Changes in the Treatment of Decompensated Advanced Heart Failure During Hospitalization and at Discharge.

BACKGROUND: In advanced heart failure (HF), each hospitalization for decompensation is a vulnerable moment, and it requires optimizing pharmacologic treatment. This study aimed to analyze changes in the pharmacologic treatment of HF before admission (P), during hospitalization (H), and at discharge (D) of patients with decompensated advanced HF. METHODS: We performed an ambispective, cross-sectional, noninterventional study conducted from January 2020 to June 2020. There were 252 consecutive patients admitted for decompensated advanced HF. The following were excluded: de novo HF cases, deceased patients, and scheduled admissions. Finally, 134 patients were analyzed, compared in 3 subgroups: pulmonary congestion (n = 90), systemic congestion (n = 31), and low output (n = 13). RESULTS: In the global analysis, an increase was detected in angiotensin receptor and neprilysin inhibitors (P: 9.7%, H: 16.4, D: 22.4%; P < .02), beta blockers (P: 67.2%, H: 77.6%, D: 84.3%; P < .004), mineralocorticoid receptor antagonists (P: 29.9%, H: 44.4%, D: 46.3%; P < .01), loop diuretics (P: 70.1%, H: 99.3%, D: 95.5%; P < .001), and nitrates (P: 6.0%, H: 22.4%, D: 9.7%; P < .001). Pulmonary congestion was predominant with a significant increase in beta blockers (P: 61.1%, H: 77.8%, D: 88.9%; P < .001) and loop diuretics (P: 64.4%, H: 100%, D: 100%; P < .001); diuretics were increased in the systemic congestion group (P: 80.6%, H: 100%, D: 100%; P < .002), and 22.6% required 3% hypertonic saline solution. In patients with low output, beta blockers and diuretics were withdrawn (P: 84.6%, H: 76.9%, D: 46.1%; P < .08 and P: 84.6%, H: 92.3%, D: 61.5%; P < .1 respectively), without variation in the other pharmacologic groups. CONCLUSIONS: In daily clinical practice, HF drugs are increased and optimized in decompensated HF with a pulmonary or systemic congestion profile. When the profile is low output, beta blockers and diuretics are reduced.

Study Protocol for the Peruvian Registry of Advanced Heart Failure (REPICAV).

Background: Heart failure (HF) is a global problem with a high mortality rate, and advanced HF (AHF) represents the stage with the highest morbidity and mortality. We have no local data on this population and its treatment. The aim of this study will be to determine the epidemiological, clinical, therapeutic, and annual survival characteristics of patients diagnosed with AHF treated in hospitals with HF units in the city of Lima, Peru. Methods and Analysis: An observational, prospective, multicenter study will be conducted with evaluation at baseline and follow-up at 1, 3, 6, and 12 months after study entry. Patients over 18 years of age with AHF seen in referral health facilities in metropolitan Lima will be included. The cumulative mortality during follow-up will be estimated by the Kaplan-Meier method, and Cox regression models will calculate hazard ratios (HRs) and 95% confidence intervals (CI). Likewise, risk ratio (RR) and 95% CI will be estimated using generalized linear models with binomial family and log link function. This study was approved by the Ethics and Research Committee of the National Cardiovascular Institute (Instituto Nacional Cardiovascular "Carlos Alberto Peschiera Carrillo"-INCOR [in Spanish]; Approval report 46/2021-CEI). Discussion: In Peru, there are no scientific data on the epidemiology of AHF in the population. This means that physicians are not adequately trained in the characteristics of the Peruvian population to identify patients who could be candidates for advanced therapies and to recognize the optimal time to refer these patients to more complex HF units. This study will be the first to examine the clinical-epidemiological characteristics of AHF in Peru with a follow-up of 1 year after the event and will provide relevant information on these observable characteristics for the management of high-complexity patients.

