Efficacy and safety of hypertonic saline therapy in ambulatory patients with heart failure: The SALT-HF trial.

AIMS: Combination of hypertonic saline solution (HSS) with intravenous loop diuretics has been suggested to improve diuretic response in patients hospitalized for heart failure (HF). The efficacy and safety of this approach in the ambulatory setting remain unexplored. METHODS AND RESULTS: In this multicentre, double-blind, randomized study, we allocated ambulatory patients with worsening heart failure (WHF) to a 1-h infusion of intravenous furosemide (ivFurosemide)-HSS versus ivFurosemide. The primary endpoint was the volume of diuresis at 3 h. Secondary endpoints included 3-h natriuresis and weight variation, 7-day congestion data, kidney function and electrolytes, and 30-day clinical events. Overall, 167 participants (median age: 81 years, 30.5% female) were randomized across 13 sites between December 2020 and March 2023. There were no differences in 3-h diuresis between treatments (ivFurosemide-HSS: 1099 ml vs. ivFurosemide: 1103 ml, p = 0.963), 3-h natriuresis (∆ +2.642 mEq/L, p = 0.559), or 3-h weight (∆ +0.012 kg, p = 0.920). Patients in the ivFurosemide-HSS arm experienced significant weight decrease at 7 days (Δ -0.586 kg, p = 0.048). There were no between-treatment differences in clinical congestion score, biomarkers, inferior vena cava diameter, or the presence of lung ultrasound B-lines. At 30 days, 26.5% of the patients in the ivFurosemide-HSS group versus 33.3% in the ivFurosemide group experienced WHF (hazard ratio 0.76, p = 0.330). The incidence of death from any cause or HF hospitalization was 6% of patients in the ivFurosemide-HSS group and 8.3% of patients in the ivFurosemide group (hazard ratio 0.69, p = 0.521). The incidence of worsening kidney function or metabolic derangements was not significantly different in the two arms. CONCLUSIONS: A single infusion of ivFurosemide-HSS did not improve 3-h diuresis or congestion parameters in patients with ambulatory WHF. This therapy showed an appropriate safety profile.

Prevalence and clinical profile of kidney disease in patients with chronic heart failure. Insights from the Spanish cardiorenal registry.

INTRODUCTION AND OBJECTIVES: Patients with combined heart failure (HF) and chronic kidney disease (CKD) have been underrepresented in clinical trials. The prevalence of CKD in these patients and their clinical profile require constant evaluation. This study aimed to analyze the prevalence of CKD, its clinical profile, and patterns of use of evidence-based medical therapies in HF across CKD stages in a contemporary cohort of ambulatory patients with HF. METHODS: From October 2021 to February 2022, the CARDIOREN registry included 1107 ambulatory HF patients from 13 HF clinics in Spain. RESULTS: The median age was 75 years, 63% were male, and 48% had heart failure with reduced left ventricular ejection fraction (HFrEF). A total of 654 (59.1%) had an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, and 122 (11%) patients with eGFR ≥ 60 mL/min/1.73 m2 had a urine albumin-creatinin ratio ≥ 30 mg/g. The most important variables associated with lower eGFR were age (R2=61%) and furosemide dose (R2=21%). The proportion of patients receiving an angiotensin-converting enzyme inhibitor (ACEI)/ angiotensin II receptor blockers (ARB), an angiotensin receptor-neprilysin inhibitor (ARNi), a sodium-glucose cotransporter 2 inhibitor (SGLT2i), or a mineralocorticoid receptor antagonist (MRA) progressively decreased with lower eGFR categories. Notably, 32% of the patients with HFrEF and an eGFR <30 mL/min/1.73 m2 received the combination of ACEI/ARB/ARNi+beta-blockers+MRA+SGLT2i. CONCLUSIONS: In this contemporary HF registry, 70% of patients had kidney disease. Although this population is less likely to receive evidence-based therapies, structured and specialized follow-up approaches within HF clinics may facilitate the adoption of these life-saving drugs.

Prognostic Factors Associated with Acute Heart Failure in Patients Admitted for COVID-19: Analysis of the SEMI-COVID-19 Registry.

