苅尾 七臣

Prasugrel reduces the recurrence of atherosclerotic cardiovascular disease and restenosis after percutaneous coronary intervention (PCI). However, its actual dosage in Japan has not been well studied. This study aimed to compare different prasugrel doses after PCI using retrospective data from the Clinical Deep Data Accumulation System (CLIDAS) database. A retrospective observational study was conducted using the CLIDAS-PCI database with a 2-year follow-up after PCI. There were 2,869 and 52 patients in the 3.75- and 2.5 mg groups, respectively. The 2.5 mg group was comprised of significantly more female, older, shorter, and lower-body-weight patients and included more patients with a history of coronary artery bypass grafting, stroke, peripheral arterial disease, or active malignancy than the 3.75 mg group. Concomitant medications included antiplatelets, anticoagulants, and statins. Laboratory data showed substantially lower hemoglobin and platelet counts in the 2.5 mg group. Most patients weighed < 50 kg; however, fewer had an estimated glomerular filtration rate < 30 mL/min/1.73 m². Major adverse cardio- and cerebrovascular events were similar between groups. The 2.5 mg group had more non-fatal strokes and major bleeding associated with antithrombotic therapy. In Japan, prasugrel 2.5 mg should be considered to reduce major bleeding in patients with low body weight, older adults, women, those receiving concomitant antithrombotic therapy, and those with low platelet counts.

Chronic kidney disease (CKD) is a major risk factor for cardiovascular events, and controlling blood pressure (BP) is essential for reducing this risk in CKD patients. Although office BP is the standard for BP control in CKD, home BP monitoring more precisely predicts cardiovascular outcomes, especially across Kidney Disease: Improving Global Outcomes (KDIGO) risk categories. This study evaluated the differential impact of office and home BP control on cardiovascular event rates across KDIGO risk levels. Data from 4264 participants in the Japan Morning Surge-Home Blood Pressure study were analyzed. Participants were stratified by KDIGO risk and classified by BP control using office (<140/90 mmHg) and home (<135/85 mmHg) thresholds. The primary outcome was a composite of cardiovascular events, including myocardial infarction, stroke, heart failure hospitalization, and cardiovascular death. Cox proportional hazards models evaluated associations between BP control and cardiovascular risk within KDIGO strata. Over a median 6.2-year follow-up, 262 cardiovascular events occurred. In the high/very high KDIGO group, controlled home BP was associated with a lower event rate (10.3 vs. 31.8 per 1000 person-years; HR = 0.38, 95% CI 0.20-0.70; P < 0.001). The interaction between home BP and KDIGO risk was significant (P = 0.024). Office BP control showed no significant association with cardiovascular outcomes. Subgroup analysis revealed that morning and evening home BP control predicted reduced cardiovascular risk in high-risk individuals. Home BP control, not office BP control, was associated with reduced cardiovascular risk, especially in individuals with high KDIGO risk. These findings support integrating home BP monitoring into CKD-related hypertension care.

BACKGROUND: Cardiovascular prognosis in people with drug-resistant hypertension, defined by office and home blood pressure, has not been fully evaluated. This Japan Morning Surge-Home Blood Pressure study data analysis evaluated the cardiovascular event rate in patients with drug-resistant hypertension defined using office and home blood pressure. METHODS: The incidence of cardiovascular events (stroke, coronary artery disease, congestive heart failure, aortic dissection) in participants with true resistant hypertension (office blood pressure ≥140/90 mm Hg and home blood pressure ≥135/85 mm Hg during treatment with ≥3 antihypertensives, including a diuretic) was determined and compared with other hypertension subgroups. RESULTS: During mean 6.2 years' follow-up in 4278 participants (mean age, 64.9±10.9 years; 46.9% male), cardiovascular events included stroke (n=96), coronary artery disease (n=125), congestive heart failure (n=42), aortic dissection (n=8), and sudden death (n=15). The incidence of cardiovascular events in patients with home blood pressure monitoring-confirmed resistant hypertension was 34.7 per 1000 person-years (significantly higher than in those with well-controlled hypertension on ≥3 drugs including a diuretic; 11.9 per 1000 person-years [P<0.001]). In the home blood pressure monitoring-confirmed resistant hypertension group, cardiovascular event incidence was highest in those with versus without cardiovascular disease history (39.4 versus 22.7 per 1000 person-years). CONCLUSIONS: These data showed that home blood pressure-confirmed resistant hypertension was associated with a high incidence of cardiovascular events over time, especially in the presence of a cardiovascular disease history. The relevance of home blood pressure monitoring for defining resistant hypertension and treatment strategies, especially compared with ambulatory blood pressure monitoring, remains to be determined. REGISTRATION: URL: https://www.umin.ac.jp/ctr; Unique identifier: UMIN000000894.

