from all of the study subjects. Our study complied with the Declaration of Helsinki, and the study protocol was approved by the Ethical Committee of Fukushima Medical University. For the purposes of this study, we defined “temporary housing” as shelter built by the national or local government for displaced individuals previously living in the evacuated area. All patients were followed after discharge. The end points were: (1) cardiac death, defined as either death from worsening heart failure or sudden cardiac death; or (2) rehospitalization due to worsening heart failure. Diagnosis of depression was defined as the use of antidepressant or by means of the Center for Epidemiologic Studies Depression (CES-D) questionnaire. Statistical analysis was performed with the use of a standard statistical program package (SPSS Japan, Tokyo, Japan). No significant differences were observed in age, sex, New York Heart Association (NYHA) functional class, prevalence of depression, vital signs, echocardiographic data, and medication at discharge between patients discharged to
Disclosures Akiomi Yoshihisa belongs to an endowed department supported by Fukuda Denshi Co. All of the other authors report no potential conflicts of interest.
Funding source: This study was supported in part by a grant from the Japanese Heart Foundation (no. 12100026). No additional external funding was received for this study.
90
Research Letter
91
Fig. 1. Kaplan-Meier analysis of event rate for (A) all cardiac events, (B) cardiac death, and (C) rehospitalization due to worsening heart failure between heart failure patients who moved into temporary housing and nonevacuees.
Table 1. Results of Univariate and Multivariate Cox Proportional Hazard Analyses Associated With Rehospitalization Due to Worsening of Heart Failure Univariate Analysis Variable Age, per 5-y increase Male vs female NYHA, per 1-grade increase Presence of Hypertension Diabetes mellitus Dyslipidemia Atrial fibrillation Chronic kidney disease Anemia IHD vs non-IHD Moving into temporary housing
Multivariate Analysis
HR
95% CI
P Value
HR
95% CI
P Value
1.127 0.871 2.055
1.056–1.205 0.624–1.215 1.625–2.598
.001 .415 <.001
1.025
0.956–1.099
.521
1.667
1.303–2.131
<.001
1.278 1.782 1.404 1.546 2.865 2.427 1.180 2.035
0.858–1.905 1.280–2.326 0.981–2.151 1.111–2.155 1.934–4.255 1.667–3.533 0.808–1.724 1.253–3.304
.227 <.001 .117 .010 <.001 <.001 .392 .004
1.563
1.043–2.045
.027
1.272 2.004 1.751
0.907–1.788 1.323–3.304 1.178–2.604
.164 .001 .006
1.846
1.120–3.041
.016
CI, confidence interval; HR, hazard ratio; IHD, ischemic heart disease; NYHA, New York Heart Association functional class.
92 Journal of Cardiac Failure Vol. 23 No. 1 January 2017 Acknowledgment This work was supported in part by the program of the network-type joint Usage/Research Center for Radiation Disaster Medical Science of Hiroshima University, Nagasaki University, and Fukushima Medical University. Satoshi Suzuki, MD Akiomi Yoshihisa, MD Yuki Kanno, MD Shunsuke Watanabe, MD Mai Takiguchi, MD Shunsuke Miura, MD Tetsuro Yokokawa, MD Takamasa Sato, MD Masayoshi Oikawa, MD Takayoshi Yamaki, MD Hiroyuki Kunii, MD Kazuhiko Nakazato, MD Hitoshi Suzuki, MD Shu-ichi Saitoh, MD Yasuchika Takeishi, MD
Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan References 1. Simons M, Minson SE, Sladen A, Ortega F, Jiang J, Owen SE, et al. The 2011 magnitude 9.0 Tohoku-Oki earthquake: mosaicking the megathrust from seconds to centuries. Science 2011;332:1421–5. 2. Suzuki S, Sakamoto S, Miki T, Matsuo T. Hanshin-Awaji earthquake and acute myocardial infarction. Lancet 1995;345:981. 3. Watanabe H, Kodama M, Tanabe N, Nakamura Y, Nagai T, Sato M, et al. Impact of earthquakes on risk for pulmonary embolism. Int J Cardiol 2008;129:152–4. 4. Watanabe H, Kodama M, Okura Y, Aizawa Y, Tanabe N, Chinushi M, et al. Impact of earthquakes on Takotsubo cardiomyopathy. JAMA 2005;294:305–7. 5. Yamauchi H, Yoshihisa A, Iwaya S, Owada T, Sato T, Suzuki S, et al. Clinical features of patients with decompensated heart failure after the Great East Japan Earthquake. Am J Cardiol 2013;112:94–9. 6. Ho KK, Anderson KM, Kannel WB, Grossman W, Levy D. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation 1993;88:107–15. http://dx.doi.org/10.1016/j.cardfail.2016.10.003
Research Letter Prognostic Impact of Living in Temporary Housing in Fukushima After the Great East Japan Earthquake