[Prognostic implications of hypo and hyperkalaemia in acute heart failure with reduced ejection fraction. Analysis of cardiovascular mortality and hospital readmissions]. / Implicaciones pronósticas de la hipo e hiperpotasemia en la insuficiencia cardíaca aguda con fracción de eyección reducida. Análisis de la mortalidad cardiovascular y reingresos hospitalarios.

BACKGROUND AND OBJECTIVES: Potassium alterations constitute a major clinical problem in decompensated heart failure (HF). This study aims to assess the prognostic implications of hypo and hyperkalaemia on admission for acute HF in cardiovascular mortality and hospital readmissions. MATERIAL AND METHOD: From January 2016 to June 2020, 1,397 cases with a diagnosis of acute HF were admitted. Admission programmed for study, elective therapies, and patients with LVEF> 40% were excluded. The study was carried out on 689 patients, 45 with K+ <3.5 mmol/L, 49K +>5.0 mmol/L and 595K+3.5-5.0 mmol/L. Medical history, baseline clinical profile, drug therapy, and potassium levels obtained upon admission were analysed. RESULTS: Annual mortality due to hypokalaemia (K+<3.5mmol/L) was 37.8% (HR 2.4; 95% CI: 1.3-4.7; P<.007); for hyperkalaemia 40.8% (HR: 1.9; 95% CI: 0.98-3.51; P<.055). Creatinine level and age were variables associated with mortality in both the hyperkalaemic and hypokalaemic cohorts. Hospital readmissions did not show statistical association with these electrolyte disorders. CONCLUSIONS: In patients admitted for decompensated HF, both hyperkalaemia and hypokalaemia determined at admission have a negative prognostic impact on survival. Creatinine and age are other independent factors associated with mortality. The effect on the probability of hospital readmission at one year is not demonstrated in this study.

The Female Sex Confers Different Prognosis in Heart Failure: Same Mortality but More Readmissions.

Introduction: Heart failure (HF) is a major cause of morbimortality both in men and women. Differences between sex in etiopathogenesis, response to treatment, and quality of care have been found in patients with HF. Females are usually under-represented in clinical trials and there is no solid evidence demonstrating the influence of sex in the prognostic of chronic HF. The primary objective of this study was to analyse the differences in mortality and probability of hospital readmission between males and females with HF. The secondary objective was to compare mortality and probability of hospital readmission by ejection fraction (reduced vs. preserved). Methods: Patients with decompensated HF that were consecutively admitted to a Cardiology Service of a tertiary hospital for 4 years were recruited. De novo HF, death during hospitalization, programmed admissions and those patients with moderate left ventricular ejection fraction (LVEF) (40-50%) were discarded. Finally, 1,291 patients were included. Clinical profiles, clinical history, functional status, treatment at admission, first blood analysis performed, readmissions and mortality at follow-up were analyzed and compared. All patients underwent an echocardiographic study at admission. HF with reduced ejection fraction (HFrEF) was considered when left ventricular ejection fraction (LVEF) was <40%, whilst HF with preserved ejection fraction (HFpEF) was considered when LVEF was ≥50%. Results: 716 participants were male (55%). Basal characteristics showed differences in some outcomes. No differences were found in probability of survival among patients with decompensated HF by sex and ejection fraction (p = 0.25), whereas there was a clear tend to a major survival in females with HFrEF (p < 0.1). Females presented more readmissions when compared to males, independently from the LVEF (females = 33.5% vs. males = 26.8%; p = 0.009). Adjusted multivariate analysis showed no association between sex and mortality (HR = 0.97, IC 95% = 0.73-1.30, p = 0.86), although there was association between female sex and probability of readmission (OR = 1.37, IC 95% = 1.04-1.82, p = 0.02). Conclusions: Sex does not influence mid-term mortality in patients admitted for decompensated HF. Nevertheless, probability of readmission is higher in females independently from LVEF. Thus, it should be considered whether healthcare may be different depending on sex, and a more personalized and frequent care may be recommended in females.

Creatinine and NT-ProBNP levels could predict the length of hospital stay of patients with decompensated heart failure.