BACKGROUND: There are few data verifying the utility of the CHADS-P2A2RC score in comparison with the CHADS2 score for estimating net adverse clinical events (NACE) in chronic coronary syndrome (CCS) patients without atrial fibrillation (AF) in real-world settings. METHODS: We performed analysis for a total of 3985 CCS patients without AF who underwent percutaneous coronary intervention (PCI) between April 2013 and March 2019 for whom information was obtained from the CLIDAS (Clinical Deep Data Accumulation System)-PCI database. The primary endpoint was NACE defined as the composite of 3-point major adverse cardiovascular events (3P-MACE) (cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke) and GUSTO moderate/severe bleeding events. RESULTS: Kaplan-Meier analysis showed that both the CHADS-P2A2RC and CHADS2 scores stratified the risks. The incidences of NACE were stratified well by the very-high-risk category, which was uniquely defined as a CHADS-P2A2RC score of ≥6 (hazard ratio: 2.38, 95 % CI = 1.91-2.97, p-value <0.001). The area under the curve (AUC) in estimating NACE within 3 years was higher when the CHADS-P2A2RC score was used than when the CHADS2 score was used (0.67 vs. 0.62, p = 0.003). This was mainly due to the accuracy in estimating bleeding events (0.66 vs. 0.60, p = 0.006). CONCLUSIONS: The accuracy in estimating NACE after PCI for CCS patients without AF was higher when the CHADS-P2A2RC score was used than when the CHADS2 score was used, mainly due to the accuracy in predicting bleeding risk. Higher incidences of endpoints were well-stratified by a very-high-risk category defined as a CHADS-P2A2RC score of ≥6.

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: Lipid-lowering therapy with high-intensity statins has not been widely implemented in Japan for patients with coronary artery disease who undergo percutaneous coronary intervention (PCI). We examined the efficacy and safety of high-intensity statin therapy in a real-world setting. METHODS AND RESULTS: We used the Clinical Deep Data Accumulation System (CLIDAS) to accumulate multimodal data from the electronic medical records of 7 cardiovascular centers. We analyzed 9,690 patients who underwent PCI between 2013 and 2019 and completed a median 2.5-year follow-up (CLIDAS-PCI database). The risk of developing major adverse cardiac and cerebrovascular events (MACCE) was significantly greater in patients with acute (ACS) than chronic (CCS) coronary syndrome. High-intensity statins were prescribed to 49% of ACS patients and 33% of CCS patients within the first 30 days after the index PCI. After propensity score matching, MACCE event rates were similar between the high- and moderate-intensity statin groups. Importantly, among ACS patients, Cox proportional hazard analysis revealed that the rate of myocardial infarction was lower (adjusted hazard ratio [aHR] 0.65; 95% confidence interval [CI] 0.44-0.97) and the rate of stroke was greater (aHR 1.71; 95% CI 1.12-2.62) in the high-intensity statin group, driven mostly by intracranial hemorrhage. CONCLUSIONS: The CLIDAS-PCI database provides real-world evidence for the efficacy and safety of high-intensity statins in Japanese ACS patients who have undergone PCI.

