In 2018, The Japanese Circulation Society and The Japanese Heart Failure Society updated the Guidelines for
Diagnosis and Treatment of Acute and Chronic Heart Failure. I provide a summary of these new guidelines. It is
necessary that not only cardiologists but also noncardiologists understand the guidelines and join in the treatment
of heart failure because the number of patients with heart failure will increase with aging in the future in Japan.
Key words: heart failure, guidelines, stage of chronic heart failure
In the cardiovascular disease area, heart failure is the final state, in which the function of the left and right ventricles decreases because of diseases such as ischemic heart disease, arrhythmia, and valvular disease, and proper
systemic circulation cannot be provided for each organ. Among heart failure types, acute heart failure often occurs
not only during the daytime but also at night, and a patient often arrives to the hospital with a severe condition.
Acute heart failure it is treated using a specified protocol, and the cause of acute heart failure is sought at the time
of treatment. In acute heart failure treatment, it is necessary to promptly stabilize respiratory status and circulatory
dynamics after the admission. At the same time, the use of a two-pronged approach to the cause and stabilization
of the patient’s conditions is required. At this time, we will mainly describe the treatment of acute heart failure
based on Japanese guidelines.
The current guidelines emphasize the importance of time allocation in the course of treatment. The guidelines
indicate that the diagnosis should be made as early as possible. Furthermore, the guidelines list different diseases
that cause acute heart failure. As a percutaneous implantation type of LVAD, which is a left ventricular assist device, IMPELLA has been available in Japan since 2017. IMPELLA assistance to systemic circulation, allows powerful circulation support to the whole body and unloads the left ventricle. In our hospital, this device saves many
patients’ lives. The use of this device is expected to continue saving lives of patients with acute heart failure.
Heart failure is a clinical syndrome, which is characterized by symptoms such as breathlessness, fatigue, and
edema that appear as a result of decompensation in cardiac function, due to a structural and/or functional cardiac
abnormality, and is accompanied by a decrease in exercise tolerance.
Heart failure is a progressive and poor-prognosis syndrome, which thus requires not only drug treatment but
also comprehensive medical treatment, such as diet therapy and exercise therapy, combined with cardiac rehabilitation.
In addition, the number of elderly patients with heart failure will increase in the future, which is called a heart
failure pandemic; therefore, it is necessary to provide medical care based on symptoms while also considering
palliative medicine and views on life.
Previously, The Japanese Circulation Society classified heart failure into acute and chronic categories, with
specific guidelines for each. However, both acute and chronic conditions are considered a series of heart failure
stages, and revisions have been made for early intervention based on heart failure stages.
Regarding chronic phase management of heart failure, the treatment and evaluation method clinically change
depending on left ventricular function, and the latest heart failure therapeutic agents are described with reference
to the evidence.
The targets of heart failure management are to prevent death and control heart failure hospitalizations, which
are the endpoints of many large clinical trials, but it is also important to improve the exercise capacity and quality
of life (QOL). The role of practitioners and medical cooperation with clinics are extremely important.
The main treatment for heart failure (HF) is medication. However, in patients with severe HF, the ventricle expands, and intraventricular conduction disturbance occurs. Most commonly, left ventricular remodeling and left
bundle branch block are detected. The conduction disturbance leads to a deviation in the timing of contraction
between the right and left ventricles, referred to as cardiac dyssynchrony, with resultant deterioration in cardiac
function. Cardiac resynchronization therapy has been developed to correct conduction disturbance and resynchronize cardiac contraction.
A ventricular assist device (VAD) is an artificial organ that assists the function of the left and/or right ventricle
of the heart in patients with severe heart failure. In 1982, our hospital was the first to achieve successful use of a
VAD in Japan. There are still only 4 institutions in Tokyo to which accreditation was granted for the use of implantable VADs. We would like to present our current clinical experience with VAD therapy and future prospects.
The INTERMACS registry includes 25,087 patients who underwent VAD therapy as of May 2020, while the
J-MACS registry (Japan) includes 945 patients as of June 2019. Recent reports have indicated that a drastic shift
occurred from pulsatile pumps to continuous flow pumps and that the timing of implantation also changed, i.e.,
earlier implantation in mild patients or at a high INTERMACS level. This is a global trend.
More than 6 decades have elapsed since the introduction of VADs. With advancement in a cutting-edge technology, VAD therapy has become an important treatment option for severe heart failure. In Western countries,
implantable VADs are regarded as an alternative to heart transplantation, and the bridge to transplantation ratio has
declined while the destination therapy (DT) ratio has increased. Since it is anticipated that DT will be approved
in Japan in a few years, it is expected that DT will become popular in Japan, where heart transplantation is infrequently conducted.
Globally, the number of patients with heart failure is rapidly increasing. The prognosis of patients with heart
failure is unfavorable, resulting in a decline in their quality of life. Therefore, in addition to heart failure treatment,
a multifaceted intervention for patients with heart failure is needed from an early stage. In this context, palliative
care for heart failure is different from end-of-life care. This section discusses palliative care for heart failure, including advance care planning
Japan is at the forefront of super-aging societies worldwide, and a “heart failure pandemic (HF)” is predicted
for the near future under the current medical system. This “pandemic” is not temporary but ongoing. We need to
work hard to prevent and treat HF throughout the region. We report the importance of regional cooperation for
preparedness for a HF pandemic and our University activities.
Our hospital established a HF team and conducted regional collaborative activities. Since December 2018, the
heart failure team has been upgraded with hospital support and going the following; 1) After the establishment
of the heart failure nursing clinic within the heart failure outpatient clinic. 2) HF case conference. 3) HF interdisciplinary conference. 4) Ventricular Assist Device conference. 5) Establishment of study groups in each local
medical association (Itabashi, Toshima, Nerima, and Kita). 6) Lecture activities at each branch of the Alumni
Association of Nihon University School of Medicine. 7) Mobilization of doctors to each facility. 8) Outpatient
hANP treatment was conducted as a multi-center study. 9) continuous positive airway pressure (CPAP) or adaptive servo ventilation (ASV) was actively conducted. 10) Medical Care Stations, a social networking service (SNS)
for medical fields, were introduced. 11) HF Registry (SAKURA-HF).
To prepare for a HF pandemic, it is important to clarify the role of each facility and share information when
engaging in treatment and prevention. University hospitals should take leadership to establish regional collaborations for HF. Information and communication technology (ICT) is considered an effective tool to strengthen such