RESUMO
AIMS: To evaluate whether the addition of hydrochlorothiazide (HCTZ) to intravenous furosemide is a safe and effective strategy for improving diuretic response in acute heart failure (AHF). METHODS AND RESULTS: A prospective, double-blind, placebo-controlled trial, including patients with AHF randomized to receive HCTZ or placebo in addition to an intravenous furosemide regimen. The coprimary endpoints were changes in body weight and patient-reported dyspnoea 72 h after randomization. Secondary outcomes included metrics of diuretic response and mortality/rehospitalizations at 30 and 90 days. Safety outcomes (changes in renal function and/or electrolytes) were also assessed. Two hundred and thirty patients (48 women, 83 years) were randomized. Patients assigned to HCTZ were more likely to lose weight at 72 h than those assigned to placebo [2.3 vs. 1.5 kg; adjusted estimated difference (notionally 95 confidence interval) 1.14 (1.84 to 0.42); P 0.002], but there were no significant differences in patient-reported dyspnoea (area under the curve for visual analogue scale: 960 vs. 720; P 0.497). These results were similar 96 h after randomization. Patients allocated to HCTZ showed greater 24 h diuresis (1775 vs. 1400 mL; P 0.05) and weight loss for each 40 mg of furosemide (at 72 and at 96 h) (P 0.001). Patients assigned to HCTZ more frequently presented impaired renal function (increase in creatinine 26.5 moL/L or decrease in eGFR 50; 46.5 vs. 17.2; P 0.001), but hypokalaemia and hypokalaemia were similar between groups. There were no differences in mortality or rehospitalizations. CONCLUSION: The addition of HCTZ to loop diuretic therapy improved diuretic response in patients with AHF.
Assuntos
Insuficiência Cardíaca , Hipopotassemia , Humanos , Feminino , Furosemida/uso terapêutico , Inibidores de Simportadores de Cloreto de Sódio/uso terapêutico , Hipopotassemia/induzido quimicamente , Hipopotassemia/complicações , Estudos Prospectivos , Diuréticos/uso terapêutico , Diuréticos/efeitos adversos , Hidroclorotiazida/uso terapêutico , DispneiaRESUMO
Portosystemic shunts are rare vascularization disorders, and an uncommon cause of confusional states. We report an 87-year-old male with a previously normal cognitive status who was repeatedly admitted for sudden symptoms of disorientation and functional limitation. The patient had high ammonium levels which lead to the suspicion of the presence a portosystemic shunt, even in the absence of pre-existing liver disease. A contrast enhanced computed tomography of the abdomen confirmed the presence an abnormal communication of the right portal vein with the suprahepatic veins. The communication was embolized and the confusional states of the patient subsided.
Assuntos
Confusão/etiologia , Veia Porta/anormalidades , Idoso de 80 Anos ou mais , Compostos de Amônio/sangue , Embolização Terapêutica/métodos , Humanos , Masculino , Veia Porta/diagnóstico por imagem , Portografia/métodos , Tomografia Computadorizada por Raios XRESUMO
BACKGROUND: The coexistence of heart and kidney diseases, also called cardiorenal syndrome, is very common, leads to increased morbidity and mortality, and poses diagnostic and therapeutic difficulties. There is a risk-treatment paradox, such that patients with the highest risk are treated with lesser disease-modifying medical therapies. SUMMARY: In this document, different scientific societies propose a practical approach to address and optimize cardiorenal therapies and related comorbidities systematically in chronic cardiorenal disease beyond congestion. Cardiorenal programs have emerged as novel models that may assist in delivering coordinated and holistic management for these patients. KEY MESSAGES: (1) Cardiorenal disease is a ubiquitous entity in clinical practice and is associated with numerous barriers that limit medical treatment. (2) The present article focuses on the practical approaches to managing chronic cardiorenal disease beyond congestion to overcome some of these barriers and improve the treatment of this high-risk population.
