Worsening renal function during an episode of acute heart failure and its relation to short- and long-term mortality: associated factors in the Epidemiology of Acute Heart Failure in Emergency Departments- Worsening Renal Function study. / Factores asociados con el empeoramiento de la función renal durante un episodio de insuficiencia cardiaca aguda y su relación con la mortalidad a corto y largo plazo: estudio EAHFE - EFRICA.

OBJECTIVES: To identify factors associated with worsening renal function (WRF) and explore associations with higher mortality in patients with acute heart failure (AHF). MATERIAL AND METHODS: Seven emergency departments (EDs) in the EAHFE-EFRICA study (Spanish acronym for Epidemiology of AHF in EDs - WRF in AHF) consecutively included patients with AHF and creatinine levels determined in the ED and between 24 and 48 hours later. Patients with WRF were identified by an increase in creatinine level of 0.3 mg/dL or more. Forty-seven clinical characteristics were explored to identify those associated with WRF. To analyze for 30-day all-cause mortality we calculated odds ratios (ORs). To analyze mortality at the end of follow-up and by trimester, adjusted for between-group differences, we calculated hazard ratios (HRs). The data were analyzed by subgroups according to age, sex, baseline creatinine levels, AHF type, and risk group. RESULTS: A total of 1627 patients were included. The subgroup of 220 (13.5%) with WRF were older, had higher systolic blood pressure, were more often treated with morphine, and had chronic renal failure; there was also a higher rate of hypertensive crisis as the trigger for AHF in patients with WRF. However, only chronic renal failure was independently associated with WRF (adjusted OR, 1.695; 95% CI, 1.264-2.273). The rate of 30-day mortality was 13.1% overall but higher in patients with WRF (20.9% vs 11.8% in patients without WRF; adjusted OR, 1.793; 95% CI, 1.207-2.664). Accumulated mortality at 18 months (average follow-up time, 14 mo/patient) was 40.0% overall but higher in patients with WRF (adjusted HR, 1.275; 95% CI, 1.018-1.598). Increased risk was greater in the first trimester. Subgroup analyses revealed no differences. CONCLUSION: AHF with WRF in the first 48 hours after ED care is associated with higher mortality, especially in the first trimester after the emergency.

OBJETIVO: Identificar los factores asociados con el empeoramiento de la función renal (EFR) y si este se asocia a mayor mortalidad en pacientes que presentan un episodio de insuficiencia cardiaca aguda (ICA). METODO: Participaron 7 servicios de urgencias (SU) que incluyeron consecutivamente pacientes con ICA con determinación de creatinina en urgencias y a las 24-48 horas, y se identificaron aquellos con EFR (incremento de creatinina $ 0,3 mg/dL). Entre 47 características clínicas, se identificó las asociadas a EFR. Se investigó la mortalidad por cualquier causa a 30 días (OR) y al final del seguimiento (HR), esta última global y por periodos trimestrales, que se ajustó por las diferencias entre grupos. Se analizaron subgrupos según edad, sexo, creatinina basal, tipo de ICA y grupo de riesgo. RESULTADOS: Se incluyeron 1.627 pacientes, 220 (13,5%) con EFR, los cuales presentaban mayor edad, presión arterial sistólica, crisis hipertensiva como precipitante, tratamiento con morfina e insuficiencia renal crónica, aunque solo esta última se asoció independientemente a EFR (ORajustada = 1,695, IC 95% = 1,264-2,273). La mortalidad a 30 días fue de 13,1% (mayor en pacientes con EFR: 20,9% vs 11,8%, ORajustada = 1,793, IC 95% = 1,207-2,664) y la mortalidad acumulada a 18 meses (tiempo medio de seguimiento 14 meses/paciente) fue del 40,0% (mayor en pacientes con EFR: HRajustada = 1,275, IC 95% = 1,018-1,598). Este incremento de riesgo fue durante el primer trimestre. El análisis de subgrupos no mostró diferencias. CONCLUSIONES: La ICA con EFR en las primeras 48 horas posteriores a la atención en el SU se asocia a mayor mortalidad, que se concentra durante el primer trimestre.

The CRAS-EAHFE study: Characteristics and prognosis of acute heart failure episodes with cardiorenal-anaemia syndrome at the emergency department.

BACKGROUND: The coexistence of other comorbidities confers poor outcomes in patients with acute heart failure. Our aim was to determine the characteristics of patients with acute heart failure and cardiorenal anaemia syndrome and the relationship between renal dysfunction and anaemia, alone or combined as cardiorenal anaemia syndrome, on short-term outcomes. METHODS: We analysed the Epidemiology of Acute Heart Failure in Emergency Departments registry (cohort of patients with acute heart failure in Spanish emergency departments). Renal dysfunction was defined by an estimated glomerular filtration rate <60 ml/min/m2, anaemia by haemoglobin values <12/<13 g/dl in women/men, and cardiorenal anaemia syndrome as the presence of both. Comparisons were made according to cardiorenal-anaemia syndrome positive (CRAS+) with respect to the rest of patients (CRAS-) and according the presence of renal dysfunction (RD+) and anaemia (A+), (alone, RD+/A-, RD-/A+) or in combination (RD+/A+; i.e. CRAS+) with respect to patients without renal dysfunction and anaemia (RD-/A-). The primary outcome was 30-day mortality, and the secondary outcomes were need for admission, prolonged hospitalisation (>10 days), in-hospital mortality during the index event, and reconsultation and the combination of 30-day post-discharge reconsultation/death. These short-term outcomes were compared and adjusted for differences among groups. RESULTS: Of the 13,307 patients analysed, CRAS+ (36.4%) was associated with older age, multiple comorbidities, chronic use of loop diuretics, oedemas and hypotension. The 30-day mortality in CRAS+ was greater than in CRAS- (hazard ratio = 1.46, 95% confidence interval = 1.26-1.68) and RD-/A- (hazard ratio = 1.83, 95% confidence interval = 1.46-2.28) control groups. The mortality level was also higher in RD+/A- (hazard ratio = 1.40, 95% confidence interval = 1.10-1.78) and higher, but not statistically significant, in RD-/A+ (hazard ratio = 1.28, 95% confidence interval = 0.99-1.63) with respect to RD-/A-. All of the secondary outcomes, when related to CRAS- and RD-/A- control groups, were worse for CRAS+ and to a lesser extent, RD+/A-, being more rarely observed in RD-/A+. CONCLUSIONS: Cardiorenal anaemia syndrome in acute heart failure is related to greater mortality and worse short-term outcomes, and the impact of renal dysfunction and anaemia seems to be additive.