小森 孝洋

Heart failure (HF) guidelines recommend screening for non-symptomatic Stage B HF. Evidence on the utility of home blood pressure (BP) for risk stratification of Stage B HF is limited. We aimed to examine the association of home BP with the prevalence of Stage B HF and the risk of symptomatic HF. This study used cohort data with 14 days of morning and evening home BP measurements, biomarker sampling, and cardiovascular event follow-up among Japanese outpatients. Stage B HF was defined as N-terminal pro-B-type natriuretic peptide ≥125 pg/mL, and/or high-sensitivity cardiac troponin >22 ng/L in men and >14 ng/L in women. Among 3077 participants without prior cardiovascular disease including coronary artery disease, symptomatic HF, stroke, and others (mean age 64.5 years, 43.1% male), 548 participants had Stage B HF. In the multivariable logistic model, home systolic BP (SBP) was associated with Stage B HF (OR [95% CI] per 10 mmHg, 1.22 [1.13-1.33]). The area under the curve (AUC) was significantly improved by adding home SBP to the model including office SBP (AUC 0.757-0.763). During the median 5.0-year follow-up, Stage B HF was associated with a higher risk of HF hospitalization (adjusted HR [95% CI], 3.94 [1.45-10.70]). Home SBP tended to be associated with an increased risk of HF hospitalization (unadjusted HR [95% CI] per 10 mmHg, 1.29 [0.97-1.71], p = 0.081), but this association was not significant after adjustment. In conclusion, appropriate BP management using home BP monitoring before the progression of HF could help prevent symptomatic HF.

BACKGROUND: Noninvasive assessment of cardiac function is useful in the management of heart failure (HF). OBJECTIVES: We developed a novel pulse waveform index, 'Sf/Am', from cuff-oscillometric ambulatory blood pressure (BP) monitoring (ABPM), to estimate cardiac function. This study aimed to investigate the usefulness of square forward pulse wave/amplitude measure pulse wave (Sf/Am), which reflects cardiac systolic function in ambulatory settings, for estimating echocardiographic left ventricular ejection fraction (LVEF) in patients with HF. METHODS: A cuff volumetric waveform was obtained from the diastolic phase of each BP measurement with a multisensor-ABPM (TM-2441, A&D). The area of the ejection is the Sf. Sf is divided by the Am, that is, Sf/Am, to eliminate the effects of arterial and cuff compliance. This index was hypothesized to represent left ventricular systolic function. LVEF was determined using the modified Simpson's method. RESULTS: A total of 195 participants with HF completed ABPM and echocardiogram. After excluding 76 participants with atrial fibrillation, 119 participants (mean age, 70.0 ± 15.9 years; 58.8% male) were included in the analysis. Sf/Am was correlated with LVEF (r = 0.550, P < 0.001). This relationship remained significant in a multivariable linear regression model adjusted for BP level and other confounders (β = 0.603, P < 0.001). The area under the curve values 95% confidence interval (CI) for Sf/Am in predicting LVEF < 40% and <30% were 0.814 (0.738-0.890) and 0.897 (0.840-0.953), respectively. CONCLUSION: Pulse waveform analysis using ABPM has potential for noninvasive estimation of echocardiographic LVEF.