BACKGROUND: Heart failure (HF) is a clinical syndrome that causes high morbidity and mortality with a high number of admissions and sometimes prolonged admissions. This study aimed at assessing whether parameters detected during the first 24 h of admission may predict a prolonged hospital stay in patients admitted to hospital for decompensated HF. METHODS: From January 2016 to December 2019, 2359 admissions of decompensated HF were recorded. In-hospital transfers, de novo HF, deaths and scheduled admissions were discarded to homogenise the sample. Finally, 1196 patients were included. The sample was divided into two groups: (a) non-prolonged admission (n = 643, admission ≤7 days) or (b) prolonged admission (n = 553, admission >7 days). Clinical, analytical, electrocardiographic and echocardiographic variables obtained during the first 24 h of admission were analysed. RESULTS: Univariate differences were found at admission in NT-ProBNP, creatinine, history of cardiac surgery, smoking and alcoholism, left and right ventricular ejection fraction, systolic blood pressure and heart rate. The ROC analysis showed significant areas under the curve for the NT-ProBNP (AUC: 0.63, 95% CI: 0.60-0.67; p < 0.001) and creatinine (AUC: 0.69, 95% CI: 0.66-0.72; p < 0.0001). The variables associated with prolonged hospital admission were NT-ProBNP (OR: 1, 95% CI: 1-1; p < 0.001), creatinine (OR: 2.2, 95% CI: 1.8-2.7; p < 0.0001) and previous smoking (OR: 1.5, 95% CI: 0.4-1; p < 0.02). CONCLUSIONS: Variables such as creatinine and NT-ProBNP at hospital admission may define a subgroup of patients who will probably have a long hospital stay. Therefore, the planning of hospital care and transition to discharge may be enhanced.

Mean Airway Pressure As a Predictor of 90-Day Mortality in Mechanically Ventilated Patients.

OBJECTIVES: To determine the association between mean airway pressure and 90-day mortality in patients with acute respiratory failure requiring mechanical ventilation and to compare the predictive ability of mean airway pressure compared with inspiratory plateau pressure and driving pressure. DESIGN: Prospective observational cohort. SETTING: Five ICUs in Lima, Peru. SUBJECTS: Adults requiring invasive mechanical ventilation via endotracheal tube for acute respiratory failure. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of potentially eligible participants (n = 1,500), 65 (4%) were missing baseline mean airway pressure, while 352 (23.5%) were missing baseline plateau pressure and driving pressure. Ultimately, 1,429 participants were included in the analysis with an average age of 59 ± 19 years, 45% female, and a mean PaO2/FIO2 ratio of 248 ± 147 mm Hg at baseline. Overall, 90-day mortality was 50.4%. Median baseline mean airway pressure was 13 cm H2O (interquartile range, 10-16 cm H2O) in participants who died compared to a median mean airway pressure of 12 cm H2O (interquartile range, 10-14 cm H2O) in participants who survived greater than 90 days (p < 0.001). Mean airway pressure was independently associated with 90-day mortality (odds ratio, 1.38 for difference comparing the 75th to the 25th percentile for mean airway pressure; 95% CI, 1.10-1.74) after adjusting for age, sex, baseline Acute Physiology and Chronic Health Evaluation III, baseline PaO2/FIO2 (modeled with restricted cubic spline), baseline positive end-expiratory pressure, baseline tidal volume, and hospital site. In predicting 90-day mortality, baseline mean airway pressure demonstrated similar discriminative ability (adjusted area under the curve = 0.69) and calibration characteristics as baseline plateau pressure and driving pressure. CONCLUSIONS: In a multicenter prospective cohort, baseline mean airway pressure was independently associated with 90-day mortality in mechanically ventilated participants and predicts mortality similarly to plateau pressure and driving pressure. Because mean airway pressure is readily available on all mechanically ventilated patients and all ventilator modes, it is a potentially more useful predictor of mortality in acute respiratory failure.

