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Núñez-Marín G, Romero-González G, Bover J, Górriz JL, Bayés-Genís A, Sanchis J, Núñez J, de la Espriella R. Urinary cell cycle arrest biomarkers and diuretic efficiency in acute heart failure. Cardiorenal Med 2024:000538774. [PMID: 38631309 DOI: 10.1159/000538774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/22/2024] [Indexed: 04/19/2024] Open
Abstract
Introduction This study aimed to evaluate the association between the NephroCheck ® Test AKIRisk® Score, diuretic efficiency (DE) and the odds of worsening kidney function (WKF) within the first 72 hours of admission in patients hospitalized for acute heart failure (AHF). Methods The study prospectively enrolled 125 patients admitted with AHF. NephroCheck ® Test was obtained within the first 24 of admission. DE was defined as net fluid urine output per 40 mg of furosemide equivalents. Results The median AKIRisk® Score was 0.11 (IQR 0.06-0.34) and 38 (30.4%) patients had an AKIRisk® Score >0.3. The median cumulative DE at 72 hours was 1963 mL (IQR 1317-3239 ml). At 72 hours, a total of 10 (8%) patients developed an absolute increase in sCr ≥0.5 mg/dL (WKF). In a multivariate setting, there was an inverse association between the AKIRisk® Score and DE within the first 72 hours. In fact, the highest the AKIRisk® Score (centered at 0.3) the higher the likelihood of poor diuretic efficiency (below the median) and WKF at 72 hours (Odds Ratio [OR] 2.04; 95%; CI 1.02-4.07; p=0.043, and OR 3.31, 95% CI 1.30-8.43; p = 0.012, respectively). Conclusion In patients with AHF, a higher NephroCheck ® AKIRisk® score is associated with poorer DE and a higher risk of WKF at 72 hours. Further research is needed to confirm the role of urinary cell cycle arrest biomarkers in the AHF scenario.
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Santas E, Llácer P, Palau P, de la Espriella R, Miñana G, Lorenzo M, Núñez-Marín G, Miró Ò, Chorro FJ, Bayés-Genís A, Sanchis J, Núñez J. Noncardiovascular morbidity and mortality across left ventricular ejection fraction categories following hospitalization for heart failure. Rev Esp Cardiol (Engl Ed) 2024; 77:206-214. [PMID: 37315921 DOI: 10.1016/j.rec.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/16/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION AND OBJECTIVES Noncardiovascular events represent a significant proportion of the morbidity and mortality burden in patients with heart failure (HF). However, the risk of these events appears to differ by left ventricular ejection fraction (LVEF) status. In this study, we sought to evaluate the risk of noncardiovascular death and recurrent noncardiovascular readmission by LVEF status following an admission for acute HF. METHODS We retrospectively assessed a cohort of 4595 patients discharged after acute HF in a multicenter registry. We evaluated LVEF as a continuum, stratified in 4 categories (LVEF ≤ 40%, 41%-49%, 50%-59%, and ≥ 60%). Study endpoints were the risks of noncardiovascular mortality and recurrent noncardiovascular admissions during follow-up. RESULTS At a median follow-up of 2.2 [interquartile range, 0.76-4.8] years, we registered 646 noncardiovascular deaths and 4014 noncardiovascular readmissions. After multivariable adjustment including cardiovascular events as a competing event, LVEF status was associated with the risk of noncardiovascular mortality and recurrent noncardiovascular admissions. When compared with patients with LVEF ≤ 40%, those with LVEF 51%-59%, and especially those with LVEF ≥ 60%, were at higher risk of noncardiovascular mortality (HR, 1.31; 95%CI, 1.02-1,68; P=.032; and HR, 1.47; 95%CI, 1.15-1.86; P=.002; respectively), and at higher risk of recurrent noncardiovascular admissions (IRR, 1.17; 95%CI, 1.02-1.35; P=.024; and IRR, 1.26; 95%CI, 1.11-1.45; P=.001; respectively). CONCLUSIONS Following an admission for HF, LVEF status was directly associated with the risk of noncardiovascular morbidity and mortality. Patients with HFpEF were at higher risk of noncardiovascular death and total noncardiovascular readmissions, especially those with LVEF ≥ 60%.
