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Background The association between corrected QT (QTc) interval and life‐threatening cardiac events in patients with hypertrophic cardiomyopathy (HCM) remains unclear. This study sought to investigate whether the prolonged QTc was associated with HCM‐related death in patients with HCM. Methods We included 445 patients with HCM (mean age 51 ± 16 years, 67% men). The QTc interval was measured at the time of the initial evaluation and the patients were classified into those with and without QTc prolongation, which was defined as a QTc interval >450 ms. HCM‐related death was defined as a combined endpoint of sudden death or potentially lethal arrhythmic events, heart failure‐related death, and stroke‐related death. Results Prolonged QTc interval was found in 120 patients (26.4%) at the time of enrollment. Over a median (IQR) follow‐up period of 8.1 (4.6–11.9) years, a total of 67 patients (15.1%) experienced HCM‐related deaths including 57 (12.8%) with the endpoint of sudden death or potentially lethal arrhythmic events. In a multivariable analysis that included prolonged QTc interval and the risk factors for life‐threatening events, prolonged QTc interval was independently associated with an HCM‐related death (adjusted hazard ratio [HR]: 1.91; 95% confidence interval [CI]: 1.16–3.16; p = .011) and this trend also persisted for the combined endpoint of sudden death or potentially lethal arrhythmic events (adjusted HR: 2.01: 95% CI: 1.17–3.46; p = .012). Conclusions In this cohort of patients with HCM, QTc prolongation may be associated with HCM‐related death, including the endpoint of sudden death or potentially lethal arrhythmic events. Prolonged QTc was associated with increased risk of HCM‐related mortality, including sudden death or lethal arrhythmias, and could serve as a simple, practical marker for identifying high‐risk patients. Our findings suggest that QTc prolongation is also valuable in Japanese populations, supporting its use in guiding personalized treatment strategies.

It remains unclear whether flecainide, a Class I antiarrhythmic drug, improves left ventricular pressure gradient (LVPG) or symptoms in patients with obstructive hypertrophic cardiomyopathy (HCM). Our study evaluated the long-term efficacy of flecainide, compared to disopyramide, when administered orally, on LVPG and symptoms in obstructive HCM patients. Among 164 obstructive HCM patients, 15 were administered oral flecainide therapy and 33 administered oral disopyramide therapy. LVPG declined from 79.8 ± 36.6 to 39.2 ± 36.7 mmHg ( p  = 0.003) after flecainide therapy and from 74.5 ± 26.4 to 31.4 ± 24.8 mmHg ( p  < 0.001) after disopyramide therapy. The percent reduction in LVPG was −47.9 ± 43.2 % in patients treated with flecainide, comparable to the results for those treated with disopyramide (−57.1 ± 33.0 %; p  = 0.425). We found no significant differences in improvement in NYHA functional class between patients treated with flecainide and those treated with disopyramide ( p  = 0.331). Patients treated with flecainide exhibited no significant adverse side effects, and there was no need for myectomy or alcohol septal ablation to reduce LVPG and symptoms. Improvements in LVPG and symptoms were similar in patients treated with flecainide and patients treated with disopyramide, suggesting that flecainide is a potentially useful alternative for symptomatic obstructive HCM patients, particularly those with disopyramide-induced vagolytic side effects, narrow angle glaucoma, or prostatic hyperplasia and pre-existing urination difficulties. Our data must be viewed with caution, however, in view of the small number of study patients. Flecainide therapy will require further proof of safety before it can be routinely recommended in patients with symptomatic obstructive HCM.

Thrombosis within the vascular system in relation to inflammation and stasis is potentially associated with poor prognosis in patients with heart failure. The aim of this study was to clarify the association between disseminated intravascular coagulation (DIC) score, a scoring system for microvascular thrombosis and multiple organ dysfunction, and outcome in hospitalized patients with acute heart failure (AHF). We retrospectively evaluated 160 AHF patients referred to a cardiac intensive care unit who had their DIC score measured according to the Japanese Association for Acute Medicine (JAAM) DIC scoring system on admission. Platelet count, prothrombin time ratio, fibrin/fibrinogen degradation products, and the criteria for systemic inflammatory response syndrome were measured. Using the JAAM DIC score, the prevalence of DIC (score ≥4) in AHF patients was 5.0% (8 of 160 patients). The risk of death for patients grouped according to the DIC score was 27.8%, 46.2%, and 87.5% for DIC scores 0–1, 2–3, and ≥4, respectively (median follow-up 460 days). In multivariate analysis adjusted for various markers of disease severity, a DIC score ≥2 was independently associated with a higher all-cause death rate (adjusted hazard ratio 2.45; P  = 0.005) and a higher rate of reaching the combined endpoint of all-cause death and readmission for AHF (adjusted hazard ratio 2.10; P  = 0.006) after admission for AHF. In an intensive care setting, measurement of DIC score on admission could help risk stratification in hospitalized patients with AHF.

