Uso de digoxina endovenosa en urgencias para tratar pacientes con insuficiencia cardiaca aguda y su impacto en la evolución a corto plazo / Use of digoxin in the emergency department to treat patients with acute heart failure and its impact on short-term outcomes

Objetivos: Analizar los factores relacionados con el uso de digoxina en urgencias en pacientes con insuficiencia cardiaca aguda (ICA) y el impacto pronóstico a corto plazo. Método: Se incluyeron pacientes diagnosticados de ICA en 45 servicios de urgencias españoles sin tratamiento crónico con digoxina, los cuales se dividieron según recibiesen digoxina endovenosa en urgencias o no. Se recogieron 51 variables relativas al paciente o al episodio de descompensación y se investigó el perfil del paciente tratado con digoxina en urgencias. Como variables evolutivas se investigaron la necesidad de ingreso, la estancia en urgencias prolongada (> 24 horas) en dados de alta y la hospitalización prolongada (> 7 días) en ingresados, y la mortalidad intrahospitalaria y a 30 días por cualquier causa. Se analizó si el tratamiento con digoxina se asoció a diferencias evolutivas, de forma cruda y ajustada a las características del paciente y el episodio de ICA. Resultados: Se analizaron 15.549 pacientes (mediana = 83 años, mujeres = 55%), de los que 1.430 (9,2%) fueron tratados con digoxina. La digoxina se utilizó más en mujeres, pacientes jóvenes, en mejor clase funcional de la New York Heart Association (NYHA), pero con descompensaciones más graves y, sobre todo, cuando existía una fibrilación auricular (FA) con respuesta ventricular rápida como desencadenante. Se hospitalizó el 75,4% de pacientes (más frecuente en tratados con digoxina; 81,6% vs 74,8%, p < 0,001), tuvo estancia prolongada en urgencias el 38,3% (52,9% vs 37,2%, p < 0,001), hospitalización prolongada el 48,1% (49,3% vs 47,9%, p = 0,385), mortalidad intrahospitalaria el 7,2% (6,9% vs 7,2%, p = 0,712) y a 30 días el 9,7% (9,3% vs 9,7%, p = 0,625). El modelo ajustado mostró que el uso de digoxina en urgencias sólo se asoció con estancia prolongada en urgencias (OR = 1,883, IC 95% = 1,359-2,608), pero no con la necesidad de ingreso, hospitalización prolongada o mortalidad. (AU)

Objectives: To analyze factors related to the use of digoxin to treat patients with acute heart failure (AHF) in emergency departments (EDs) and the impact of digoxin treatment on short-term outcomes. Methods: We included patients diagnosed with AHF in 45 Spanish EDs. The patients, who were not undergoing long-term treatment for heart failure, were classified according to whether or not they were given intravenous digoxin in the ED. Fifty-one patient or cardiac decompensation episode variables were recorded to profile ED patients treated with digoxin. Outcome variables studied were the need for hospital admission, prolonged stay in the ED (> 24 hours) for discharged patients, prolonged hospitalization (> 7 days) for admitted patients, and all-cause in-hospital or 30-day mortality. The associations between digoxin treatment and the outcomes were studied with odds ratios (ORs) adjusted for patient and AHF episode characteristics. Results: Data for 15 549 patients (median age, 83 years; 55% women) were analyzed; 1430 (9.2%) were treated with digoxin. Digoxin was used more often in women, young patients, and those with better New York Heart Association (NYHA) classifications but more severe cardiac decompensation, especially if the trigger was atrial fibrillation with rapid ventricular response. Admissions were ordered for 75.4% of the patients overall (81.6% of digoxin-treated patients vs 74.8% of nontreated patients; P < .001). The ED stay was prolonged in 38.3% of patients discharged from the ED (52.9% of digoxin-treated patients vs 37.2% of nontreated patients; P < .001). The duration of hospital stay was prolonged in 48.1% (digoxin-treated, 49.3% vs 47.9%; P = .385). In-hospital mortality was 7.2% overall (6.9% vs 7.2%, P= .712), and 30-day mortality was 9.7% (9.3% vs 9.7%, P = .625). ED use of digoxin was associated with a prolonged stay in the department (adjusted OR, 1.883; 95% CI, 1.359-2.608) but not with hospitalization or mortality. (AU)

Use of digoxin in the emergency department to treat patients with acute heart failure and its impact on short-term outcomes. / Uso de digoxina endovenosa en urgencias para tratar pacientes con insuficiencia cardiaca aguda y su impacto en la evolución a corto plazo.

OBJECTIVES: To analyze factors related to the use of digoxin to treat patients with acute heart failure (AHF) in emergency departments (EDs) and the impact of digoxin treatment on short-term outcomes. MATERIAL AND METHODS: We included patients diagnosed with AHF in 45 Spanish EDs. The patients, who were not undergoing long-term treatment for heart failure, were classified according to whether or not they were given intravenous digoxin in the ED. Fifty-one patient or cardiac decompensation episode variables were recorded to profile ED patients treated with digoxin. Outcome variables studied were the need for hospital admission, prolonged stay in the ED (> 24 hours) for discharged patients, prolonged hospitalization (> 7 days) for admitted patients, and all-cause in-hospital or 30-day mortality. The associations between digoxin treatment and the outcomes were studied with odds ratios (ORs) adjusted for patient and AHF episode characteristics. RESULTS: Data for 15 549 patients (median age, 83 years; 55% women) were analyzed; 1430 (9.2%) were treated with digoxin. Digoxin was used more often in women, young patients, and those with better New York Heart Association (NYHA) classifications but more severe cardiac decompensation, especially if the trigger was atrial fibrillation with rapid ventricular response. Admissions were ordered for 75.4% of the patients overall (81.6% of digoxin-treated patients vs 74.8% of nontreated patients; P .001). The ED stay was prolonged in 38.3% of patients discharged from the ED (52.9% of digoxin-treated patients vs 37.2% of nontreated patients; P .001). The duration of hospital stay was prolonged in 48.1% (digoxin-treated, 49.3% vs 47.9%; P = .385). In-hospital mortality was 7.2% overall (6.9% vs 7.2%, P= .712), and 30-day mortality was 9.7% (9.3% vs 9.7%, P = .625). ED use of digoxin was associated with a prolonged stay in the department (adjusted OR, 1.883; 95% CI, 1.359-2.608) but not with hospitalization or mortality. CONCLUSION: Digoxin continues to be used in one out of ten ED patients who are not already on long-term treatment with the drug. Digoxin use is associated with cardiac decompensation triggered by atrial fibrillation with rapid ventricular response, younger age, women, and patients with better initial NYHA function status but possibly more severe decompensation. Digoxin use leads to a longer ED stay but is safe, as it is not associated with need for admission, prolonged hospitalization, or short-term mortality.

