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.

Prognostic utility of pulse pressure in patients with heart failure with preserved ejection fraction: The RICA Registry.

BACKGROUND AND AIMS: The prognostic role of pulse pressure (PP) in heart failure (HF) patients with preserved left ventricular ejection fraction (LVEF) is not well understood. Our aim was to evaluate it in acute and stable HF. MATERIAL AND METHODS: This work is a retrospective observational study of patients included in the RICA registry between 2008 and 2021. Blood pressure was collected on admission (decompensation) and 3 months later on an outpatient basis (stability). Patients were categorized according to whether the PP was greater or less than 50mmHg. All-cause mortality was assessed at 1year after admission. RESULTS: A total of 2291 patients were included, with mean age 80.1±7.7 years. 62.9% were women and 16.7% had a history of coronary heart disease. In the acute phase, there was no difference in mortality according to PP values, but in the stable phase PP<50mmHg was independently associated with all-cause mortality at 1-year follow-up (HR 1.57, 95% CI 1.21-2.05, p=0.001), after adjusting for age, sex, New York Heart Association functional class, previous HF, chronic kidney disease, valvular heart disease, cerebrovascular disease, score on the Barthel and Pfeiffer scales, hemoglobin and sodium levels. CONCLUSIONS: Low stable-phase PP was associated with increased all-cause mortality in HF patients with preserved LVEF. However, PP was not useful as a prognostic marker of mortality in acute HF. Further studies are needed to assess the relationship of this variable with mortality in HF patients.

Prevalence and impact on prognosis of right-bundle branch block in patients with acute heart failure: Findings from the RICA registry.

OBJECTIVES: This work aims to determine the prevalence, characteristics, and impact on prognosis of right bundle branch block (RBBB) in a cohort of acute heart failure (AHF) patients. METHODS: We prospectively analyzed 3,638 AHF patients included in the RICA registry (National Heart Failure Registry of the Spanish Internal Medicine Society). We independently analyzed the relationship between baseline and clinical characteristics and the presence of RBBB as well as the potential impact of RBBB on 1-year all-cause mortality and a composite endpoint of 90-day post-discharge hospitalization or death. RESULTS: The prevalence of RBBB was 10.9%. Patients with RBBB were older, a higher proportion were male, had more pulmonary comorbidities, had higher left ventricular ejection fraction values, and had worse functional status. There were no differences in risk for patients with RBBB, with an adjusted hazard ratio (95% confidence interval) for 1-year mortality of 1.05 (0.83-1.32), and for the composite endpoint of 90-day post-discharge hospitalization or death of 0.97 (0.74-1.25). These results were consistent on the sensitivity analyses. CONCLUSIONS: Few patients with AHF present with RBBB, which is consistently associated with advanced age, male sex, pulmonary comorbidities, preserved left ventricular ejection fraction, and worse functional status. Nonetheless, after considering these factors, RBBB in AHF patients is not associated with worse outcomes.

Changes over time in the association between type 2 diabetes and post-discharge outcomes in decompensated chronic heart failure patients: Findings from the RICA Registry.

AIMS: Heart failure (HF) and diabetes are 2 strongly associated diseases. The main objective of this work was to analyze changes in the prognosis of patients with diabetes who were admitted for heart failure in 2 time periods. METHODS: This work is a prospective study comparing prognosis at one year of follow-up among patients with diabetes who were hospitalized for HF in either 2008-2011 or 2018. The patients are from the Spanish Society of Internal Medicine's National Heart Failure Registry (RICA, for its initials in Spanish). The primary endpoint was to analyze the composite outcome of total mortality and/or readmission due to HF in 12 months. A multivariate Cox regression model was used to evaluate the strength of association (hazard ratio [HR]) between diabetes and the outcomes between both periods. RESULTS: A total of 936 patients were included in the 2018 cohort, of which 446 (48%) had diabetes. The baseline characteristics of the populations from the 2 periods were similar. In patients with diabetes, the composite outcome was observed in 233 (47.5%) in the 2008-2011 cohort and 162 (36%) in the 2018 cohort [HR 1.48; 95% confidence interval (95%CI) 1.18-1.85; p < .001]. The proportion of readmissions (HR 1.39; 95%CI 1.07-1.80; p = .015) and total mortality (HR 1.60; 95%CI 1.20-2.14; p < .001) were also significantly higher in patients with diabetes from the 2008-2011 cohort compared to the 2018 cohort. CONCLUSIONS: In 2018, an improvement was observed in the prognosis for all-cause mortality and readmissions over one year of follow-up in patients with diabetes hospitalized for HF compared to the 2008-2011 period.

Morbidity and mortality in elderly patients with heart failure managed with a comprehensive care model vs. usual care: The UMIPIC program.