BACKGROUND: It remains unclear whether the newly adopted high-power, short-duration (HP-SD) setting in ablation for atrial fibrillation (AF) impacts periprocedural thrombotic markers or silent stroke (SS) onset. OBJECTIVE: The aim of the present study was to investigate the clinical impact of HP-SD setting ablation on changes in periprocedural thrombotic markers and the onset of SS. METHODS: We enrolled 101 AF patients: the HP-SD group (n = 67) using 50 W and the conventional ablation group (n = 34) using 30 to 40 W. D-dimer, thrombin-antithrombin complex (TAT), and total plasminogen activator inhibitor-1 (tPAI-1) were analyzed the day before, immediately after, and 1 day after the procedure. Magnetic resonance imaging was performed within 48 hours after the procedure. RESULTS: Left atrial dwelling time was significantly shorter in the HP-SD group (P < .05). In the conventional ablation group, the D-dimer and tPAI-1 levels continued to increase until 1 day postprocedure, while the TAT peaked immediately after the ablation. On the other hand, the range of the variation of these thrombotic markers in the HP-SD group was smaller. SS occurred more frequently in the conventional ablation group than in the HP-SD group (26% vs 5%, P < .05). In the logistic regression analysis, the HP-SD setting and TAT difference (postprocedure - preprocedure) were independent predictors for SS (odds ratios 0.141 and 5.838, respectively; P < .05). CONCLUSIONS: The HP-SD setting led to a shorter left atrial dwelling time and reduced change in thrombotic markers, resulting in lower prevalence of SS.

Hypertension (HTN) is one of the major risk factors for developing atrial fibrillation (AF), and it has been estimated that approximately 70% of hypertensive patients are at risk of developing AF. On the other hand, 60-80% of AF patients have HTN. These two diseases share many risk factors such as diabetes mellitus, obesity, alcohol consumption, and sleep apnea syndrome during their onset and disease progression. The mutual presence of these diseases has the potential to create a negative spiral, exacerbating each other's impact and ultimately leading to cardiovascular events such as heart failure and cerebrovascular disorders, thereby increasing mortality rates. With regard to the treatment of HTN, the variety of antihypertensive drugs and treatment options have significantly increased. Alongside the widespread adoption of antihypertensive therapy, a certain level of efficacy has been recognized in suppressing the incidence of new-onset AF. Catheter ablation is an established and effective treatment for AF. However, a notable recurrence rate persists. In recent years, management of these multiple risk factors has been recognized to be essential for suppressing AF recurrence, and recent guidelines for AF underscore the significance of proactively managing these risks before treatment. Notably, effective HTN management assumes paramount importance given its impact on the morbidity of AF patients. This review summarizes the correlation between HTN control before and after ablation and the risk of AF recurrence. The focus is on elucidating the pathophysiological background and its impact on clinical outcomes.

BACKGROUND: The precise details of atrial activation around the triangle of Koch (ToK) remain unknown. We evaluated the relationship between the atrial-activation pattern around the ToK and success sites for slow-pathway (SP) modification ablation in slow-fast atrioventricular reentrant tachycardia (AVNRT). METHODS: Thirty patients with slow-fast AVNRT who underwent successful ablation were enrolled. Atrial activation around the ToK during sinus rhythm was investigated using ultra-high-density mapping pre-ablation. The relationships among features of atrial-activation pattern and success sites were examined. RESULTS: Of 30 patients (22 cryoablation; 8 radiofrequency ablation), 26 patients had a collision site of two wavefronts of delayed atrial activation within ToK, indicating a success site. The activation-search function of Lumipoint software, which highlights only atrial activation with a spatiotemporal consistency, showed non-highlighted area on the tricuspid-annulus side of ToK. In 23 of the patients, a spiky potential was recorded at that collision site outside the Lumipoint-highlighted area. Fifteen cryoablation patients with a success site coincident with a collision site outside the Lumipoint-highlighted area had significantly more frequent disappearances of SP after initial cryoablation (46.7% vs. 0%, p = .029), fewer cryoablations (3.7 ± 1.8 vs. 5.3 ± 1.3, p = .045), and shorter procedure times (170 ± 57 vs. 228 ± 91 min, p = .082) compared to the seven cryoablation patients without such sites. Four patients had transient AV block by ablation inside the Lumipoint-highlighted area with fractionated signals, but no patient developed permanent AV block or recurrence post-procedure (median follow-up: 375 days). CONCLUSIONS: SP modification ablation at the collision site of atrial activation of the tricuspid-annulus side along with a spiky potential could provide a better outcome.