Benefits of a comprehensive care model in patients with heart failure and preserved ejection fraction: The UMIPIC program.

BACKGROUND: Patients with heart failure (HF) and preserved ejection fraction (HFpEF), in contrast to those with reduced ejection fraction, are older, have more comorbidities, and are not candidates for effective therapeutic measures. Therefore, they are at high risk for hospital admission and mortality. This study evaluated the benefit of a comprehensive continuous care program (UMIPIC program) in patients with HFpEF. METHODS: We prospectively analyzed data on 2401 patients with HFpEF attended to in internal medicine departments who form part of the RICA registry. They were divided into 2 groups: one was followed-up on in the UMIPIC program (UMIPIC group, n: 1011) and another received conventional care (RICA group, n: 1390). A total of 753 patients in each group were selected by propensity score matching and admissions and mortality were assessed during 12 months of follow-up after an episode of hospitalization due to HF. RESULTS: Compared to the RICA group, the UMIPIC group had a lower rate of HF admissions (19.2% versus 36.5%, respectively; hazard ratio [HR] = 0.56; 95% confidence interval [CI]: 0.45-0.68; p < 0.001) and mortality (12.6% versus 28%, respectively; HR = 0.40; 95% CI: 0.31-0.51; p < 0.001). There were no differences in hospitalizations for non-HF causes. CONCLUSIONS: Implementation of the UMIPIC program, which is based on comprehensive continuous care, for patients with HFpEF and a high degree of comorbidity reduces both admissions and mortality in the first year of follow-up.

Comprehensive therapeutic approach for patients with heart failure and comorbidity. / Abordaje terapéutico integral del paciente con insuficiencia cardiaca y comorbilidad.

The prevalence of heart failure increases with age and is accompanied by other diseases, which are encompassed within a «cardiometabolic phenotype¼. Their interrelation changes the evolution and treatment that each disease would have in isolation. Patients with heart failure and comorbidity are frail and complex. They require a comprehensive assessment (not just biomedical), which includes functional, cognitive, affective and psychosocial aspects. The overall treatment, which is not covered in the clinical practice guidelines, should adapt to each and every one of the comorbidities. Polypharmacy should be avoided as much as possible, due to its interactions and reduced adherence. Treatment needs to be optimised and adapted to the evolutionary phase of the disease and the specific needs of each patient. The complexity of the care process for patients with heart failure and comorbidities requires the coordination of healthcare providers and support from family and others involved in the patient's care.

[Influence of age in mortality of patients with heart failure]. / Influencia de la edad en la mortalidad de pacientes con insuficiencia cardiaca.

OBJECTIVE: Heart failure (HF) is one of the most frequent diagnosis in Internal Medicine Units. High age of patients is an important characteristic in these admissions. Our objective was to evaluate how age interact with mortality, to medium-term, in HF after a decompensated episode. METHOD: Through the patient medical record we obtained data about patients hospitalised in a Internal Medicine Unit, with HF diagnosis, for a year (from September 2000 to August 2001) and their survival at 1st January 2003. 215 patients were reviewed. RESULTS: During follow-up, 60 patients died (27.9% of overall). In elderly patients, we observed a higher number of women and less use of echocardiography and treatment with beta-blockers and warfarin (in patients with atrial fibrillation). In Cox proportional-hazards model, age (OR 1.043 IC 95% 1.002-1.085), days of hospitalization (OR 1.04 IC 95% 1.003-1.078), diabetes mellitus (OR 2.51 IC 95% 1.37-4.60) and do not prescribe warfarin in patients with atrial fibrillation (OR 2.71 IC 95% 1.10-6.60) were independent prognostic factors. CONCLUSIONS: Age was an important prognostic factor in patients with HF. Clinical trials should be done in patients with these characteristics. So, we can know better clinical evolution of HF in this population.

[Value of C-reactive protein for detecting bacteremia in febrile patients]. / Utilité de la protéine C réactive dans la détection de bactériémie chez les patients fébriles.

OBJECTIVES: Mortality among bacteremic adults ranges between 14 and 35%, and there is no biological clue to identify such patients a priori. As C-reactive protein (CRP) blood level rises in children during bacteremia, we investigated its accuracy to identify bacteremic patients among febrile adults who were admitted to our hospital either for study or treatment. METHODS: Patients older than 14 entering the emergency room with objective axilar temperature above 37.5 degrees C and admitted either for study or treatment were elligible for enrollment. After initial examination, samples were obtained for blood cultures and CRP measurement. Follow-up during hospitalization was assessed. All variables were related with one another by bivariant statistical methods performed with Sigma Horus hardware. After bivariant study we used the program BMDP Statistical Software (1991) to perform the multivariate study in its discriminant analysis. RESULTS: One hundred seventy-four patients entered the study with an average age of 58.9 years; 47.7% were over 65 years of age; 88% of febrile syndromes were of infectious origin and among them, bacteremia ranged up to 17.2%. Values of CRP were significantly related with the following variables: "age": patients younger than 45 had average CRP concentrations of 9.5 mg%, age over 45 had 17.4 mg% (Mann Whitney U (MW) p < 0.001); "clinical situation on admission": for poor, intermediate and stabilized situations average CRP levels were 14.7, 18.5 and 12.4 mg% respectively (MW p < 0.05); "time from fever onset"; "clinical outcome": for death average CRP was 23.01 mg% and for cure 14.6 mg% (MW, p < 0.05), in that way probability of death was 21%, 9% and 3% for CRP concentrations higher than 20, between 10 and 20 and under 10 mg% respectively. There was no link between CRP serum levels and sex, severity of chronic illness, cause of fever, localization of infection and existence of bacteremia. The multivariate study in its discriminate mode was of no use to identify bacteremic patients. CONCLUSION: According to our findings CRP determination can not be used alone or associated to identify patients with positive blood cultures among the febrile ones. CRP blood determination should not be considered before 24 hours from disease onset as this time is required for CRP to stabilize. Patients with CRP levels higher than 20 mg% on admission have a higher risk of dying during hospitalization.