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Affiliation(s)
- Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Pau Llácer
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Patricia Palau
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Gema Miñana
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Miguel Lorenzo
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Gonzalo Núñez-Marín
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Òscar Miró
- Servicio de Urgencias, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Francisco Javier Chorro
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Antoni Bayés-Genís
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
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de la Espriella R, Núñez-Marín G, Cobo M, de Castro Campos D, Llácer P, Manzano L, Zegrí I, Rodriguez-Pérez Á, Santas E, Lorenzo M, Miñana G, Núñez E, Górriz JL, Bayés-Genís A, Fudim M, Mullens W, Núñez J. Intrarenal Venous Flow Pattern Changes Do Relate With Renal Function Alterations in Acute Heart Failure. JACC Heart Fail 2024; 12:304-318. [PMID: 37676214 DOI: 10.1016/j.jchf.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND There is scarce evidence supporting the clinical utility of congestive intrarenal venous flow (IRVF) patterns in patients with acute heart failure. OBJECTIVES This study aims to: 1) investigate the association between IRVF patterns and the odds of worsening renal function (WRF); 2) track the longitudinal changes of serum creatinine (sCr) across IRVF at predetermined points and its association with decongestion; and 3) explore the relationship between IRVF/WRF categories and patient outcomes. METHODS IRVF was assessed at baseline (pre-decongestive therapy), 72 hours, and 30 and 90 days postdischarge. Changes in sCr trajectories across dynamic IRVF variations and parameters of decongestion were assessed using linear mixed effect models. The association between IRVF/WRF categories and outcomes was evaluated using univariable/multivariable models. RESULTS In this prospective, multicenter study with 188 participants, discontinuous IRVF patterns indicated higher odds of WRF (OR: 3.90 [95% CI: 1.24-12.20]; P = 0.020 at 72 hours; and OR: 5.76 [95% CI: 1.67-19.86]; P = 0.006 at 30 days) and an increase in sCr (Δ-72 hours 0.14 mg/dL [95% CI: 0.06-0.22]; P = 0.001; Δ-discharge 0.13 mg/dL [95% CI: 0.03-0.23]; P = 0.007). However, the diuretic response and decongestion significantly influenced the magnitude of these changes. Patients exhibiting both WRF and discontinuous IRVF at 30 days experienced an increased hazard of adverse events (HR: 5.96 [95% CI: 2.63-13.52]; P < 0.001). CONCLUSIONS Discontinuous IRVF identifies patients with higher odds of WRF during admission and postdischarge periods. Nonetheless, adequate diuretic response and decongestion could modify this association. Patients showing both WRF and discontinuous IRVF at 30 days had increased rates of adverse events.
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Affiliation(s)
- Rafael de la Espriella
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Gonzalo Núñez-Marín
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Marta Cobo
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda (IDIPHISA), Madrid, Spain
| | - Daniel de Castro Campos
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda (IDIPHISA), Madrid, Spain
| | - Pau Llácer
- Department of Internal Medicine, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Luis Manzano
- Department of Internal Medicine, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Isabel Zegrí
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Enrique Santas
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Miguel Lorenzo
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Gema Miñana
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Eduardo Núñez
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain
| | - Jose Luis Górriz
- Department of Nephrology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain; Department of Medicine, Universitat de València. Valencia, Spain
| | - Antoni Bayés-Genís
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg, Genk and Hasselt University, Hasselt, Belgium
| | - Julio Núñez
- Department of Cardiology, Hospital Clínico Universitario de Valencia (INCLIVA), Valencia, Spain; Department of Medicine, Universitat de València. Valencia, Spain; Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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de la Espriella R, Núñez-Marín G, Codina P, Núñez J, Bayés-Genís A. Biomarkers to Improve Decision-making in Acute Heart Failure. Card Fail Rev 2023; 9:e13. [PMID: 37942188 PMCID: PMC10628997 DOI: 10.15420/cfr.2023.08] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/19/2023] [Indexed: 11/10/2023] Open
Abstract
Acute heart failure (AHF) is a complex clinical syndrome that requires prompt diagnosis, risk stratification and effective treatment strategies to reduce morbidity and mortality. Biomarkers are playing an increasingly important role in this process, offering valuable insights into the underlying pathophysiology and facilitating personalised patient management. This review summarises the significance of various biomarkers in the context of AHF, with a focus on their clinical applications to stratify risk and potential for guiding therapy choices.
