Development of Nursing Protocol for Preventing Interruptions during Clinical Examinations and Treatments in the Early Days of Hospitalization for Acute Exacerbation of Chronic Heart Failure in Patients with Impaired Cognitive Function

The purpose of this study is to prepare a nursing protocol for preventing interruptions during clinical examinations and treatments performed in the early days of hospitalization for acute exacerbation of chronic heart failure in patients with impaired cognitive function. For the first stage of the research, we prepared a draft of the nursing protocol based on a basic survey. For the second stage, semi-structured interviews were conducted with 5 nurses specialized in chronic heart failure and 11 nurses in dementia care to ensure content validity of the draft protocol. For the third stage, we examined the possibility of clinical application of the revised version of the protocol draft prepared in the second stage of the study. For assessment items, significant points of nursing care, and specific nursing care practice in this revised version, 73 subjects (84.9%) considered effective for patients, in terms of prevention of interruptions during clinical examinations and treatments in the early days of hospitalization. All items and contents were considered useful by more than 60% of the nurses. Considering that the nurses working in the clinical setting reported 84.9% of usefulness, we concluded that this nursing protocol remained valid at a certain level. We consider that this nursing protocol will be useful especially for newly graduated/employed nurses as a procedure manual which can reduce their anxiety or stress caused by lack of knowledge or experiences.

Associations of body mass index and hospital-acquired disability with post-discharge mortality in older patients with acute heart failure

OBJECTIVES To investigate the effect of hospital-acquired disability(HAD)on all-cause mortality after discharge according to the body mass index(BMI)in older patients with acute decompensated heart failure.METHODS We included 408 patients aged≥65 years who were hospitalized for acute decompensated heart failure and had undergone an acute phase of cardiac rehabilitation at the Sakakibara Heart Institute between April 2013 and September 2015(me-dian age:82 years,interquartile range(IQR):76-86;52%male).Patients were divided into three groups based on BMI at hospital admission:underweight(<18.5 kg/m^(2)),normal weight(18.5 to 25 kg/m^(2)),and overweight(≥25 kg/m^(2)).HAD was defined as a decrease of at least five points at discharge compared to before hospitalization according to the Barthel Index.RESULTS The median follow-up period was 475(IQR:292-730)days,and all-cause mortality during the follow-up period was 84 deaths(21%).According to multivariate Cox regression analysis,being underweight(HR:1.941,95%CI:1.134−3.321,P=0.016)or overweight(HR:0.371,95%CI:0.171−0.803,P=0.012),with normal BMI as the reference,and HAD(HR:1.857,95%CI:1.062−3.250,P=0.030)were independently associated with all-cause mortality.Patients with HAD exhibited a significantly lower cumulative survival rate in the underweight group(P=0.001)and tended to have a lower cumulative survival rate in the normal weight group(P=0.072).HAD was not significantly associated with cumulative survival in the overweight group(P=0.392).CONCLUSIONS BMI and HAD independently predicted all-cause mortality after discharge in older patients with acute de-compensated heart failure.Furthermore,HAD was significantly associated with higher all-cause mortality after discharge,espe-cially in the underweight group.

Discharge heart rate and future events among Japanese patients with acute heart failure receiving beta-blocker therapy

Background: Randomized trials have demonstrated the efficacy of beta-blockers (BBs) in heart failure (HF) patients. We sought to assess the impact of BBs on long-term outcome;in particular, we assessed the association between outcome and BB dose and discharge heart rate. Methods and Results: Prescriptions for dispensed medication and outcomes were identified from a prospective, single-institution HF registry. Long-term prognosis was compared between users and non-users of BBs. BB users were further divided into 2 groups based on dose (full and non-full dose) and discharge heart rate (70 bpm was significantly associated with impaired long-term outcome (HR = 1.872, P = 0.04). Conclusions: Optimizing heart rate, rather than maximizing BB dose, appears to be an appropriate treatment strategy for the beta-sensitive Japanese population.

Clinical evidence of exaggerated inflammation in patients with a cardiogenic shock complicating ST-segment elevation myocardial infarction