Assuntos
Síndrome Cardiorrenal , Humanos , Síndrome Cardiorrenal/terapia , Síndrome Cardiorrenal/fisiopatologia , Gerenciamento ClínicoRESUMO
Aims: To determine the projected benefits of dapagliflozin after an acute heart failure (HF) event in Spain. Methods: A multicenter and prospective study that included subjects aged 50 years or older consecutively admitted with HF to internal medicine departments in Spain. The projected clinical benefits of dapagliflozin were calculated via pooled analysis of the DAPA-HF and DELIVER trials. Results: A total of 5644 subjects were analyzed, of whom 79.2% were eligible for dapagliflozin, according to criteria of the DAPA-HF and DELIVER trials. Full implementation of dapagliflozin would imply a 1-year absolute risk reduction of 2.3% for death (number needed to treat = 43) and 5.7% (number needed to treat = 17) for HF rehospitalization. Conclusion: Treatment with dapagliflozin could significantly reduce HF burden in clinical practice.
Heart failure is a severe condition that is associated with a high risk of complications. This means that it is important to start using new therapies that have demonstrated a clinical benefit. Clinical trials have shown that dapagliflozin reduces the risk of developing these complications in patients with heart failure. However, it is important to find out whether the results of clinical trials are also seen in real-life populations. We estimated the potential benefits of dapagliflozin in people admitted to hospital more than once with heart failure. The study took place in Spain. Our data suggest that treatment with dapagliflozin could reduce the complications associated with heart failure in real-life patients.
Assuntos
Compostos Benzidrílicos , Insuficiência Cardíaca , Humanos , Estudos Prospectivos , Compostos Benzidrílicos/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Sistema de Registros , Volume SistólicoRESUMO
BACKGROUND: Individuals suffering from heart failure (HF) and cardiorenal syndrome (CRS) represent a special group of patients considering their age, multiple health issues, and treatment challenges. These factors make them more susceptible to frequent hospital stays and a higher mortality rate. UMIPIC is a multidisciplinary care model program for patients with heart failure follow up provided by internists and nurses who are experts in this entity. Our study delved into the effectiveness of this specialized care program (UMIPIC) in mitigating these risks for HF and CRS patients. METHODS: We analyzed the medical records of 3255 patients diagnosed with HF and CRS types 2 and 4, sourced from the RICA registry. These patients were divided into two distinct groups: those enrolled in the UMIPIC program (1205 patients) and those under standard care (2050 patients). Using propensity score matching, we ensured that both groups were comparable. The study focused on tracking hospital admissions and mortality rates for one year after an HF-related hospital stay. RESULTS: Patients in the UMIPIC group experienced fewer hospital readmissions due to HF compared to their counterparts (20% vs. 32%; Hazard Ratio [HR] = 0.48; 95% Confidence Interval [95% CI]: 0.40-0.57; p < 0.001). They also showed a lower mortality rate (24% vs. 36%; HR = 0.64; 95% CI: 0.54-0.75; p < 0.001). Furthermore, the UMIPIC group had fewer total hospital admissions (36% vs. 47%; HR = 0.58; 95% CI: 0.51-0.66; p < 0.001). CONCLUSIONS: The UMIPIC program, centered on holistic and ongoing care, effectively reduces both hospital admissions and mortality rates for HF and CRS patients after a one-year follow-up period.