INTRODUCTION: Since the beginning of the COVID-19 pandemic in March 2020, an intimate relationship between this disease and cardiovascular diseases has been seen. However, few studies assess the development of heart failure during this infection. This study aims to determine the predisposing factors for the development of heart failure (HF) during hospital admission of COVID-19 patients. METHODOLOGY: A retrospective and multicenter study of patients with HF admitted for COVID-19 in 150 Spanish hospitals (SEMI-COVID-19 Registry). A bivariate analysis was performed to relate the different variables evaluated in patients developing heart failure during hospital admission. A multivariate analysis including the most relevant clinical variables obtained in bivariate analyses to predict the outcome of heart failure was performed. RESULTS: A total of 16.474 patients hospitalized for COVID-19 were included (57.5% men, mean age 67 years), 958 of them (5.8%) developed HF during hospitalization. The risk factors for HF development were: age (odds ratio [OR]): 1.042; confidence interval 95% (CI 95%): 1.035-1.050; p < 0.001), atrial fibrillation (OR: 2.022; CI 95%: 1.697-2.410; p < 0.001), BMI > 30 kg/m2 (OR: 1.460 CI 95%: 1.230-1.733; p < 0001), and peripheral vascular disease (OR: 1.564; CI 95%: 1.217-2.201; p < 0.001). Patients who developed HF had a higher rate of mortality (54.1% vs. 19.1%, p < 0.001), intubation rate (OR: 2,36; p < 0.001), and ICU admissions (OR: 2.38; p < 0001). CONCLUSIONS: Patients who presented a higher risk of developing HF were older with cardiovascular risk factors. The risk factors for HF development were age, atrial fibrillation, obesity, and peripheral vascular disease. In addition, patients who developed HF more frequently required to be intubated or admitted to the ICU.

Usefulness of Systemic Venous Ultrasound Protocols in the Prognosis of Heart Failure Patients: Results from a Prospective Multicentric Study.

Mortality and re-admission rates for decompensated acute heart failure (AHF) is increasing overall and risk stratification might be challenging. We sought to evaluate the prognostic role of systemic venous ultrasonography in patients hospitalized for AHF. We prospectively recruited 74 AHF patients with a NT-proBNP level above 500 pg/mL. Then, multi-organ ultrasound assessments (lung, inferior vena cava (IVC), pulsed-wave Doppler (PW-Doppler) of hepatic, portal, intra-renal and femoral veins) were performed at admission, discharge, and follow-up (for 90 days). We also calculated the Venous Excess Ultrasound System (VExUS), a new score of systemic congestion based on IVC dilatation and pulsed-wave Doppler morphology of hepatic, portal and intra-renal veins. An intra-renal monophasic pattern (area under the curve (AUC) 0.923, sensitivity (Sn) 90%, specificity (Sp) 81%, positive predictive value (PPV) 43%, and negative predictive value (NPV) 98%), a portal pulsatility > 50% (AUC 0.749, Sn 80%, Sp 69%, PPV 30%, NPV 96%) and a VExUS score of 3 corresponding to severe congestion (AUC 0.885, Sn 80%, Sp 75%, PPV 33%, and NPV 96%) predicted death during hospitalization. An IVC above 2 cm (AUC 0.758, Sn 93.l% and Sp 58.3) and the presence of an intra-renal monophasic pattern (AUC 0. 834, sensitivity 0.917, specificity 67.4%) in the follow-up visit predicted AHF-related re-admission. Additional scans during hospitalization or the calculation of a VExUS score probably adds unnecessary complexity to the assessment of AHF patients. In conclusion, VExUS score does not contribute to the guidance of therapy or the prediction of complications, compared with the presence of an IVC greater than 2 cm, a venous monophasic intra-renal pattern or a pulsatility > 50% of the portal vein in AHF patients. Early and multidisciplinary follow-up visits remain necessary for the improvement of the prognosis of this highly prevalent disease.

Mortality risk factors in patients with SARS-CoV-2 infection and atrial fibrillation: Data from the SEMI-COVID-19 registry.

