ARGEN SHOCK: Mortality related to the use of Swan Ganz and to the hemodynamic pattern found in patients with AMICS.

The Swan Ganz Catheter (SGC) allows us to diagnose different types of cardiogenic shock (CS). OBJECTIVES: 1) Determine the frequency of use of SGC, 2) Analyze the clinical characteristics and mortality according to its use and 3) Analyze the prevalence, clinical characteristics and mortality according to the type of Shock. METHODS: The 114 patients (p) from the ARGEN SHOCK registry were analyzed. A "classic" pattern was defined as PCP > 15 mm Hg, CI < 2.2 L/min/ m2, SVR > 1,200 dynes × sec × cm-5. A "vasoplegic/mixed" pattern was defined when p did not meet the classic definition. CS due to right ventricle (RV) was excluded. RESULTS: SGC was used in 35 % (n:37). There were no differences in clinical characteristics according to SGC use, but those with SGC were more likely to receive dobutamine, levosimendan, and intra aortic balloon pump (IABP). Mortality was similar (59.4 % vs 61.3 %). The pattern was "classic" in 70.2 %. There were no differences in clinical characteristics according to the type of pattern or the drugs used. Mortality was 54 % in patients with the classic pattern and 73 % with the mixed/vasoplegic pattern, but the difference did not reach statistical significance (p:0.23). CONCLUSIONS: SGC is used in one third of patients with CS. Its use does not imply differences in the drugs used or in mortality. Most patients have a classic hemodynamic pattern. There are no differences in mortality or in the type of vasoactive agents used according to the CS pattern found.

Prognostic Value of Insulin Resistance Assessed by HOMA-IR in Non-Diabetic Patients with Decompensated Heart Failure.

The predictive value of insulin resistance in patients hospitalized with heart failure is unknown. To evaluate prognostic value of insulin resistance (defined by a HOMA IR ≥ 2.5) for the combined event of death and readmission at 90 and 365 days post discharge and to determine if there are differences according to ejection fraction. Prospective study of 156 p hospitalized for acute heart failure without diabetes. A total of 83 years, 48% female, EF ≤ 45% 48%. Of 28% presented HOMA ≥2.5. HOMA IR ≥2.5 was associated with combined event (OR 2.4; 95% CI 1.9-5.1; P: 0.02) at 90 days. A multivariate analysis demonstrated its independent predictive value (OR 2.5, 95% CI 1.1-5.8; P: 0.03). At 1 year follow-up HOMA IR did not predict events. The predictive value of HOMA-IR was not associated with ventricular function. HOMA IR index was a predictor of a combined event at 90 days in our population. It is a simple determination that could contribute to identify higher risk patients during this vulnerable post-discharge phase. These data must be validated in larger studies.

Consensus document on anemia and iron deficiency in heart failure: Consejo Interamericano de Falla Cardiaca e Hipertensión Pulmonar (CIFACAH) of the Interamerican Society of Cardiology (IASC).

Heart failure is a pathology that affects 1% of the population and is accompanied by iron deficiency as a comorbidity in 50% of cases. Anemia, meanwhile, is present between 22-37%. This is a consensus document that seeks to synthesize the information available on anemia and iron deficiency and its behavior in patients with HF, which is divided into pathophysiology, classification, clinical scenarios and algorithms (clinical pathways), treatment, and follow-up. This article integrates international recommendations based on evidence and presents a synthesis of management strategies.

La insuficiencia cardíaca (IC) es una patología que afecta al 1% de la población y se encuentra acompañada de deficiencia de hierro como comorbilidad en el 50% de los casos. La anemia, por su parte, está presente en el 22-37% de los casos de IC. Este es un documento de consenso que busca sintetizar la información disponible sobre la anemia y la deficiencia de hierro, y su comportamiento en pacientes con IC, que se divide en fisiopatología, clasificación, escenarios clínicos y algoritmos (rutas de manejo), tratamiento y seguimiento. Este artículo integra las recomendaciones internacionales basadas en la evidencia y se presenta una síntesis de las estrategias de manejo.

Shock Index, Modified Shock Index, and Age-adjusted Shock Index as Predictors of In-hospital Death in Acute Heart Failure. Sub Analysis of the ARGEN IC.

Decompensated heart failure (DHF) is an important cause of in-hospital death in the coronary care unit. Estimating this risk becomes a clinical challenge. The shock index (IShock) and its variances have proven to be useful in predicting mortality in other pathologies and are easily obtained at admission. Evaluate the predictive capacity of IShock and its variants for in-hospital mortality in patients with DHF. Retrospective study of patients (p) prospectively and consecutively included in the ARGEN IC national registry. IShock, was calculated using the formula: HR/TAS, IShockM was calculated using HR/TAM, and IShock adjusted for age was calculated using the formula IShock x age. These indices were analyzed using the ROC curve and the Youden index to find the value that predicted in-hospital mortality with the greatest sensitivity and specificity. The prognostic value of the indices for in-hospital mortality was analyzed. Univariate and multivariate analyses were performed. Patients with cardiogenic shock were excluded from the analysis. Eight hundred seventy-nine patients. Age 74 years (IQR 25-75 64-83). 60% male. 74% hypertensive, 33% diabetic and 42% had ejection fraction <40%. In-hospital mortality was 6.6%. According to Youden 's test, the best value for predicting IShock mortality was 0.9, for IShockM of 1.26 with and for the adjusted IShock of 50.4. The last two showed an independent predictive value in different multivariate models. The IShockM and the IShock x age, taken at the patient´s admission for decompensated heart failure, are very easily obtained at no additional cost providing useful information on hospital major outcomes.