temporary housing and those discharged home. Blood sample data revealed that hemoglobin (11.6 ± 2.3 vs 12.5 ± 2.3 g/ dL; P = .012), estimated glomerular filtration rate (45.8 ± 26.9 vs 55.7 ± 24.7 mL • min−1 • 1.73 m−2; P = .030), and highdensity lipoprotein cholesterol level (40.8 ± 12.0 vs. 50.8 ± 21.1 mg/dL; P = .011) were significantly lower and serum albumin level tended to be lower (3.46 ± 0.69 vs 3.70 ± 0.61 g/dL; P = .075) in patients who moved into temporary housing than in those who did not. These results suggested that evacuees in temporary housing may have been in poorer overall health. The incidence of subsequent cardiac events was significantly higher in patients that moved into temporary housing (6 cardiac deaths and 18 rehospitalizations) than in those who were not evacuees (77 cardiac deaths and 123 rehospitalizations; 47.0% vs 28.9%; P = .036). Although there was no significant difference regarding the incidence of cardiac death (Fig. 1B), the incidence of rehospitalization with worsening heart failure was significantly higher in the temporary housing group than in the nonevacuation group (35.3% vs 17.7%; P = .007; Fig. 1C). Multivariate Cox proportional hazard regression analysis revealed that moving into temporary housing was one of the independent predictors of rehospitalization due to worsening heart failure (hazard ratio 1.846, 95% confidence interval 1.120–3.041; P = .016) in addition to NYHA functional class and presence of diabetes mellitus, chronic kidney disease, or anemia (Table 1). There are several limitations in the present study. First, it is not based on a population-based cohort, but rather it is a prospective observational analysis of data derived from a single institution which is located inland, ~45 km from the coast and ~60 km from the power plant. Second, actual nutritional intake could not be assessed in temporary housing, although it may explain the increase in hospitalization. Additional research is required to assess if there are long-term effects on HF prognosis among evacuees. In conclusion, patients with heart failure who moved into temporary housing after the Great East Japan Earthquake had higher rates of rehospitalization due to worsening heart failure. These results suggest that such patients should be monitored carefully regarding nutrition following a large-scale natural disaster.
To the Editor: On March 11, 2011, the Great East Japan Earthquake hit the northeast area of Japan and, along with its subsequent tsunami, caused great damage, including more than 15,000 deaths directly related to the disaster and 3000 related deaths.1 Previous studies have reported that the disaster increased the risk of several cardiovascular diseases,2–4 and we reported that the incidence of heart failure increased.5 Many residents were forced to evacuate to temporary housing due to the earthquake and the associated Fukushima Daiichi Nuclear Power Plant accident. Therefore, we examined the impact of displacement into temporary housing after the earthquake and tsunami in patients with heart failure. We enrolled 743 consecutive patients with heart failure who were hospitalized at Fukushima Medical University Hospital from March 11, 2011, to September 30, 2014 (mean age 68.0 ± 13.6 y, 450 male). Symptomatic heart failure diagnosis was defined by well trained cardiologists with the use of the Framingham criteria.6 Written informed consents were obtained from all of the study subjects. Our study complied with the Declaration of Helsinki, and the study protocol was approved by the Ethical Committee of Fukushima Medical University. For the purposes of this study, we defined “temporary housing” as shelter built by the national or local government for displaced individuals previously living in the evacuated area. All patients were followed after discharge. The end points were: (1) cardiac death, defined as either death from worsening heart failure or sudden cardiac death; or (2) rehospitalization due to worsening heart failure. Diagnosis of depression was defined as the use of antidepressant or by means of the Center for Epidemiologic Studies Depression (CES-D) questionnaire. Statistical analysis was performed with the use of a standard statistical program package (SPSS Japan, Tokyo, Japan). No significant differences were observed in age, sex, New York Heart Association (NYHA) functional class, prevalence of depression, vital signs, echocardiographic data, and medication at discharge between patients discharged to
Disclosures Akiomi Yoshihisa belongs to an endowed department supported by Fukuda Denshi Co. All of the other authors report no potential conflicts of interest.