OBJETIVO: Analizar los factores relacionados con el uso de digoxina en urgencias en pacientes con insuficiencia cardiaca aguda (ICA) y el impacto pronóstico a corto plazo. METODO: Se incluyeron pacientes diagnosticados de ICA en 45 servicios de urgencias españoles sin tratamiento crónico con digoxina, los cuales se dividieron según recibiesen digoxina endovenosa en urgencias o no. Se recogieron 51 variables relativas al paciente o al episodio de descompensación y se investigó el perfil del paciente tratado con digoxina en urgencias. Como variables evolutivas se investigaron la necesidad de ingreso, la estancia en urgencias prolongada (> 24 horas) en dados de alta y la hospitalización prolongada (> 7 días) en ingresados, y la mortalidad intrahospitalaria y a 30 días por cualquier causa. Se analizó si el tratamiento con digoxina se asoció a diferencias evolutivas, de forma cruda y ajustada a las características del paciente y el episodio de ICA. RESULTADOS: Se analizaron 15.549 pacientes (mediana = 83 años, mujeres = 55%), de los que 1.430 (9,2%) fueron tratados con digoxina. La digoxina se utilizó más en mujeres, pacientes jóvenes, en mejor clase funcional de la New York Heart Association (NYHA), pero con descompensaciones más graves y, sobre todo, cuando existía una fibrilación auricular (FA) con respuesta ventricular rápida como desencadenante. Se hospitalizó el 75,4% de pacientes (más frecuente en tratados con digoxina; 81,6% vs 74,8%, p 0,001), tuvo estancia prolongada en urgencias el 38,3% (52,9% vs 37,2%, p 0,001), hospitalización prolongada el 48,1% (49,3% vs 47,9%, p = 0,385), mortalidad intrahospitalaria el 7,2% (6,9% vs 7,2%, p = 0,712) y a 30 días el 9,7% (9,3% vs 9,7%, p = 0,625). El modelo ajustado mostró que el uso de digoxina en urgencias sólo se asoció con estancia prolongada en urgencias (OR = 1,883, IC 95% = 1,359-2,608), pero no con la necesidad de ingreso, hospitalización prolongada o mortalidad. CONCLUSIONES: La digoxina continúa utilizándose en uno de cada 10 pacientes con ICA atendidos en urgencias que no utilizaban este fármaco de manera habitual. Su uso se relaciona con un paciente cuya ICA ha sido descompensada por una FA con respuesta ventricular rápida, más joven y más frecuentemente mujer, en mejor clase funcional de la NYHA basal y con una descompensación posiblemente más grave. El uso de digoxina conlleva una estancia en urgencias más prolongada, pero su uso es seguro, pues no se asocia a la necesidad de ingreso, hospitalización prolongada o mortalidad a corto plazo.

Impact of the MEESSI-AHF tool to guide disposition decision-making in patients with acute heart failure in the emergency department: a before-and-after study.

OBJECTIVES: To determine the impact of risk stratification using the MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with acute heart failure) scale to guide disposition decision-making on the outcomes of ED patients with acute heart failure (AHF), and assess the adherence of emergency physicians to risk stratification recommendations. METHODS: This was a prospective quasi-experimental study (before/after design) conducted in eight Spanish EDs which consecutively enrolled adult patients with AHF. In the pre-implementation stage, the admit/discharge decision was performed entirely based on emergency physician judgement. During the post-implementation phase, emergency physicians were advised to 'discharge' patients classified by the MEESSI-AHF scale as low risk and 'admit' patients classified as increased risk. Nonetheless, the final decision was left to treating emergency physicians. The primary outcome was 30-day all-cause mortality. Secondary outcomes were days alive and out of hospital, in-hospital mortality and 30-day post-discharge combined adverse event (ED revisit, hospitalisation or death). RESULTS: The pre-implementation and post-implementation cohorts included 1589 and 1575 patients, respectively (median age 85 years, 56% females) with similar characteristics, and 30-day all-cause mortality was 9.4% and 9.7%, respectively (post-implementation HR=1.03, 95% CI=0.82 to 1.29). There were no differences in secondary outcomes or in the percentage of patients entirely managed in the ED without hospitalisation (direct discharge from the ED, 23.5% vs 24.4%, OR=1.05, 95% CI=0.89 to 1.24). Adjusted models did not change these results. Emergency physicians followed the MEESSI-AHF-based recommendation on patient disposition in 70.9% of cases (recommendation over-ruling: 29.1%). Physicians were more likely to over-rule the recommendation when 'discharge' was recommended (56.4%; main reason: need for hospitalisation for a second diagnosis) than when 'admit' was recommended (12.8%; main reason: no appreciation of severity of AHF decompensation by emergency physician), with an OR for over-ruling the 'discharge' compared with the 'admit' recommendation of 8.78 (95% CI=6.84 to 11.3). CONCLUSIONS: Implementing the MEESSI-AHF risk stratification tool in the ED to guide disposition decision-making did not improve patient outcomes.

Decisions to admit vs. discharge patients with acute heart failure from the emergency department: consistency with a measure of severity of decompensation and the impact on prognosis. / Decisión de hospitalización o alta en pacientes con insuficiencia cardiaca aguda en urgencias, su adecuación con la gravedad de la descompensación e impacto pronóstico.

OBJECTIVES: To analyze the consistency between decisions to discharge or admit patients with acute heart failure (AHF) treated in emergency departments (EDs) and the level of risk of adverse events, and to analyze the impact of decisions to discharge patients. MATERIAL AND METHODS: Prospective study of baseline clinical data collected from patients diagnosed with AHF in 16 Spanish emergency departments. Patients were stratified by severity of decompensated AHF based on MEESSI assessment (Multiple Estimation of Risk Based on the Spanish Emergency Department Score). The distribution of severity was described for patients who were hospitalized (overall and for departments receiving the largest number of admissions) and for discharged patients. We analyzed the data for discharged patients for associations with the following quality-of-care indicators: all-cause mortality of less than 2% at 30 days, revisits to the ED for AHF in less than 10% of patients within 7 days of discharge, and revisits to the ED or admission for AHF in less than 20% within 30 days of discharge. RESULTS: We included 2855 patients with a median (interquartile range) age of 84 (76-88) years. Fifty-four percent were women, 1042 (36.5%) were classified as low risk, 1239 (43.4%) as intermediate risk, 301 (10.5%) as high risk, and 273 (9.6%) as very high risk. Thirty-day mortality rates by level of low to very high risk were 1.9%, 9.3%, 15.3%, and 38.4%, respectively. One-year mortality rates by risk level were 15.4%, 35.6%, 52.0%, and 74.2%. Admission rates by risk level were 62.2%, 77.4%, 87.0%, and 88.3%. Overall, 47.1% o patients discharged from the ED were in the 3 higher-risk categories (intermediate to very high), and 30.7% were in the lowest risk category. The 5 hospital areas receiving the most admissions, in order of lowest-to-highest risk classification, were internal medicine, the short-stay unit, cardiology, intensive care, and geriatrics. Rates and 95% CIs for quality-of-care indicators in patients discharged from EDs were as follows: 30-day mortality, 4.3% (3.0%-6.1%); ED revisits within 7 days, 11.4% (9.2%-14.0%), and ED revisits or admissions within 30 days, 31.5% (28.0%-35.1%). In patients classified as low risk on ED discharge, these percentages were lower, as follows, respectively: 0.5% (0.1%-1.8%), 10.5% (7.6%-14.0%), and 29.5% (26.6%-32.6%). CONCLUSION: We detected disparity between severity of AHF decompensation and the decision to discharge or admit patients. Outcomes in patients discharged from EDs do not reach the recommended quality-of-care standards. Reducing inconsistencies between severity of decompensation and ED decisions could help to improve quality targets.