RESUMO
BACKGROUND: Sacubitril-valsartan has been shown to reduce hospitalizations and mortality in patients with heart failure (HF) and reduced ejection fraction. The PIONEER-HF trial demonstrated that initiation of the drug during acute HF hospitalization reduced NT-proBNP levels and a post-hoc analysis of the trial found a reduction in HF hospitalizations and deaths. Real-life studies in the elderly population are scarce. The aim of our study was to assess the effectiveness of sacubitril-valsartan versus angiotensin converting enzyme inhibitors (ACEI) in elderly patients who initiate this treatment during hospitalization for acute HF. METHODS: We conducted a retrospective cohort study using the Spanish acute heart failure registry (RICA) comparing rehospitalizations and deaths at 3 months and 1 year among patients aged 70 years or older who had initiated treatment with sacubitril-valsartan during hospitalization for acute HF versus those treated with ACEI. RESULTS: One hundred and ninety-nine patients hospitalized between October 2016 and November 2020 were included, with a median age of 82 years and high rate of comorbidity. Of these, 107 were treated with sacubitril-valsartan and 92 with ACEI. The adjusted OR for readmission for HF at 3 months was 0.906 (95% CI: 0.241-3.404) and for the combined variable readmission for HF or death at 3 months was 0.696 (95% CI: 0.224-2.167). The adjusted OR for HF readmission at one year was 0.696 (95% CI: 0.224 -2.167). and for the combined variable HF readmission or death at one year 0.724 (95% CI: 0.325-1.612). CONCLUSION: Treatment with sacubitril-valsartan initiated early in hospitalization for HF in elderly patients with high comorbidity was associated with a trend towards a reduction in readmissions and death due to HF compared to treatment with ACEI, which did not reach statistical significance either at 3 months or 1 year of follow-up.
RESUMO
Alcohol dependence is a chronic disease whose treatment begins with detoxification, followed by rehabilitation. We present a descriptive and retrospective study of 147 patients admitted to our unit during the period 2003-2005. Median age was 46.07 years, with 77.6% men and 22.4% women. Admission diagnosis was alcohol withdrawal syndrome in 31 patients (21.1%) and programmed alcohol detoxification in 116 patients (78.9%). On the CIWA-Ar scale: mild withdrawal, 100 patients (68.5%), moderate, 35 patients (24%), severe, 11 patients (7.5%). Mild group showed a statistically significantly lower proportion of hepatopathy, by comparison with the moderate and severe groups. Statistically significant differences were found between the mild and severe groups on comparing mean age, duration of stay, quantity of alcohol and parameters of chronic consumption (ferritine, fe, VCM, UBE, AST, bilirubin and Mg) for AST and bilirubin. There were 11 seizures: 4 patients from the programmed group, with mild withdrawal on the CIWA-Ar scale, and 7 patients with moderate-severe withdrawal. No relationship was found between patients intensity of withdrawal syndrome, age or sex. There was higher intensity on the CIWA-Ar score (moderate and severe) among patients who had already begun withdrawal syndrome, compared to those admitted on a planned detoxification programme. The CIWA-Ar is a useful tool for assessing withdrawal symptoms and risks of complication and for planning treatment. Clinical practice must provide patients with access to health resources for the appropriate treatment of their addiction, with standardized assistance during their stay in hospital.
Assuntos
Alcoolismo/epidemiologia , Alcoolismo/reabilitação , Inativação Metabólica , Medicina Interna/estatística & dados numéricos , Etanol/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Síndrome de Abstinência a Substâncias/epidemiologia , Síndrome de Abstinência a Substâncias/etiologiaRESUMO
BACKGROUND: Dependence for basic activities of the daily living (ADL) relates to adverse outcomes in elderly acute heart failure (AHF) patients. METHODS: We evaluated patients ≥75years admitted because of AHF, divided according to preadmission Barthel Index (BI) category: severe (BI 0-60), moderate (BI 61-90) and slight dependence or independence for basic ADL (BI 91-100). We compared their baseline characteristics and used logistic regression models to determine whether a BI≤60 confers higher one-year mortality risk. RESULTS: We included 2195 patients, mean age 83years; 57% women, Charlson Index 3, 65% with preserved left ventricular ejection fraction. Their median preadmission BI was 90 (65-100); 21.7% had BI≤60. Patients with BI≤60 were older, more often females, with higher comorbid and cognitive burden and more likely to be institutionalized. 560 patients (26%) died within the follow-up period. A preadmission BI≤60 was significantly associated with higher risk of 12-month mortality (HR 1.42, 95% CI 1.14-1.77) together with male sex (1.27, 1.04-1.54), valve disease (1.49, 1.20-1.83), worse preadmission NYHA class (1.44, 1.20-1.73), stage IV chronic kidney disease (1.70, 1.35-2.15), pulmonary edema (1.33, 1.01-1.76), no family support (1.47, 1.06-2.06), and higher Charlson Comorbidity Index (1.09, CI 1.05-1.13) and Pfeiffer cognitive screening questionnaire scores (1.10, 1.05-1.14). CONCLUSION: Among elderly AHF patients, the presence of severe (BI≤60) preadmission dependence for basic ADL confers a significant and independent risk of one-year post-discharge mortality.