Premature, Opportune, and Delayed Weaning in Mechanically Ventilated Patients: A Call for Implementation of Weaning Protocols in Low- and Middle-Income Countries.

OBJECTIVES: Weaning protocols establish readiness-to-wean criteria to determine the opportune moment to conduct a spontaneous breathing trial. Weaning protocols have not been widely adopted or evaluated in ICUs in low- and middle-income countries. We sought to compare clinical outcomes between participants whose weaning trials were retrospectively determined to have been premature, opportune, or delayed based on when they met readiness-to-wean criteria. DESIGN: Prospective, multicenter observational study. SETTING: Five medical ICUs in four public hospitals in Lima, Perú. SUBJECTS: Adults with acute respiratory failure and at least 24 hours of invasive mechanical ventilation (n = 1,657). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We established six readiness-to-wean criteria and retrospectively categorized our sample into three weaning groups: 1) premature: if the weaning trial took place before fulfilling all criteria, 2) opportune: if the weaning trial took place within 24 hours after fulfilling the criteria, and 3) delayed: if the weaning trial took place over 24 hours after fulfilling criteria. We compared 90-day mortality, ventilator-free days, ICU-free days, and hospital-free days between premature, opportune, and delayed weaning groups. In our sample, 761 participants (60.8%) were classified as having a premature weaning trial, 196 underwent opportune weaning (15.7%), and 295 experienced delayed weaning (23.6%). There was no significant difference in 90-day mortality between the groups. Both the premature and delayed weaning groups had poorer clinical outcomes with fewer ventilator-free days (-2.18, p = 0.008) and (-3.49, p < 0.001), ICU-free days (-2.25, p = 0.001) and (-3.72, p < 0.001), and hospital-free days (-2.76, p = 0.044) and (-4.53, p = 0.004), respectively, compared with the opportune weaning group. CONCLUSIONS: Better clinical outcomes occur with opportune weaning compared with premature and delayed weaning. If readiness-to-wean criteria can be applied in resource-limited settings, it may improve ICU outcomes associated with opportune weaning.

Risk factors for the development of acute respiratory distress syndrome in mechanically ventilated adults in Peru: a multicenter observational study.

BACKGROUND: Clinical and epidemiological differences between acute respiratory distress syndrome (ARDS) that presents at the initiation of mechanical ventilation [MV] (ARDS at MV onset) and that which develops during the course of MV (ARDS after MV onset) are not well understood. We conducted an observational study in five Peruvian ICUs to characterize differences between ARDS at MV onset and after MV onset and identify risk factors for the development of ARDS after MV onset. METHODS: We consecutively enrolled critically ill patients with acute respiratory failure requiring at least 24 h of mechanical ventilation and followed them prospectively during the first 28 days and compared baseline characteristics and clinical outcomes by ARDS status. RESULTS: We enrolled 1657 participants on MV (mean age 60.0 years, 55% males) of whom 334 (20.2%) had ARDS at MV onset and 180 (10.9%) developed ARDS after MV onset. Average tidal volume at the initiation of MV was 8.7 mL/kg of predicted body weight (PBW) for participants with ARDS at MV onset, 8.6 mL/kg PBW for those who developed ARDS after MV onset, and 8.5 mL/kg PBW for those who never developed ARDS (p = 0.23). Overall, 90-day mortality was 56% and 55% for ARDS after MV onset and ARDS at MV onset, respectively, as compared to 46% among those who never developed ARDS (p < 0.01). Adults with ARDS had a higher body mass index (BMI) than those without ARDS (27.3 vs 26.5 kg/m2, p < 0.01). Higher peak pressure (adjusted interquartile OR = 1.51, 95% CI 1.21-1.88), higher mean airway pressure (adjusted interquartile OR = 1.41, 95% CI 1.13-1.76), and higher positive end-expiratory pressure (adjusted interquartile OR = 1.29, 95% CI 1.10-1.50) at MV onset were associated with a higher odds of developing ARDS after MV onset. CONCLUSIONS: In this study of mechanically ventilated patients, 31% of study participants had ARDS at some point during their ICU stay. Optimal lung-protective ventilation was not used in a majority of patients. Patients with ARDS after MV onset had a similar 90-day mortality as those with ARDS at MV onset. Higher airway pressures at MV onset, higher PEEP, and higher BMI were associated with the development of ARDS after MV onset.

