Incidence and outcomes of hospital treated acute myocarditis from 2003 to 2015 in Spain.

BACKGROUND: There are no data on population-based epidemiological changes in acute myocarditis in Europe. Our aim was to evaluate temporal trends in incidence, clinical features and outcomes of hospital treated acute myocarditis (AM) in Spain from 2003 to 2015. METHODS: We conducted a retrospective longitudinal study using information of all hospital discharges of the Spanish National Health System. All episodes with a discharge diagnosis of AM from 1 January 2003 to 31 December 2015 were included. The risk-standardized in-hospital mortality ratio (RSMR) was calculated using a multilevel risk-adjustment model developed by the Medicare and Medicaid Services. Temporal trends for in-hospital mortality were modelled using Poisson regression analysis. RESULTS: A total of 11 147 episodes of AM were analysed, most of them idiopathic (94.7%). The rate of AM discharges increased along the period, from 13 to 30/million inhabitants/year (2003-2015), and this increase was statistically significant when weighted by age and sex (incidence rate ratio, IRR 1.06, 95% CI 1.04-1.08, P = .001). In-hospital crude mortality rate was 3.1%, diminishing significantly along 2003-2015 (IRR 0.95, 95% CI 0.92-0.99, P = .02). RSMR also significantly diminished along the period (IRR 0.95, 95% CI 0.92-0.99, P = .01). Renal failure (OR 7.03, 5.38-9.18, P = .001), liver disease (OR 4.61, 2.59-8.21, P = .001), pneumonia (OR 4.13, 2.75-6.20, P = .001) and heart failure (OR 1.91, 95% CI 1.47-2.47, P = .001) were the strongest independent factors associated with in-hospital mortality. CONCLUSIONS: Acute myocarditis is an uncommon entity, although hospital discharges have increased in Spain along the study period. Most of AM were idiopathic. Adjusted mortality was low and seemed to decrease from 2003 to 2015, suggesting an improvement in AM management.

Hypoalbuminemia in acute heart failure patients: causes and its impact on hospital and long-term mortality.

BACKGROUND: The causes of hypoalbuminemia in patients with acute heart failure (HF) remain poorly defined, and the association between hypoalbuminemia and hospital and long-term mortality has been only partially evaluated. This study sought to analyze the causes of hypoalbuminemia in acute HF patients and determine its impact on hospital and long-term mortality. METHODS AND RESULTS: A total of 362 consecutive acute HF patients were assessed. The patients were divided into 2 groups according to the presence or absence of hypoalbuminemia (albumin ≤3.4 g/dL), and the independent association of each variable with hypoalbuminemia and hospital mortality was assessed with the use of multiple logistic regression. The association between hypoalbuminemia and long-term mortality was assessed with the use of Cox multivariate analysis. In total, 108 patients (29.8%) were classified as having hypoalbuminemia. Older age, higher C-reactive protein levels, and lower levels of total protein, prealbumin, transferrin, and lymphocytes were independently associated with hypoalbuminemia. Hospital mortality was 8% and was independently associated with hypoalbuminemia. A total of 333 patients were discharged. Hypoalbuminemia was an independent predictor of mortality. CONCLUSIONS: Hypoalbuminemia in acute HF patients was associated with higher hospital mortality and served as an independent predictor of long-term mortality. Malnutrition and inflammation were factors causing hypoalbuminemia in this clinical setting.

[Hospital admissions and outcomes for systolic and diastolic heart failure in Spain between 2016 and 2019: A population-based study]. / Hospitalizaciones y eventos por insuficiencia cardiaca sistólica y diastólica en España entre 2016 y 2019. Un estudio de base poblacional.

BACKGROUND AND PURPOSE: In Spain there is a lack of population data that specifically compare hospitalization for systolic and diastolic heart failure (HF). We assessed clinical characteristics, in-hospital mortality and 30-day cardiovascular readmission rates differentiating by HF type. METHODS: We conducted a retrospective observational study of patients discharged with the principal diagnosis of HF from The National Health System' acute hospital during 2016-2019, distinguishing between systolic and diastolic HF. The source of the data was the Minimum Basic Data Set. The risk-standardized in-hospital mortality ratio and risk-standardized 30-day cardiovascular readmission ratio were calculated using multilevel risk adjustment models. RESULTS: The 190,200 episodes of HF were selected. Of these, 163,727 (86.1%) were classified as diastolic HF and were characterized by older age, higher proportion of women, diabetes mellitus, dementia and renal failure than those with systolic HF. In the multilevel risk adjustment models, diastolic HF was a protective factor for both in-hospital mortality (odds ratio [OR]: 0.79; 95% confidence interval [CI]: 0.75-0.83; P<.001) and 30-day cardiovascular readmission versus systolic HF (OR: 0.93; 95% CI: 0.88-0.97; P=.002). CONCLUSIONS: In Spain, between 2016 and 2019, hospitalization episodes for HF were mostly due to diastolic HF. According to the multilevel risk adjustment models, diastolic HF compared to systolic HF was a protective factor for both in-hospital mortality and 30-day cardiovascular readmission.