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: Patients with surgically repaired tetralogy of Fallot (rTOF) often develop chronic pulmonary regurgitation (PR), necessitating pulmonary valve replacement (PVR). While cardiac MRI is crucial for PVR timing, its availability is limited. This study evaluates electrocardiographic (ECG) findings - specifically the R-wave amplitude in lead V1 (V1R) and the sum of the R-wave amplitude in lead V1 and the deepest S-wave amplitude in lead V5 or V6 (V1R + V5S or V6S) - as predictors of cardiac MRI findings. PATIENTS AND METHODS: We retrospectively analyzed 35 rTOF patients (mean age 34 ± 9 years; 60% male) who underwent cardiac MRI from 2019 to 2022, assessing correlations between ECG parameters (V1R, V1R + V5S or V6S, and QRS duration) and MRI findings (RVESVI and RVEDVI). RESULTS: V1R showed significant correlation with RVESVI (r = 0.486, p = 0.003) and was notably higher in patients with RVESVI ≥ 80 mL/m2. A V1R cutoff of 20 mm identified RVESVI ≥ 80 mL/m2 with 67% sensitivity and 77% specificity. CONCLUSIONS: V1R on ECG may help predict the need for cardiac MRI, aiding in the timely PVR planning for rTOF patients.

BACKGROUND: Dual antiplatelet drug administration is recommended after percutaneous coronary intervention (PCI) stent placement. Although prasugrel, a newer P2Y12 inhibitor, reportedly suppresses cardiovascular events more effectively than the traditional agent clopidogrel, its preventive effects on cerebrovascular disorders remain a topic of ongoing debate. This study aimed to examine the cerebrovascular efficacy and safety of post-PCI prasugrel and clopidogrel using extensive real-world data in Japan. METHODS: Using the CLIDAS (Clinical Deep Data Accumulation System) database, 7412 post-PCI patients who received dual antiplatelet therapy between April 2013 and March 2019 were identified. The primary end point was defined as the incidence of any stroke, while secondary end points included individual ischemic and hemorrhagic cerebrovascular events. The incidence of cerebrovascular events was compared between the prasugrel (2.5–3.75 mg daily; n=2219) and clopidogrel (75 mg daily; n=5193) groups using propensity-score inverse probability of treatment weighting and Fine and Gray models to account for competing risks. RESULTS: Within 1 year after PCI, the prasugrel group had a significantly lower incidence of cerebrovascular events (subdistribution hazard ratio, 0.46 [95% CI, 0.24–0.91]; P =0.027) than the clopidogrel group. The subgroup analyses did not show significant differences in the incidence of ischemic (subdistribution hazard ratio, 0.54 [95% CI, 0.25–1.14]; P =0.11) and hemorrhagic cerebrovascular events (subdistribution hazard ratio, 0.30 [95% CI, 0.084–1.10]; P =0.070) between the use of prasugrel and clopidogrel. One-year health care costs between patients treated with prasugrel and those treated with clopidogrel showed no significant differences. CONCLUSIONS: Our data suggest that post-PCI prasugrel use was associated with lower cerebrovascular events compared with the use of clopidogrel in combination with aspirin. Further research is necessary to substantiate the potential of prasugrel in lowering cerebrovascular risks after post-PCI while upholding a satisfactory safety profile.

BACKGROUND: Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) provides an alternative treatment for high-risk patients with failed surgical bioprosthetic aortic valves. However, limited data exist on ViV-TAVR outcomes in patients with small aortic annuli, particularly among the relatively small-statured Japanese population. METHODS: We analyzed data from the J-TVT (Japan Transcatheter Valve Therapy) registry, which included all TAVR institutions across Japan, with data collected from July 2018, when ViV-TAVR was approved, through December 2022. A small aortic annulus was defined as an aortic annulus area of ≤314 mm², measured using preoperative computed tomography for ViV-TAVR. Prosthesis-patient mismatch (PPM) was defined as an indexed effective orifice area <0.85 cm²/m², assessed using echocardiography within 30 days after ViV-TAVR. The composite endpoint was evaluated at 30 days and 1 year. RESULTS: Among 47 800 individuals, 1029 underwent ViV-TAVR, resulting in a final sample of 405 patients. The mean indexed effective orifice area was 0.83 cm²/m² in the small annulus group (n=225) and 0.94 cm²/m² in the nonsmall group (n=180), with PPM rates of 59.2% and 44.4%, respectively. Small annuli were independently associated with PPM (hazard ratio, 1.9 [95% CI, 1.26-2.87]; P=0.002). No differences in 30-day and 1-year outcomes were observed between groups. Among the 225 patients with small annuli, the mean indexed effective orifice area was 0.76 cm2/m2 in the balloon-expandable valve group (n=61) and 0.86 cm2/m2 in the supraannular self-expanding valve group (n=164), with PPM rates of 67.2% and 56.1%, respectively. No differences in outcomes were noted based on the type of valve implanted. CONCLUSIONS: ViV-TAVR for small aortic annuli in Japanese patients was associated with an increased risk of PPM; however, no differences in clinical outcomes were observed according to aortic annulus size or valve type. Due to the small size of our sample, further research is required to validate these findings.