The HeartMate Risk Score (HMRS), a simple clinical prediction rule based on the patients’ age, albumin, creatinine, and the international normalized ratio of the prothrombin time (PT-INR), is correlated with mortality in the cohort of left ventricular assist device (LVAD) recipients. However, in an aging society, an LAVD is indicated for only a small proportion of patients with acute heart failure (AHF), and whether the HMRS has prognostic implications for unselected patients with AHF is unknown. This study aimed to assess the prognostic value of HMRS categories on admission in patients with AHF. We analyzed 339 hospitalized patients with AHF who had albumin, creatinine, and the PT-INR recorded on admission. The patients were categorized as follows: the High group (HMRS > 2.48, n  = 131), Mid group (HMRS of 1.58–2.48, n  = 97) group, and Low group (HMRS < 1.58, n  = 111). The endpoints of this study were all-cause death and readmission for heart failure (HF). During a median follow-up of 247 days, 24 (18.3%) patients died in the High group, 7 (7.2%) died in the Mid group, and 8 (7.2%) died in the Low group. In a multivariable analysis adjusted for highly imbalanced baseline variables, a high HMRS was independently associated with survival, with a hazard ratio of 2.90 (95% confidence interval 1.42–5.96, P  = 0.004). With regard to the composite endpoint of all-cause death and readmission for HF, the Mid group had a worse prognosis than the Low group, and the High group had the worst prognosis. A high HMRS on admission is associated with all-cause mortality and readmission for HF, and a mid-HMRS is associated with readmission for HF after AHF hospitalization. The HMRS may be a valid clinical tool to stratify the risk of adverse outcomes after hospitalization in unselected patients with AHF.

A mitral L-wave indicates advanced diastolic dysfunction with elevated left ventricular filling pressure. Previous studies have reported that the presence of a mitral L-wave is associated with a poor prognosis in patients with heart failure. However, whether the L-wave can predict adverse events in patients with hypertrophic cardiomyopathy (HC) is still unclear. Therefore, we aimed to investigate the prevalence of a mitral L-wave in patients with HC, and the prognosis of patients with or without an L-wave. We analyzed 445 patients with HC. The end points of this study were HC-related death, such as sudden death or potentially lethal arrhythmic events, heart failure-related death, and stroke-related death. A mitral L-wave was defined as a distinct mid-diastolic flow velocity after the E wave with a peak velocity >20 cm/s. The prevalence of an L-wave was 32.4% in patients with HC. Patients with an L-wave were significantly younger, more likely to be women, had higher New York Heart Association functional class, and had a higher prevalence of atrial fibrillation than did patients without an L-wave. Patients with an L-wave had a significantly higher incidence of HC-related death compared with those without an L-wave (log-rank, p < 0.001). The L-wave was an independent determinant of HC-related death in multivariate analysis adjusted for imbalanced baseline variables (adjusted hazard ratio 2.38; 95% confidence interval 1.42 to 4.01; p = 0.001). In conclusion, the presence of a mitral L-wave may be associated with adverse outcome in patients with HC.

•Renal dysfunction had an incremental risk of future sudden death or potentially lethal arrhythmic events in patients with hypertrophic cardiomyopathy (HC).•Every 10 ml/min decline in the eGFR have a 24% increased risk of sudden death or potentially lethal arrhythmic events in HC patients.•An early risk stratification and active surveillance of the renal function may be favorable in the HC population. Renal dysfunction is a known risk of sudden cardiac death in patients with ischemic heart disease. However, the association between renal dysfunction and sudden death in hypertrophic cardiomyopathy (HC) patients remains unknown. This study investigated the significance of an impaired renal function for the sudden death risk in a cohort of patients with HC. We included 450 patients with HC (mean age 52.9 years, 65.1% men). The estimated glomerular filtration rate (eGFR) was evaluated at the time of the initial evaluation. Renal dysfunction was defined as an eGFR <60 ml/min/1.73 m2. Renal dysfunction was found in 171 patients (38.0%) at the time of enrollment. Over a median (IQR) follow-up period of 8.8 (5.0 to 12.5) years, 56 patients (12.4%) experienced the combined end point of sudden death or potentially lethal arrhythmic events, including 20 with sudden death (4.4%), 11 resuscitated after a cardiac arrest, and 25 with appropriate implantable defibrillator shocks. Patients with renal dysfunction were at a significantly higher risk of sudden death (Log-rank p = 0.034) and the combined end point (Log-rank p <0.001) than patients without renal dysfunction. After adjusting for the highly imbalanced baseline variables, the eGFR remained as an independent correlate of the combined end point (adjusted hazard ratio: 1.24 per 10 ml/min decline in the eGFR; 95% confidence interval 1.04 to 1.47; p = 0.013). In conclusion, an impaired renal function may be associated with an incremental risk of sudden death or potentially lethal arrhythmic events in patients with HC.