Diabetes as a Predictor of In-Hospital and One-Year Outcomes After Decompensated Heart Failure.

Diabetes and heart failure are closely interdependent, but its significance in decompensated heart failure (DHF) is not uniformly accepted. OBJECTIVE: To compare mortality between diabetics and nondiabetics with DHF. METHODS AND RESULTS: In-hospital and 1-year mortality of 1004 consecutive patients with DHF: 25.6% diabetics; median age was 81, 53% male. Diabetics were younger, more often male, with higher prevalence of ischemic etiology and reduced ejection fraction. Congestion was the most prevalent finding in both groups. In hospital mortality was 6.3% vs 6.6 % in nondiabetics and diabetics respectively and 1-year mortality was 35.77% in nondiabetics and 29.3% in diabetics. There were no significant differences in mortality at univariate and multivariate analyses. We applied a propensity score restricted to 378 patients, 189 (50%) diabetics and 189 (50%) and no significant differences were found. CONCLUSION: Diabetes had no impact on prognosis in DHF. Advanced age may played a major role in outcomes i thus making less relevant the presence of diabetes.

Care bundle to reduce readmission in patients with heart failure: a modified Delphi consensus panel in Argentina.

OBJECTIVES: The aim of this study was to develop consensus among Argentine cardiologists on a care bundle to reduce readmissions of patients with heart failure (HF). SETTING: Hospitals and cardiology clinics in Argentina that provide in-hospital care for patients with HF. PARTICIPANTS: Twenty-four cardiology experts participated in the two online rounds and 18 (75%) of them participated in the third-round meeting. METHODS: This study used a mixed-method design; it was conducted between August 2019 and January 2020. The development of a care bundle (a set of evidence-based interventions applied to improve clinical outcomes) involved three phases: (1) a literature review to define the list of interventions to be evaluated; (2) a modified Delphi panel to select interventions for the bundle and (3) definition of the HF care bundle. Also, the process included three rounds of scoring. RESULTS: Twenty-six interventions were evaluated. The interventions in the final bundle covered four categories: medication, continuum of care, lifestyle habits, predischarge tests. These were: medication: beta-blockers, angiotensin receptor neprilysin inhibitors or ACE-inhibitors, furosemide and antimineralocorticoids; continuum of care: follow-up appointment, daily weight monitoring; lifestyle habits: smoking cessation counselling and low-sodium diet; predischarge tests: renal function, ionogram, blood pressure control, echocardiogram and determination of decompensating cause. CONCLUSION: Following a systematic mixed-method approach, we have developed a care bundle of interventions that could decrease readmission of patients with HF. The application of this bundle could contribute to scale evidence-based interventions.

Association between hypo- and hyperkalemia and outcome in acute heart failure patients: the role of medications.

BACKGROUND: The interaction between chronic medications on admission and the association between serum potassium level and outcome in patients with acute heart failure (AHF) are unknown. METHODS: Observational intercontinental study of patients admitted with AHF. 15954 patients were included from 12 cohorts in 4 continents. Main outcome was 90-day mortality. Clinical presentation (medication use, hemodynamics, comorbidities), demographic, echocardiographic, and biochemical data on admission were recorded prospectively in each cohort, with prospective adjudication of outcomes. RESULTS: Positive and negative linear relationships between 90-day mortality and sK+ above 4.5 mmol/L (hyperkalemia) and below 3.5 mmol/L (hypo-kalemia) were observed. Hazard ratio for death was 1.46 [1.34-1.58] for hyperkalemia and 1.22 [1.06-1.40] for hypokalemia. In a fully adjusted model, only hyperkalemia remained associated with mortality (HR 1.03 [1.02-1.04] for each 0.1 mmol/l change of sK+ above 4.5 mmol/L). Interaction tests revealed that the association between hyperkalemia and outcome was significantly affected by chronic medications. The association between hyperkalemia and mortality was absent for patients treated with beta blockers and in those with preserved renal function. CONCLUSIONS: In patients with AHF, sK+ > 4.5 mmol/L appears to be associated with 90-day mortality. B-blockers have potentially a protective effect in the setting of hyperkalemia.

[Continuous monitoring of cardiac surgery quality indicators]. / La monitorización continua de la calidad de los resultados de la cirugía cardíaca.