Clinical implications of high peak nighttime home blood pressure (BP) are currently unknown. This study investigated the association between peak nighttime home systolic BP (SBP) and cardiovascular events in individuals with at least one cardiovascular risk factor. In the Japan Morning Surge-Home Blood Pressure (J-HOP) study, nighttime home BP was automatically measured three times each night for 14 days at baseline using a nighttime home BP monitoring device (HEM-5001, Omron Healthcare). Peak nighttime home SBP was defined as average of the highest three values over the 14-night measurement period. Cardiovascular events (stroke, coronary artery disease, heart failure, aortic dissection) were tracked over a mean follow-up period of 7.1 years. This analysis included 2545 individuals (mean age 63.3 ± 10.3 years, 49% male). After adjusting for covariates (including age, sex, and average office, morning, evening, and nighttime home SBP), stroke risk was significantly higher in individuals with peak nighttime home SBP in the highest quintile (≥149.0 mmHg) compared to the lowest quintile (<119.3 mmHg) (hazard ratio [HR] 4.24, 95% confidence interval [CI] 1.07-16.77; p = 0.039 overall and 8.92, 1.49-53.43; p = 0.017 in the subgroup with ≥6 nighttime home SBP measurements). This increased stroke risk remained significant after controlling for day-by-day average real variability of nighttime BP. The average peak nighttime home SBP cut-off value for predicting an increased risk of incident stroke was 136 mmHg. We propose that exaggerated peak nighttime home SBP, determined from ≥6 measurements, is a novel risk factor for stroke, independent of conventional office and home BP values. The exaggerated peak nighttime home systolic blood pressure (HSBP) determined from six or more measurements as a novel risk factor for stroke, independent of conventional office and home blood pressure (BP) values.

The prognostic impact of vascular biomarkers and supine blood pressure (BP) is not well understood. The multicenter, prospective Coupling study determined the prognostic impact of vascular biomarkers and supine BP in outpatients aged ≥30 years with ≥1 cardiovascular risk factor. Occurrence of major cardiovascular events during follow-up was recorded. The primary outcome was time to onset of a major cardiovascular event. Office and supine BP, the cardio-ankle vascular index (CAVI), and the ankle-brachial index (ABI) were determined annually. Of the 5109 participants in the Coupling study, 4716 were analyzed (51.9% male, mean age 68.5 ± 11.4 years); participants mostly had hypertension treated based on seated office/home BP according to relevant guidelines. During a median follow-up of 5.0 years (interquartile range 3.6-5.2), 231 major cardiovascular events occurred. After adjustment for age, sitting office systolic BP, and other covariates, a 1-unit increase in CAVI (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.01-1.24) and a 0.1-unit decrease in ABI (HR 1.41, 95% CI 1.18-1.68) were significantly associated with cardiovascular event risk; risk was greatest when CAVI was ≥8.0 and ABI was ≤1.10. Uncontrolled supine hypertension (≥140/90 mmHg) was also significantly associated with adjusted cardiovascular event risk (HR 1.36, 95% CI 1.02-1.81); seated office BP control was not significantly associated with cardiovascular event risk. Increased arterial stiffness, mildly lower ABI, and supine hypertension are risk factors for cardiovascular events during standard clinical practice. Supine evaluation of BP and vascular biomarkers has highlighted a blind spot in current hypertension management (Clinical trial registration: University Hospital Medical Information Network Clinical Trials Registry, UMIN000018474).