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Affiliation(s)
| | - Gonzalo Núñez-Marín
- Department of Cardiology, Hospital Clínico Universitario de ValenciaValencia, Spain
| | - Pau Codina
- Heart Institute, Hospital Universitari Germans Trias i PujolBarcelona, Spain
| | - Julio Núñez
- Department of Cardiology, Hospital Clínico Universitario de ValenciaValencia, Spain
- Department of Medicine, Universitat de ValènciaValencia, Spain
- Centro de Investigación Biomédica en Red en Enfermedades CardiovascularesMadrid, Spain
| | - Antoni Bayés-Genís
- Heart Institute, Hospital Universitari Germans Trias i PujolBarcelona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades CardiovascularesMadrid, Spain
- Department of Medicine, Universitat Autònomoa de BarcelonaBarcelona, Spain
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Núñez-Marín G, Iraola D, Lorenzo M, de la Espriella R, Villar S, Santas E, Miñana G, Sanchis J, Carratalá A, Miró Ò, Bayés-Genís A, Núñez J. An update on utilising brain natriuretic peptide for risk stratification, monitoring and guiding therapy in heart failure. Expert Rev Mol Diagn 2023:1-13. [PMID: 37216616 DOI: 10.1080/14737159.2023.2216386] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/04/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023]
Abstract
INTRODUCTION Heart failure (HF) is a dominant health problem with an overall poor prognosis. Natriuretic peptides (NPs) are upregulated in HF as a compensatory mechanism. They have extensively been used for diagnosis and risk stratification. AREAS COVERED This review addresses the history and physiology of NPs in order to understand their current role in clinical practice. It further provides a detailed and updated narrative review on the utility of those biomarkers for risk stratification, monitoring, and guiding therapy in HF. EXPERT OPINION NPs show excellent predictive ability in heart failure patients, both in acute and chronic settings. Understanding their pathophysiology and their modifications in specific situations is key for an adequate interpretation in specific clinical scenarios in which their prognostic value may be weaker or less well evaluated. To better promote risk stratification in HF, NPs should be integrated with other predictive tools to develop multiparametric risk models. Both inequalities of access to NPs and evidence caveats and limitations will need to be addressed by future research in the coming years.
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Affiliation(s)
- Gonzalo Núñez-Marín
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Diego Iraola
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Miguel Lorenzo
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Sandra Villar
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
| | - Arturo Carratalá
- Clinical Chemistry Department, Hospital Clínico Universitario, INCLIVA
| | - Òscar Miró
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Antoni Bayés-Genís
- Cardiology Department, Hospital Universitari Germas Trias i Pujol. Badalona, Spain
- CIBER Cardiovascular, Madrid, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia. Valencia, Spain. Valencia, Spain
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
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Núñez-Marín G, de la Espriella R, Santas E, Lorenzo M, Miñana G, Núñez E, Bodí V, González M, Górriz JL, Bonanad C, Sanchis J, Bayés-Genís A, Núñez J. CA125 but not NT-proBNP predicts the presence of a congestive intrarenal venous flow in patients with acute heart failure. Eur Heart J Acute Cardiovasc Care 2021; 10:475-483. [PMID: 33829233 DOI: 10.1093/ehjacc/zuab022] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/14/2021] [Accepted: 03/19/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Intrarenal venous flow (IRVF) measured by Doppler ultrasound has gained interest as a potential surrogate marker of renal congestion and adverse outcomes in heart failure. In this work, we aimed to determine if antigen carbohydrate 125 (CA125) and plasma amino-terminal pro-B-type natriuretic peptide (NT-proBNP) are associated with congestive IRVF patterns (i.e., biphasic and monophasic) in acute heart failure (AHF). METHODS AND RESULTS We prospectively enrolled a consecutive