Epidemiological aspects, clinical management and short-term outcomes in elderly patients diagnosed with acute heart failure in the emergency department in Spain: results of the EDEN-34 study

OBJECTIVE

To estimate the incidence of acute heart failure (AHF) diagnosis in elderly patients in emergency departments (ED), diagnostic confirmation in hospitalized patients, and short-term adverse events.

METHODS

All patients aged ≥65 years attended in 52 Spanish EDs during 1 week were included and those diagnosed with AHF were selected. In hospitalized patients, those diagnosed with AHF at discharge were collected. As adverse events, in-hospital and 30-day mortality, and combined adverse event (death or hospitalization) at 30 days post-discharge were collected. Adjusted odds ratios (OR) for association of demographic variables, baseline status and constants at ED arrival with mortality and 30-day post-discharge adverse event were calculated.

RESULTS

We included 1,155 patients with AHF (annual incidence: 26.5 per 1000 inhabitants ≥65 years, 95% CI: 25.0-28.1). In 86% the diagnosis of AHF was known at discharge. Overall 30-day mortality was 10.7% and in-hospital mortality was 7.9%, and the combined event in 15.6%. In-hospital and 30-day mortality was associated with arterial hypotension (adjusted OR: 74.0, 95% CI: 5.39-1015. and 42.6, 3.74-485, respectively and hypoxemia (2.14, 1.27-3.61; and 1.87, 1.19-2.93) on arrival at the ED and requiring assistance with ambulation (2.24, 1.04-4.83; and 2.48, 1.27-4.86) and age (per 10-year increment; 1.54, 1.04-2.29; and 1.60, 1.13-2.28). The combined post-discharge adverse event was not associated with any characteristic.

CONCLUSIONS

AHF is a frequent diagnosis in elderly patients consulting in the ED. The functional impairment, age, hypotension and hypoxemia are the factors most associated with mortality.

Prognostic impact of metformin in patients with type 2 diabetes mellitus and acute heart failure: Combined analysis of the EAHFE and RICA registries

INTRODUCTION

Patients with diabetes mellitus (DM) and heart failure (HF) have a worse prognosis despite therapeutic advances in both diseases. Sodium-glucose co-transporter type 2 and GLP-1 receptor agonists have shown cardiovascular benefits and they have been positioned as the first step in the treatment of DM in patients with HF or high cardiovascular risk. However, in the pivotal trials the majority of patients receive concomitant treatment with metformin. Randomized clinical trials have not yet been developed to assess the prognostic impact of metformin at the cardiovascular level. Our objective has been centered in analyzing whether patients with DM and acute HF who receive treatment with metformin at the time of discharge may have a better prognosis at one year of follow-up.

METHODS

Prospective cohort trial using the combined analysis of the two main Spanish HF registries, the EAHFE Registry (Epidemiology of Acute Heart Failure in Emergency Departments) and the RICA (National Registry of Patients with Heart Failure).

RESULTS

33% (1453) of a total of 4403 patients with DM type 2 received treatment with metformin. This group presents significantly lower mortality after one year of treatment (22 versus 32%; Log Rank test P < 0.001). In the adjusted analysis of mortality, patients receiving treatment with metformin have lower mortality at one year of follow-up regardless of the rest of the variables (RR 0,814; 95%IC 0,712-0,930; P < 0.01).

CONCLUSIONS

Patients with DM type 2 and acute HF who receive metformin have a better prognosis after one year of follow-up, so we believe that this drug should continue to be a fundamental pillar in the treatment of these patients.

Factors associated with unjustified chronic treatment with digoxin in patients with acute heart failure and relationship with short-term prognosis

OBJECTIVES

To analyze the factors related to inadequate chronic treatment with digoxin and whether the inadequacy of treatment has an impact on short-term outcome.

METHOD

Patients diagnosed with AHF who were in chronic treatment with digoxin, were selected. Digoxin treatment was classified as adequate or inadequate. We investigated factors associated to inadequacy and whether such inadequacy was associated with in-hospital and 30-day mortality, prolonged hospital stay (>7 days) and combined adverse event (re-consultation to the ED or hospitalization for AHF or death from any cause) during the 30 days after discharge.