A home blood pressure (BP)-centered strategy is emerging as the optimal approach to achieve adequate BP control in individuals with hypertension, but a simple cardiovascular risk score based on home BP level and variability is lacking. This study used prospective data from the Japan Morning Surge-Home Blood Pressure (J-HOP) extended study to develop a simple home BP stability score for the prediction of cardiovascular risk. The J-HOP extended study included 4070 participants (mean age 64.9 years) who measured home BP three times in the morning and evening for 14 days at baseline. During the mean 6.3-year follow-up, there were 260 cardiovascular events. A home BP stability score was calculated based on the average of morning and evening systolic BP (SBP; MEave), and three home BP variability metrics: average real variability (average absolute difference between successive measurements); average peak (average of the highest three SBP values for each individual), and time in therapeutic range (proportion of time spent with MEave home SBP 100-135 mmHg). There was a curvilinear association between the home BP stability score and the risk of cardiovascular events. Compared with individuals in the optimal home SBP stability score group (9-10 points), those in the very high-risk group (0 points) had significantly higher cardiovascular event risk during follow-up (adjusted hazard ratio 3.97, 95% confidence interval 2.22-7.09; p < 0.001), independent of age, sex, medication, cardiovascular risk factors, and office BP. These data show the potential for a simple home BP-based score to predict cardiovascular event risk in people with hypertension.

BACKGROUND: There has been no study about the association of longitudinal change in ambulatory blood pressure (BP) variability and level with cognitive decline. OBJECTIVES: The purpose of the study was to evaluate whether BP changes via ambulatory BP monitoring predict cognitive decline progression. METHODS: Twice-annual ambulatory BP readings were examined during 5 years and their relationship with changes in the Japanese version of the Montreal Cognitive Assessment (MoCA-J) scores. BP variability was assessed using SD, coefficient of variation, and average real variability (ARV). Cognitive decline, defined as a change in the MoCA-J score, was assessed, with the threshold set at the quartile showing the greatest decrease, which we categorized as cognitive dysfunction (-4 points or less). RESULTS: Among 206 participants (mean age 79.9 [± 7.5] years), baseline 24-hour systolic blood pressure (SBP)/diastolic blood pressure (DBP) averaged 115.2/67.0 mm Hg. Over 4.98 years (IQR: 4.94-5.04 years), MoCA-J scores showed a nonsignificant decline from 20.2 (± 0.4) to 19.9 (± 0.4). A generalized linear mixed model showed that increased SD of daytime SBP (-0.064 [95% CI: -0.121 to -0.007]; P < 0.029) and DBP (-0.125 [95% CI: -0.213 to -0.037]; P = 0.005) were significantly linked to MoCA-J score decline, with similar trends for most measures except nighttime ARV. Logistic regression revealed higher ORs for cognitive decline with increased SD of daytime SBP (1.52 [95% CI: 1.18-1.96]; P = 0.001) and DBP (1.36 [95% CI: 1.09-1.71]; P = 0.007), consistent across coefficient of variation and ARV. No association was found between changes in BP level and MoCA-J score decline. CONCLUSIONS: In older adults with controlled BP, increased BP variability was linked to cognitive decline, warranting further study as a prevention target.

BACKGROUND: Ambulatory blood pressure (BP) is influenced by physical activity and the BP response to physical activity (actisensitivity) differs between individuals. This study investigated associations between daytime actisensitivity and nighttime BP dipping status and morning BP surge. METHODS: Twenty-four-hour ambulatory BP monitoring (ABPM) with simultaneously monitored physical activity using a multisensor all-in-one device (TM-2441; A&D Company) was performed at baseline in HI-JAMP study participants. Those with complete BP measurements and complete physical activity monitoring data were included in this analysis. Actisensitivity was calculated as the slope of the regression line between daytime SBP and log-transformed physical activity over a 5 min period before each BP reading. Hyper and negative reactivity were defined as actisensitivity greater than 90th and less than 10th percentile, respectively. RESULTS: Data from 2692 individuals (mean age 69.9 ± 11.9 years; mean BMI 24.8 ± 4.1 kg/m 2 , 53.6% men) were analyzed. Those with hyper reactivity had a high prevalence of the extreme dipper pattern of nighttime BP and exaggerated morning BP surge; those with negative reactivity had higher nighttime BP and a riser pattern of nighttime BP. Results remained significant after adjusting for 24-h physical activity. Differences in diurnal BP variability based on actisensitivity were augmented in individuals aged at least 75 years. CONCLUSION: This study is the first to investigate associations between actisensitivity and 24-h ambulatory BP profiles using an all-in-one multisensor device in a large real-world population. The associations seen between either hyper or negative actisensitivity and abnormal diurnal BP variability, especially in the elderly, could contribute to increased cardiovascular event risk. CLINICAL TRIAL REGISTRATION: University Hospital Medical Information Network Clinical Trials Registry, UMIN000029151 (HI-JAMP study).

