Based on a review of Palliative Care Team consultations, patients who were hospitalized for HF and died during the hospitalization despite optimal pharmacological and/or nonpharmacological therapy were selected and defined as terminally ill HF patients. We excluded patients who were intubated or receiving mechanical circulatory support at the time of death. Patients who were administered intravenous sedation within the last week at life were defined as patients receiving palliative sedation 4 and were included in this analysis. Among patients without palliative sedation, we investigated the reasons of non-usage and the patients' baseline characteristics. Palliative sedation was preceded by thorough discussion with the multidisciplinary Palliative Care Team and attending doctors, and was administered to the patients with intractable severe symptoms that were refractory to ordinary palliative care approaches at the end of life. Definition and Measurements We investigated the efficacy of palliative sedation using the Richmond Agitation-Sedation Scale (RASS). 5 Additionally, we obtained data on temporal changes in vital signs, including respiratory rate, oxygen saturation, blood pressure and heart rate, from the patients' charts. 6 These data were evaluated before treatment, approximately 1 h after starting seda-H eart failure (HF) is a progressive disease with a poor prognosis and is a major growing public health problem worldwide in aging societies. 1 Palliative care is a multidisciplinary approach to improving quality of life and is highly relevant for HF patients. 2 Palliative sedation is considered to be a therapeutic option as part of palliative care when symptoms become uncontrollable and intractable at the end of life. 3 To date, there are limited reports and no specific recommendations about palliative sedation in terminally ill HF patients. Thus, the aims of this study were to survey the practice of palliative sedation in patients with HF at a tertiary cardiovascular referral center in Japan, and to investigate the feasibility of sedative agents in terminally ill HF patients. Methods Study Design and Population This was a single-center retrospective study conducted by members of the Palliative Care Team at the National Cerebral and Cardiovascular Center, which is a tertiary cardiovascular referral center in Japan. Palliative Care Team activities commenced in September 2013 and we retrospectively reviewed consecutive patients who were hospitalized and referred to the Palliative Care Team between September

Background: In the field of palliative care, morphine is known to be effective for alleviating dyspnea in cancer patients. However, little is known regarding the safety and efficacy of morphine therapy for refractory dyspnea as palliative care in advanced heart failure (HF) patients. Methods: We retrospectively reviewed consecutive advanced HF patients who were referred to the Palliative Care Team at our institution and administered morphine for refractory dyspnea during hospitalization between September 2013 and December 2018. We investigated the details of morphine usage, vital signs, an 11-point quantitative symptom scale, and adverse events at baseline, 24 h, and 72 h after the start of treatment. Results: Morphine was administered for refractory dyspnea in 43 advanced HF patients [mean age: 73.5 years, male: 28 (65%), New York Heart Association functional class IV: 43 (100%), median left ventricular ejection fraction: 25%, median B-type natriuretic peptide level: 927 pg/ml, concurrent intravenous inotrope: 33 (77%)]. Median initial dose of morphine was 5 mg/day in both oral and intravenous administration and median duration of administration was 5 days. Significant decreases in an 11-point quantitative symptom scale [7 (5, 9) vs. 2 (1, 6); p < 0.01, (data available in 8 patients)] and respiratory rate (22.2 AE 6.1 vs. 19.7 AE 5.2 breaths per minute; p < 0.01) were observed 24 h after the start of morphine administration. Meanwhile, oxygen saturation, blood pressure, and heart rate were not significantly altered after treatment (NS). Common adverse events were delirium (18%) and constipation (8%); however, no lethal adverse event definitely related to morphine therapy occurred during treatment. Conclusions: This single-center retrospective study revealed the clinical practice of morphine therapy and suggested that morphine therapy might be feasible for refractory dyspnea as palliative care in advanced HF patients.

Background: The present comparative study with healthy volunteers was conducted to investigate the depressive status and temperament in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Methods and Results:The results of the temperament and personality scale test, and the Quick Inventory of Depressive Symptomatology-Self Report revealed that CTEPH patients have a significantly higher depressive status than healthy volunteers.Conclusions: It may be that CTEPH patients are more likely to have a depressive temperament in origin. It is expected that the relationship between the biological traits of CTEPH (e.g., genetics) and patients' depressive temperament will be elucidated in the future.

Background: Duplex ultrasound scanning (DUS) plays a major role in less invasive diagnosis and assessment of lesion severity in lower extremity peripheral artery disease (PAD). In this study, we evaluated the efficacy of each DUS parameter measured in patients with PAD and established a simple method for PAD evaluation. Methods and Results:We retrospectively investigated 211 patients (270 limbs) who underwent assessment with both angiography and DUS. During DUS of the common femoral artery (CFA) and popliteal artery, we measured 3 parameters: acceleration time (AcT), peak systolic velocity (PSV), and waveform contour. We compared these parameters with the degree of angiographic stenosis. AcT at the CFA had a significantly higher value in prediction of aortoiliac artery lesions with >50% stenosis (c-index, 0.85; 95% confidence interval (CI), 0.79-0.91), with a sensitivity of 0.82 and specificity of 0.76 at the best cutoff point, compared with PSV and waveform contour (P<0.001, respectively). For femoropopliteal lesions, the ratio of AcT at the popliteal artery to AcT at the CFA is the most predictive parameter, with sensitivity of 0.86 and specificity of 0.92 at the best cutoff point (c-index, 0.93; 95% CI, 0.90-0.97), compared with others (P<0.001, respectively). Conclusions:For the assessment of PAD with DUS, AcT and AcT ratio are simple and reliable parameters for evaluating aortoiliac and femoropopliteal artery disease.

Heterozygous familial hypercholesterolemia (HeFH) is a genetic disorder that elevates low-density lipoprotein cholesterol and increases the risk of premature atherosclerotic cardiovascular disease (ASCVD). However, despite their atherogenic lipid profiles, the cardiovascular risk of HeFH varies in each individual. Their variety of phenotypic features suggests the need for better risk stratification to optimize their therapeutic management. The current review summarizes three potential approaches, including (1) definition of familial hypercholesterolemia (FH)-related risk scores, (2) genetic analysis, and (3) biomarkers. The International Atherosclerosis Society has recently proposed a definition of severe FH to identify very high-risk HeFH subjects according to their clinical characteristics. Furthermore, published studies have shown the association of FH-related genetic phenotypes with ASCVD, which indicates the genetic analysis’s potential to evaluate individual cardiovascular risks. Biomarkers reflecting disease activity have been considered to predict the formation of atherosclerosis and the occurrence of ASCVD in HeFH subjects. Incorporating these risk stratifications will be expected to allocate adequate intensity of lipid-lowering therapies in HeFH subjects, which ultimately improves cardiovascular outcomes.