RESULTS

We analyzed 2,366 patients on chronic digoxin treatment (median age = 83 years, women = 61%), which was considered adequate in 1,373 cases (58.0%) and inadequate in 993 (42.0%). The inadequacy was associated with older age, less comorbidity, less treatment with beta-blockers and renin-angiotensin inhibitors, better ventricular function, and worse Barthel index. In-hospital and 30-day mortality was higher in patients with inadequate digoxin treatment (9.9% versus 7.6%, p = 0.05; and 12.6% versus 9.1%, p < 0.001, respectively). No differences were recorded in prolonged stay (35.7% versus 33.8%) or post-discharge adverse events (32.9% versus 31.8%). In the model adjusted for baseline and decompensation episode differences, inadequate treatment with digoxin was not significantly associated with any outcome, with an odds ratio of 1.31 (95%CI = 0.85-2.03) for in-hospital mortality; 1.29 (0.74-2.25) for 30-day mortality; 1.07 (0.82-1.40) for prolonged stay; and 0.88 (0.65-1.19) for post-discharge adverse event.

CONCLUSION

There is a profile of patients with AHF who inadequately receive digoxin, although this inadequateness for chronic digitalis treatment was not associated with short-term adverse outcomes.

Original articleAnalysis of the effectiveness and safety of short-stay units in the hospitalization of patients with acute heart failure. Propensity Score SSU-EAHFE

OBJECTIVES

This work aims to analyze if hospitalization in short-stay units (SSU) of patients diagnosed in the emergency department with acute heart failure (AHF) is effective in terms of the length of hospital stay and if it is associated with differences in short-term progress.

METHOD

Patients from the EAHFE registry diagnosed with AHF who were admitted to the SSU (SSU group) were included and compared to those hospitalized in other departments (non-SSU group) from all hospitals (comparison A) and, separately, those from hospitals with an SSU (comparison B) and without an SSU (comparison C). For each comparison, patients in the SSU/non-SSU groups were matched by propensity score. The length of hospital stay (efficacy), 30-day mortality, and post-discharge adverse events at 30 days (safety) were compared.

RESULTS

A total of 2,003 SSU patients and 12,193 non-SSU patients were identified. Of them, 674 pairs of patients were matched for comparison A, 634 for comparison B, and 588 for comparison C. The hospital stay was significantly shorter in the SSU group in all comparisons (A: median 4 days (IQR = 2-5) versus 8 (5-12) days, p < 0.001; B: 4 (2-5) versus 8 (5-12), p < 0.001; C: 4 (2-5) versus 8 (6-12), p < 0.001). Admission to the SSU was not associated with differences in mortality (A: HR = 1.027, 95%CI = 0.681-1.549; B: 0.976, 0.647-1.472; C: 0.818, 0.662-1.010) or post-discharge adverse events (A: HR = 1.002, 95%CI = 0.816-1.232; B: 0.983, 0.796-1.215; C: 1.135, 0.905-1.424).

CONCLUSION

The hospitalization of patients with AHF in the SSU is associated with shorter hospital stays but there were no differences in short-term progress.

Early standardized clinical judgement for syncope diagnosis in the emergency department

BACKGROUND

The diagnosis of cardiac syncope remains a challenge in the emergency department (ED).

OBJECTIVE

Assessing the diagnostic accuracy of the early standardized clinical judgement (ESCJ) including a standardized syncope-specific case report form (CRF) in comparison with a recommended multivariable diagnostic score.

METHODS

In a prospective international observational multicentre study, diagnostic accuracy for cardiac syncope of ESCJ by the ED physician amongst patients ≥ 40 years presenting with syncope to the ED was directly compared with that of the Evaluation of Guidelines in Syncope Study (EGSYS) diagnostic score. Cardiac syncope was centrally adjudicated independently of the ESCJ or conducted workup by two ED specialists based on all information available up to 1-year follow-up. Secondary aims included direct comparison with high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) concentrations and a Lasso regression to identify variables contributing most to ESCJ.