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.

Previous studies have reported that blood pressure variability (BPV) is associated with the risk of cardiovascular events independent of blood pressure (BP) levels. While there is little evidence from intervention trials examining whether suppressing BPV is useful in preventing cardiovascular disease, it is suggested that detection of abnormally elevated BPV may be useful in reducing cardiovascular events adding by complementing management of appropriate BP levels. Cuffless BP devices can assess beat-to-beat BPV. Although cuffless BP monitoring devices have measurement accuracy issues that need to be resolved, this is an area of research where the evidence is accumulating rapidly, with many publications on beat-to-beat BPV over several decades. Ambulatory BP monitoring (ABPM) can assess 24-hour BPV and nocturnal dipping patterns. Day-to-day BPV and visit-to-visit BPV are assessed by self-measured BP monitoring at home and office BP measurement, respectively. 24 h, day-to-day, and visit-to-visit BPV have been reported to be associated with cardiovascular prognosis. Although there have been several studies comparing whether ABPM and self-measured BP monitoring at home is the superior measurement method of BPV, no strong evidence has been accumulated that indicates whether ABPM or self-measured home BP is superior. ABPM and self-measured BP monitoring have their own advantages and complement each other in the assessment of BPV.

BACKGROUND: Home blood pressure (BP) is more closely associated with cardiovascular event risk than office BP, but cardiovascular risk prediction based on home BP variability is lacking. This study developed a simple cardiovascular event prediction score, including home BP variability data, from the J-HOP study (Japan Morning Surge-Home Blood Pressure). METHODS: The J-HOP study extended follow-up from December 2017 to May 2018 generated the study data set (4231 patients). Cardiovascular events included fatal/nonfatal stroke (n=94), coronary heart disease (n=124), heart failure (n=42), and aortic dissection (n=8). Cox proportional hazards models were used to predict overall cardiovascular risk. Potential covariates included age, sex, body mass index, smoking, history of diabetes, statin use, history of cardiovascular disease, total cholesterol:high-density lipoprotein cholesterol ratio, office systolic BP (SBP), mean of morning-evening average (MEave), home SBP, and average real variability of MEave home SBP. A risk score and models were constructed, and model performance was assessed. RESULTS: Model performance was best when average real variability of MEave SBP was included (C statistic, 0.760). The risk score assigns points for age (5-year bands), sex, cardiovascular disease history, high-density lipoprotein cholesterol, mean MEave home SBP, and average real variability of MEave home SBP. Estimated 10-year cardiovascular risk ranged from ≤0.6% (score ≤0) to >32% (score ≥26). Calibration 2 statistics values for the model (2.66) and risk score (5.29) indicated excellent goodness of fit. CONCLUSIONS: This simple cardiovascular disease prediction algorithm, including day-by-day home BP variability, could be used as part of a home BP-centered approach to hypertension management in clinical practice.

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: Polypharmacy is associated with an increased risk of adverse events due to the higher number of drugs used. This is particularly notable in patients with chronic coronary syndrome (CCS), who are known to use a large number of drugs. Therefore, we investigated polypharmacy in patients with CCS, using CLIDAS, a multicenter database of patients who underwent percutaneous coronary intervention. METHOD AND RESULTS: Between 2017 and 2020, 1411 CCS patients (71.5 ± 10.5 years old; 77.3 % male) were enrolled. The relationship between cardiovascular events occurring during the median follow-up of 514 days and the number of drugs at the time of PCI was investigated. The median number of drugs prescribed was nine. Major adverse cardiovascular events (MACE), defined as cardiovascular death, myocardial infarction, stroke, heart failure, transient ischemic attack, or unstable angina, occurred in 123 patients, and all-cause mortality occurred in 68 patients. For each additional drug, the adjusted hazard ratios for MACE and all-cause mortality increased by 2.069 (p = 0.003) and 1.102 (p = 0.010). The adjusted hazard ratios for MACE and all-cause mortality were significantly higher in the group using nine or more drugs compared to the group using eight or fewer drugs (1.646 and 2.253, both p < 0.001). CONCLUSION: This study showed that an increase in the number of drugs used for CCS may be associated with MACE and all-cause mortality. In patients with CCS, it might be beneficial to minimize the number of medications as much as possible, while managing comorbidities and using guideline-recommended drugs.