Characteristics and in-hospital mortality of elderly patients with heart failure in Spanish hospitals.

BACKGROUND: The prevalence of heart failure (HF) increases with age, and it is one of the leading causes of hospitalization and death in older patients. However, there are little data on in-hospital mortality in patients with HF ≥ 75 years in Spain. METHODS: A retrospective analysis of the Spanish Minimum Basic Data Set was performed, including all HF episodes discharged from public hospitals in Spain between 2016 and 2019. Coding was performed using the International Classification of Diseases, 10th Revision. Patients ≥ 75 years with HF as the principal diagnosis were selected. We calculated: (1) the crude in-hospital mortality rate and its distribution according to age and sex; (2) the risk-standardized in-hospital mortality ratio; and (3) the association between in-hospital mortality and the availability of an intensive cardiac care unit (ICCU) in the hospital. RESULTS: We included 354,792 HF episodes of patients over 75 years. The mean age was 85.2 ± 5.5 years, and 59.2% of patients were women. The most frequent comorbidities were renal failure (46.1%), diabetes mellitus (35.5%), valvular disease (33.9%), cardiorespiratory failure (29.8%), and hypertension (26.9%). In-hospital mortality was 12.7%, and increased with age [odds ratio (OR) = 1.07, 95% CI: 1.07-1.07, P < 0.001] and was lower in women (OR = 0.96, 95% CI: 0.92-0.97, P < 0.001). The main predictors of mortality were the presence of cardiogenic shock (OR = 19.5, 95% CI: 16.8-22.7, P < 0.001), stroke (OR = 3.5, 95% CI: 3.0-4.0, P < 0.001) and advanced cancer (OR = 2.6, 95% CI: 2.5-2.8, P < 0.001). In hospitals with ICCU, the in-hospital risk-adjusted mortality tended to be lower (OR = 0.85, 95% CI: 0.72-1.00, P = 0.053). CONCLUSIONS: In-hospital mortality in patients with HF ≥ 75 years between 2016 and 2019 was 12.7%, higher in males and elderly patients. The main predictors of mortality were cardiogenic shock, stroke, and advanced cancer. There was a trend toward lower mortality in centers with an ICCU.

One-year readmissions for circulatory diseases and in-hospital mortality after an index episode of heart failure in elderly patients. A nationwide data from public hospitals in Spain between 2016 and 2018.

INTRODUCTION: Heart failure (HF) is one of the leading causes of hospitalization and death in elderly patients. However, there is limited evidence on readmission and mortality 1-year after discharge for HF. METHODS: Retrospective analysis of the Minimum Basic Data Set, including HF episodes, discharged from Spanish hospitals between 2016 and 2018 in ≥ 75 years. We calculated: (a) the rate of readmissions due to circulatory system diseases (CSD) 365 days after index episode; (b) in-hospital mortality in readmissions; and (c) predictors of mortality and readmission. RESULTS: We included 178,523 patients (59.2% women) aged 85.1 ± 5.5 years. The most frequent comorbidities were arrhythmias (56.0%) and renal failure (39.5%). During the follow-up, 48,932 patients (27.4%) had at least one readmission for CSD and a crude rate of 40.2%, the most frequent one HF (52.8%). The median between the date of readmission and discharge from the last admission was 70 days [IQI 24; 171] for the first readmission. The most relevant predictors of the number of readmissions were valvular heart disease and myocardial ischemia. During the readmissions, 26,757 patients (79.1%) died, representing a cumulative in-hospital mortality of 47,945 (26.9%). The factors in the index episode predictors of mortality during readmissions were cardio-respiratory failure and stroke. The number of readmissions was a risk factor for in-hospital mortality (OR 1.13; 95% CI 1.11-1.14). CONCLUSIONS: The readmission rate for CSD 1-year after the index episode of HF in patients ≥ 75 years was 28.4%. The cumulative in-hospital mortality rate during the readmissions was 26.9%, and the number of rehospitalizations was identified as one of the main predictors of mortality.

Optimizing the management of patients with worsening heart failure: beyond heart failure hospitalization.

INTRODUCTION: Worsening heart failure (HF) is associated with a high risk of death and HF hospitalization. AREAS COVERED: A systematic search was conducted on PubMed (MEDLINE), using the MeSH terms [Heart failure] + [Worsening] + [Treatment] + [Vulnerable period] up to February 2023. Original data from clinical trials, and observational studies were critically analyzed. EXPERT OPINION: Although the vulnerable period has been traditionally limited to the first 6 months after HF hospitalization, the fact is that there are other clinical scenarios in which the patient is particularly vulnerable. These vulnerable patients may also include those that require parenteral administration of diuretics in the day hospital or emergency department, those in which the increase of oral diuretic dose in an outpatient setting is needed to relief congestive symptoms, as well as those that remain symptomatic despite treatment. On the other hand, HF is a complex disease in which different neurohormonal systems are involved. Therefore, to actually reduce the HF burden, a comprehensive management, targeting all the neurohormonal systems that are involved in the pathogenesis of HF, through the use of those drugs that have demonstrated to positively modify the clinical course of HF, is needed.