Abstract Aims The association between kinetics of blood urea nitrogen (BUN) levels in hospital and cardiovascular outcomes in patients with acutely decompensated congestive heart failure (HF) is unclear. We aimed to estimate the impact of changes in BUN level during hospitalization on clinical prognosis in patients with acute HF. Methods and results A total of 353 consecutive patients that were urgently hospitalized due to acutely decompensated HF and discharged alive were divided into four subgroups depending on their BUN level at admission and discharge, using a cut-off level of 21.0 mg/dL. Among 206 patients with high baseline BUN level, 46 (22%) and 160 (78%) had normal and persistent high BUN levels at discharge, respectively. In contrast, of the 147 patients with normal baseline BUN level, 55 (37%) and 92 (63%) had high and normal BUN levels at discharge, respectively. During the observational period after discharge, Kaplan–Meier analysis showed the highest rate of combined outcome of cardiovascular death and HF readmission in patients with persistent high BUN (log-rank test: P < 0.001). After adjustment for comorbidities, the hazard ratio for a combined outcome was significantly lower in patients with normalized BUN level compared with those with persistent high BUN (hazard ratio 0.48, 95% confidence interval 0.23–0.99, P = 0.049). Conclusions Persistent high BUN levels in hospital are associated with an increased risk of cardiovascular death and HF readmission. Normalization of BUN levels during hospitalization may be associated with long-term clinical outcomes.

Abstract Aims There are regional differences in the patient characteristics, management, and outcomes of hospitalized patients with heart failure (HF). The aim of this study was to evaluate the clinical characteristics and outcomes of Japanese patients who are hospitalized with HF on the basis of the left ventricular ejection fraction (LVEF) stratum. Methods and results We retrospectively conducted a multicentre cohort study of 1245 hospitalized patients with decompensated HF between 2013 and 2014. Of these patients, 36% had an LVEF < 40% [HF with reduced ejection fraction (HFrEF), median age 72 years, 71% male], 21% had an LVEF 40–49% [HF with mid-range EF (HFmrEF), 77 years, 56% male], and 43% had an LVEF ≥ 50% [HF with preserved EF (HFpEF), 81 years, 44% male]. The primary outcome was death from any cause, and the secondary outcomes were cardiac death and re-hospitalization due to worsened HF after hospital discharge. There were high proportions of non-ischaemic cardiomyopathy (32%) in HFrEF patients, coronary artery disease (44%) in HFmrEF patients, and valvular disease (39%) in HFpEF patients. The frequencies of intravenous diuretic and natriuretic peptide administration during hospitalization were 66% and 30%, respectively. The median hospital stay for the overall population was 19 days, and the length of stay was >7 days for >90% of patients. In-hospital mortality was 7%, but was not different among the LVEF groups (HFrEF 7%, HFmrEF 6%, and HFpEF 8%). After a median follow-up of 19 months (range, 3–26 months), 192 (17%) of the 1156 patients who were discharged alive died, and 534 (46%) were re-hospitalized after hospital discharge. There were no significant differences in mortality after hospital discharge among the three LVEF groups (HFrEF 18%, HFmrEF 16%, and HFpEF 16%). There were no differences in cardiac death or re-hospitalization due to worsened HF after hospital discharge among the LVEF groups (cardiac death: HFrEF 8%, HFmrEF 7%, and HFpEF 7%; re-hospitalization due to worsened HF: HFrEF 19%, HFmrEF 16%, and HFpEF 17%). Multivariable-adjusted analyses showed that the HFmrEF and HFrEF groups, compared with the HFpEF group, were not associated with an increased risk for in-hospital death or death after hospital discharge. Non-cardiac causes of death and re-hospitalization after hospital discharge accounted for 35% and 38%, respectively. Conclusions Our results revealed different clinical characteristics but similar mortality rates in the HFrEF, HFmrEF, and HFpEF groups. The most common cause of death and re-hospitalization after hospital discharge was HF, but non-cardiac causes also contributed to their prognosis. Integrated management approaches will be required for HF patients.

The aim of this study was to evaluate the association of functional mitral regurgitation (FMR), preserved or reduced ejection fraction (EF), and ischemic or nonischemic origin with outcomes in patients discharged alive after hospitalization for acute decompensated heart failure (HF). Of the 4,842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 3,357 patients were evaluated to assess the association of FMR, preserved or reduced EF, and ischemic or nonischemic origin with the primary end point (all-cause death and readmission for HF after discharge). At the time of discharge, FMR was assessed semiquantitatively (classified as none, mild, or moderate to severe) by color Doppler analysis of the regurgitant jet area. According to multivariable analysis, in the ischemic group, either mild or moderate to severe FMR in patients with a preserved EF had a significantly higher risk of the primary end point than patients without FMR (hazard ratio [HR] 1.60; 95% confidence interval [CI] 1.12 to 2.29; p = 0.010 and HR 1.98; 95% CI 1.30 to 3.01; p = 0.001, respectively). In patients with reduced EF with an ischemic origin, only moderate to severe FMR was associated with a significantly higher risk of the primary end point (HR 1.67; 95% CI 1.11 to 2.50; p = 0.014). In the nonischemic group, there was no significant association between FMR and the primary end point in patients with either a preserved or reduced EF. In conclusion, among patients with acute decompensated HF with a preserved or reduced EF, the association of FMR with adverse outcomes may differ between patients who had an ischemic or nonischemic origin of HF.