Clinical Practice for Acute Heart Failure in Japan From the Nationwide Registry
Article ID: CJ-23-0815
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Article ID: CJ-23-0815
Heart failure (HF) is the leading cause of death from cardiovascular disease, and the number of HF patients is increasing with aging of populations. The Japanese Circulation Society (JCS) and the Japanese Heart Failure Society (JHFS) have collaboratively published guidelines for the treatment of acute and chronic HF to standardize the quality of HF care.1,2 However, there are few reports examining the clinical practice of medical care for patients hospitalized with acute HF (AHF), and studies from large-scale nationwide registries have been needed. In this issue of the Journal, Kanaoka et al3 report the characteristics and prognosis of patients hospitalized for AHF using the Japanese Registry of All Cardiac and Vascular Diseases and the Diagnosis Procedure Combination (JROAD-DPC) database. Their results indicated that during the study period 2012–2020, the age of patients hospitalized with AHF increased, the proportion of male patients slightly increased, and in-hospital mortality and 30-day readmission rates decreased particularly in older adults. This improved prognosis for older patients with AHF can be attributed to the development of new medications, such as sodium-glucose cotransporter 2 (SGLT-2) inhibitors, and increased implementation of cardiac rehabilitation (CR).
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The guidelines for the treatment of acute and chronic HF recommend the use of β-blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and mineralocorticoid receptor antagonists (MRAs) based on established evidence.1,2 In the EARLIER trial, treatment with eplerenone, a selective MRA, in patients with AHF, reduced the risk of cardiovascular death or readmission due to HF within 6 months by 45%.4 In post-hoc analysis from this trial, eplerenone treatment improved clinical stability in the short-term following hospitalization for AHF, as indicated by decreased diuretic doses, B-type natriuretic peptide levels and reduced left ventricular volume.5 From their JROAD-DPC study, Kanaoka et al report that the proportion of hospital-level prescriptions of β-blockers, ACE inhibitors, and ARBs, respectively, was only 50–60% during observational period, although the use of these drugs slightly increased.3 The reason for this finding may be that some patients had comorbidities that would be contraindicated for these drugs, such as chronic obstructive pulmonary disease for β-blockers or hyperkalemia for ARBs. A recent study reported that prescription of guideline-recommended treatment decreased as severity of physical frailty increased among HF patients, which might cause the poor prognosis among those with frailty,6 and effective treatment strategies for frail patients with AHF are desired.
The current JROAD-DPC study showed an increased proportion of prescriptions for SGLT-2 inhibitors and tolvaptan.3 A meta-analysis of randomized controlled trials reported that the initiation of SGLT-2 inhibitor therapy at admission or within 3 days of discharge reduced the risk of readmission for patients with AHF.7 It may be that clinicians actively choose SGLT-2 inhibitors because of their evidence-based adequate therapeutic effect in patients with AHF. Concerning tolvaptan, the JCS/JHFS 2017 guideline recommended the use of low-dose tolvaptan for the treatment of fluid retention in patients with inadequate response to other diuretics such as loop diuretics, but recommended the use of tolvaptan only during hospitalization because there is insufficient evidence for improvement in long-term prognosis.1 Prescriptions for tolvaptan have been increasing for AHF patients since the guideline was published in Japan, although its use did not appear to affect in-hospital deaths,8 and there may be ongoing prescription of tolvaptan for patients with AHF after discharge. A nationwide large-scale database study is needed to investigate the use of tolvaptan after discharge and its effect on the prognosis of patients hospitalized with AHF.
A notable finding in the current JROAD-DPC study was an increase in the proportion of CR over time,3 which may be related to the accumulated good evidence from Japan regarding the efficacy of CR for AHF patients. A recent study reported that initiation of acute-phase CR improved short-term clinical outcomes including length of stay, 30-day readmission rate due to HF, and all-cause 30-day readmission in patients aged ≥90 years with AHF.9 Additionally, initiation of outpatient CR after discharge reduced deaths and readmissions for HF without increasing medical costs.10 However, in the FLAGSHIP study, outpatient CR after discharge of older adults with HF improved the short-term but not the long-term prognosis.11 Further evidence on the long-term effects of CR in patients with AHF is needed.
To improve the life expectancy of patients with AHF, it is necessary not only to implement effective pharmacotherapy during and after hospitalization and CR from the early stage of hospitalization, but to also provide lifestyle guidance including weight management after discharge. Some studies from Japan have suggested that patients hospitalized for AHF had a higher risk of in-hospital death on readmission if weight greatly decreased or increased before rehospitalization, and that poor adherence to lifestyle guidance and drug therapy increased the risk of readmission and all-cause death after discharge.12,13 Atrial fibrillation (AF) is also a known prognostic factor in patients with AHF, and interventions for AF could improve patient outcomes. A study from a nationwide database in Japan has reported that catheter ablation for AF within 90 days after admission for HF improved long-term outcomes, including cardiovascular and HF death in HF patients with AF.14 To improve the prognosis of AHF patients, further research is needed from various perspectives including effective pharmacotherapy, lifestyle guidance, and also cost-effective treatment in the registry for older patients (Figure).
Improving the prognosis of acute heart failure through further research from the perspectives of the efficacy of the intervention for some specific populations, such as older patients and those with frailty, and the cost-effectiveness of the intervention.
