AimsFew studies have reported the impact of high‐dose loop diuretics at discharge on prognosis in Japanese patients with heart failure (HF). Our purpose was to assess the relationship between the dose of loop diuretics at discharge and cardiovascular mortality in patients with HF.Methods and resultsWe enrolled decompensated HF patients who were admitted to our hospital between March 2010 and March 2015, and compared HF patients who received high‐dose loop diuretics at discharge (HD group) with low‐dose loop diuretics at discharge (LD group) with regard to risk of cardiovascular mortality, and all‐cause mortality. High‐dose loop diuretic was defined as ≥40 mg/day of oral furosemide at discharge. A total of 215 patients were enrolled to the study. The median follow‐up duration was 641 days. All‐cause and cardiovascular mortality were significantly lower in the LD group than in the HD group (10.4% vs. 31.6%, P < 0.001; 2.2% vs. 24.6%, P < 0.001, respectively). High‐dose loop diuretics were associated with cardiovascular mortality in multivariate Cox proportional hazards model (hazard ratio, 16.06, 95% confidence interval 3.457 to 116.8; P < 0.001). The largest area under the receiver operating characteristic curve (0.85) for cardiovascular death was obtained with a threshold of 40 mg furosemide.ConclusionsHigh‐dose loop diuretic use at discharge was one of the predictors of cardiovascular mortality in patients with HF. An oral furosemide dose of 40 mg daily may be defined as ‘high‐dose’ loop diuretics in Japanese patients with chronic HF.

Objectives Using optical coherence tomography (OCT), we evaluated the effect of a cutting balloon (CB) compared with a conventional balloon after rotational atherectomy (RA) and before stenting in severely calcified coronary lesions. Background A CB is designed to create discrete incisions to facilitate fracture of severely calcified plaque. Methods OCT was performed preintervention (if possible), post‐RA, and poststent implantation. RA modification of calcium was defined as a polished, concave, round‐shaped surface. Calcium fracture was defined as a break in the calcium plate. The effects of calcium modification and stent expansion between CB (n = 18) versus conventional balloon (n = 23) following RA were compared. Results Median patient age was 72 years with 24% on hemodialysis. The amount of calcium and the length of RA modification were comparable between the CB and conventional balloon groups. Final poststent OCT showed that the number and thickness of calcium fracture were greater after CB versus conventional balloon, resulting better stent expansion (78.9% [IQR: 72.4–88.1] vs. 66.7% [IQR: 55.0–76.7], p < 0.01). In the multivariable model, after adjusting for the amount of calcium, CB use was an independent predictor of the presence of calcium fracture (odds ratio 30.0; 95% confidence interval 2.7–994.1, p = 0.004) and an independent predictor for greater stent expansion (regression coefficient 7.4; 95% confidence interval 0.5–14.3, p = 0.04). Conclusion In severely calcified lesions calcium fracture was more often associated with RA followed by CB compared with RA followed by conventional balloon predilation before stenting. CB use was also a determinant of greater stent expansion.

A 32‐year‐old man presented with palpitation. He was diagnosed with pulmonary sarcoidosis by lung biopsy. The electrocardiogram showed first‐degree atrioventricular block and complete right bundle branch block (CRBBB). We planned to examine laboratory data, echocardiography, Holter monitoring, and gallium‐67 scintigraphy. Before he went through all these exams, he developed ventricular tachycardia. After defibrillation was performed, his electrocardiogram revealed complete atrioventricular block. We observed elevation of serum angiotensin‐converting enzyme levels. In addition, both of gallium‐67 scintigraphy and 18F‐fluorodeoxyglucose positron emission tomography showed abnormal uptake in the ventricular septum. We diagnosed the patient with cardiac sarcoidosis associated with these arrhythmias. We started treatment with methylprednisolone pulse therapy (1 g daily). After 3 days of steroid pulse therapy, we administered prednisolone 30 mg daily. On day 15, electrocardiogram changed from complete atrioventricular block to first‐degree atrioventricular block and CRBBB. He was discharged with no progression with cardiac sarcoidosis for 2 years.

Aims Our purpose was to investigate the association between the B-type natriuretic peptide (BNP) level at discharge, the occurrence of worsening renal function (WRF), and long-term outcomes in patients with heart failure (HF). Methods and results We enrolled hospitalized acute HF patients. We divided patients into four groups on the basis of BNP <250 pg/mL (BNPÀ) or BNP ≥250 pg/mL (BNP+) at discharge and the occurrence of WRF during admission: BNPÀ/WRFÀ, BNPÀ/WRF+, BNP+/WRFÀ, and BNP+/WRF+. We evaluated the association between BNP at discharge, WRF, and cardiovascular/all-cause mortality/hospitalization due to HF. Clinical follow-up was completed in 301 patients. At discharge, percentages of the patients with clinical signs of HF were low and similar among four groups. The median follow-up period was 1206 days (interquartile range, 733-1825 days). The composite endpoint of cardiovascular mortality and HF hospitalization was significantly different between the four groups [12.9% (BNPÀ/WRFÀ), 22.7% (BNPÀ/WRF+), 35.8% (BNP+/WRFÀ), and 55.4% (BNP+/WRF+), P < 0.0001]. All-cause mortality was also different etween the four groups (15.1%, 38.6%, 28.7%, and 39.3%, respectively, P = 0.003). In the multivariate Cox proportional hazards model, the combination of BNP ≥250 pg/mL and WRF showed the highest hazard ratio (HR) for composite endpoint (HR, 5.201; 95% confidence interval, 2.582-11.11; P < 0.0001), and BNPÀ/WRF+ was associated with increased all-cause mortality (HR, 2.286; 95% confidence interval, 1.089-4.875; P = 0.03). Patients in BNP+/WRF+ had a higher cardiovascular mortality (28.6%), and those in BNPÀ/WRF+ had a high non-cardiovascular mortality (29.5%). Conclusions Heart failure patients with BNP ≥250 pg/mL at discharge and in-hospital occurrence of WRF had the highest risk for the composite endpoint (cardiovascular mortality and HF hospitalization) among groups.

SUMMARYBackground: Heart failure (HF) with hypoalbuminemia is associated with poor response to conventional therapy. We investigated whether tolvaptan, a potent aquaretic agent, might be of benefit in HF patients with hypoalbuminemia. Methods: We prospectively enrolled 40 patients hospitalized for HF. Patients received conventional therapy including loop diuretics. We subsequently added tolvaptan in the range of 3.75-15 mg daily and it was discontinued after improvement of HF symptoms. We compared clinical and laboratory data in HF patients with and without hypoalbuminemia (defined as serum albumin <3.0 g/ dL). Results: Tolvaptan was administered in 18 HF patients with hypoalbuminemia (Group A) and 22 HF patients without hypoalbuminemia (Group B). The mean serum albumin was 2.63 AE 0.27 and 3.46 AE 0.25 g/dL, respectively. The average urine output on tolvaptan increased significantly in both groups (1644.4 AE 797.6-3011.6 AE 1453.8 mL/day, P = 0.004; 1459 AE 612.7-2112.2 AE 724.5 mL/day, P = 0.008; respectively). In addition, we observed higher urine output on therapy in Group A than in Group B (P = 0.015). There was a moderate negative correlation between serum albumin and average urine output on tolvaptan (r = À0.42, P = 0.007). Conclusions: The addition of tolvaptan to low dose loop diuretics might be an effective strategy for treatment of HF patients with hypoalbuminemia.