RESULTS

Cardiac syncope was adjudicated in 252/1494 patients (15.2%). The diagnostic accuracy of ESCJ for cardiac syncope as quantified by the area under the curve (AUC) was 0.87 (95% CI: 0.84-0.89), and higher compared with the EGSYS diagnostic score (0.73 (95% CI: 0.70-0.76)), hs-cTnI (0.77 (95% CI: 0.73-0.80)) and BNP (0.77 (95% CI: 0.74-0.80)), all P < 0.001. Both biomarkers (alone or in combination) on top of the ESCJ significantly improved diagnostic accuracy.

CONCLUSION

ESCJ including a standardized syncope-specific CRF has very high diagnostic accuracy and outperforms the EGSYS score, hs-cTnI and BNP.

[Analysis of the evolution of patients attended in Spanish emergency departments during the first wave of the pandemic]

BACKGROUND

To describe the number of visits (total and per COVID-19) attended by the Spanish hospital emergency departments (EDs) during the first wave of the pandemic (March-April 2020) compared to the same period in 2019, and to calculate the quantitative changes in healthcare activity and investigate the possible influence of hospital size and COVID-19 seroprevalence.

METHOD

Cross-sectional study that analyzes the number of visits to Spanish public EDs, reported through a survey of ED chiefs during the study periods. Changes in healthcare activity were described in each autonomous community and com-pared according to hospital size and the provincial impact of the pandemic.

RESULTS

A total of 187 (66?%) of the 283 Spanish EDs participated in the study. The total number of patients attended de-creased to 49.2?% (<?30?% in the Castilla-La Mancha region), with a 60?% reduction in non-COVID-19 patients (reduction <?50?% in the regions of Asturias and Extremadura). While there were no differences in changes of healthcare activity according to the size of the hospital, there were differences in relation to the provincial impact of the pandemic, with a direct correla-tion related to the decrease in non-COVID-19 activity (the greater the impact, the greater the decrease; R2?=?0.05; p?=?0.002) and an inverse correlation to the overall activity (the greater the impact, the lesser the decrease; R2?=?0.05; p?=?0.002).

CONCLUSION

There was a very significant decrease in the number of ED visits during the first pandemic wave, although this decrease cannot be explained solely by the local incidence of the pandemic.

Consensus on improving the comprehensive care of patients with acute heart failure

The latest acute heart failure consensus document from the Spanish Society of Cardiology, Spanish Society of Internal Medicine, and Spanish Society of Emergency Medicine was published in 2015, which made an update covering the main novelties regarding acute heart failure from the last few years necessary. These include publication of updated European guidelines on heart failure in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding acute heart failure such as early treatment, intermittent treatment, advanced heart failure, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to acute heart failure and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease.

Consensus on improving the comprehensive care of patients with acute heart failure

The latest acute heart failure (AHF) consensus document from the Spanish Society of Cardiology (SEC, for its initials in Spanish), Spanish Society of Internal Medicine (SEMI), and Spanish Society of Emergency Medicine (SEMES) was published in 2015, which made an update covering the main novelties regarding AHF from the last few years necessary. These include publication of updated European guidelines on HF in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding AHF such as early treatment, intermittent treatment, advanced HF, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to AHF and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease.

Frequency, profile and results of patients with acute heart failure transferred directly to home hospitalisation from emergency departments

OBJECTIVE

To describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU).

METHOD

We included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge.

RESULTS

The study included 1473 patients (HH/IM/SSU: 68/979/384). The HH rate was 4.7% (95% CI, 3.8-6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5-12), similar to that of IM (median stay, 8 days; IQR, 5-13; p=.106) and longer than that of SSU (median stay, 4 days; IQR, 3-7; p<.001). The all-cause mortality at 1 year for HH did not differ from that of IM (HR, 0.91; 95% CI, 0.73-1.14) or SSU (HR, 0.77; 95% CI, 0.46-1.27); however, the emergency department readmission rate during the 30 days postdischarge was lower than that of IM (HR, 0.50; 95% CI, 0.25-0.97) and SSU (HR, 0.37; 95% CI, 0.19-0.74). There were no differences in the need for new hospitalisations or in the 30-day mortality rate.