BACKGROUND AND OBJECTIVE: Although usage of variable life-adjusted display (VLAD) in medicine was proposed a decade ago, there is only little experience in mortality and morbidity monitoring with this method. The work objective was to study the utility of VLAD for continuous monitoring of cardiac surgery quality indicators. METHODS: A continuous monitoring of morbidity and mortality with VLADs, was performed in a prospective series of 502 cardiac surgeries. VLAD plots for mortality, reopening for bleeding, deep sternal wound infection, stroke, myocardial infarction and need for postoperative dialysis were done. Mortality was risk-adjusted with Euro-SCORE, while postoperative complications were adjusted with a morbidity risk score. Additionally, internal thoracic artery graft usage in coronary surgery was plotted. RESULTS: VLADs based on risk-adjusted morbidities and mortality could identify several clusters of adverse results, occurring at different periods of time, as well as its temporal relations. In the same way, it could be determined along the series, the net lives saved, the complications avoided and the internal thoracic artery graft usage. CONCLUSIONS: Continuous monitoring with VLAD plots would provide on-line control of cardiac surgery outcomes. This method would be, not only useful for mortality supervision, but to check risk-adjusted morbidity and to control other quality indicators, such as internal thoracic artery usage.

El índice de shock e índice de shock ajustado por edad como predictores de muerte en la insuficiencia cardíaca descompensada / Shock Index and Age-Adjusted Shock Index as Predictors of Mortality in Decompensated Heart Failure

RESUMEN Introducción: El índice de shock (IShock), calculado a partir de los valores al ingreso de la frecuencia cardíaca (FC) y tensión arterial sistólica (TAS) y el IShock ajustado por edad, son herramientas que han demostrado utilidad pronóstica en algunos contextos clínicos; sin embargo, su valor pronóstico en la insuficiencia cardíaca descompensada (ICD) es desconocido. Objetivo: evaluar la capacidad pronóstica para mortalidad total intrahospitalaria de ambos índices en pacientes ingresados a unidad coronaria por ICD. Material y métodos: Estudio retrospectivo de pacientes consecutivos ingresados en 2 unidades coronarias durante el periodo enero 2010/agosto 2020. Se calcularon ambos índices, se determinó su valor predictivo y mediante curva ROC se definieron los valores de corte con mejor combinación de sensibilidad y especificidad. Se efectuó análisis multivariado para encontrar los predictores independientes de mortalidad intrahospitalaria. Resultados: Población: 1472 pacientes. Edad (mediana) 81 años, 50% con fracción de eyección ventricular izquierda <40%, y 50% con antecedentes de ICD previa. Mortalidad intrahospitalaria 6,2%. Un IShock ≥0,58 e IShock ajustado por edad ≥45,6 (hallados por índice de Youden) fueron predictores de mortalidad. En el análisis multivariado que incluyó edad, tensión arterial sistólica (TAS) <115 mmHg, nitrógeno ureico en sangre (BUN) >43 mg/dL, creatinina >2,75 mg/dL, hemoglobina <10 g/dL y el ISHock ≥0,58, solo mantuvieron su valor predictivo la edad, el BUN >43 mg/dL y la anemia. En un modelo multivariado donde se evaluó al IShock ajustado por edad ≥45,6 junto a las otras variables (excepto edad), éste fue predictor independiente (OR 2,41 IC95% 1,37-4,2 p <0,01) al igual que el BUN >43 mg/dL y la anemia. Conclusión: Un cálculo sencillo como el IShock ajustado por edad es de gran utilidad en la predicción de la mortalidad hospitalaria de los pacientes internados con ICD y agrega información adicional a las variables pronósticas clásicas.

ABSTRACT Background: Shock index (SI), calculated as the ratio of heart rate (HR) to systolic blood pressure (SBP) obtained on admission, and age-adjusted SI are tools that have already demonstrated prognostic value in some clinical contexts, but their prognostic value in decompensated heart failure (DHF) is unknown. Objective: The aim of this study was to evaluate the prognostic ability of both indices for total in-hospital mortality in patients admitted to the coronary unit for DHF. Methods: We conducted a retrospective study of consecutive patients admitted to 2 coronary care units between January 2010 and August 2020. Both indices and their respective predictive values were calculated. The cutoff point values with the best combination of sensitivity and specificity were defined using the ROC curve. Multivariate analysis was performed to identify independent predictors of in-hospital mortality. Results: Population: 1472 patients. Median age was 81 years, 50 had left ventricular ejection fraction <40% and 50% had a history of DHF. In-hospital mortality 6.2%. Youden's index identified SI ≥0.58 and age-adjusted SI ≥45.6 as predictors of mortality. On multivariate analysis including age, systolic blood pressure (SBP) <115 mmHg, blood urea nytrogen (BUN) >43 mg/ dL, creatinine level >2.75 mg/dL, hemoglobin (Hb) <10 g/dL and SI ≥0.58, only age, BUN >43 mg/dL and anemia remained as independent predictors of in-hospital mortality. On multivariate analysis, when age-adjusted SI ≥45.6 was analyzed with the other variables (but not with age), the independent predictors were age-adjusted SI ≥45.6 (OR 2.41; 95% CI, 1.37-4.2; p <0.01), BUN >43 mg/dL and anemia. Conclusion: A simple calculation as age-adjusted SI is highly useful to predict in-hospital mortality in patients hospitalized with DHF and provides additional information to the classic prognostic variables.