BACKGROUND: Elderly patients with heart failure (HF) have a high degree of comorbidity which leads to fragmented care, with frequent hospitalizations and high mortality. This study evaluated the benefit of a comprehensive continuous care model (UMIPIC program) in elderly HF patients. METHODS AND RESULTS: We prospectively analyzed data from the RICA registry on 2862 patients with HF treated in internal medicine departments. They were divided into two groups: one monitored in the UMIPIC program (UMIPIC group, n: 809) and another which received conventional care (RICA group, n: 2.053). We evaluated HF readmissions during 12 months of follow-up and total mortality after episodes of HF hospitalization. UMIPIC patients were older with higher rates of comorbidity and preserved ejection fraction than the RICA group. However, the UMIPIC group had a lower rate of HF readmissions (17% vs. 26%, p < .001) and mortality (16% vs. 27%, respectively; p < .001). In addition, we selected 370 propensity score-matched patients from each group and the differences in HF readmissions (15% UMIPIC vs. 30% RICA; hazard ratio [HR] = 0.44; 95% confidence interval [CI] 0.32-0.60; p < .001) and mortality (17% UMIPIC vs. 28% RICA; hazard ratio = 0.58; 95% CI 0.42-0.79; p = .001) were maintained. CONCLUSIONS: The implementation of the UMIPIC program, based on comprehensive continuous care of elderly patients with HF and high comorbidity, markedly reduce HF readmissions and total mortality.

Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study.

INTRODUCTION: Ambulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis. METHODS AND RESULTS: Prospective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (± 8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p=.024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95% CI 1.70-7.26; p=.001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926-0.997; p=.032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year. CONCLUSION: In older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF.

Comorbidity in patients with type 2 diabetes mellitus and heart failure with preserved ejection fraction. Cluster analysis of the RICA registry. Opportunities for improvement. / Comorbilidad en pacientes con diabetes mellitus tipo 2 e insuficiencia cardíaca con fracción de eyección preservada. Análisis de clusters del registro RICA. Oportunidades de mejora.

AIM: The heterogeneity of patients with heart failure and preserved ejection fraction (HFpEF) is high, thusthis entity tends to be grouped into phenotypes to act with precision. Within these groups, patients with type 2 diabetes mellitus (T2DM) hold this heterogeneity. Our aim is to describe subgroups of patients with HFpEF and T2DM based on other comorbidities. MATERIAL AND METHODS: Patients were recruited from the national registry of heart failure (RCIA). Patients with ejection fraction greater than or equal to 50% without valvular disease and with T2DM were included. A hierarchical agglomerative analysis was performed with Ward's method including the following variables: dyslipidemia, liver disease, Chronic obstructive pulmonary disease (COPD), dementia, cerebrovascular disease, arrhythmia, systolic blood pressure, body mass index (BMI), estimation of glomerular filtration and hemoglobin. RESULTS: 1934 patients with ICFEP were included, of which 907 (46.9%) had T2DM with a predominance of women (60.9%) and with a BMI of 31.1 (5.9) Kg / m2. Four groups were obtained, two with high vascular risk (one with arrhythmia and the other without it) with 263 patients the first and 201 the second. A third group had a predominance of COPD (140 patients) and a last group with 303 patients older but with less comorbidity. CONCLUSIONS: In our patients with ICFEP and T2DM, obesity and female sex predominated. All four groups offered treatment chances to improve their prognosis not only based on the use of new antidiabetic drugs but also on other options that may be a starting point for further research.

External validation of the CACE-HF risk score for mortality in patients with heart failure.

AIMS: To validate externally the CACE-HF clinical prediction rule, which predicts 1-year mortality in patients with heart failure (HF). METHODS: We performed an external validation of the CACE-HF risk score in patients included in the RICA heart failure registry who had completed 1 year of follow-up, comparing the characteristics of the derivation and validation cohorts. The performance of the risk score was evaluated in terms of calibration, using calibration-in-the-large (a), calibration slope (b), and the Hosmer-Lemeshow test, and in terms of discrimination, using the area under the ROC curve. RESULTS: In total, 3337 patients were included in the validation cohort. There were no significant differences between the derivation and validation cohorts in 1-year mortality (24.63% vs. 22.98%) or in the risk score and risk classes. The discrimination capacity in the validation cohort was slightly lower, 0.67 (95% CI: 0.65, 0.69), compared to that of the derivation cohort. Calibration results were a -0.05 (95% CI: -0.14, 0.03), indicating that the average predictions did not differ from the average outcome frequency, and b = 0.75 (95% CI: 0.64, 0.86), indicating a modest inconsistency in predictor effects. Observed mortality versus predicted mortality according to the deciles and risk classes were very similar in both cases, indicating good calibration. CONCLUSIONS: The results of the external validation of the CACE-HF risk score show that although the capacity for discrimination was slightly lower than in the derivation cohort, the calibration was excellent. This tool, therefore, can assist in decision-making in the management of these patients.

