The occurrence of heart failure (HF) and its clinical features after a great disaster have not been rigorously examined. We retrospectively examined the effect of the Great East Japan Earthquake on the occurrence of decompensated HF. The number of patients admitted for treatment of decompensated HF and their clinical features were compared between 2 periods, March 11, 2011 to September 10, 2011 (after the earthquake) and the same period in the previous year. The number of admissions increased from 55 in 2010 to 84 in 2011. A comparison of the clinical features showed that the patients admitted after the earthquake had (1) older age (p = 0.031), (2) greater systolic blood pressure (p = 0.039), (3) a greater incidence of new-onset HF due to valvular heart disease (p = 0.040), (4) interruption of drugs (p = 0.001), (5) a greater incidence of infection (p = 0.019), (6) greater B-type natriuretic peptide (p = 0.005) and C-reactive protein (p = 0.003) levels, (7) a lower estimated glomerular filtration rate (p = 0.048) and lower albumin levels (p = 0.021), and (8) a larger diameter of the inferior vena cava (p = 0.008). In conclusion, these results suggest that the earthquake increased the incidence of HF in association with high blood pressure, interruption of drugs, inflammation, malnutrition, and fluid retention. Taking appropriate measures to control blood pressure, nutritional status, and hygiene environment might decrease the occurrence of HF in future disasters.
On March 11, 2011, northeastern Japan was struck by major ocean-trench earthquakes (the Great East Japan Earthquake). Several reports have suggested an association between increased cardiovascular mortality and acute or chronic psychological stress caused by earthquakes. Although published data have demonstrated an increased occurrence of acute coronary syndrome, stroke, deep vein thrombus, pulmonary embolism, takotubo cardiomyopathy, and hypertension after previous major earthquakes, the occurrence of heart failure (HF) after a disaster has not yet been reported. Aoki et al were the first to report that HF was increased in Miyagi Prefecture after the Great East Japan Earthquake. However, the occurrence and clinical features of HF after the earthquake are not sufficiently clear. Our institution, Fukushima Medical University, is a central hospital located approximately 215 km inland from the epicenter of the earthquake and 58 km inland from the nuclear power plant ( Figure 1 ). It would be helpful to determine the clinical features of patients who developed HF after the earthquake and how to protect people in future disasters. The aim of the present study was to investigate the occurrence and clinical features of HF in patients who needed hospitalization after the Great East Japan Earthquake.
Methods
We retrospectively searched the medical records of patients with decompensated HF admitted to Fukushima Medical University Hospital, 1 of the largest hospitals in the Fukushima area, with 778 beds for in-patient service. We then reviewed the effect of the Great East Japan Earthquake on the occurrence of decompensated HF by comparing the 6 months after the earthquake (March 11, 2011 to September 10, 2011) with the same period in the previous year (March 11, 2010 to September 10, 2010) in our hospital. We analyzed the clinical features and backgrounds of patients with decompensated HF admitted to our hospital before and after the earthquake. The present study enrolled 139 patients with decompensated HF who were hospitalized at Fukushima Medical University Hospital. The diagnosis of symptomatic HF was defined using the Framingham criteria by well-trained cardiologists. All cases were identified by the presence of an initial admission diagnosis and then confirmed in adjudication by attending cardiologists. The admission criteria were not different between the control and post-earthquake periods. Patients with acute coronary syndrome were excluded. We investigated patient characteristics, including age, gender, vital signs at hospitalization, etiology of HF, co-morbidities, place of residence, worsening factors for HF, medications at hospitalization, laboratory data, and echocardiographic data. New-onset HF was defined as having no symptoms of HF before the earthquake and no history of hospitalization for HF. The clinical scenario subset was defined as previously reported. HF with a preserved ejection fraction was defined as an ejection fraction >45%. The interruption of drugs was defined as interruption or reduction of drugs for >3 days. Infection episodes included respiratory infection, gastrointestinal infection, urinary tract infection, infectious endocarditis, and others. The estimated glomerular filtration rate was defined using the Modification of Diet in Renal Disease formula. The ethical committee of Fukushima Medical University approved the study protocol.
Echocardiography was performed by an experienced echocardiographer using standard techniques. Two-dimensional echocardiographic images were acquired from the parasternal long and short axes, apical long axis, and apical 4-chamber views. The echocardiographic parameters investigated included the left ventricular ejection fraction, interventricular septum thickness, estimated right ventricular systolic pressure, and the ratio of early transmitral flow velocity to mitral annular velocity (E/E′) demonstrating the left ventricular filling pressure. The left ventricular ejection fraction was calculated using a modification of Simpson’s method. The estimated right ventricular systolic pressure was calculated using a transtricuspid pressure gradient. E/E′ was calculated using transmitral Doppler flow and tissue Doppler imaging. All recordings were performed on ultrasound systems (Acuson Sequoia, Siemens Medical Solutions, Mountain View, California).
Normally distributed data are presented as the mean ± SD, non-normally distributed data as the median and interquartile range, and categorical variables as numbers and percentages. The characteristics between the 2 groups were compared using the independent Student t test for normally distributed data and the Mann-Whitney U test for non-normally distributed data for continuous variables; the chi-square test was used for categorical variables. p Values <0.05 were considered significant for all comparisons. All analyses were performed using a statistical software package (SPSS Japan, Tokyo, Japan).