Dobutamine stress echocardiography can predict reversible ventricular dysfunction after acute myocardial infarction.

BACKGROUND: The aim of early treatment of acute myocardial infarction (AMI) is to achieve the rapid reperfusion of the culprit artery, which correlates with improvement in ventricular function and survival. With the widespread use of thrombolytic agents or coronary angioplasty as reperfusion strategies for AMI, it is possible to reduce the amount of myocardial necrosis. HYPOTHESIS: The assessment of residual viability with dobutamine stress echocardiography (DSE) in the infarcted area after AMI is relevant to subsequent management and prognosis. METHODS: Thirty-seven patients with AMI (mean age 59 +/- 12, 31 male, 22 with anterior AMI, 15 with inferior AMI) admitted to the coronary care unit within 3.8 +/- 1.8 h of the onset of symptoms were included. Two-dimensional echocardiography (2-D echo) study and DSE were performed at a mean of 4.7 +/- 1.8 days. Follow-up 2-D echo was performed at a mean of 25 +/- 11 days. To assess left ventricular regional systolic function, 2-D echo images were obtained at rest and during dobutamine-induced stress and were analyzed off-line according to the 13-segment model. Improvement in wall motion score (WMS) was defined by a decrease of at least two grades in the score. RESULTS: Wall motion score improved in 13 of the 37 patients after DSE (rest WMS 20.9 +/- 2.0 vs. D-WMS 17.7 +/- 2.2; p<0.001), which correlated with clinical or angiographic signs of reperfusion of the culprit vessel in all cases. Follow-up WMS evidenced a significant correlation with WMS after DSE (r = 0.91; p < 0.001). Sensitivity, specificity, and positive and negative predictive values of DSE in detecting patients whose left ventricular function (LVF) improved at 2-D echo follow-up were 72,96,92.8, and 82.7%, respectively. CONCLUSIONS: (1) Dobutamine stress echocardiography improved WMS in 35% of patients and correlated with signs of patency of the culprit vessel; (2) LVF improvement after dobutamine was predictive of late LVF recovery; (3) DSE can be a useful and safe tool for detecting reversible myocardial dysfunction after AMI.

Clinical presentation and outcome by age categories in acute heart failure: results from an international observational cohort.

AIMS: To assess, according to age groups, patients' characteristics according to region of origin, the chronic therapeutic management, prognostic utility of clinical variables, and natriuretic peptides. METHODS AND RESULTS: The GREAT registry consisted of patients identified as presenting with acute heart failure at the emergency department. Four groups of patients were defined according to age: the young patient group (<65 years); 'middle-old' (65-74 years), 'old-old' (75-84 years) and the 'oldest-old' (85-94 years). Follow-up at 1 year was performed via personal contact or national data registries at 1 year. Dataset consisted of 14 758 patients aged up to 95 years, with the 'oldest-old' group being more prevalent in North America and Western Europe. The 30-day mortality rate were, respectively, 8.1%, 8.9%, 10.3%, and 16.3% among the four age groups and 1-year mortality rates were, respectively, 3.1%, 17.1%, 24.7%, and 39.9%. Chronic heart failure treatment was less frequently administered with age (percentage of the 'fully treated' group was 14% in the 'young' compared with 2% in the 'oldest-old' patient group). Reduced left ventricular ejection fraction was present in 70%, 62.3%, 52.5%, and 46.8% among the four age groups, respectively. The prognostic utility of most variables for short- and long-term outcome was attenuated with age, with the exception of natriuretic peptides. CONCLUSION: This study found a large heterogeneity in age among geographic regions and that the eldest are less likely to be treated in accordance with recommendations of current heart failure guidelines. Natriuretic peptide concentrations retained prognostic value in patients across age strata.

A new scoring system to stratify risk in unstable angina.

BACKGROUND: We performed this study to develop a new scoring system to stratify different levels of risk in patients admitted to hospital with a diagnosis of unstable angina (UA), which is a complex syndrome that encompasses different outcomes. Many prognostic variables have been described but few efforts have been made to group them in order to enhance their individual predictive power. METHODS: In a first phase, 473 patients were prospectively analyzed to determine which factors were significantly associated with the in-hospital occurrence of refractory ischemia, acute myocardial infarction (AMI) or death. A risk score ranging from 0 to 10 points was developed using a multivariate analysis. In a second phase, such score was validated in a new sample of 242 patients and it was finally applied to the entire population (n = 715). RESULTS: ST-segment deviation on the electrocardiogram, age > or = 70 years, previous bypass surgery and troponin T > or = 0.1 ng/mL were found as independent prognostic variables. A clear distinction was shown among categories of low, intermediate and high risk, defined according to the risk score. The incidence of the triple end-point was 6 %, 19.2 % and 44.7 % respectively, and the figures for AMI or death were 2 %, 11.4 % and 27.6 % respectively (p < 0.001). CONCLUSIONS: This new scoring system is simple and easy to achieve. It allows a very good stratification of risk in patients having a clinical diagnosis of UA. They may be divided in three categories, which could be of help in the decision-making process.