OBJETIVO: Analizar cómo se ajusta la decisión de ingreso o alta del paciente con insuficiencia cardiaca aguda (ICA) atendido en urgencias a su riesgo de evento adverso, así como su impacto en el pronóstico en aquellos dados de alta desde urgencias. METODO: Se recogieron datos basales y clínicos de pacientes diagnosticados de ICA en 16 servicios de urgencias españoles. Los pacientes se estratificaron según la gravedad de la descompensación mediante la escala MEESSI y se analizó la distribución de dicha gravedad en hospitalizados (en conjunto, e individualmente para los servicios con mayor número de hospitalizaciones) y dados de alta desde urgencias. En este último grupo, se analizó el cumplimiento de los siguientes indicadores de calidad: mortalidad por cualquier causa a 30 días ( 2%), reconsulta a urgencias por ICA a 7 días posalta ( 10%), y reconsulta a urgencias u hospitalización por ICA a 30 días posalta ( 20%). RESULTADOS: Se incluyeron 2.855 pacientes (edad mediana = 84 años, RIC = 76-88; mujeres = 54%): 1.042 pacientes (36,5%) de riesgo bajo, 1.239 (43,4%) intermedio, 301 (10,5%) alto y 273 (9,6%) muy alto. La mortalidad a 30 días por categorías de riesgo fue 1,9%, 9,3%, 15,3% y 38,4%, respectivamente; la mortalidad al año 15,4%, 35,6%, 52,0% y 74,2%; y la hospitalización 62,2%, 77,4%, 87,0% y 88,3%. El 47,1% de pacientes dados de alta de urgencias tenía un riesgo incrementado (intermedio, alto o muy alto) y el 30,7% de hospitalizados eran de bajo riesgo. La gravedad de la descompensación según el servicio de hospitalización se incrementaba en el siguiente orden: medicina interna, corta estancia, cardiología, intensivos y geriatría. El 4,3% de pacientes dados de alta de urgencias (IC 95%: 3,0-6,1) falleció a los 30 días, el 11,4% (9,2-14,0) reconsultó en urgencias a los 7 días, y el 31,5% (28,0-35,1) reconsultó en urgencias o se hospitalizó a los 30 días. Si sólo se consideran los pacientes dados de alta de bajo riesgo, estos porcentajes descienden al 0,5% (0,1-1,8), 10,5% (7,6-14,0) y 29,5% (26,6-32,6), respectivamente. CONCLUSIONES: Existe disparidad entre la gravedad de la descompensación y la decisión en urgencias de hospitalizar o dar de alta a los pacientes con ICA. Los resultados que se obtienen en los pacientes dados de alta desde urgencias no alcanzan los estándares de calidad recomendados. Disminuir las incongruencias entre gravedad de la descompensación y toma de decisión podría contribuir a cumplir con estos estándares.

Impact of the COVID-19 pandemic on demand for emergency department care for older patients: the EDEN-7 COVID cohort study. / Estudio EDEN-7: impacto de la pandemia COVID-19 sobre la demanda asistencial de personas mayores en los servicios de urgencias españoles.

OBJECTIVES: To analyze the impact of the COVID-19 pandemic on Spanish emergency department (ED) care for patients aged 65 years or older during the first wave vs. a pre-pandemic period. MATERIAL AND METHODS: Retrospective cross-sectional study of a COVID-19 portion of the EDEN project (Emergency Department and Elder Needs). The EDEN-COVID cohort included all patients aged 65 years or more who were treated in 52 EDs on 7 consecutive days early in the pandemic. We analyzed care variables, discharge diagnoses, use of diagnostic and therapeutic resources, use of observation units, need for hospitalization, rehospitalization, and mortality. These data were compared with data for an EDEN cohort in the same age group recruited during a similar period the year before the pandemic. RESULTS: The 52 participating hospital EDs attended 33 711 emergencies during the pandemic vs. 96 173 emergencies in the pre-COVID period, representing a 61.7% reduction during the pandemic. Patients aged 65 years or older accounted for 28.8% of the caseload during the COVID-19 period and 26.4% of the earlier cohort (P .001). The COVID-19 caseload included more men (51.0%). Comorbidity and polypharmacy were more prevalent in the pandemic cohort than in the earlier one (comorbidity, 92.6% vs. 91.6%; polypharmacy, 65.2% vs. 63.6%). More esturesources (analgesics, antibiotics, heparins, bronchodilators, and corticosteroids) were applied in the pandemic period, and common diagnoses were made less often. Observation wards were used more often (for 37.8% vs. 26.2% in the earlier period), and hospital admissions were more frequent (in 56.0% vs. 25.3% before the pandemic). Mortality was higher during the pandemic than in the earlier cohort either in ED (1.8% vs 0.5%) and during hospitalization (11.5 vs 2.9%). CONCLUSION: The proportion of patients aged 65 years or older decreased in the participating Spanish EDs. However, more resources were required and the pattern of diagnoses changed. Observation ward stays were longer, and admissions and mortality increased over the numbers seen in the reference period.

OBJETIVO: Analizar el impacto de la pandemia COVID-19 sobre la asistencia a las personas mayores ($ 65 años) en los servicios de urgencias hospitalarios (SUH) españoles durante la primera oleada pandémica, comparándola con un periodo previo. METODO: Estudio transversal retrospectivo de la cohorte EDEN-COVID (Emergency Department and Elder Needs during COVID), que incluyó a todos los pacientes $ 65 años atendidos en 52 SUH españoles durante 7 días consecutivos de un periodo pandémico. Se analizaron variables asistenciales, diagnósticos de alta, consumo de recursos diagnósticos y terapéuticos, utilización de las unidades de observación, necesidad de ingreso, rehospitalización y mortalidad. Estos datos se compararon con la cohorte EDEN (Emergency Department and Elder Needs), que reclutó a pacientes del mismogrupo de edad durante un periodo similar del año anterior. RESULTADOS: Durante el periodo COVID-19 se atendieron 33.711 episodios en los 52 SUH participantes, frente a 96.173 del periodo pre-COVID, lo que supone una disminución de la demanda de 61,7%. La proporción de asistencias a pacientes de 65 o más años fue de 28,8% en el periodo COVID-19 y 26,4% en el periodo previo (p 0,001). Durante el periodo COVID hubo mayor proporción de hombres (51,0% vs 44,9%), mayor comorbilidad (92,6% vs 91,6%) y polifarmacia (65,2% vs 63,6%), mayor uso de recursos, de analgésicos, antibióticos, heparinas, broncodilatadores y corticoides, menor proporción de los diagnósticos más habituales, mayor utilización de las unidades de observación (37,8% vs 26,2%) y un incremento de la proporción de ingresos (56,0% vs 25,3%), y de mortalidad en urgencias (1,8% vs 0,5%) y durante la hospitalización (11,5% vs 2,9%). CONCLUSIONES: La primera ola de la pandemia COVID-19 ha provocado una disminución global de las asistencias a personas mayores ($ 65 años) en los SUH españoles analizados, mayor consumo de recursos, un mapa diferente de procesos diagnósticos asistidos y un aumento proporcional de estancias en observación, de ingresos y de mortalidad, respecto al periodo de referencia.