We characterized the degree of systemic and coronary inflammation and the impact of those on clinical state in patients with a cardiogenic shock complicating first anterior ST-segment elevation myocardial infarction (STEMI). Methods: We recruited 14 consecutive patients with cardiogenic shock (10 men, 69 ± 12 years) and 18 well-matched baseline characteristics without shock (17 men, 64 ± 9 years) undergoing percutaneous coronary intervention (PCI) for an early phase of a first anterior STEMI in whom plasma level of cardiac enzyme was less elevated. We measured systemic and coronary levels of C-reactive protein, interleukin-6, and angiotensin II, and evaluated the relation of those to myocardial tissue-level reperfusion using both angiographic myocardial blush grade from 0 to 3, with the highest grade indicating normal myocardial perfusion, and a resolution of the sum of ST-segment elevation in 12-lead electrocardiogram. Results: In-hospital mortality was 57% in patients with cardiogenic shock and 6% without shock (p = 0.005). Coronary levels of C-reactive protein (9.2 ± 6.9 vs. 1.7 ± 2.1 mg/L, p = 0.001), interleukin-6 (379 ± 137 vs. 24 ± 20 pg/mL, p = 0.003), and angiotensin II (19 ± 10 vs. 10 ± 6 pg/mL, p = 0.010) were extremely higher in patients with shock than without shock. Interleukin-6 and angiotensin II, but not C-reactive protein, revealed higher in coronary levels than in systemic levels. The presence of both myocardial blush grade el reperfusion (p = 0.012). Conclusions: The exaggerated systemic and coronary inflammation, presumably associated with myocardial mal-reperfusion, was presented in patients with a cardiogenic shock complicating first anterior STEMI.

A new diagnostic feasibility for cardiomyopathy utilizing acoustic microscopy

Aims: Dilated cardiomyopathy often shows left ventricular systolic dysfunction, although histologically it always exhibits non-specific abnormality. We hypothesized that myocyte sound speed might be altered due to incomplete protein accumulation in cells. Methods and Results: Ninety eight biopsied samples were obtained from 49 patients comprising 43 with clinical dilated cardiomyopathy and 6 with hypertrophic cardiomyopathy. Sound speed was evaluated in deparaffinized 10 μm thick sections using an acoustic microscope (frequency range: 50 - 105 MHz). Conventional histology revealed 7 cases of persistent myocarditis derived from clinical dilated cardio- myopathy samples. Histology of the remaining dilated cardiomyopathy patients indicated non-specific abnormality. All hypertrophic cardiomyopathy cases exhibited myocardial disarray. Ten normal autopsied hearts were compared as controls. The sound speed of controls was 1627 ± 30m/sec. The sound speed in dilated cardiomyopathy samples (1700 ±51m/sec) was 1.045-fold faster compared to controls. The sound speed in hypertrophic cardiomyopathy samples (1734 ±51m/sec, 1.066-fold compared to controls) was faster than that of the myocarditis group (1672 ±30m/sec, 1.028-fold) (P = 0.0218). Furtheremore, desmin expression was evaluated as extent of emergence (grading 0 - 4). The desmin expression score in hypertrophic cardiomyopathy samples (2.7 ± 0.8) was significantly higher than in other groups (dilated 2.0 ± 1.4, myocarditis 1.6 ± 1.5 vs., controls 0, P ≤ 0.0001, 0.0001, 0.0129, respectively). Conclusion: Cardio-myopathy enhanced the sound speed, which correlated with the elasticity of myocytes, following the impaired compliance of left ventricle, despite the absence of histological changes. The elevation of sound speed of myocytes may be linked to cytoskeletal changes. Myocyte sound speed may be a new diagnostic tool for diagnosis of idiopathic cardiomyopathy independently of conventional histological diagnosis.

缺血性和非缺血性心肌病功能性二尖瓣反流的超声心动图决定因素不同

Background: Functional mitral regurgitation(MR) is one of the common and severe complications in patients with dilated cardiomyopathy. The detailed mechanisms that cause functional MR remain to be elucidated. Using two-dimensional transthoracic echocardiography, we inves- tigated the differences in major determinants of MR severity between ischemic cardiomyopathy(ICM) and non-ICM patients. Methods: We enrolled 103 patients(91 males; age 64± 12 years) with significant left ventricular(LV) dilatation. They were divided into ICM group(n=69) with significant coronary disease, and non-ICM(n=34) group without coronary disease. We devised a novel and simple parameter; the short-axis sphericity index(SI), to evaluate global LV remodeling, and used coaptation depth(CD) and tenting area(TA) to evaluate mitral deformity. Results: In all cases, CD, TA and left atrium diameter(LAD) correlated positively with maximum regurgitation area(MRA)(r=0.54, 0.57, 0.57; P< 0.0001). A negative correlation was observed between MRA and SI(r=-0.33, P=0.0008). There was no significant relationship between MRA and LV ejection fraction(EF). In non-ICM cases, SI tended to be lower with reduced EF.Multivariate stepwise linear regression analysis showed the following equations; ICM: MRA=-9.4 + 0.81CD + 0.21LAD(r2=0.47, P< 0.0001), non-ICM: MRA=-7.2 + 0.17LVDs(LV end systolic diameter)-8.7SI + 0.27LAD(r2=0.63, P< 0.0001). Conclusions: The strongest determinants of functional MR severity differ in ICM and non-ICM. While LV diameter and SI(global LV remodeling index) mainly determine the severity in non-ICM, CD that reflects mitral deformity is the major determinant in ICM.