Predictores de la elección de nuevos anticoagulantes directos en la fibrilación auricular y su adherencia al año / Predictors for the Use of New Direct Anticoagulants in Atrial Fibrillation and Their One-Year Adherence

RESUMEN Introducción: Los hombres con CHA2DS2-Vasc ≥ 1 o las mujeres con CHA2DS2-Vasc ≥ 2 y fibrilación/aleteo auricular tienen indicación de tratamiento antitrombótico al alta. Objetivos: Analizar la prevalencia del uso de anticoagulantes en esta población; hallar predictores del uso de nuevos anticoagulantes orales; y analizar la persistencia al año del tratamiento con nuevos anticoagulantes orales. Resultados: Pacientes consecutivos: 484. Los criterios de exclusión fueron la muerte intrahospitalaria (n: 12) y CHA2DS2-Vasc de 0 en ambos géneros y de 1 en mujeres (67 pacientes). Los pacientes analizados fueron 405. Edad mediana: 76 años, género femenino: 46%, HTA: 76%, diabetes: 25%, accidente cerebrovascular previo: 10%, antecedentes de fibrilación/aleteo auricular: 30%. Estrategia de control de ritmo: 66%. Fueron anticoagulados al alta 293 pacientes (72%). Entre los pacientes anticoagulados, los nuevos anticoagulantes orales fueron los más utilizados: 63,5%, especialmente en los menos añosos (74 versus 79,5 años, p: 0,001), con menos antecedentes de accidente cerebrovascular (5,8% versus 18%, p < 0,001), menor CHA2DS2-Vasc mediana (3 versus 4, p < 0,01) y HAS-BLED mediana (1 versus 2, p < 0,01) y en más pacientes con ritmo sinusal al momento del alta (73,8% versus 54,7%, p < 0,001). De los 165 pacientes externados con nuevos anticoagulantes orales y seguidos al año, el 55,7% mantuvieron el nuevo anticoagulante oral indicado, un 29,69% habían discontinuado la anticoagulación y el 14,5% rotó a acenocumarol. Conclusiones: En nuestro trabajo, se anticoagula al alta solo al 70% de los pacientes. Se utilizaron nuevos anticoagulantes orales en más de la mitad de los casos, especialmente en los pacientes de menor riesgo clínico. Al año de seguimiento, cada 10 pacientes medicados al alta con nuevos anticoagulantes orales, 6 persisten con ese tratamiento, 1 rota a acenocumarol y 3 dejan de estar anticoagulados.

ABSTRACT Background: Men with CHA2DS2-Vasc score ≥1 or women with CHA2DS2-Vasc score ≥2 and atrial fibrillation/flutter have high indication of antithrombotic treatment. Objective: The aim of this study was to analyze the prevalence of anticoagulant therapy in this population, to find predictors for the use of new oral anticoagulants and to analyze the one-year adherence to treatment. Methods: A total of 484 consecutive patients were included in the study. Exclusion criteria were in-hospital mortality (n=12) and CHA2DS2-Vasc score of 0 in both genders and 1 in women (n=67). Finally, 405 patients were analyzed with median age of 76 years, 46% women, 76% hypertensive, 25% diabetic, 10% with previous stroke and 30% with history of atrial fibrillation/flutter. Results: A rhythm control strategy was used in 66% of cases and 293 patients were anticoagulated at discharge (72%). Among anticoagulated patients, 63.5% received new oral anticoagulants, especially those who were younger (74 vs. 79.5 years, p=0.001), with lower history of stroke (5.8% vs.18%, p<0.001), lower median CHA2DS2-Vasc (3 vs.4, p<0.01) and HAS-BLED (1 vs. 2, p<0.01) scores and with sinus rhythm at discharge (73.8% vs. 54.7%, p<0.001). Among 165 patients discharged with new oral anticoagulants and followed up for one year, 55.7% adhered to the indicated new oral anticoagulant, 29.69% had discontinued the anticoagulation treatment and 14.5% had switched to acenocoumarol. Conclusions: The study shows that only 70 of patients are anticoagulated at discharge. New oral anticoagulants were used in more than half of cases, especially in patients at lower clinical risk. At one-year follow-up, 6 out of every 10 patients with indication of new oral anticoagulants at discharge continue this treatment, 1 switches to acenocoumarol and 3 abandon anticoagulant therapy.