Assuntos
Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Hospitalização/tendências , Recuperação de Função Fisiológica/fisiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Mortalidade/tendências , Valor Preditivo dos Testes , Estudos Prospectivos , Sistema de Registros , Espanha/epidemiologia , Fatores de TempoRESUMO
BACKGROUND: Natriuretic peptides or the blood urea nitrogen to creatinine ratio (BUN/creat) can identify high- vs low-risk renal impairment (RI) in patients with heart failure and reduced ejection fraction (HF-REF). However, the situation in HF patients with preserved ejection fraction (HF-PEF) and mid-range ejection fraction (HF-MREF) remains unclear. METHODS: We evaluated patients from the Spanish National Registry of Heart Failure (RICA) that were admitted to Internal Medicine units with acute decompensated HF. Median admission values were used to define elevated NT-proBNP and BUN/creat. RESULTS: A total of 935 patients were evaluated, 743 with HF-PEF and 192 with HF-MREF). In patients with both NT-proBNP and BUN/creat below median admission values, RI was not associated with mortality (HR 1.15; 95% CI 0.7-1.87, p=0.581 in HF-PEF and HR 1.27; 95% CI 0.58-2.81, p=0.548 in HF-MREF). However, in patients with both elevated NT-proBNP and BUN/creat, those with RI had worse survival than those without RI (HR 2.01, 95% CI 1.33-3.06, p<0.001 in HF-PEF and HR 2.79, 95% CI 1.37-5.67, p=0.005 in HF-MREF). In HF-PEF even patients with RI with only 1 of the 2 parameters elevated, had a substantially higher risk of death compared to patients without RI (HR 1.53; 95% CI 1.04 to 2.26; p=0.031). CONCLUSIONS: In this clinical cohort of acute decompensated HF-PEF and HF-MREF patients, the combined use of NT-proBNP and BUN/creat stratifies patients with RI into groups with significantly different prognoses.
Assuntos
Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Nefropatias/mortalidade , Nefropatias/fisiopatologia , Fenótipo , Volume Sistólico/fisiologia , Idoso , Idoso de 80 Anos ou mais , Nitrogênio da Ureia Sanguínea , Estudos de Coortes , Feminino , Seguimentos , Taxa de Filtração Glomerular/fisiologia , Insuficiência Cardíaca/sangue , Humanos , Nefropatias/sangue , Masculino , Peptídeo Natriurético Encefálico/sangue , Fragmentos de Peptídeos/sangue , Estudos Prospectivos , Sistema de Registros , Espanha/epidemiologiaRESUMO
Portosystemic shunts are rare vascularization disorders, and an uncommon cause of confusional states. We report an 87-year-old male with a previously normal cognitive status who was repeatedly admitted for sudden symptoms of disorientation and functional limitation. The patient had high ammonium levels which lead to the suspicion of the presence a portosystemic shunt, even in the absence of pre-existing liver disease. A contrast enhanced computed tomography of the abdomen confirmed the presence an abnormal communication of the right portal vein with the suprahepatic veins. The communication was embolized and the confusional states of the patient subsided.