QT interval and short-term outcome in acute heart failure.

OBJECTIVE: To investigate the association of corrected QT (QTc) interval duration and short-term outcomes in patients with acute heart failure (AHF). METHODS: We analyzed AHF patients enrolled in 11 Spanish emergency departments (ED) for whom an ECG with QTc measurement was available. Patients with pace-maker rhythm were excluded. Primary outcome was 30-day all-cause mortality and secondary outcomes were need of hospitalization, in-hospital mortality and prolonged hospitalization (> 7 days). Association between QTc and outcomes was explored by restricted cubic spline (RCS) curves. Results were expressed as odds ratios (OR) and 95%CI adjusted by patients baseline and decompensation characteristics, using a QTc = 450 ms as reference. RESULTS: Of 1800 patients meeting entry criteria (median age 84 years (IQR = 77-89), 56% female), their median QTc was 453 ms (IQR = 422-483). The 30-day mortality was 9.7%, while need of hospitalization, in-hospital mortality and prolonged hospitalization were 77.8%, 9.0% and 50.0%, respectively. RCS curves found longer QTc was associated with 30-day mortality if > 561 ms, OR = 1.86 (1.00-3.45), and increased up to OR = 10.5 (2.25-49.1), for QTc = 674 ms. A similar pattern was observed for in-hospital mortality; OR = 2.64 (1.04-6.69), for QTc = 588 ms, and increasing up to OR = 8.02 (1.30-49.3), for QTc = 674 ms. Conversely, the need of hospitalization had a U-shaped relationship: being increased in patients with shorter QTc [OR = 1.45 (1.00-2.09) for QTc = 381 ms, OR = 5.88 (1.25-27.6) for the shortest QTc of 200 ms], and also increasing for prolonged QTc [OR = 1.06 (1.00-1.13), for QTc = 459 ms, and reaching OR = 2.15 (1.00-4.62) for QTc = 588 ms]. QTc was not associated with prolonged hospitalization. CONCLUSION: In ED AHF patients, initial QTc provides independent short-term prognostic information, with increasing QTc associated with increasing mortality, while both, shortened and prolonged QTc are associated with need of hospitalization.

Impact of worsening renal function detected at emergency department arrival on acute heart failure short-term outcomes.

BACKGROUND AND IMPORTANCE: Deterioration of renal function with respect to baseline during an acute heart failure (AHF) episode is frequent, but impact on outcomes is still a matter of debate. OBJECTIVE: To investigate the association of creatinine deterioration detected at emergency department (ED) arrival and short-term outcomes in patients with AHF. DESIGN: Secondary analysis of a large multipurpose registry. SETTINGS AND PARTICIPANTS: Patients with AHF were diagnosed in 10 Spanish ED for whom a previous baseline creatinine was available. EXPOSURE: Difference between creatinine at ED arrival and at baseline was calculated (∂-creatinine). OUTCOME MEASURES AND ANALYSIS: Primary outcome was 30-day all-cause death, and secondary outcomes were inhospital all-cause death, prolonged hospitalization (>7 days) and 7-day postdischarge adverse events. Associations between ∂-creatinine and outcomes were explored using logistic regression by restricted cubic spline (RCS) curves and expressed as odds ratio (OR) with 95% confidence interval (CI), taking ∂-creatinine = 0 mg/dl as reference. Curves were adjusted by age, sex, comorbidities, patient baseline status, chronic treatments, and vitals and laboratory results at ED arrival. Interactions for the primary outcome also were investigated. MAIN RESULTS: We analyzed 3036 patients (median age = 82 years; IQR = 75-87; women = 55%), with ∂-creatinine ranged from -0.3 to 3 mg/dl. The 30-day mortality was 11.6%. Increments of ∂-creatinine were associated with progressive increase in risk of 30-day death, although adjustment attenuated this association: ∂-creatinine of 0.3/1/2/3 mg/dl were, respectively, associated with adjusted OR of 1.41 (1.02-1.95), 1.69 (1.02-2.80), 1.46 (0.56-3.80) and 1.27 (0.27-5.83). Distinctively significant higher risk was found for patients over 80 years old, female, nondiabetic, functionally disabled and on digoxin therapy. With respect to secondary outcomes, inhospital mortality was 8.1%, prolonged hospitalization was 33.6% and 7-day postdischarge adverse event was 9.7%. Inhospital death steadily increased with increments in ∂-creatinine [from 1.50 (1.04-2.17) with ∂-creatinine = 0.3 to 3.78 (0.78-18.3) with ∂-creatinine = 3], as well as prolonged hospitalization did [from 1.41 (1.11-1.77) to 2.24 (1.51-3.33), respectively]. Postdischarge adverse events were not associated with ∂-creatinine. CONCLUSION: WRF detected at ED arrival has prognostic value in AHF, being associated with increased risk of death and prolonged hospitalization. These associations showed different patterns of risk but, remarkably, risk started with increments as low as 0.3 mg/dl.

Safety and Revisit Related to Discharge the Sixty-one Spanish Emergency Department Medical Centers Without Hospitalization in Patients with COVID-19 Pneumonia. A Prospective Cohort Study UMC-Pneumonia COVID-19

ABSTRACT Background: Information is needed on the safety and efficacy of direct discharge from the emergency department (ED) of patients with COVID-19 pneumonia. Objectives: The objectives of the study were to study the variables associated with discharge from the ED in patients presenting with COVID-19 pneumonia, and study ED revisits related to COVID-19 at 30 days (EDR30d). Methods: Multicenter study of the SIESTA cohort including 1198 randomly selected COVID patients in 61 EDs of Spanish medical centers from March 1, 2020, to April 30, 2020. We collected baseline and related characteristics of the acute episode and calculated the adjusted odds ratios (aOR) for ED discharge. In addition, we analyzed the variables related to EDR30d in discharged patients. Results: We analyzed 859 patients presenting with COVID-19 pneumonia, 84 (9.8%) of whom were discharged from the ED. The variables independently associated with discharge were being a woman (aOR 1.890; 95%CI 1.176-3.037), age < 60 years (aOR 2.324; 95%CI 1.353-3.990), and lymphocyte count > 1200/mm3 (aOR 4.667; 95%CI 1.045-20.839). The EDR30d of the ED discharged group was 40.0%, being lower in women (aOR 0.368; 95%CI 0.142-0.953). A total of 130 hospitalized patients died (16.8%) as did two in the group discharged from the ED (2.4%) (OR 0.121; 95%CI 0.029-0.498). Conclusion: Discharge from the ED in patients with COVID-19 pneumonia was infrequent and was associated with few variables of the episode. The EDR30d was high, albeit with a low mortality.