Cálculo dinámico del filtrado glomerular en los pacientes con insuficiencia cardíaca descompensada / Estimation of Kinetic Glomerular Filtration Rate in Patients with Decompensated Heart Failure

RESUMEN Introducción: La coexistencia de insuficiencia cardíaca descompensada (ICD) e insuficiencia renal aguda (IRA) conlleva internaciones más prolongadas y, en algunos casos, mayor mortalidad. Objetivos: Evaluar si la tasa de filtrado glomerular dinámico (TFGD) calculada mediante la fórmula de Chen permite predecir el desarrollo de IRA o muerte durante la internación en pacientes con ICD. Material y métodos: Estudio retrospectivo de pacientes consecutivos. Se calculó la TFGD utilizando los valores de creatinina del ingreso y a las 24 h. Se realizó una curva ROC para hallar el punto que con mejor sensibilidad y especificidad predijera eventos. Se evaluó un punto final de evento combinado (EC) definido como el desarrollo de IRA o muerte. Se definió la IRA de acuerdo a la guía KDIGO. El seguimiento fue hospitalario. El criterio de exclusión principal fue la existencia de antecedentes de insuficiencia renal crónica. Resultados: De un total de 813 pacientes, 190 fueron excluidos por tener insuficiencia renal crónica. Se analizaron 608 pacientes. Edad (mediana): 81 años (RIC 25-75%: 73-87), hombres: 48%, diabéticos: 25,5%, hipertensos: 76%, infarto previo: 19,4%, disfunción sistólica (Fey < 45%): 46,8%, creatinina de ingreso (mediana): 1,05 mg/dl. La incidencia de EC fue de 41,1%. La edad, el sexo y la presencia de comorbilidades no incidieron en la tasa de presentación de EC, pero la TFGD de este grupo de pacientes fue significativamente menor (mediana: 50,7 ml/min, vs. 57,9 ml/min, p < 0,01) y esta variable fue un predictor independiente de mortalidad. El mejor valor por curva ROC para EC de la TFGD fue 60 ml/min (ABC 0,60) y estuvo presente en el 58,9% de los pacientes. Fueron predictores de ello la edad, el sexo femenino y la presencia de HTA y de diabetes. Conclusiones: La TFGD resulta ser un predictor independiente de EC intrahospitalarios en la ICD; sin embargo, presenta escasa relevancia clínica por su baja especificidad.

ABSTRACT Background: The coexistence of decompensated heart failure (DHF) and acute renal failure (ARF) is associated with longer hospital stay and greater mortality. Objectives: The aim of this study was to evaluate whether kinetic glomerular filtration rate (KeGFR) estimated with Chen´s equation can predict the development of ARF or mortality during hospitalization in patients with DHF. Methods: We conducted a retrospective study of consecutive patients with estimated kinetic glomerular filtration rate using serum creatinine levels on admission and at 24 hours. The primary endpoint was a composite of ARF or mortality, and a ROC curve was built to find the cutoff value with the best sensitivity and specificity to predict events. Acute renal failure was defined according to the KDIGO guideline. Patients were followed-up throughout hospitalization and those with a history of chronic renal failure were excluded from the study. Results: Among 813 patients, 190 were excluded due to chronic renal failure and 608 patients were analyzed. Median age was 81 years (IQR 25-75%: 73-87) and 48% were men; 25.5% were diabetics, 76% had hypertension, 19.4% had history of prior myocardial infarction and 46.8% presented left ventricular systolic dysfunction defined as left ventricular ejection fraction <45%. Median creatinine level on admission was 1.05 mg/dl. The incidence of the composite event was 41.1%. Age, sex and comorbidities were similar in patients with and without the composite event, but KeGFR was significantly lower in this group of patients (median: 50.7 ml/min vs. 57.9 ml/min, p<0.01) and resulted an independent predictor of mortality. The analysis of the ROC curve revealed that a cutoff point of 60 ml/kg/min for KeGFR (AUC 0.60) had the best diagnostic accuracy to predict the composite event and was present in 58.9% of the patients. Age, female sex, hypertension and diabetes were predictors of the composite event. Conclusions: Kinetic glomerular filtrate rate can be used as an independent predictor of the composite event, but has no clinical relevance due to its low specificity.

Body mass index and mortality in acutely decompensated heart failure across the world: a global obesity paradox.

OBJECTIVES: This study sought to define the relationship between body mass index (BMI) and mortality in heart failure (HF) across the world and to identify specific groups in whom BMI may differentially mediate risk. BACKGROUND: Obesity is associated with incident HF, but it is paradoxically associated with better prognosis during chronic HF. METHODS: We studied 6,142 patients with acute decompensated HF from 12 prospective observational cohorts followed-up across 4 continents. Primary outcome was all-cause mortality. Cox proportional hazards models and net reclassification index described associations of BMI with all-cause mortality. RESULTS: Normal-weight patients (BMI 18.5 to 25 kg/m(2)) were older with more advanced HF and lower cardiometabolic risk. Despite worldwide heterogeneity in clinical features across obesity categories, a higher BMI remained associated with decreased 30-day and 1-year mortality (11% decrease at 30 days; 9% decrease at 1 year per 5 kg/m(2); p < 0.05), after adjustment for clinical risk. The BMI obtained at index admission provided effective 1-year risk reclassification beyond current markers of clinical risk (net reclassification index 0.119, p < 0.001). Notably, the "protective" association of BMI with mortality was confined to persons with older age (>75 years; hazard ratio [HR]: 0.82; p = 0.006), decreased cardiac function (ejection fraction <50%; HR: 0.85; p < 0.001), no diabetes (HR: 0.86; p < 0.001), and de novo HF (HR: 0.89; p = 0.004). CONCLUSIONS: A lower BMI is associated with age, disease severity, and a higher risk of death in acute decompensated HF. The "obesity paradox" is confined to older persons, with decreased cardiac function, less cardiometabolic illness, and recent-onset HF, suggesting that aging, HF severity/chronicity, and metabolism may explain the obesity paradox.