Introduction: Atrial fibrillation and associated comorbidities pose a risk factor for mortality, morbidity and development of complications in patients admitted for COVID-19. Objectives: To describe the clinical, epidemiological, radiological and analytical characteristics of patients with AF admitted for COVID-19 in Spain. Secondarily, we aim to identify those variables associated with mortality and poor prognosis of COVID-19 in patients with AF. Methods: Retrospective, observational, multicenter, nationwide, retrospective study of patients hospitalized for COVID-19 from March 1 to October 1, 2020. Data were obtained from the SEMI-COVID-19 Registry of the Spanish Society of Internal Medicine (SEMI) in which 150 Spanish hospitals participate. Results: Between March 1 and October 1, 2020, data from a total of 16,461 patients were entered into the SEMI-COVID-19 registry. 1,816 (11%) had a history of AF and the number of deaths among AF patients amounted to 738 (41%). Regarding clinical characteristics, deceased patients were admitted with a higher heart rate (88.38 vs 84.95; p > 0.01), with a higher percentage of respiratory failure (67.2% vs 20.1%; p < 0.01) and high tachypnea (58% vs 30%; p < 0.01). The comorbidities that presented statistically significant differences in the deceased group were: age, hypertension and diabetes with target organ involvement. There was also a higher prevalence of a history of cardiovascular disease in the deceased. On multivariate analysis, DOACs treatment had a protective role for mortality (OR:0,597) IC (0,402-0,888 ; p = 0.011). Conclusions: Previous treatment with DOACs and DOACs treatment during admission seem to have a protective role in patients with AF, although this fact should be verified in prospective studies.

Introducción: La fibrilación auricular y las comorbilidades asociadas a ella suponen un factor de riesgo de mortalidad, morbilidad y desarrollo de complicaciones en los pacientes ingresados por COVID-19. Objetivos: Describir las características clínicas, epidemiológicas, radiológicas y analíticas de los pacientes con FA ingresados por COVID-19 en España. De forma secundaria, se pretende identificar aquellas variables que se asocian con mortalidad y mal pronóstico de la COVID-19 en pacientes que presentan FA. Métodos: Estudio retrospectivo, observacional y multicéntrico de ámbito nacional de pacientes hospitalizados por COVID-19 desde el 1 de marzo al 1 de octubre de 2020. Los datos fueron obtenidos del Registro SEMI-COVID-19 de la Sociedad Española de Medicina Interna (SEMI) en el que participan 150 hospitales españoles. Resultados: De un total de 16.461 pacientes en el registro SEMI-COVID-19, 1.816 (11%) tenían antecedente de FA y el número de fallecidos entre los pacientes con FA ascendió a 738 (41%). En cuanto a la clínica, los pacientes fallecidos ingresaron con una frecuencia cardíaca mayor (88,38 vs 84,95; p > 0,01), con mayor porcentaje de insuficiencia respiratoria (67,2% vs 20,1%; p < 0,01) y mayor taquipnea (58% vs 30%; p < 0,09). En el análisis multivariante, el tratamiento con ACOD tuvo un papel protector para la mortalidad por infección por COVID 19 (OR:0,597; IC (0,402-0,888; p = 0.011). Conclusiones: El tratamiento previo con ACOD como el tratamiento con ACOD durante el ingreso parecen tener un papel protector en los pacientes con FA, aunque este hecho debería ser comprobado con estudios prospectivos.

Impact of lung ultrasound during the SARS-CoV-2 pandemic: Distinction between viral and bacterial pneumonia.

INTRODUCTION: Lung Ultrasound is an accessible, low-cost technique that has demonstrated its usefulness in the prognostic stratification of COVID-19 patients. In addition, according to previous studies, it can guide us towards the potential aetiology, especially in epidemic situations such as the current one. PATIENTS AND METHODS: 40 patients were prospectively recruited, 30 with confirmed SARS-CoV-2 pneumonia and 10 with community-acquired pneumonia (CAP). The patients included underwent both a chest X-ray and ultrasound. RESULTS: There were no differences in the 2 groups in terms of clinical and laboratory characteristics. The main ultrasound findings in the SARS-CoV-2 group were the presence of confluent B lines and subpleural consolidations and hepatinization in the CAP group. Pleural effusion was more frequent in the CAP group. There were no normal lung ultrasound exams. Analysis of the area under the curve (AUC) curves showed an area under the curve for Lung Ultrasound of 89.2% (95% CI: 75%.0-100%, p < .001) in the identification of SARS-CoV-2 pneumonia. The cut-off value for the lung score of 10 had a sensitivity of 93.3% and a specificity of 80.0% (p < .001). DISCUSSION: The combination of the findings of the Lung Ultrasound, with a Lung Score greater than 10, added to the rest of the additional tests, can be an excellent tool to predict the aetiology of the pneumonia.