Sedation practices and clinical outcomes in mechanically ventilated patients in a prospective multicenter cohort.

OBJECTIVES: We sought to study the association between sedation status, medications (benzodiazepines, opioids, and antipsychotics), and clinical outcomes in a resource-limited setting. DESIGN: A longitudinal study of critically ill participants on mechanical ventilation. SETTING: Five intensive care units (ICUs) in four public hospitals in Lima, Peru. PATIENTS: One thousand six hundred fifty-seven critically ill participants were assessed daily for sedation status during 28 days and vital status by day 90. RESULTS: After excluding data of participants without a Richmond Agitation Sedation Scale score and without sedation, we followed 1338 (81%) participants longitudinally for 18,645 ICU days. Deep sedation was present in 98% of participants at some point of the study and in 12,942 ICU days. Deep sedation was associated with higher mortality (interquartile odds ratio (OR) = 5.42, 4.23-6.95; p < 0.001) and a significant decrease in ventilator (- 7.27; p < 0.001), ICU (- 4.38; p < 0.001), and hospital (- 7.00; p < 0.001) free days. Agitation was also associated with higher mortality (OR = 39.9, 6.53-243, p < 0.001). The most commonly used sedatives were opioids and benzodiazepines (9259 and 8453 patient days respectively), and the latter were associated with a 41% higher mortality in participants with a higher cumulative dose (75th vs 25th percentile, interquartile OR = 1.41, 1.12-1.77; p < 0.01). The overall cumulative dose of benzodiazepines and opioids was high, 774.5 mg and 16.8 g, respectively, by day 7 and by day 28; these doses approximately doubled. Haloperidol was only used in 3% of ICU days; however, the use of it was associated with a 70% lower mortality (interquartile OR = 0.3, 0.22-0.44, p < 0.001). CONCLUSIONS: Deep sedation, agitation, and cumulative dose of benzodiazepines were all independently associated with higher 90-day mortality. Additionally, deep sedation was associated with less ventilator-, ICU-, and hospital-free days. In contrast, haloperidol was associated with lower mortality in our study.

Establishment of a prospective cohort of mechanically ventilated patients in five intensive care units in Lima, Peru: protocol and organisational characteristics of participating centres.

INTRODUCTION: Mechanical ventilation is a cornerstone in the management of critically ill patients worldwide; however, less is known about the clinical management of mechanically ventilated patients in low and middle income countries where limitation of resources including equipment, staff and access to medical information may play an important role in defining patient-centred outcomes. We present the design of a prospective, longitudinal study of mechanically ventilated patients in Peru that aims to describe a large cohort of mechanically ventilated patients and identify practices that, if modified, could result in improved patient-centred outcomes and lower costs. METHODS AND ANALYSIS: Five Peruvian intensive care units (ICUs) and the Medical ICU at the Johns Hopkins Hospital were selected for this study. Eligible patients were those who underwent at least 24 h of invasive mechanical ventilation within the first 48 h of admission into the ICU. Information on ventilator settings, clinical management and treatment were collected daily for up to 28 days or until the patient was discharged from the unit. Vital status was assessed at 90 days post enrolment. A subset of participants who survived until hospital discharge were asked to participate in an ancillary study to assess vital status, and physical and mental health at 6, 12, 24 and 60 months after hospitalisation, Primary outcomes include 90-day mortality, time on mechanical ventilation, hospital and ICU lengths of stay, and prevalence of acute respiratory distress syndrome. In subsequent analyses, we aim to identify interventions and standardised care strategies that can be tailored to resource-limited settings and that result in improved patient-centred outcomes and lower costs. ETHICS AND DISSEMINATION: We obtained ethics approval from each of the four participating hospitals in Lima, Peru, and at the Johns Hopkins School of Medicine, Baltimore, USA. Results will be disseminated as several separate publications in different international journals.