Comorbidity in heart failure. Results of the Spanish RICA Registry.

BACKGROUND: We sought to identify the comorbidities associated with heart failure (HF) in a non-selected cohort of patients, and its influence on mortality and rehospitalization. DESIGN AND METHODS: Data were obtained from the 'Registro de Insuficiencia Cardiaca' (RICA) of the Spanish Society of Internal Medicine. The registry includes patients prospectively admitted in Internal Medicine units for acute HF. Variables included in Charlson Index (ChI) were collected and analysed according to age, gender, left ventricular ejection fraction (LVEF) and Barthel Index. The primary end point of study was the likelihood of rehospitalization and death for any cause during the year after discharge. RESULTS: We included 2051 patients, mean age 78 and 53% females. LVEF was ⩾ 50% in 59.1% of the cohort. There was a high degree of dependency as measured by Barthel Index (14.8 % had an index ≤ 60). Mean ChI was 2.91 (SD ± 2.4). The most frequent comorbidities included in ChI were diabetes mellitus (44.3%), chronic renal impairment (30.8%) and chronic obstructive pulmonary disease (COPD) (27.4%). Age, myocardial infarction, peripheral artery disease, dementia, COPD, chronic renal impairment and diabetes with target-organ damage were all identified as independent prognostic factors for the combined end point of rehospitalization and death at 1 year. However, if multivariate analysis was done including ChI, only this remained as an independent prognostic factor for the combined end point (P < 0.001). CONCLUSIONS: HF is a comorbid condition. ChI is a simple and feasible tool for estimating the burden of comorbidities in such population. We believe that a holistic approach to HF would improve prognosis and the relief the pressure exerted on public health services.

[Diagnostic limitations of positron emission tomography. What are we seeking?]. / Limitaciones diagnósticas de la tomografía por emisión de positrones. ?Qué buscamos?

Positron emission tomography is an imaging technique based on the use of radiopharmaceuticals. The most extended one is the glucose analogue 18F fluorodeoxyglucose (FDG) that is deposited where there is an increase of glycolytic metabolism, whether this is caused by neoplastic, inflammatory or infectious diseases. It is used in oncology for the initial staging, to assess response to treatment, residual disease, recurrent diagnosis and restaging, but specifically among the different types of tumor. It also has a field in the study of large vessel vasculitis, in granulomatous diseases and in dementias.

Lack of clinical usefulness of interleukin-6 in long-term follow-up of acutely decompensated heart failure.

INTRODUCTION: Interleukin-6 (IL-6) has been identified as a predictor of death, new heart failure (HF) episodes and need for heart transplantation in patients with advanced HF. The aim of this study was to examine the relationship between plasma IL-6 levels in patients with decompensated HF and either survival or new admissions due to HF. METHODS: We studied 111 patients admitted due to decompensated HF. Long-term survival was assessed from the day of admission to the hospital to the day of death or new admissions due to HF. RESULTS: The mean IL-6 concentration was 90 +/- 115 pg/ml (range 1.5-743 pg/ml). There were no differences in IL-6 concentration with regard to age, gender and cause of HF. At the end of follow-up period, 22 patients (20 percent) had died due to causes related to HF and 54 patients (48 percent) had been readmitted to the hospital due to new HF episodes. Using regression analyses, serum IL-6 levels were not identified as a prognostic factor. Systolic dysfunction, previous diagnosis of HF and diabetes mellitus were independent predictors of death. CONCLUSION: These findings suggest that a single measurement of serum IL-6 in patients with decompensated HF lacks clinical usefulness in long-term follow-up.

[Acute transverse myelopathy associated to S. aureus: a difficult differential diagnosis]. / Mielopatía transversa aguda asociada a S. aureus: la dificultad del diagnóstico diferencial.

Acute myelopathy includes a group of diseases with an important associated morbidity, thus early diagnosis and treatment is important. The most frequent etiology is extramedullary compression. Magnetic resonance (MR) is the most suitable procedure in this type of disease since it also offers information on extramedullar lesions and makes it possible to assess spine involvement. We present the case of a 57 year-old man who was admitted because of back pain for several weeks and systemic infection due to S. aureus. Later, he suffered a sudden neurological deficit with spine involvement but without compressive images on the MRI. We discuss the differential diagnosis among intramedullary abscess, epidural abscess, acute transverse myelitis and spondylodiscitis associated to acute myelopathy. We carry out a brief review of the medical literature on diagnosis criteria of those entities.