Diagnosis and Management of Malnutrition in Patients with Heart Failure.

Heart failure is a disease with an increasingly greater prevalence due to the aging population, the development of new drugs, and the organization of healthcare processes. Malnutrition has been identified as a poor prognostic factor in these patients, very often linked to frailty or to other comorbidities, meaning that early diagnosis and treatment are essential. This paper reviews some important aspects of the pathophysiology, detection, and management of malnutrition in patients with heart failure.

What do Spanish registries report about worsening events in chronic heart failure? Needs and challenges.

INTRODUCTION: Worsening heart failure (HF) is associated with a high risk of death and rehospitalization. Despite that, real world evidence about the impact of worsening HF on clinical practice is scarce. AREAS COVERED: A narrative review about registries addressing recent worsening HF events in Spain, with special emphasis on patients recently hospitalized for HF was performed. EXPERT OPINION: Worsening HF can be defined as situations where the patient's HF deteriorates to the extent that it necessitates initiation or intensification of diuretic treatment (mainly intravenous). The events can occur at the outpatient level, generally in the day hospital, in the emergency department or even hospitalization. Early identification of worsening HF events is essential to establish appropriate treatment as soon as possible. In this context, robust clinical benefits have been reported for renin-angiotensin system inhibitors, sacubitril-valsartan, beta-blockers, mineralocorticoid receptor antagonists, SGLT2 inhibitors, and vericiguat. In Spain, several registries of patients with HF have been developed, some of them including patients recently hospitalized for HF, but not with recent worsening HF events. Therefore, registries addressing recent worsening events would be desirable. Using a practical approach, this review analyzes the importance of worsening HF events, with special emphasis on Spanish data.

Identifying the patient with heart failure to be treated with vericiguat.

The pathophysiology of heart failure with reduced ejection fraction (HFrEF) is a complex process in which a number of neurohormonal systems are involved. Targeting only some of these systems, but not all, translates into a partial benefit of HF treatment. The nitric oxide-soluble guanylate cyclase (sGC)-cGMP pathway is impaired in HF, leading to cardiac, vascular and renal disturbances. Vericiguat is a once-daily oral stimulator of sGC that restores this system. No other disease-modifying HF drugs act on this system. Despite guidelines recommendations, a substantial proportion of patients are not taking all recommended drugs or when taking them, they do so at low doses, limiting their potential benefits. In this context, treatment should be optimized considering different parameters, such as blood pressure, heart rate, renal function, or potassium, as they may interfere with their implementation at the recommended doses. The VICTORIA trial showed that adding vericiguat to standard therapy in patients with HFrEF significantly reduced the risk of cardiovascular death or HF hospitalization by 10% (NNT 24). Furthermore, vericiguat does not interfere with heart rate, renal function or potassium, making it particularly useful for improving the prognosis of patients with HFrEF in specific settings and clinical profiles.

Prevalence, Incidence, and Outcomes of Hyperkalaemia in Patients with Chronic Heart Failure and Reduced Ejection Fraction from a Spanish Multicentre Study: SPANIK-HF Design and Baseline Characteristics.

Hyperkalaemia is a growing concern in the treatment of patients with heart failure and reduced ejection fraction (HFrEF) as it limits the use of some prognostic-modifying drugs and has a negative impact on prognosis. The objective of the present study was to estimate the prevalence of hyperkalaemia in outpatients with HFrEF and its impact on achieving optimal medical treatment. For this purpose, a multicentre, prospective, and observational study was carried out on consecutive HFrEF patients who were monitored as outpatients in heart failure (HF) units and who, in the opinion of their doctor, received optimal medical treatment. A total of 565 HFrEF patients were included from 16 specialised HF units. The mean age was 66 ± 12 years, 78% were male, 45% had an ischemic cause, 39% had atrial fibrillation, 43% were diabetic, 42% had a glomerular filtration rate < 60 mL/min/1.7 m2, and the mean left ventricular ejection fraction was 31 ± 7%. Treatment at the study entry included: 76% on diuretics, 13% on ivabradine, 7% on digoxin, 18.9% on angiotensin-conversing enzyme inhibitors (ACEi), 11.3% on angiotensin receptors blockers (ARBs), 63.8% on angiotensin-neprilysin inhibitors (ARNi), 78.5% on mineralocorticoid receptor antagonists (MRAs), and 92.9% on beta-blockers. Potassium levels in the baseline analysis were: ≤5 mEq/L = 80.5%, 5.1−5.4 mEq/L = 13.8%, 5.5−5.9 mEq/L = 4.6%, and ≥6 mEq/L = 1.06%. Hyperkalaemia was the reason for not prescribing or reaching the target dose of an MRAs in 34.8% and 12.5% of patients, respectively. The impact of hyperkalaemia on not prescribing or dropping below the target dose in relation to ACEi, ARBs, and ARNi was significantly less. In conclusion, hyperkalaemia is a frequent problem in the management of patients with HFrEF and a limiting factor in the optimisation of medical treatment.