CONCLUSIONS

Direct transfer from the emergency department to HH is infrequent despite being a safe option for a certain patient profile with AHF.

[Comparison of the demographic characteristics and comorbidities of patients with COVID-19 who died in Spanish hospitals based on whether they were or were not admitted to an intensive care unit]

Objetivo

Describir las características demográficas y de comorbilidad de los pacientes con COVID-19 fallecidos en hospitales españoles durante el brote pandémico de 2020 y compararlas según si ingresaron o no en una Unidad de Cuidados Intensivos (UCI) antes del fallecimiento.

Métodos

Análisis secundario de los pacientes de la cohorte SIESTA (formada por pacientes COVID de 62 hospitales españoles) fallecidos durante la hospitalización. Se recogieron sus características demográficas y comorbilidades, individuales y globalmente, estimadas mediante el índice de comorbilidad de Charlson (ICC). Se identificaron los factores independientes relacionados con ingreso en UCI, y se realizaron diversos análisis de sensibilidad para contrastar la consistencia de los hallazgos del análisis principal.

Resultados

Se incluyeron los 338 pacientes de la cohorte SIESTA fallecidos; de ellos, 77 (22,8%) accedieron a una UCI previamente al fallecimiento. En el análisis multivariable, tres de las 20 características basales analizadas se asociaron independientemente con ingreso en UCI de los pacientes fallecidos: demencia (no hubo pacientes fallecidos con demencia que ingresasen en UCI; OR = 0, IC 95% = no calculable), cáncer activo (OR = 0,07, IC 95% = 0,02-0,21) y edad (< 70 años: OR = 1, referencia; 70-74 años: OR = 0,21, IC 95% = 0,08-0,54; 75-79 años: OR = 0,21, IC 95% = 0,08-0,54; ≥ 80 años: OR = 0,02, IC 95% = 0,01-0,05). La probabilidad de ingreso en UCI de los pacientes que fallecieron disminuyó significativamente al aumentar el ICC, incluso tras ajustarla por edad (ICC 0 puntos: OR = 1, referencia; ICC 1 punto: OR = 0,36, IC 95% = 0,16-0,83; ICC 2 puntos: OR = 0,36, IC 95% = 0,16-0,83; ICC > 2 puntos: OR = 0,09, IC 95% = 0,04-0,23). Los análisis de sensibilidad no mostraron diferencias destacables respecto al análisis principal.

Conclusiones

El perfil de los pacientes COVID fallecidos sin ingresar en UCI se ajustó a lo observado en la práctica médica habitual antes de la pandemia, y las características basales que limitaron su ingreso fueron la edad y la carga de comorbilidad global, especialmente la demencia y el cáncer activo.

Assessment of the knowledge and perception of support of patients with heart failure SOPICA study IN SPAIN

OBJECTIVE

To understand the perceptions of patients with heart failure (HF) concerning their disease, treatment and support, as well as the specialists who provide care after a decompensation, and to determine whether there is a relationship between the type of specialist involved in the follow-up and the medium-term prognosis.

METHODS

A multicentre, prospective cohort study consecutively included patients with acute HF in the emergency department. The patients were interviewed by telephone 91-180days after their emergency department visit. We investigated the relationship between the type of specialist who performed the follow-up and the emergency department visits or hospitalisations using Cox regression models, with progressive adjustment by groups of potential confounders of these relationships.

RESULTS

We interviewed 785 patients. Thirty-three percent (95%CI: 30%-36%) considered their disease mild, 64% (60%-67%) required help from third parties for daily activities, 65% (61%-68%) had no recent therapeutic changes, and 69% (67%-72%) received the same treatment in the exacerbations. The perceived support varied significantly depending on the factor under consideration (from greater to lesser: family, hospital, emergency department, health centre, religion and patient associations; p<.05 in all comparisons). Thirty-nine percent (36%-43%) of the patients with decompensations consulted directly with the emergency department, with no prior changes in treatment. At discharge, general practitioners (74%, 71%-77%) and cardiologists (74%, 70%-77%) were the most involved in the follow-up, although the specialty was not related to the prognosis.