Safety and Revisit Related to Discharge the Sixty-one Spanish Emergency Department Medical Centers Without Hospitalization in Patients with COVID-19 Pneumonia. A Prospective Cohort Study UMC-Pneumonia COVID-19.

BACKGROUND: Information is needed on the safety and efficacy of direct discharge from the emergency department (ED) of patients with COVID-19 pneumonia. OBJECTIVES: The objectives of the study were to study the variables associated with discharge from the ED in patients presenting with COVID-19 pneumonia, and study ED revisits related to COVID-19 at 30 days (EDR30d). METHODS: Multicenter study of the SIESTA cohort including 1198 randomly selected COVID patients in 61 EDs of Spanish medical centers from March 1, 2020, to April 30, 2020. We collected baseline and related characteristics of the acute episode and calculated the adjusted odds ratios (aOR) for ED discharge. In addition, we analyzed the variables related to EDR30d in discharged patients. RESULTS: We analyzed 859 patients presenting with COVID-19 pneumonia, 84 (9.8%) of whom weredischarged from the ED. The variables independently associated with discharge were being a woman (aOR 1.890; 95%CI 1.176 3.037), age < 60 years (aOR 2.324; 95%CI 1.353-3.990), and lymphocyte count > 1200/mm3 (aOR 4.667; 95%CI 1.045-20.839). The EDR30d of the ED discharged group was 40.0%, being lower in women (aOR 0.368; 95%CI 0.142-0.953). A totalof 130 hospitalized patients died (16.8%) as did two in the group discharged from the ED (2.4%) (OR 0.121; 95%CI 0.029-0.498). CONCLUSION: Discharge from the ED in patients with COVID-19 pneumonia was infrequent and was associated with few variables of the episode. The EDR30d was high, albeit with a low mortality.

Sociodemographic characteristics, functional status, and health resource use of older patients treated in Spanish emergency departments: a description of the EDEN cohort. / Características sociodemográficas, funcionales y consumo de recursos de la población mayor atendida en los servicios de urgencias españoles: una aproximación desde la cohorte EDEN.

OBJECTIVES: To describe the sociodemographic characteristics of and the health care resources used to treat patients aged 65 years or older who come to hospital emergency departments (EDs) in Spain, according to age groups. MATERIAL AND METHODS: We studied the phase-1 data for the EDEN cohort (Emergency Department and Elder Needs). Forty Spanish EDs collected data on all patients aged 65 years or older who were treated on the first 7 days in April 2019. We registered information on 6 sociodemographic and 5 function variables for all patients. For health resource use we used 6 diagnostic, 13 therapeutic, and 5 physical structural variables, for a total of 24 variables. Differences were analyzed according to age in blocks of 5 years. RESULTS: A total of 18 374 patients with a median age of 78 years were included; 55% were women. Twenty-seven percent arrived by ambulance, 71% had not previously been seen by a physician, and 13% lived alone without assistance. Ten percent had a high level of functional dependence, and 14% had serious comorbidity. Resources used most often were blood analysis (in 60%) and radiology (59%), analgesics (25%), intravenous fluids (21%), antibiotics (14%), oxygen (13%), and bronchodilators (11%). Twenty-six percent were kept under observation in the ED, 26% were admitted to wards, and 2% were admitted to intensive care units (ICUs). The median stay in the ED was 3.5 hours, and the median hospital stay was 7 days. Sociodemographic characteristics changed according to age. Functional dependence worsened with age, and resource requirements increased in general. However, benzodiazepine use was unaffected, while the use of nonsteroidal anti-inflammatory drugs and ICU admission decreased. CONCLUSION: The functional dependence of older patients coming to EDs increases with age and is associated with a high level of health care resource use, which also increases with age. Planners should take into consideration the characteristics of the older patients and the proportion of the caseload they represent when arranging physical spaces and designing processes for a specific ED.

OBJETIVO: Investigar las características sociodemográficas y consumo de recursos de los pacientes de 65 o más años que consultan en servicios de urgencias hospitalarios (SUH) en España, y su modificación por grupos etarios. METODO: Se utilizaron datos de la cohorte EDEN obtenidos en fase 1 (Emergency Department and Elder Needs). Cuarenta SUH españoles incluyeron todos los pacientes de $ 65 años atendidos del 1-4-2019 al 7-4-2019 (7 días). Se analizaron 6 características sociodemográficas, 5 funcionales y 24 referidas a consumo de recursos (6 diagnósticos, 13 terapéuticos, 5 estructurales) y sus cambios a medida que avanza la edad (agrupada en bloques de 5 años). RESULTADOS: Se analizaron 18.374 pacientes (mediana edad: 78 años; 55% mujeres). El 27% acude a urgencias en ambulancia, el 71% sin consulta médica previa y el 13% vive solo sin cuidadores. Funcionalmente, el 10% tiene dependencia grave y el 14% comorbilidad grave. La solicitud de analítica sanguínea (60% de casos) y radiología (59%) destaca entre el consumo de recursos diagnósticos, y el uso de analgésicos (25%), sueroterapia (21%), antibioticoterapia (14%), oxigenoterapia (13%) y broncodilatadores (11%), entre los terapéuticos. El 26% requiere observación en urgencias, el 26% hospitalización y el 2% cuidados intensivos. La mediana de estancia en urgencias es de 3:30 horas y la de hospitalización es de 7 días. Las características sociodemográficas se modifican con la edad, las funcionales empeoran y el consumo de recursos aumenta (excepto benzodiacepinas, que no se modifica, y antinflamatorios no esteroideos y cuidados intensivos, que disminuye). CONCLUSIONES: Las características funcionales de la población mayor que consulta en los SUH empeora a medida que su edad avanza, y se asocia a un consumo de recursos alto que también se incrementa con la edad. Las características de esta población y su proporción en un determinado SUH deben tenerse en cuenta en su planificación estructural y funcional.

Thirty-day outcomes in frail older patients discharged home from the emergency department with acute heart failure: effects of high-risk criteria identified by the DEED FRAIL-AHF trial. / Resultados a 30 días en los pacientes mayores frágiles con insuficiencia cardiaca aguda dados de alta desde urgencias o sus unidades vinculadas que cumplen los criterios de alto riesgo del estudio DEED FRAIL-AHF.