Percepción del equipo quirúrgico sobre la utilidad y aplicación de la lista de verificación para una cirugía cardiovascular segura en el Servicio de Centro Quirúrgico del Instituto Nacional Cardiovascular de EsSalud - 2014 / Perception of the surgical team about the utility and application of the checklist of safe cardiovascular surgery in the Service of Surgical Center at the Cardiovascular National Institute of EsSalud - 2014

La seguridad del paciente es un grave problema de salud pública mundial, y dentro de esta problemática, los efectos adversos como consecuencia de las intervenciones quirúrgicas son considerados un grave problema. Las complicaciones más frecuentes que se encuentran están relacionadas con la identificación incorrecta del paciente o el sitio incorrecto de la cirugía, complicaciones anestésicas y altos índices de infección de la herida operatoria. Ante esta problemática la OMS reconoce la importancia de mejorar la seguridad del tratamiento quirúrgico para lo cual implementó el Programa de Seguridad del Paciente del cual nace la Lista de Verificación para una Cirugía Segura "LVCS" consistente en un conjunto sencillo de normas para la seguridad de las prácticas quirúrgicas, La cual es aplicada en cada cirugía bajo el liderazgo de la Enfermera Circulante y con la participación del Equipo Quirúrgico; con esto se pretende abordar complicaciones quirúrgicas , tales como: las prácticas anestésicas inseguras, las infecciones quirúrgicas y la comunicación deficiente dentro de los equipos, las cuales son considerados problemas comunes, letales y evitables. En el Centro Quirúrgico del Instituto Cardiovascular de ESSALUD, donde se realizan diariamente en promedio 5 cirugías cardiacas de alta complejidad a pacientes adultos y pediátricos, la Enfermera Circulante aplica la Lista de Verificación para una Cirugía Segura "LVCS" con la participación activa del Equipo Quirúrgico con el objetivo de reducir complicaciones quirúrgicas prevenibles y mejorar los resultados de las cirugías cardiacas. Sin embargo se observa cierta renuencia de parte del equipo quirúrgico al aplicar la ôLVCSõ, lo cual afecta el cumplimiento de esta según instructivo. Por ello, se deduce que no reflejaría el real cumplimiento de normas de seguridad y la real preparación de un entorno seguro para el paciente quirúrgico. Ante esta problemática y considerando que el éxito de la aplicación de la "LVCS" depende...

Patient safety is a serious problem of global public health, and within these issues, adverse effects as a result of the surgical interventions are considered a serious problem. The most common complications encountered are related to incorrect identification of the patient or the wrong site surgery and anesthetic complications and high rates of wound infection. Before this problem WHO recognizes the importance of improving the safety of surgical treatment for which implemented the Program of Patient Safety from which was born the checklist for safe surgery "LVCS" consisting of a simple set of rules for the safety of the surgical practices, which is applied in each surgery under the leadership of the Circulator and the participation of the surgical team; This is to address surgical complications, such as: anesthetic unsafe practices, surgical infections and poor team communication , which are considered common, deadly and preventable problems. In the Cardiovascular Institute of ESSALUD, where are performed in average 5 heart complex surgeries daily to adult and pediatric patients, the circulating nurse applies the "LVCS" in each surgery with the active participation of the surgical team with the aim of reducing preventable surgical complications and improve outcomes of cardiac surgeries. However, there is some reluctance on the part of the surgical team to apply the LVCS, which affects the compliance of this according to instructions. Therefore, it follows that it would not reflect actual compliance with safety rules and real preparation of a secure environment for the surgical patient. Therefore, considering that the successful implementation of the "LVCS" depends largely on the perception that the Circulator and the rest of the surgical team have on the "LVCS", the researcher has raised the following objective: to determine the perception of the surgical team of application and usefulness of the LVCS at the surgical center of the Cardiovascular...