Usefulness of Multi-Organ Point-of-Care Ultrasound as a Complement to the Decision-Making Process in Internal Medicine.

Accumulated data show the utility of diagnostic multi-organ point-of-care ultrasound (PoCUS) in the assessment of patients admitted to an internal medicine ward. We assessed whether multi-organ PoCUS (lung, cardiac, and abdomen) provides relevant diagnostic and/or therapeutic information in patients admitted for any reason to an internal medicine ward. We conducted a prospective, observational, and single-center study, at a secondary hospital. Multi-organ PoCUS was performed during the first 24 h of admission. The sonographer had access to the patients' medical history, physical examination, and basic complementary tests performed in the Emergency Department (laboratory, X-ray, electrocardiogram). We considered a relevant ultrasound finding if it implied a significant diagnostic and/or therapeutic change. In the second semester of 2019, we enrolled 310 patients, 48.7% were male and the mean age was 70.5 years. Relevant ultrasound findings were detected in 86 patients (27.7%) and in 60 (19.3%) triggered a therapeutic change. These findings were associated with an older age (Mantel−Haenszel χ2 = 25.6; p < 0.001) and higher degree of dependency (Mantel−Haenszel χ2 = 5.7; p = 0.017). Multi-organ PoCUS provides relevant diagnostic information, complementing traditional physical examination, and facilitates therapy adjustment, regardless of the cause of admission. Multi-organ PoCUS to be useful need to be systematically integrated into the decision-making process in internal medicine.

Mortality risk factors in patients with SARS-CoV-2 infection and atrial fibrillation: Data from the SEMI-COVID-19 registry. / Factores de riesgo de mortalidad en pacientes con infección por SARS-CoV-2 y fibrilación auricular: datos del registro SEMI-COVID-19.

INTRODUCTION: Atrial fibrillation and associated comorbidities pose a risk factor for mortality, morbidity and development of complications in patients admitted for COVID-19. OBJECTIVES: To describe the clinical, epidemiological, radiological and analytical characteristics of patients with atrial fibrillation admitted for COVID-19 in Spain. Secondarily, we aim to identify those variables associated with mortality and poor prognosis of COVID-19 in patients with atrial fibrillation. METHODS: Retrospective, observational, multicenter, nationwide, retrospective study of patients hospitalized for COVID-19 from March 1 to October 1, 2020. Data were obtained from the SEMI-COVID-19 Registry of the Spanish Society of Internal Medicine (SEMI) in which 150 Spanish hospitals participate. RESULTS: Between March 1 and October 1, 2020, data from a total of 16,461 patients were entered into the SEMI-COVID-19 registry. 1816 (11%) had a history of atrial fibrillation and the number of deaths among AF patients amounted to 738 (41%). Regarding clinical characteristics, deceased patients were admitted with a higher heart rate (88.38 vs. 84.95; P>0.01), with a higher percentage of respiratory failure (67.2 vs. 20.1%; P<0.01) and high tachypnea (58 vs. 30%; P<0.01). The comorbidities that presented statistically significant differences in the deceased group were: age, hypertension and diabetes with target organ involvement. There was also a higher prevalence of a history of cardiovascular disease in the deceased. On multivariate analysis, DOACs treatment had a protective role for mortality (OR: 0.597; CI: 0.402-0.888; P=0.011). CONCLUSIONS: Previous treatment with DOACs and DOACs treatment during admission seem to have a protective role in patients with atrial fibrillation, although this fact should be verified in prospective studies.

Usefulness of Serial Multiorgan Point-of-Care Ultrasound in Acute Heart Failure: Results from a Prospective Observational Cohort.