Funding source: This study was supported in part by a grant from the Japanese Heart Foundation (no. 12100026). No additional external funding was received for this study.
90
Research Letter
91
Fig. 1. Kaplan-Meier analysis of event rate for (A) all cardiac events, (B) cardiac death, and (C) rehospitalization due to worsening heart failure between heart failure patients who moved into temporary housing and nonevacuees.
Table 1. Results of Univariate and Multivariate Cox Proportional Hazard Analyses Associated With Rehospitalization Due to Worsening of Heart Failure Univariate Analysis Variable Age, per 5-y increase Male vs female NYHA, per 1-grade increase Presence of Hypertension Diabetes mellitus Dyslipidemia Atrial fibrillation Chronic kidney disease Anemia IHD vs non-IHD Moving into temporary housing
Multivariate Analysis
HR
95% CI
P Value
HR
95% CI
P Value
1.127 0.871 2.055
1.056–1.205 0.624–1.215 1.625–2.598
.001 .415 <.001
1.025
0.956–1.099
.521
1.667
1.303–2.131
<.001
1.278 1.782 1.404 1.546 2.865 2.427 1.180 2.035
0.858–1.905 1.280–2.326 0.981–2.151 1.111–2.155 1.934–4.255 1.667–3.533 0.808–1.724 1.253–3.304
.227 <.001 .117 .010 <.001 <.001 .392 .004
1.563
1.043–2.045
.027
1.272 2.004 1.751
0.907–1.788 1.323–3.304 1.178–2.604
.164 .001 .006
1.846
1.120–3.041
.016
CI, confidence interval; HR, hazard ratio; IHD, ischemic heart disease; NYHA, New York Heart Association functional class.
92 Journal of Cardiac Failure Vol. 23 No. 1 January 2017 Acknowledgment This work was supported in part by the program of the network-type joint Usage/Research Center for Radiation Disaster Medical Science of Hiroshima University, Nagasaki University, and Fukushima Medical University. Satoshi Suzuki, MD Akiomi Yoshihisa, MD Yuki Kanno, MD Shunsuke Watanabe, MD Mai Takiguchi, MD Shunsuke Miura, MD Tetsuro Yokokawa, MD Takamasa Sato, MD Masayoshi Oikawa, MD Takayoshi Yamaki, MD Hiroyuki Kunii, MD Kazuhiko Nakazato, MD Hitoshi Suzuki, MD Shu-ichi Saitoh, MD Yasuchika Takeishi, MD
Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan References 1. Simons M, Minson SE, Sladen A, Ortega F, Jiang J, Owen SE, et al. The 2011 magnitude 9.0 Tohoku-Oki earthquake: mosaicking the megathrust from seconds to centuries. Science 2011;332:1421–5. 2. Suzuki S, Sakamoto S, Miki T, Matsuo T. Hanshin-Awaji earthquake and acute myocardial infarction. Lancet 1995;345:981. 3. Watanabe H, Kodama M, Tanabe N, Nakamura Y, Nagai T, Sato M, et al. Impact of earthquakes on risk for pulmonary embolism. Int J Cardiol 2008;129:152–4. 4. Watanabe H, Kodama M, Okura Y, Aizawa Y, Tanabe N, Chinushi M, et al. Impact of earthquakes on Takotsubo cardiomyopathy. JAMA 2005;294:305–7. 5. Yamauchi H, Yoshihisa A, Iwaya S, Owada T, Sato T, Suzuki S, et al. Clinical features of patients with decompensated heart failure after the Great East Japan Earthquake. Am J Cardiol 2013;112:94–9. 6. Ho KK, Anderson KM, Kannel WB, Grossman W, Levy D. Survival after the onset of congestive heart failure in Framingham Heart Study subjects. Circulation 1993;88:107–15. http://dx.doi.org/10.1016/j.cardfail.2016.10.003