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AimsThe clinical outcome of heart failure (HF) is complicated by the presence of multiple comorbidities including malnutrition and cachexia, and prediction of the outcome is still difficult in each patient. Metabolomics including amino acid profiling enables detection of alterations in whole body metabolism. The aim of this study was to determine whether plasma amino acid profiling improves prediction of clinical outcomes in patients with HF. Methods and resultsWe retrospectively examined 301 HF patients (70 ± 15 years old; 59% male). Blood samples for measurements of amino acid concentrations were collected in a fasting state after stabilization of HF. Plasma amino acid concentrations were measured using ultraperformance liquid chromatography. Clinical endpoint of this study was adverse event defined as all-cause death and unscheduled readmission due to worsening HF or lethal arrhythmia. During a mean follow-up period of 380 ± 214 days, 40 patients (13%) had adverse events. Results of analyses of variable importance in projection score, a measure of a variable's importance in partial least squares-discriminant analysis (PLS-DA) showed that the top five amino acids being associated with adverse events were 3-methylhistidine (3-Me-His), β-alanine, valine, hydroxyproline, and tryptophan. Multivariate Cox-proportional hazard analyses indicated that a high 3-Me-His concentration and low β-alanine and valine concentrations were independently associated with adverse events. When HF patients were divided according to the cut-off values of amino acids calculated from receiver operating characteristic curves, Kaplan-Meier survival curves showed that event-free survival rates were lower in HF patients with high 3-Me-His than in HF patients with low 3-Me-His (68% vs. 91%, P < 0.01). In a subgroup with high 3-Me-His, HF patients with low β-alanine and those with low valine had significantly lower event-free survival rates than did HF patients with high β-alanine and those with high valine, respectively. On the other hand, Kaplan-Meier curves of event-free survival rates did not differ between HF patients with and those without low β-alanine and low valine in subgroups of patients with low 3-Me-His. Inclusion of both high 3-Me-His and low β-alanine or low valine into the adjustment model including N-terminal pro-brain natriuretic peptide improved the accuracy of prediction of adverse events after discharge. 3-Me-His concentration was associated with muscle mass and nutritional status. Conclusions Simple measurement of 3-Me-His with either β-alanine or valine improved the predictive ability for adverse events, indicating the utility of plasma amino acid profiling in risk stratification of hospitalized HF patients.

Background Although high body mass index (BMI) is a risk factor of heart failure (HF), HF patients with a higher BMI had a lower mortality rate than that in HF patients with normal or lower BMI, a phenomenon that has been termed the “obesity paradox”. However, the relationship between body composition, i.e., fat or muscle mass, and clinical outcome in HF remains unclear. Methods We retrospectively analyzed data for 198 consecutive HF patients (76 years of age; males, 49%). Patients who were admitted to our institute for diagnosis and management of HF and received a dual-energy X-ray absorptiometry scan were included regardless of left ventricular ejection fraction (LVEF) categories. Muscle wasting was defined as appendicular skeletal muscle mass index < 7.0 kg/m2 in males and < 5.4 kg/m2 in females. Increased percent body fat mass (increased FM) was defined as percent body fat > 25% in males and > 30% in females. Results The median age of the patients was 76 years (interquartile range [IQR], 67–82 years) and 49% of them were male. The median LVEF was 47% (IQR, 33–63%) and 33% of the patients had heart failure with reduced ejection fraction. Increased FM and muscle wasting were observed in 58 and 67% of the enrolled patients, respectively. During a 180-day follow-up period, 32 patients (16%) had cardiac events defined as cardiac death or readmission by worsening HF or arrhythmia. Kaplan-Meier survival curves showed that patients with increased FM had a lower cardiac event rate than did patients without increased FM (11.4% vs. 22.6%, p = 0.03). Kaplan-Meier curves of cardiac event rates did not differ between patients with and those without muscle wasting (16.5% vs. 15.4%, p = 0.93). In multivariate Cox regression analyses, increased FM was independently associated with lower cardiac event rates (hazard ratio: 0.45, 95% confidence interval: 0.22–0.93) after adjustment for age, sex, diabetes, muscle wasting, and renal function. Conclusions High percent body fat mass is associated with lower risk of short-term cardiac events in HF patients.

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In 2009, the "Guidelines for diagnosis and treatment of myocarditis (JCS 2009)" were issued by the Japanese Circulation Society (JCS). 1 Although this guideline has been widely used in clinical practice for more than a decade, it is certain that they now require adjustment in line with recent trends.Recent Position Statements and Expert Consensuses published in Europe 3 and the USA 2 have shown a shift to general classification of myocarditis into acute myocarditis and chronic inflammatory cardiomyopathy, resulting in a decrease in the use of the term "chronic myocarditis" worldwide. This is attributable to the fact that the understanding of the etiology, pathological condition, and clinical course of myocarditis has gradually deepened through AKIN Acute Kidney Injury Network APACHE Acute Physiology and Chronic Health Evaluation AST aspartate aminotransferase BNP B-type natriuretic peptide BTT bridge to transplantation BiVAD biventricular assist device CK creatine kinase CK-MB creatine kinase myocardial bound COVID-19 COronaVirus Infectious Disease, emerged in 2019 CRP C-reactive protein CRT-D cardiac resynchronization therapy defibrillator CTLA-4 cytotoxic T lymphocyte-associated protein 4 CQs Clinical Questions DI disagreement index DIC disseminated intravascular coagulation DLST drug-induced lymphocyte stimulation test 1. Process of Preparation ▋ 1.1 Purpose, Users, and Targeted Patients of the Guidelines ▋ 1.1.1 Purpose To provide practice guidelines for appropriate diagnosis and treatment management to physicians engaged in clinical care of patients with myocarditis. ▋ 1.1.2 Expected Users The present Guidelines were prepared in the expectation that cardiologists, cardiovascular surgeons, pediatricians, intensive care physicians, general internists, general practitioners, nurses, and other medical personnel who are engaged in the clinical care of myocarditis patients would use them when devising treatment strategies. It is alsoStep 4: Evaluation and Finalization of the Clinical Practice Guidelines The content of the Guidelines was reviewed by external reviewers and based their reports, modifications were made as necessary. ▋ 1.5 PublicationThe final draft was published after approval of the JCS Clinical Practice Guidelines Committee. ▋ 1.6 Conflict of Interest (COI)Conflict of interest, if any, was declared according to the rules prescribed by the JCS. The declaration covered 3 years from 2020 to 2022.