BACKGROUND: Previous studies with several limitations have comparatively analyzed the relationship between ambulatory blood pressure (BP) and self-measured BP and biomarkers of organ damage. This study extends this line of research by examining the relationship between ambulatory and self-measured BP and cardiac, renal, and atherosclerotic biomarkers in outpatients at cardiovascular risk. METHODS: In 1,440 practice outpatients who underwent office, ambulatory, and self-measured BP monitoring, we assessed the relationships of each BP with organ damage biomarkers including b-type natriuretic peptide (BNP), echocardiographic left ventricular mass index (LVMI), urine-albumin-creatinine ratio (UACR), and brachial-ankle pulse wave velocity (baPWV). RESULTS: In the comparison of correlation, self-measured systolic BP (SBP) was more strongly correlated to log-transformed (Ln) BNP (n=1,435; r=0.123 vs. r = -0.093, P<0.001), LVMI (n=1,278; r=0.223 vs. r=0.094, P<0.001), Ln-UACR (n=1,435; r=0.244 vs. r=0.154, P=0.010), and baPWV (n=1,360; r=0.327 vs. r=0.115, P<0.001) than daytime ambulatory SBP. In the linear regression models including office, ambulatory, and self-measured SBP, only self-measured SBP was significantly related to Ln-BNP (P=0.016) and LVMI (P<0.001). In the logistic regression models for the top quartile of LVMI, adding self-measured SBP improved the model predictability (P=0.027), but adding daytime ambulatory SBP did not. However, adding daytime ambulatory SBP improved the model predictability in the logistic model including office and self-measured SBP. CONCLUSIONS: Our study findings suggested that self-measured BP was associated with cardiac biomarkers independent of ambulatory BP.

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.

Lack of the typical nocturnal blood pressure (BP) fall, i.e non-dipper, has been known as a cardiovascular risk. However, the influence of non-dipper on atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) has been unclear. We investigated the clinical impact of non-dipping as evaluated by 24-hour ambulatory BP monitoring on the long-term outcome of AF recurrence post-PVI in 76 AF patients with a history of increased BP. The PVI procedure was successful in all 76 patients (mean age, 66±9years; antihypertensive medication, 89%; non-paroxysmal AF, 24%). Twenty patients had AF recurrence during a median follow-up of 1138 days. There was no difference in BP levels between the AF recurrence and non-recurrence groups (average 24 h systolic BP:126 ± 17 vs.125 ± 14 mmHg; P = 0.84). On the other hand, the patients with non-dipper had a higher AF recurrence than those with dipper (38.9% vs.15.0%; P = 0.018). In Cox hazard analysis adjusted by age, non-paroxysmal AF and average 24-hr systolic BP level, the non-dipper was an independent predictor of AF recurrence (HR 2.78 [95%CI:1.05-7.34], P = 0.039). Non-dipper patients had a larger left atrial (LA) volume index than the dipper patients (45.9 ± 17.3 vs.38.3 ± 10.2 ml/m2, P = 0.037). Among the 58 patients who underwent high-density voltage mapping in LA, 11 patients had a low-voltage area (LVA) defined as an area with a bipolar voltage < 0.5 mV. However, there was no association of LVA with non-dipper or dipper (22.2% vs.16.1%, P = 0.555). Non-dipper is an independent predictor of AF recurrence post-PVI. Management of abnormal diurnal BP variation post-PVI may be important.