Síndromes coronarios agudos sin elevación del segmento ST y troponina ultrasensible. ¿Es el final de la estrategia conservadora? / Non-ST Segment Elevation Acute Coronary Syndromes and High-Sensitivity Cardiac Troponin T: Is this the end of the Conservative Strategy?

RESUMEN Introducción: Los síndromes coronarios agudos sin elevación del segmento ST con troponina ultrasensible elevada son considerados de alto riesgo por lo que se recomienda una estrategia invasiva . Objetivos: Evaluar los eventos hospitalarios de los pacientes tratados con una estrategia conservadora; analizar la prevalencia de troponina ultrasensible positiva y su correlación con eventos hospitalarios; y establecer el valor predictivo de la troponina ultrasensible para eventos hospitalarios y compararla con un modelo de riesgo clínico. Materiales y métodos: Estudio observacional y retrospectivo. Fueron incluidos pacientes ingresados a una unidad coronaria de 2 centros con síndrome coronario agudo sin elevación del segmento ST, tratados con una estrategia conservadora en el período 2012/2017. El modelo de riesgo clínico utilizado se basó en el Score TIMI con las siguientes variables: edad superior a 65 años, 2 o más dolores en la últimas 24 h, cambios electrocardiográficos, factores de riesgo coronario, antecedentes coronarios y aspirina previa, excluida la troponina ultrasensible. Se comparó mediante curva ROC la precisión pronóstica de la troponina ultrasensible y el puntaje del modelo de riesgo clínico para eventos hospitalarios. Eventos hospitalarios combinados: Angina recurrente, infarto de miocardio y muerte. El punto de corte utilizado para considerar la troponina ultrasensible elevada fue igual o mayor de 14 pg/ml. Resultados: Fueron incluidos 245 pacientes. La edad mediana era 65 años (57-76), y el 74% eran hombres. El puntaje del modelo de riesgo clínico fue 3 (1-4) y la troponina ultrasensible positiva se ubicó en el 65%. Eventos hospitalarios: 55/245 pacientes (22,4%): Angina recurrente, 20,4%: infarto tipo, Q 1,6%; muerte, 0,4%. La precisión pronóstica para eventos hospitalarios de la troponina ultrasensible fue 0,56 (0,48-0,65), para el modelo de riesgo clínico 0,58 (0,49-0,67); (p = 0,92) y el Score TIMI 0,56 (p: 0,16). Conclusiones: En pacientes con síndrome coronario agudo sin elevación del segmento ST ni la troponina ultrasensible ni las variables clínicas al ingreso fueron consistentes para predecir los eventos hospitalarios. Utilizar solo los niveles de troponina ultrasensible para guiar la estrategia terapéutica puede determinar una indicación innecesaria de procedimientos con el consecuente riesgo inherente.

ABSTRACT Background: An invasive strategy is recommended in high-risk non-ST segment elevation acute coronary syndromes with elevated high-sensitivity cardiac troponin T levels. Objectives: The aim of this study was to evaluate in-hospital events in patients undergoing a conservative strategy, analyze the prevalence of elevated high-sensitivity cardiac troponin T levels and its correlation with in-hospital events and establish the predictive value of the biomarker for in-hospital events comparing it with a clinical risk model. Methods: We conducted an observational and retrospective study. Patients admitted to a coronary care unit with non-ST segment elevation acute coronary syndrome in two centers and treated with a conservative strategy between 2012 and 2017 were included. The clinical risk model was based on the TIMI risk score using the following variables: age > 65 years, two episodes of angina or greater within the past 24 hours, electrocardiographic changes, coronary risk factors, history of coronary artery disease and previous aspirin, excluding high-sensitivity cardiac troponin T levels. The predictive value of high-sensitivity cardiac troponin was compared with the clinical risk model to predict in-hospital events using ROC curves. Combined inhospital events: recurrent angina, myocardial infarction and mortality High-sensitivity cardiac troponin T levels > 14 pg/ dL were considered elevated. Results: A total of 245 patients were included. Median age was 65 years (57-76) and 74% were men. Median clinical risk score was 3 (1-4) and 65% of the patients had elevated high-sensitivity cardiac troponin levels. In-hospital events: 55/245 patients (22.4%): recurrent angina, 20,4%; Q-wave myocardial infarction,1.6%; mortality, 0.4%. The prognostic accuracy of high-sensitivity cardiac troponin T to predict in-hospital events was 0.56 (0.48-0.65) compared with the clinical risk model [0.58 (0.49-0.67); p = 0.92] and the TIMI risk score (0.56; p: 0.16). Conclusions: In patients with non-ST segment elevation acute coronary syndrome, neither high-sensitivity cardiac troponinT levels nor clinical variables were consistent to predict in-hospital events. High-sensitivity cardiac troponin T levels used to guide the therapeutic strategy could lead to an unnecessary indication of procedures with the associated inherent risk.