OBJECTIVES: To study the effect of high-risk criteria on 30-day outcomes in frail older patients with acute heart failure (AHF) discharged from an emergency department (ED) or an ED's observation and short-stay areas. MATERIAL AND METHODS: Secondary analysis of discharge records in the Older AHF Key Data registry. We selected frail patients (aged > 70 years) discharged with AHF from EDs. Risk factors were categorized as modifiable or nonmodifiable. The outcomes were a composite endpoint for a cardiovascular event (revisits for AHF, hospitalization for AHF, or cardiovascular death) and the number of days alive out-of-hospital (DAOH) within 30 days of discharge. RESULTS: We included 380 patients with a mean (SD) age of 86 (5.5) years (61.2% women). Modifiable risk factors were identified in 65.1%, nonmodifiable ones in 47.8%, and both types in 81.6%. The 30-day cardiovascular composite endpoint occurred in 83 patients (21.8%). The mean 30-day DAOH observed was 27.6 (6.1) days. Highrisk factors were present more often in patients who developed the cardiovascular event composite endpoint: the rates for patients with modifiable, nonmodifiable, or both types of risk were, respectively, as follows in comparison with patients not at high risk: 25.0% vs 17.2%, P = .092; 27.6% vs 16.7%, P = .010; and 24.7% vs 15.2%, P = .098). The 30-day DAOH outcome was also lower for at-risk patients, according to type of risk factor present: modifiable, 26.9 (7.0) vs 28.4 (4.4) days, P = .011; nonmodifiable, 27.1 (7.0) vs 28.0 (5.0) days, P = .127; and both, 27.1 (6.7) vs 28.8 (3.4) days, P = .005). After multivariate analysis, modifiable risk remained independently associated with fewer days alive (adjusted absolute difference in 30-day DAOH, -1.3 days (95% CI, -2.7 to -0.1 days). Nonmodifiable factors were associated with increased risk for the 30-day cardiovascular composite endpoint (adjusted absolute difference, 10.4%; 95% CI, -2.1% to 18.7%). CONCLUSION: Risk factors are common in frail elderly patients with AHF discharged home from hospital ED areas. Their presence is associated with a worse 30-day prognosis.

OBJETIVO: Estudiar el efecto a 30 días de los criterios de alto riesgo (CAR) en los mayores frágiles con insuficiencia cardiaca aguda (ICA) dados de alta desde urgencias o unidades vinculadas (URG_UV). METODO: Análisis secundario del registro OAK-Discharge. Se seleccionaron pacientes frágiles 70 años con ICA dados de alta desde URG_UV. Los CAR se clasificaron en modificables (CAR_M) y no modificables (CAR_NM). Las variables de resultado fueron la compuesta cardiovascular (VC_CV) (revisita u hospitalización por ICA o mortalidad cardiovascular) y días vivos fuera del hospital (DVFH) a 30 días del alta. RESULTADOS: Se incluyeron 380 pacientes con una edad media de 86 (DE 5,5) años, 61,2% mujeres. Un 65,1% tuvo CAR_M, 47,8% CAR_NM y 81,6% ambos. Ochenta y tres pacientes (21,8%) presentaron la VC_CV a 30 días. La media de DVFH a 30 días fue de 27,6 (DE 6,1) días. La presencia de CAR modificable, no modificable o ambos, se asoció más frecuentemente a la VC_CV a 30 días (25,0% vs 17,2%, p = 0,092; 27,6% vs 16,7%, p = 0,010; 24,7% vs 15,2%, p = 0,098) y a menos DVFH a 30 días [26,9 (7,0) vs 28,4 (4,4), p = 0,011; 27,1 (7,0) vs 28,0 (5,0), p = 0,127; 27,1 (6,7) vs 28,8 (3,4), p = 0,005], respectivamente. Tras el análisis multivariante, los CAR_M se asociaron de forma independiente con menos DVFH a 30 días (diferencia absoluta ajustada ­1,3 días; IC 95% ­2,7 a ­0,1) y los CAR_NM con más eventos en la VC_CV a 30 días (diferencia absoluta ajustada 10,4%; IC 95% 2,1% a 18,7%). CONCLUSIONES: Los CAR son frecuentes en los mayores frágiles con ICA dados de alta desde URG_UV y su presencia se asocia a peores resultados a 30 días tras alta.

Worsening renal function during an episode of acute heart failure and its relation to short- and long-term mortality: associated factors in the Epidemiology of Acute Heart Failure in Emergency Departments- Worsening Renal Function study. / Factores asociados con el empeoramiento de la función renal durante un episodio de insuficiencia cardiaca aguda y su relación con la mortalidad a corto y largo plazo: estudio EAHFE - EFRICA.

OBJECTIVES: To identify factors associated with worsening renal function (WRF) and explore associations with higher mortality in patients with acute heart failure (AHF). MATERIAL AND METHODS: Seven emergency departments (EDs) in the EAHFE-EFRICA study (Spanish acronym for Epidemiology of AHF in EDs - WRF in AHF) consecutively included patients with AHF and creatinine levels determined in the ED and between 24 and 48 hours later. Patients with WRF were identified by an increase in creatinine level of 0.3 mg/dL or more. Forty-seven clinical characteristics were explored to identify those associated with WRF. To analyze for 30-day all-cause mortality we calculated odds ratios (ORs). To analyze mortality at the end of follow-up and by trimester, adjusted for between-group differences, we calculated hazard ratios (HRs). The data were analyzed by subgroups according to age, sex, baseline creatinine levels, AHF type, and risk group. RESULTS: A total of 1627 patients were included. The subgroup of 220 (13.5%) with WRF were older, had higher systolic blood pressure, were more often treated with morphine, and had chronic renal failure; there was also a higher rate of hypertensive crisis as the trigger for AHF in patients with WRF. However, only chronic renal failure was independently associated with WRF (adjusted OR, 1.695; 95% CI, 1.264-2.273). The rate of 30-day mortality was 13.1% overall but higher in patients with WRF (20.9% vs 11.8% in patients without WRF; adjusted OR, 1.793; 95% CI, 1.207-2.664). Accumulated mortality at 18 months (average follow-up time, 14 mo/patient) was 40.0% overall but higher in patients with WRF (adjusted HR, 1.275; 95% CI, 1.018-1.598). Increased risk was greater in the first trimester. Subgroup analyses revealed no differences. CONCLUSION: AHF with WRF in the first 48 hours after ED care is associated with higher mortality, especially in the first trimester after the emergency.

OBJETIVO: Identificar los factores asociados con el empeoramiento de la función renal (EFR) y si este se asocia a mayor mortalidad en pacientes que presentan un episodio de insuficiencia cardiaca aguda (ICA). METODO: Participaron 7 servicios de urgencias (SU) que incluyeron consecutivamente pacientes con ICA con determinación de creatinina en urgencias y a las 24-48 horas, y se identificaron aquellos con EFR (incremento de creatinina $ 0,3 mg/dL). Entre 47 características clínicas, se identificó las asociadas a EFR. Se investigó la mortalidad por cualquier causa a 30 días (OR) y al final del seguimiento (HR), esta última global y por periodos trimestrales, que se ajustó por las diferencias entre grupos. Se analizaron subgrupos según edad, sexo, creatinina basal, tipo de ICA y grupo de riesgo. RESULTADOS: Se incluyeron 1.627 pacientes, 220 (13,5%) con EFR, los cuales presentaban mayor edad, presión arterial sistólica, crisis hipertensiva como precipitante, tratamiento con morfina e insuficiencia renal crónica, aunque solo esta última se asoció independientemente a EFR (ORajustada = 1,695, IC 95% = 1,264-2,273). La mortalidad a 30 días fue de 13,1% (mayor en pacientes con EFR: 20,9% vs 11,8%, ORajustada = 1,793, IC 95% = 1,207-2,664) y la mortalidad acumulada a 18 meses (tiempo medio de seguimiento 14 meses/paciente) fue del 40,0% (mayor en pacientes con EFR: HRajustada = 1,275, IC 95% = 1,018-1,598). Este incremento de riesgo fue durante el primer trimestre. El análisis de subgrupos no mostró diferencias. CONCLUSIONES: La ICA con EFR en las primeras 48 horas posteriores a la atención en el SU se asocia a mayor mortalidad, que se concentra durante el primer trimestre.

