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

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循環器領域において，虚血性心疾患，不整脈，弁膜症 などの疾患で心臓の機能が低下し，各臓器へ良好な血流 が得られなくなる最終状態が心不全である． 特に心不全の中でも急性心不全は，日中のみならず， 夜間にも多く発症し，軽症ではなく重症で来院すること が多い．我々は急性心不全加療に関しては，ある一定の パターンを持ちながら治療を行い，治療と同時になぜ急 性心不全を発症したかの原因検索を行なっている． すなわち，急性心不全加療は来院後の呼吸状態，循環 動態の安定を早急に図り，同時に原因へのアプローチの 2 本立てのアプローチが必要である．今回特に急性心不 全の治療部分についてガイドラインをもとに述べてい く

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慢性心不全治療で大切なことは左室収縮能 (Ejection Fraction: EF) によって，治療反応性が異なるという点 である．日本循環器学会ガイドラインでは EF < 40％を 駆出率が低下した心不全 (Heart Failure with reduced EF: HFrEF)，50％以上を駆出率が保たれた心不全 (HF with preserved EF: HFpEF)，この間にある治療反応性が 40％ 以上 50％未満を駆出率が軽度低下した心不全 (HF with mid-range EF: HFmrEF) と定義している．本邦の急性心 不全の疫学研究である ATTEND 試験2）などの大規模研 究からは心不全の約 3–5 割が HFrEF と考えられている． また，HFpEF においては HFrEF と比べ，高齢女性，糖 尿病や高血圧，心房細動のほかに COPD といった非心 血管疾患の併存が多い．JCARE-CARD 研究3）では，最 も多い背景として HFrEF では虚血性心疾患が 39.8％， HFpEF では高血圧が 44.3％と大きな違いを認め，予後 に関しては 1 年死亡率（全死亡）11％で同等とされる が，様々な大規模疫学研究により相違があり一定の報告 はない．HFrEF に対しては，予後改善効果をもってガ イドラインによる治療 (guideline-directed medical therapy: GDMT) が，推奨されており (Tables 1, 2)，HFmrEF では， HFrEF において有効な治療薬がある程度の効果を示す症 例がある．しかし，HFpEF については現在も予後が確 立された治療がなく，来る心不全パンデミックの課題で ある．

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1992 年，Xiao らは拡張型心筋症患者において QRS 幅 の拡大がピーク dp/dt の低下とピーク dp/dt への到達時 間と相関することを報告し，QRS 短縮により心機能改 善の可能性があると報告した1） ．1994 年，Bakker らは左 脚ブロック (CLBBB) を有する NYHA III-IV の重症心不 全 5 例に対し開胸にて左室心筋電極を留置し，両室ペー シングを行ったところ，4 例の自覚症状が改善，左室駆 出率が平均 8％増加し，2 例で僧帽弁閉鎖不全 (MR) が 有意に減少したと報告した2） ．さらに，1996 年に Cazeau らは 8 例の心室内伝導障害あるいは CLBBB を有する重 症心不全に両室ペーシングを行い，25％の心係数の改 善，17％の肺動脈楔入圧の減少，4 例に NYHA の改善 （IV → II 度）を認めたと報告した3） ．これらの報告を もとに，伝導障害，CLBBB の是正による心不全の治療 CRT が開発された.

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This section provides new insights into rhythm control for atrial fibrillation in the era of a heart failure pandemic.

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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.

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I report the effects of and a program and instructions for cardiac rehabilitation and the current status of cardiac rehabilitation for heart failure at our hospital.

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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

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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 collaboration.

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