Uso de la estrategia de alta intensidad con estatinas ¿Se cumplen las pautas establecidas? / Use of High-Intensity Statin Strategy. Are the Guidelines Followed?

RESUMEN: Introducción: La prevención secundaria en pacientes menores de 76 años que han padecido un evento vascular o han sido revascularizados incluye el uso de estatinas en altas dosis. Objetivo: Evaluar la adherencia al año a dicho tratamiento instituido desde el alta de la internación en UCO. Materiales y métodos: Estudio prospectivo de pacientes consecutivos durante el período enero-noviembre de 2015. Seguimiento (mediana) 9 meses. Resultados: Doscientos diez pacientes. El 83% eran hombres. La edad (mediana) alcanzó los 59 años (52-67,5). El 74,5% tuvo alta con atorvastatina a 40 mg/día; un 19%, con rosuvastatina a 20 mg/día; un 2,7%, con atorvastatina a 80 mg/día; y un 3,9%, con rosuvastatina a 40 mg/día. Un 50% de los pacientes continuaron tomando estatinas de alta intensidad, 28% redujeron la dosis y 22% abandonaron el tratamiento. Conclusiones: Solo la mitad de los pacientes con alto riesgo vascular o procedimiento de revascularización reciente mantiene el tratamiento al año.

ABSTRACT: Background: Secondary prevention in patients < 76 years with history of a vascular event or previous revascularization includes the use of high intensity-statin therapy. Objective: The aim of this study is to evaluate the 1-year adherence to treatment since patients' discharge from the coronary care unit. Methods: We conducted a prospective study of consecutive patients between January and November 2015. Median follow-up was 9 months. Results: A total of 210 patients were included; 83% were men and median age was 59 years (52-67.5). Most patients (74.5%) were discharged with atorvastatin 40 mg/day, 19% with rosuvastatin 20 mg/day, 2.7% with atorvastatin 80 mg/day and 3.9% with rosuvastatin 40 mg/day. Half of the patients continued with high-intensity statins, 28% reduced the dose and 22% stopped the treatment. Conclusions: Only half of the patients with high vascular risk or history of recent revascularization continues with the treat-ment after one year.

Insuficiencia cardíaca descompensada. ¿De qué estamos hablando? / Decompensated Heart Failure. What Are We Talking About?

RESUMEN El objetivo del trabajo es conocer la problemática de una franja significativa de pacientes hospitalizados por insuficiencia cardíaca en centros urbanos privados que no son receptores de derivaciones de pacientes en estadios avanzados. Se analizaron las características basales y la evolución de 865 pacientes consecutivos hospitalizados por insuficiencia cardíaca en dos centros con las características precitadas. Se trata de una población anciana -mediana de edad 81 años- 48% mujeres. La etiología coronaria era de 25,5%, y la chagásica, 0,4% y el 78%, hipertensos. El promedio de comorbilidades fue de 3 por paciente. La mitad tenía función sistólica preservada. La presión sistólica de ingreso fue de 145mmHg, y en el 25% fue ≥ 170 mmHg. La estadía promedio fue 6 días, y la mortalidad intrahospitalaria 6,13%. Es muy preocupante la evolución de estos pacientes al año, con un 70% de reinternación y 40,12% de mortalidad. Debe destacarse que cerca de la mitad de los fallecimientos posalta no fueron debido a insuficiencia cardíaca.

ABSTRACT The aim of this study was to know the problematic posed by a significant range of patients hospitalized for heart failure in private urban centers which do not receive patients referred with end-stage disease. Baseline characteristics and outcome of 865 consecutive elderly patients hospitalized due to heart failure were analyzed in two of the above-mentioned centers. Mean age was 81 years and 48% were women. Heart failure was of coronary etiology in 25.5% of cases and chagasic in 0.4%, and 78% of patients were hypertensive. Average comorbidities were 3 per patient. Half of the patients had preserved systolic function. Systolic blood pressure on admission was 145 mmHg and ≥ 170 mmHg in 25% of cases. Average hospital stay was 6 days and in-hospital mortality 6.13%. The one-year evolution of these patients is a matter of great concern, with 70% of readmissions and 40.12% mortality. It should be pointed out that half of the post discharge deaths were not due to heart failure.

Significado clínico de las alteraciones en las pruebas de función hepática en la insuficiencia cardíaca descompensada / Clinical Significance of Impaired Liver Function Tests in Decompensated Heart Failure

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Participación de la Argentina en el Registro Europeo de Insuficiencia Cardíaca / Participation of Argentina in the European Registry of Heart Failure

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