The short-term prognostic value of C-reactive protein in elderly patients with acute heart failure. / Valor pronóstico a corto plazo de la proteína C reactiva en ancianos con insuficiencia cardíaca aguda.

INTRODUCTION AND OBJECTIVES: Plasma c-reactive protein (crp) has been tested as a prognostic marker in acute heart failure (ahf). Whether its measurement really provides significant prognostic information when applied to elderly patients with ahf episodes remains unclear. METHODS: We measured the plasma crp values of patients admitted because of any type of ahf to internal medicine services. We evaluated the association of these values with the patients' baseline clinical characteristics and their 3-month posdischarge all-cause mortality or readmission rates. For comparison purposes, we divided the sample in tertiles of low, medium and high crp values (<2,24mg/l, 2,25-11,8mg/l and>11,8mg/l). RESULTS: We included 1443 patients with a median age of 80 years (interquartile range 73-85); 680 (47%) were men, with a moderate comorbid burden. 60.1% had preserved left ventricular ejection fraction (> 50%). Multivariate analysis confirmed an independent association between higher crp values and the presence of respiratory infection, lower systolic blood pressure and deteriorated renal function upon admission. Three months after the index admission, a total of 142 patients (9.8%) had died, and 268 (18.6%) had either been readmitted or died. admission crp values did not correlate with 3-month all-cause mortality (P=0.79), 3-month all-cause readmission (P=0.96) or the combination of both events (P=0.96). However, higher crp values were associated with a longer length of stay (P<0.001). CONCLUSION: Our study does not confirm an association between admission plasma crp values in elderly ahf patients and subsequent higher 3-month mortality or readmission risks.

Hemoconcentration as a prognostic factor after hospital discharge in acute heart failure in the RICA registry. / Hemoconcentración como predictor de supervivencia al año de ingreso por insuficiencia cardiaca aguda en el registro RICA.

OBJECTIVE: Several studies have reported that a higher degree of hemoconcentration in patients admitted for the treatment of acute heart failure (HF) constitutes a favorable prognostic factor in the year following the index episode. The objective of this study was to evaluate whether the highest degree of hemoconcentration at 3 months after admission for HF is also a prognostic factor for mortality and/or readmission in the 12 months after admission. PATIENTS AND METHOD: The hemoconcentration group was the upper quartile of the sample distributed according to hemoglobin increase at month 3 after discharge with respect to hemoglobin at the time of admission for HF in a multicenter prospective cohort of 1,659 subjects with HF. RESULTS: The mean follow-up until the first event was 294 days, and a total of 487 deaths and 1,125 readmissions were recorded. The hemoconcentration group had a lower risk of mortality or readmission for any cause (RR=0.75, 95% CI: 0.51-1.09 and RR=0.86, 95% CI: 0.70-1.05), although statistical significance was lost after multivariate analysis, while it was retained for other factors with recognized negative impact on the prognosis of patients with HF, such as age and functional class. CONCLUSIONS: The degree of hemoconcentration at 3 months after admission for HF is not prognostic of readmission or death in the subsequent year.

Consensus for improving the comprehensive care of patients with acute heart failure: summarised version.

The purpose of this consensus document was to reach an agreement among experts on the multidisciplinary care of patients with acute heart failure. Starting with a narrative review of the care provided to these patients and a critical analysis of the healthcare procedures, we identified potential shortcomings and improvements and formalised a document on recommendations for optimising the clinical and therapeutic approach for acute heart failure. This document was validated through an in-person group session guided using participatory techniques. The process resulted in a set of 36 recommendations formulated by experts of the Spanish Society of Cardiology, the Spanish Society of Internal Medicine and the Spanish Society of Urgent and Emergency Care. The recommendations are designed to optimise the healthcare challenge presented by the care of patients with acute heart failure in the context of Spain's current National Health System.

Organ protection possibilities in acute heart failure.

Unlike chronic heart failure (HF), the treatment for acute HF has not changed over the last decade. The drugs employed have shown their ability to control symptoms but have not achieved organ protection or managed to reduce medium to long-term morbidity and mortality. Advances in our understanding of the pathophysiology of acute HF suggest that treatment should be directed not only towards correcting the haemodynamic disorders and achieving symptomatic relief but also towards preventing organ damage, thereby counteracting myocardial remodelling and cardiac and extracardiac disorders. Compounds that exert vasodilatory and anti-inflammatory action in the acute phase of HF and can stop cell death, thereby boosting repair mechanisms, could have an essential role in organ protection.

Reduction in hospitalisations and emergency department visits for frail patients with heart failure: Results of the UMIPIC healthcare programme.