Background and Objectives: Acute heart failure (AHF) is a common disease and a cause of high morbidity and mortality, constituting a major health problem. The main purpose of this study was to determine the impact of multiorgan ultrasound in identifying pulmonary hypertension (PH), a major prognostic factor in patients admitted due to AHF, and assess whether there are significant changes in the venous excess ultrasonography (VE × US) score or femoral vein Doppler at discharge. Materials and Methods: Patients were evaluated with a standard protocol of lung ultrasound, echocardiography, inferior vena cava (IVC) and hepatic, portal, intra-renal and femoral vein Doppler flow patterns at admission and on the day of discharge. Results: Thirty patients were enrolled during November 2021. The mean age was seventy-nine years (Standard Deviation-SD 13.4). Seven patients (23.3%) had a worsening renal function during hospitalization. Regarding ultrasound findings, VE × US score was calculated at admission and at discharge, unexpectedly remaining unchanged or even worsened (21 patients, 70.0%). The area under the curve for the lung score was 83.9% (p = 0.008), obtaining a cutoff value of 10 that showed a sensitivity of 82.6% and a specificity of 71.4% in the identification of intermediate and high PH. It was possible to monitor significant changes between both exams on the lung score (16.5 vs. 9.3; p < 0.001), improvement in the hepatic vein Doppler pattern (2.4 vs. 2.1; p = 0.002), improvement in portal vein Doppler pattern (1.7 vs. 1.4; p = 0.023), without significant changes in the intra-renal vein Doppler pattern (1.70 vs. 1.57; p = 0.293), VE × US score (1.3 vs. 1.1; p = 0.501), femoral vein Doppler pattern (2.4 vs. 2.1; p = 0.161) and IVC collapsibility (2.0 vs. 2.1; p = 0.420). Conclusions: Our study results suggest that performing serial multiorgan Point-of-Care ultrasound can help us to better identify high and intermediate probability of PH patients with AHF. Currently proposed multi-organ, venous Doppler scanning protocols, such as the VE × US score, should be further studied before expanding its use in AHF patients.

The Impact of Different Lung Ultrasound Protocols in the Assessment of Lung Lesions in COVID-19 Patients: Is There an Ideal Lung Ultrasound Protocol?

BACKGROUND: In the past months, several lung ultrasonography (LUS) protocols have been proposed, mainly on previously validated schemes independent of coronavirus disease 2019 (COVID-19). OBJECTIVES: The main purpose of this study was to determine the impact and accuracy of different LUS protocols proposed in COVID-19. METHODS: Patients were evaluated with a standard sequence of LUS scans in 72 intercostal spaces along 14 anatomic lines in the chest. A scoring system of LUS findings was reported and then analyzed separately according to each proposed LUS protocol zones. This score was then correlated to a validated Pulmonary Inflammation Index (PII) on chest Computed Tomography (CT). RESULTS: Thirty-two patients were enrolled. The most frequent pattern was ground-glass opacities in the chest X-ray (53.1%), chest CT (59.1%) and subpleural or lobar consolidations (40.8%) in the posteroinferior areas (p < 0.001) on LUS. The Interclass Correlation Coefficient (ICC) was significantly correlated with almost every protocol analyzed except the 8-zone (p = 0.119) and the 10-zone protocol that only included one posterior point (p = 0.052). The highest ICC was obtained with a 12-zone protocol (ICC 0.500; p = 0.027) and decreased as more points were included. CONCLUSIONS: In conclusion, our study results suggest that performing an ultrasound protocol with 12-zone scanning, including the superior and inferior areas of the anterior, lateral and posterior regions of the chest was consistent with higher ICC and higher degree of concordance with CT. We emphasize the need of a more standardization technique to further implement and develop this imaging modality in COVID-19.

[Impact of Lung Ultrasound dUring the SARS-CoV-2 Pandemic: Distinction Between Viral and Bacterial Pneumonia]. / Impacto de la ecografía pulmonar Durante la pandemia por SARS-CoV-2: distinción entre la neumonía viral y la bacteriana.