Results
As shown in Figure 2 , the number of hospital admissions for decompensated HF after the earthquake during the 6 months increased from 55 in the period from March 11 to September 10, 2010 to 84 in the period from March 11 to September 10, 2011 (+52.7% increase), especially in the first 1 to 14 weeks. Eleven patients (13.1%) with decompensated HF after the earthquake were evacuated from the stricken area. The features of the patients with HF who were admitted after the earthquake in 2011 compared with those admitted in 2010 were older age, greater systolic blood pressure, greater number of residents in the coastal area, a longer period from symptom onset to hospital presentation, more occurrences of new-onset symptomatic HF due to valvular heart disease, more cases of clinical scenario 1, interruption of drugs, and infection ( Table 1 ). The differences between patients with HF after the earthquake in 2011 compared with those in 2010 included greater B-type natriuretic peptide and C-reactive protein levels, lower estimated glomerular filtration rate and albumin levels, and a larger diameter of the inferior vena cava ( Table 2 ). No significant differences were present between the 2 groups with respect to sodium, total protein, total bilirubin, D-dimer, lipid and glucose profile; cardiac function such as left ventricular ejection fraction, interventricular septum thickness, and E/E′; hospitalization length; and mortality.
| Variable | Before (n = 55) (3/11/2010–9/10/2010) | After (n = 84) (3/11/2011–9/10/2011) | p Value |
|---|---|---|---|
| Age (yrs) | 65.2 ± 14.8 | 70.4 ± 13.4 | 0.031 |
| Men | 33 (60.0%) | 52 (61.9%) | 0.822 |
| Body mass index (kg/cm 2 ) | 22.5 ± 5.3 | 22.7 ± 7.0 | 0.880 |
| Systolic blood pressure (mm Hg) | 128.9 ± 35.6 | 140.3 ± 40.1 | 0.039 |
| Diastolic blood pressure (mm Hg) | 76.4 ± 23.2 | 80.5 ± 22.3 | 0.295 |
| Heart rate (beats/min) | 92.6 ± 27.8 | 88.5 ± 26.6 | 0.383 |
| SPO 2 (%) | 94.2 ± 7.8 | 94.1 ± 7.7 | 0.963 |
| Body temperature (°C) | 36.4 ± 0.8 | 36.6 ± 0.8 | 0.158 |
| Residents in the coastal area | 2 (3.6%) | 15 (17.9%) | 0.012 |
| Symptom onset to hospital visiting (days) | 4.7 ± 6.8 | 9.3 ± 12.2 | 0.014 |
| New-onset decompensated HF | 25 (45.5%) | 50 (59.5%) | 0.104 |
| New-onset HF due to valvular disease | 6 (10.9%) | 21 (25.0%) | 0.040 |
| Clinical scenario | 0.043 | ||
| 1 | 11 | 35 | |
| 2 | 33 | 32 | |
| 3 | 7 | 11 | |
| 4 | 0 | 0 | |
| 5 | 4 | 6 | |
| Episode of clinical scenario 1 | 11 (20.0%) | 35 (41.7%) | 0.008 |
| Etiology | |||
| Ischemic | 15 (27.3%) | 25 (29.8%) | 0.751 |
| Cardiomyopathy | 9 (19.0%) | 16 (19.0%) | 0.687 |
| Valve | 12 (21.8%) | 28 (33.3%) | 0.143 |
| Arrhythmia | 3 (5.5%) | 3 (3.6%) | 0.593 |
| Congenital | 5 (9.1%) | 4 (4.8%) | 0.310 |
| Other | 11 (20.0%) | 8 (9.5%) | 0.079 |
| Heart failure with preserved ejection fraction | 20 (36.4%) | 32 (38.1%) | 0.837 |
| Co-morbidity | |||
| Hypertension | 27 (49.1%) | 45 (53.6%) | 0.605 |
| Diabetes | 24 (43.6%) | 35 (41.7%) | 0.818 |
| Dyslipidemia | 30 (54.5%) | 44 (52.4%) | 0.803 |
| Anemia | 32 (58.2%) | 62 (73.8%) | 0.054 |
| Atrial fibrillation | 23 (41.8%) | 39 (46.4%) | 0.593 |
| Chronic obstructive pulmonary disease | 4 (7.3%) | 6 (7.1%) | 0.977 |
| Worsening factors of HF | |||
| Interruption of drugs | 0 | 15 (17.9%) | 0.001 |
| Infection events | 8 (14.5%) | 27 (32.1%) | 0.019 |
| Medications at admission | |||
| β Blockers | 30 (54.5%) | 36 (42.9%) | 0.177 |
| ACE inhibitors/ARBs | 36 (65.5%) | 53 (63.1%) | 0.777 |
| Calcium channel blockers | 12 (21.8%) | 24 (28.6%) | 0.374 |
| Diuretics | 42 (76.4%) | 56 (66.7%) | 0.220 |
| Statins | 15 (27.3%) | 21 (25.0%) | 0.765 |
| Nitroglycerine/isosorbide dinitrate | 8 (14.5%) | 17 (20.2%) | 0.393 |
| Amiodarone | 6 (10.9%) | 13 (15.5%) | 0.443 |
| Inotropic agents | 6 (10.9%) | 16 (19.0%) | 0.199 |
| Warfarin | 27 (49.1%) | 42 (50.0%) | 0.917 |
| Digitalis | 7 (12.7%) | 13 (15.5%) | 0.652 |
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