Hypertension, a disease whose prevalence increases with age, induces pathological conditions of ischemic vascular disorders such as cerebral infarction and myocardial infarction due to accelerated arteriosclerosis and circulatory insufficiency of small arteries and sometimes causes hemorrhagic conditions such as cerebral hemorrhage and ruptured aortic aneurysm. On the other hand, as it is said that aging starts with the blood vessels, impaired blood flow associated with vascular aging is the basis for the development of many pathological conditions, and ischemic changes in target organs associated with vascular disorders result in tissue dysfunction and degeneration, inducing organ hypofunction and dysfunction. Therefore, we hypothesized that hypertension is associated with all age-related vascular diseases, and attempted to review the relationship between hypertension and diseases for which a relationship has not been previously well reported. Following our review, we hope that a collaborative effort to unravel age-related diseases from the perspective of hypertension will be undertaken together with experts in various specialties regarding the relationship of hypertension to all pathological conditions.

Thirty-year % increase of adults with hypertension in the European/ Americas and South-East Asia/ Western Pacific (WHO region). Create using the data from: World Health Organization. Global report on hypertension: the race against a silent killer. Geneva, Switzerland: 2023.

BACKGROUND: The long-term benefit of achieving the Japanese Society of Hypertension home systolic blood pressure (SBP) target of <125 mm Hg has not been fully evaluated. This study investigated the long-term risk of cardiovascular disease events in individuals with home SBP <125 versus 125 to <135 or ≥135 mm Hg who participated in the J-HOP study (Japan Morning Surge-Home Blood Pressure). METHODS: The J-HOP study enrolled outpatients with ≥1 cardiovascular risk factor between 2005 and 2012, with follow-up until March 2015 and extended follow-up from December 2017 to May 2018. Cardiovascular disease events (stroke, coronary artery disease, congestive heart failure, and aortic dissection) were compared between home SBP subgroups. RESULTS: During mean 5.9 years of follow-up in 4231 participants (mean age, 65 years), cardiovascular events included stroke (n=89), coronary artery disease (n=116), congestive heart failure (n=37), and aortic dissection (n=8). The adjusted 10-year risk of total cardiovascular disease was slightly higher, and stroke risk was significantly higher when baseline home SBP was ≥135 versus <125 mm Hg (adjusted hazard ratio, 1.39 [95% CI, 0.97-2.00] for overall cardiovascular disease and 2.68 [95% CI, 1.34-5.38] for stroke; this was largely due to between-group differences in the first 5 years of follow-up, which were maintained over the subsequent 5 years). Findings were similar in the subgroup of high-risk patients (those with diabetes or stroke history). CONCLUSIONS: These data highlight the potential long-term benefit of strict home SBP control and validate this as an appropriate Japanese Society of Hypertension guideline target although confirmation in larger populations is needed. REGISTRATION: URL: https://www.umin.ac.jp/ctr/; University Hospital Medical Information Network Clinical Trials Registry; Unique identifier: UMIN000000894 (Japan Morning Surge-Home Blood Pressure study).

Time in therapeutic range (TTR) for office systolic blood pressure (SBP) is an independent predictor of major cardiovascular events. However, the clinical implications of TTR for home SBP have not yet been investigated. This study determined the association between TTR of home SBP and cardiovascular events in individuals with ≥1 cardiovascular risk factor who were enrolled in The Japan Morning Surge-Home Blood Pressure (J-HOP) study. The therapeutic range for home SBP was defined as home SBP of 100-135 mmHg during the 13-day baseline period of the J-HOP study. Participants were divided into subgroups based on quartiles of TTR for home SBP, and the risk of cardiovascular events was determined in each quartile. During a mean 6.3 years of follow-up in 4070 participants (mean age 65 years), cardiovascular events included stroke in 92, coronary artery disease in 119, heart failure in 41 and aortic dissection in 8. The adjusted hazard ratio (95% confidence interval) for the risk of total cardiovascular events in participants with home SBP TTR in the lowest (100%) versus highest quartile (<15.3%) was 1.74 (1.16-2.61); the corresponding hazard ratio for stroke events was 2.11 (1.06-4.21). A 10% decrease in home SBP TTR was associated with a 4% increase in the risk of total cardiovascular events (p = 0.033) and a 9% increase in the risk of stroke (p = 0.004). The significant association seen between home SBP TTR and the occurrence of cardio- and cerebrovascular events highlights the importance of achieving stable reductions in home SBP and minimizing day-by-day home BP variability.Clinical Trial Registration: University Hospital Medical Information Network Clinical Trials Registry, UMIN000000894 (J-HOP study).