CONCLUSION

There are various aspects of the perception of patients with HF concerning their disease that are susceptible to future interventions. Patient follow-up involves various specialties, but all achieve similar results in the medium term.

Mitochondrial and apoptotic in vitro modelling of differential HIV-1 progression and antiretroviral toxicity

OBJECTIVES

Ex vivo analysis of mitochondrial function may reveal HIV progression and the impact of ART. We propose a mitochondrial and apoptotic in vitro model using Jurkat T cells incubated with plasma. The objectives of this study were to evaluate mitochondrial and apoptotic lesions in this model in relation to HIV progression, and to assess the effect of >1 year of standard non-thymidine-containing therapy.

METHODS

This was a cross-sectional comparison among three age- and gender-matched groups (n = 19 × 3): healthy non-HIV-infected participants, HIV-infected long-term non-progressors (LTNPs) and standard antiretroviral-naive chronically infected patients [standard progressors (Sps)], longitudinally evaluated before (Sp1) and after (Sp2) >1 year of efavirenz + tenofovir + emtricitabine therapy. We analysed mitochondrial DNA content by RT-PCR, mitochondrial function by spectrophotometry, mitochondrial protein synthesis by western blot analysis, mitochondrial dynamics by western blot analysis (MFN2), apoptotic transition pore formation by western blot analysis (VDAC-1) and mitochondrial membrane potential and annexin V/propidium iodide fluorescence by flow cytometry.

RESULTS

There was a decreasing non-significant trend towards lower mitochondrial parameters for HIV-infected values with respect to uninfected control reference values. HIV progression (LTNP versus Sp1) was associated with decreased mitochondrial genetic, functional and translational parameters, which partially recovered after treatment intervention (Sp2). Mitochondrial fusion showed a trend to decrease non-significantly in Sp patients compared with LTNP patients, especially after therapy. All apoptotic parameters showed a trend to increase in Sp1 with respect to LTNP, followed by recovery in Sp2.

CONCLUSIONS

We proposed an in vitro model for mitochondrial and apoptotic assessment to test the effects of HIV infection and its therapy, resembling in vivo conditions. This model could be useful for clinical research purposes.

[Review of initiatives carried out in Spain to implement teaching of basic cardiopulmonary reanimation in schools]

Cardiorespiratory arrest (CRA) is a situation of maximum medical emergency which can be potentially reversed if basic cardiopulmonary resuscitation manoeuvres (CPR) are provided by the first bystander. Nonetheless, this is done in less than 25 % of the cardiorespiratory arrests (CRA) witnessed by bystanders. Thus, it is urgent to increase the knowledge of such basic CPR manoeuvres among the public in general. One strategy consists in the teaching of basic CPR techniques in schools following the recommendations made by specialized institutions. This study analyzes the initiatives carried out in Spain, including the authors' own experience acquired during the development of PROCES, a program aimed a students from 15 to 16 years of age and carried out during the last 10 years in Barcelona.

Mitochondrial injury in human acute carbon monoxide poisoning: the effect of oxygen treatment

The best oxygen therapy for acute carbon monoxide poisoning (ACOP) remains unestablished. Reported mitochondrial complex IV (mtCIV) inhibition, together with carboxyhaemoglobin (COHb)-induced hypoxia, may influence acute clinical symptoms and outcome. To "mitochondrially" evaluate treatment efficacy, we correlated intoxication severity and symptoms with mitochondrial function (mtCIV activity) and oxidative stress (lipid peroxidation) in 60 poisoned patients and determined ACOP recovery depending on either normobaric or hyperbaric oxygen therapy along a 3-month follow-up. In the present article we positively evaluate mtCIV as a good marker of ACOP recovery, treatment effectiveness, and late neurological syndrome development, which advocates for hyperbaric oxygen therapy as the treatment of choice. However, we discourage its usefulness as a severity marker because of its excessive sensitivity. We additionally evaluate oxidative stress role and prognostic factors for neurological sequelae development.