OBJECTIVES: Heart failure (HF) is a disease with high morbidity and mortality. We evaluated the usefulness of the Comprehensive Management Units for Patients with HF (Unidades de Manejo Integral para Pacientes con IC [UMIPIC]) programme. PATIENTS AND METHOD: We analysed the patient data from the UMIPIC programme, which was recorded in the HF registry (RICA) of the Spanish Society of Internal Medicine. We compared emergency department visits and hospitalisations for any cause and for HF during the year prior to inclusion in the programme against those that occurred during the subsequent follow-up year, using the chi-squared test. RESULTS: A total of 258 patients (mean age, 80years; 51.9% women) were included in the study. During the previous year, there were 693 hospitalisations for all causes and 174 hospitalisations during the follow-up (75% reduction, P<.001). There were 613 hospitalisations for HF during the previous year and 92 during the follow-up (85% reduction, P<.001); 655 vs. 302 in terms of emergency department visits for any cause (53.9% reduction, P<.001); and 440 vs. 120 for emergency department visits for HF (72% reduction, P<.001). There were no significant differences in the number of hospitalisations or emergency department visits for causes other than HF. CONCLUSIONS: The UMIPIC programme based on the comprehensive care of elderly patients with HF and comorbidity reduces the rate of hospital readmissions and emergency department visits during the first year of follow-up.

Gender related differences in clinical profile and outcome of patients with heart failure. Results of the RICA Registry. / Diferencias en función del sexo en el perfil clínico y pronóstico de pacientes con insuficiencia cardiaca. Resultados del Registro RICA.

HISTORY AND OBJECTIVES: To analyze the differential clinical characteristics according to gender of patients with heart failure in terms of etiology, comorbidity, triggers, treatment, hospital stay and overall mortality at one year. PATIENTS AND METHOD: We employed data from the RICA registry, a multicenter prospective cohort of patients hospitalized in internal medicine departments for heart failure, with a follow-up of one year. We analyzed the differences between the gender in terms of the etiology of the heart disease, comorbidity, triggers, left ventricle ejection fraction, functional state, mental condition, treatment, length of stay and mortality at 1 year. RESULTS: A total of 1772 patients (47.2% men) were included. The women were older than the men (p<.001) and had a higher prevalence of hypertension, obesity, chronic kidney disease, atrial fibrillation and preserved left ventricle ejection fraction (p<.001). The men's medical history had a predominance of myocardial infarction, chronic obstructive pulmonary disease, peripheral arteriopathy (p<.001) and anemia (p=.02). In the women, a hypertensive etiology was predominant, followed by valvular. The main triggers were hypertension and atrial fibrillation. Treatment with beta-blockers, ACEIs and/or ARBs did not differ by sex. The women had poorer functional capacity (p<.001), according to the Barthel index. After adjusting for age and other prognostic factors, the mortality at one year was lower among the women (RR: 0.69; 95% CI 0.53-0.89; p=.004). CONCLUSIONS: HF in women occurs at a later age and with different comorbidities. The hypertensive and valvular etiology is predominant, with preserved left ventricle ejection fraction, and the age-adjusted mortality is lower than in men.

Prognostic value of glomerular filtration rate estimation equations in acute heart failure with preserved versus reduced ejection fraction.

AIMS: Renal function is an important prognostic factor in heart failure. The aim of this study was to compare the predictive value of estimated renal function calculated by the Chronic Kidney Disease-Epidemiology Collaboration equation (CKD-EPI) and the abbreviated Modification of Diet in Renal Disease (MDRD-4) equation for long-term all-cause mortality in patients admitted for acute decompensated heart failure (ADHF) with both preserved ejection fraction (HF-PEF) and reduced ejection fraction (HF-REF). METHODS AND RESULTS: We evaluated patients included in the Spanish National Registry of Heart Failure (RICA). RICA is a multicentre, prospective, cohort study that included patients admitted to the Internal Medicine units with ADHF. Estimated glomerular filtration rate (eGFR) was calculated with CKD-EPI and MDRD-4 equations. A total of 1805 patients admitted for ADHF were studied (52% women; median age 80 years, interquartile range 73.9-84.6 years); of these, 1044 (58%) had HF-PEF. eGFR values were lower with the CKD-EPI formula than with the MDRD-4 formula (51 ml/min/1.73 m(2) vs. 55.7 ml/min/1.73 m(2) ; p < 0.001). The two formulas provided independent prognostic information over long-term follow-up, in both HF-PEF and HF-REF patients. However, in HF-PEF patients, CKD-EPI equation was associated with a significant improvement in reclassification analyses (net reclassification improvement 6.78%; p = 0.009). CONCLUSIONS: In this clinical cohort of ADHF patients, eGFR as calculated by both the CKD-EPI and the MDRD-4 formulas offered similar prognostic information, irrespective of ejection fraction status, but in HF-PEF patients specifically, the CKD-EPI formula seems to improve clinical risk stratification as compared with MDRD-4.