Factores asociados con el empeoramiento de la función renal durante un episodio de insuficiencia cardiaca aguda y su relación con la mortalidad a corto y largo plazo: estudio EAHFE - EFRICA / Worsening renal function during an episode of acute heart failure and its relation to short- and long-term mortality: associated factors in the Epidemiology of Acute Heart Failure in Emergency Departments- Worsening Renal Function study

OBJETIVO: Identificar los factores asociados con el empeoramiento de la función renal (EFR) y si este se asocia a mayor mortalidad en pacientes que presentan un episodio de insuficiencia cardiaca aguda (ICA). MÉTODO: Participaron 7 servicios de urgencias (SU) que incluyeron consecutivamente pacientes con ICA con determinación de creatinina en urgencias y a las 24-48 horas, y se identificaron aquellos con EFR (incremento de creatinina $ 0,3 mg/dL). Entre 47 características clínicas, se identificó las asociadas a EFR. Se investigó la mortalidad por cualquier causa a 30 días (OR) y al final del seguimiento (HR), esta última global y por periodos trimestrales, que se ajustó por las diferencias entre grupos. Se analizaron subgrupos según edad, sexo, creatinina basal, tipo de ICA y grupo de riesgo. RESULTADOS: Se incluyeron 1.627 pacientes, 220 (13,5%) con EFR, los cuales presentaban mayor edad, presión arterial sistólica, crisis hipertensiva como precipitante, tratamiento con morfina e insuficiencia renal crónica, aunque solo esta última se asoció independientemente a EFR (ORajustada = 1,695, IC 95% = 1,264-2,273). La mortalidad a 30 días fue de 13,1% (mayor en pacientes con EFR: 20,9% vs 11,8%, ORajustada = 1,793, IC 95% = 1,207-2,664) y la mortalidad acumulada a 18 meses (tiempo medio de seguimiento 14 meses/paciente) fue del 40,0% (mayor en pacientes con EFR: HRajustada = 1,275, IC 95% = 1,018-1,598). Este incremento de riesgo fue durante el primer trimestre. El análisis de subgrupos no mostró diferencias. CONCLUSIÓN: La ICA con EFR en las primeras 48 horas posteriores a la atención en el SU se asocia a mayor mortalidad, que se concentra durante el primer trimestre

OBJECTIVE: To identify factors associated with worsening renal function (WRF) and explore associations with higher mortality in patients with acute heart failure (AHF). METHODS: Seven emergency departments (EDs) in the EAHFE-EFRICA study (Spanish acronym for Epidemiology of AHF in EDs - WRF in AHF) consecutively included patients with AHF and creatinine levels determined in the ED and between 24 and 48 hours later. Patients with WRF were identified by an increase in creatinine level of 0.3 mg/dL or more. Forty-seven clinical characteristics were explored to identify those associated with WRF. To analyze for 30-day all-cause mortality we calculated odds ratios (ORs). To analyze mortality at the end of follow-up and by trimester, adjusted for between-group differences, we calculated hazard ratios (HRs). The data were analyzed by subgroups according to age, sex, baseline creatinine levels, AHF type, and risk group. RESULTS: A total of 1627 patients were included. The subgroup of 220 (13.5%) with WRF were older, had higher systolic blood pressure, were more often treated with morphine, and had chronic renal failure; there was also a higher rate of hypertensive crisis as the trigger for AHF in patients with WRF. However, only chronic renal failure was independently associated with WRF (adjusted OR, 1.695; 95% CI, 1.264-2.273). The rate of 30-day mortality was 13.1% overall but higher in patients with WRF (20.9% vs 11.8% in patients without WRF; adjusted OR, 1.793; 95% CI, 1.207-2.664). Accumulated mortality at 18 months (average follow-up time, 14 mo/patient) was 40.0% overall but higher in patients with WRF (adjusted HR, 1.275; 95% CI, 1.018-1.598). Increased risk was greater in the first trimester. Subgroup analyses revealed no differences. CONCLUSION: AHF with WRF in the first 48 hours after ED care is associated with higher mortality, especially in the first trimester after the emergency

Analysis of clinical characteristics and outcomes in patients with COVID-19 based on a series of 1000 patients treated in Spanish emergency departments. / Evaluación de las características clínicas y evolución de pacientes con COVID-19 a partir de una serie de 1000 pacientes atendidos en servicios de urgencias españoles.

OBJECTIVES: To describe the clinical characteristics of patients with coronavirus disease 2019 (COVID-19) treated in hospital emergency departments (EDs) in Spain, and to assess associations between characteristics and outcomes. MATERIAL AND METHODS: Prospective, multicenter, nested-cohort study. Sixty-one EDs included a random sample of all patients diagnosed with COVID-19 between March 1 and April 30, 2020. Demographic and baseline health information, including concomitant conditions; clinical characteristics related to the ED visit and complementary test results; and treatments were recorded throughout the episode in the ED. We calculated crude and adjusted odds ratios for risk of in-hospital death and a composite outcome consisting of the following events: intensive care unit admission, orotracheal intubation or mechanical ventilation, or in-hospital death. The logistic regression models were constructed with 3 groups of independent variables: the demographic and baseline health characteristics, clinical characteristics and complementary test results related to the ED episode, and treatments. RESULTS: The mean (SD) age of patients was 62 (18) years. Most had high- or low-grade fever, dry cough, dyspnea, and diarrhea. The most common concomitant conditions were cardiovascular diseases, followed by respiratory diseases and cancer. Baseline patient characteristics that showed a direct and independent association with worse outcome (death and the composite outcome) were age and obesity. Clinical variables directly associated with worse outcomes were impaired consciousness and pulmonary crackles; headache was inversely associated with worse outcomes. Complementary test findings that were directly associated with outcomes were bilateral lung infiltrates, lymphopenia, a high platelet count, a D-dimer concentration over 500 mg/dL, and a lactate-dehydrogenase concentration over 250 IU/L in blood. CONCLUSION: This profile of the clinical characteristics and comorbidity of patients with COVID-19 treated in EDs helps us predict outcomes and identify cases at risk of exacerbation. The information can facilitate preventive measures and improve outcomes.