cohort of 70 patients hospitalized for AHF. Renal Doppler ultrasound was assessed within the first 24-h of hospital admission. The mean age of the sample was 73.5 ± 12.3 years; 47.1% were female, and 42.9% exhibited heart failure with preserved ejection fraction. The median (interquartile range) for NT-proBNP and CA125 were 6149 (3604-12 330) pg/mL and 64 (37-122) U/mL, respectively. The diagnostic performance of both exposures for identifying congestive IRVF patterns was tested using the receiving operating curve (ROC). The cut-off for CA125 of 63.5 U/mL showed a sensibility and specificity of 67% and 74% and an area under the ROC curve of 0.71. After multivariate adjustment, CA125 remained non-linearly and positively associated with congestive IRVF (P-value = 0.008) and emerged as the most important covariate explaining the variability of the model (R2: 47.5%). Under the same multivariate setting, NT-proBNP did not show to be associated with congestive IRVF patterns (P-value = 0.847). CONCLUSIONS CA125 and not NT-proBNP is a useful marker for identifying patients with AHF and congestive IRVF patterns.
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Affiliation(s)
- Gonzalo Núñez-Marín
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Departamento de Medicina, Universitat de València, Avda. Blasco Ibáñez 17, Valencia 46010, Spain
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Departamento de Medicina, Universitat de València, Avda. Blasco Ibáñez 17, Valencia 46010, Spain
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Departamento de Medicina, Universitat de València, Avda. Blasco Ibáñez 17, Valencia 46010, Spain
| | - Miguel Lorenzo
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Departamento de Medicina, Universitat de València, Avda. Blasco Ibáñez 17, Valencia 46010, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Departamento de Medicina, Universitat de València, Avda. Blasco Ibáñez 17, Valencia 46010, Spain
| | - Eduardo Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Departamento de Medicina, Universitat de València, Avda. Blasco Ibáñez 17, Valencia 46010, Spain
| | - Vicent Bodí
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Departamento de Medicina, Universitat de València, Avda. Blasco Ibáñez 17, Valencia 46010, Spain
| | - Miguel González
- Nephrology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Departamento de Medicina, Universitat de València, Avda. Blasco Ibáñez 17, Valencia 46010, Spain
| | - José Luis Górriz
- Nephrology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Departamento de Medicina, Universitat de València, Avda. Blasco Ibáñez 17, Valencia 46010, Spain
| | - Clara Bonanad
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Departamento de Medicina, Universitat de València, Avda. Blasco Ibáñez 17, Valencia 46010, Spain
| | - Juan Sanchis
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Departamento de Medicina, Universitat de València, Avda. Blasco Ibáñez 17, Valencia 46010, Spain.,CIBER in Cardiovascular Diseases (CIBERCV), Madrid, Spain
| | - Antoni Bayés-Genís
- CIBER in Cardiovascular Diseases (CIBERCV), Madrid, Spain.,Heart Institute, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, 08916 Badalona, Barcelona, Spain.,Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA, Departamento de Medicina, Universitat de València, Avda. Blasco Ibáñez 17, Valencia 46010, Spain.,CIBER in Cardiovascular Diseases (CIBERCV), Madrid, Spain
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Núñez-Marín G, Martín-Sánchez FJ, Bonanad C. [Cardiorenal Syndrome in Elderly: An Endless Loop Between Heart and Kidneys]. Rev Esp Geriatr Gerontol 2020; 56:1-2. [PMID: 33280925 DOI: 10.1016/j.regg.2020.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Gonzalo Núñez-Marín
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia; INCLIVA, Valencia, España
| | - Francisco Javier Martín-Sánchez
- Servicio de Urgencias, Hospital Universitario Clínico San Carlos; Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC); Departamento de Medicina, Facultad de Medicina, Universidad Complutense, Madrid, España
| | - Clara Bonanad
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia; INCLIVA, Valencia, España.
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