Introduction: Lung ultrasound is an accessible, low-cost technique that has demonstrated its usefulness in the prognostic stratification of COVID-19 patients. In addition, according to previous studies, it can guide us towards the potential aetiology, especially in epidemic situations such as the current one. Patients and methods: 40 patients were prospectively recruited, 30 with confirmed SARS-CoV-2 pneumonia and 10 with community-acquired pneumonia. The patients included underwent both a chest X-ray and ultrasound. Results: There were no differences in the 2 groups in terms of clinical and laboratory characteristics. The main ultrasound findings in the SARS-CoV-2 group were the presence of confluent B lines and subpleural consolidations and hepatinization in the community-acquired pneumonia group. Pleural effusion was more frequent in the community-acquired pneumonia group. There were no normal lung ultrasound exams. Analysis of the area under the curve curves showed an area under the curve for lung ultrasound of 89.2% (95% CI: 75.0-100%, p < .001) in the identification of SARS-CoV-2 pneumonia. The cut-off value for the lung score of 10 had a sensitivity of 93.3% and a specificity of 80.0% (p < .001). Discussion: The combination of the findings of the lung ultrasound, with a lung score greater than 10, added to the rest of the additional tests, can be an excellent tool to predict the aetiology of the pneumonia.

Estudio retrospectivo sobre las diferencias entre insuficiencia cardíaca sistólica y diastólica en un registro de 1.000 pacientes del hospital Puerta de Hierro-Majadahonda-Madrid. Comparación con el Registro Nacional español de Insuficiencia Cardíaca (RICA) / Retrospective study on the differences between systolic and diastolic heart failure in a registry of 1,000 patients from the Puerta de Hierro-Majadahonda Hospital, Madrid. Comparison with the Spanish National Heart Failure Registry

Resumen Objetivo: Comparar las diferencias entre insuficiencia sistólica y diastólica en pacientes ingresados en el Hospital Puerta de Hierro Majadahonda, con diagnóstico al alta de ``primer episodio de insuficiencia cardiaca''. Los resultados se cotejan con el registro nacional español de insuficiencia cardiaca (RICA). Material y método: Estudio retrospectivo que incluye a 1.000 pacientes ingresados desde octubre 2008 hasta mayo 2010. El seguimiento se realizó hasta mayo 2015. Resultados: El 70,6% procedían de Medicina Interna, con predominio del sexo femenino (62%) y una mediana de 87 años de edad. La mortalidad global fue de 69,8%, mayor en pacientes con insuficiencia cardiaca-diastólica. OR 1,03 (IC 95% 0,73-1,45). El 59% de los pacientes reingresaron al menos una vez; en su mayoría eran varones (61%) e hipertensos (89,3%). Conclusiones: Los pacientes con insuficiencia cardiaca-diastólica ingresan preferentemente en Medicina Interna (76,2%); la mayoría son mujeres hipertensas y de edad más avanzada que en el grupo de insuficiencia cardiaca-sistólica. Los resultados fueron similares a los del registro RICA, salvo mayor mortalidad y reingresos, probablemente por la edad más avanzada de los pacientes y el mayor tiempo de seguimiento.

Abstract Objective: To compare the differences between systolic and diastolic dysfunction in patients admitted to the Hospital Puerta de Hierro Majadahonda, Madrid, with a diagnosis on discharge of ``first episode of heart failure''. The results were compared with the Spanish National Heart Failure Registry (RICA). Material and method: A retrospective study that included 1,000 patients admitted from October 2008 to May 2010. The follow-up was carried out up to May 2015. Results The majority of patients were admitted to Internal Medicine, with a majority of females (62%), and with a median age of 87 years. The overall mortality was 69.8%, and was higher in patients with diastolic heart failure (OR: 1.03, 95% CI; 0.73 - 1.45). More than half of the patients (59%) were admitted at least once, with the majority being males (61%) and with hypertension (89.3%). Conclusions: Patients with diastolic heart failure were mainly admitted to Internal Medicine (76.2%). The majority were women with hypertension, and of a more advanced age than the systolic heart failure group. The results were similar to the RICA, except for the higher mortality and admissions, probably due to the more advanced age of the patients, and the longer follow-up time.