OBJETIVO: Describir las características clínicas de los pacientes con COVID-19 atendidos en los servicios de urgencias hospitalarios (SUH) españoles y evaluar su asociación con los resultados de su evolución. METODO: Estudio multicéntrico, anidado en una cohorte prospectiva. Participaron 61 SUH que incluyeron pacientes seleccionados aleatoriamente de todos los diagnosticados de COVID-19 entre el 1 de marzo y el 30 de abril de 2020. Se recogieron características basales, clínicas, de exploraciones complementarias y terapéuticas del episodio en los SUH. Se calcularon las odds ratio (OR) asociadas a la mortalidad intrahospitalaria y al evento combinado formado por el ingreso en unidad de cuidados intensivos (UCI), la intubación orotraqueal o ventilación mecánica invasiva (IOT/ VMI), crudas y ajustadas con modelos de regresión logística para tres grupos de variables independientes: basales, clínicas y de exploraciones complementarias. RESULTADOS: La edad media fue de 62 años (DE 18). La mayoría manifestaron fiebre, tos seca, disnea, febrícula y diarrea. Las comorbilidades más frecuentes fueron las enfermedades cardiovasculares, seguidas de las respiratorias y el cáncer. Las variables basales que se asociaron independientemente y de forma directa a peores resultados evolutivos (tanto a mortalidad como a evento combinado) fueron edad y obesidad; las variables clínicas fueron disminución de consciencia y crepitantes a la auscultación pulmonar, y de forma inversa cefalea; y las variables de resultados de exploraciones complementarias fueron infiltrados pulmonares bilaterales y cardiomegalia radiológicos, y linfopenia, hiperplaquetosis, dímero-D > 500 mg/dL y lactato-deshidrogenasa > 250 UI/L en la analítica. CONCLUSIONES: Conocer las características clínicas y la comorbilidad de los pacientes con COVID-19 atendidos en urgencias permite identificar precozmente a la población más susceptible de empeorar, para prever y mejorar los resultados.

Eventos adversos en pacientes con insuficiencia cardiaca aguda clasificados de bajo riesgo por la escala MEESSI y dados de alta desde urgencias: cuantificación y predictibilidad / Patients with acute heart failure discharged from the emergency department and classified as low risk by the MEESSI score (multiple risk estimate based on the Spanish emergency department scale): prevalence of adverse events and predictability

Objetivo: Investigar la tasa de eventos adversos en pacientes con insuficiencia cardiaca aguda (ICA) clasificados de bajo riesgo por la escala MEESSI y dados de alta desde urgencias, la capacidad discriminativa de dicha escala para estos eventos en dichos pacientes y las variables asociadas. Método: Se estratificó el riesgo de los pacientes del Registro EAHFE (cohortes 2-5) mediante la escala MEESSI y se analizaron los clasificados de bajo riesgo dados de alta desde urgencias. Se investigó la mortalidad por cualquier causa a 30 días (M-30d), la revisita a urgencias por ICA a 7 días (REV-7d) y la revisita a urgencias u hospitalización por ICA a 30 días (REV-H-30d). Se calculó el área bajo la curva (ABC) de la característica operativa del receptor (COR) de la escala MEESSI para estos eventos. Se analizó la relación entre 42 variables y RV-7d y RV-H-30d mediante regresión logística multivariable. Resultados: Se incluyeron 1028 pacientes. La M-30d fue 1,6% (IC 95%: 0,9-2,5), la REV-7d fue 8,0% (6,4-9,8) y la REV-H-30d fue 24,7% (22,1-25,7). El ABC ROC de la puntuación MEESSI para discriminar estos eventos adversos fue 0,69 (0,58-0,80), 0,56 (0,49-0,63) y 0,54 (0,50-0,59), respectivamente. Se asociaron con RV-7d: tratamiento diurético crónico (OR 2,45; 1,01-5,98), hemoglobina < 110 g/L (1,68; 1,02-2,75) y tratamiento diurético intravenoso en urgencias (0,53; 0,31-0,90). Se asociaron con REV-H-30d: arteriopatía periférica (1,74; 1,01-3,00), episodios previos de ICA (1,42; 1,02-1,98), tratamiento crónico con inhibidores de receptores mineralocorticoides (1,71; 1,09-2,67), índice de Barthel en urgencias < 90 puntos (1,48; 1,07-2,06) y tratamiento diurético intravenoso en urgencias (0,58; 0,40-0,84). Conclusiones: Los pacientes con ICA de bajo riesgo dados de alta desde urgencias presentan tasas de eventos adversos cercanas a los estándares recomendados internacionalmente. La escala MEESSI, diseñada para predecir M-30d, tiene escasa capacidad predictiva para REV-7d y REV-H-30d en los pacientes de bajo riesgo. Este estudio describe otros factores asociados a tales eventos

Objective: To determine the rate of adverse events in patients with acute heart failure (AHF) who were discharged from the emergency department (ED) after classification as low risk according to MEESSI score (multiple risk estimate based on the Spanish ED scale), to analyze the ability of the score to predict events, and to explore variables associated with adverse events. Methods: Patients in the EAHFE registry (Epidemiology of Acute Heart Failure in EDs) were stratified according to risk indicated by MEESSI score in order to identify those considered at low risk on discharge. All-cause 30-day mortality and revisits related to AHF within 7 days and 30 days were recorded. The area under the receiver operating characteristic curve (AUC) was calculated for the MEESSI score's ability to predict these events. Associations between 42 variables and 7-day and 30-day revisits to the ED were analyzed by multivariable logistic regression. Results: A total of 1028 patients were included. The 30-day mortality rate was 1.6% (95% CI, 0.9%-2.5%). The 7-day and 30-day revisit rates were 8.0% (95% CI, 6.4%-9.8%) and 24.7% (95% CI, 22.1%-25.7%), respectively. The AUCs for MEESSI score discrimination between patients with and without these outcomes were as follows: 30-day mortality, 0.69 (95% CI, 0.58-0.80); 7-day revisiting, 0.56 (95% CI, 0.49-0.63); and 30-day revisiting, 0.54 (95% CI, 0.50-0.59). Variables associated with 7-day revisits were long-term diuretic treatment (odds ratio [OR], 2.45; 95% CI, 1.01-5.98), hemoglobin concentration less than 110 g/L (OR, 1.68; 95% CI, 1.02-2.75), and intravenous diuretic treatment in the ED (OR, 0.53; 95% CI, 0.31-0.90). Variables associated with 30-day revisits were peripheral artery disease (OR, 1.74; 95% CI, 1.01-3.00), prior history of an AHF episode (OR, 1.42; 95% CI, 1.02-1.98), long-term mineralocorticoid receptor antagonist treatment (OR, 1.71; 95% CI, 1.09-2.67), Barthel index less than 90 points in the ED (OR, 1.48; 95% CI, 1.07-2.06), and intravenous diuretic treatment in the ED (OR, 0.58; 95% CI, 0.40-0.84). Conclusions: Patients with AHF who are at low risk for adverse events on discharge from our EDs have event rates that are near internationally recommended targets. The MEESSI score, which was designed to predict 30-day mortality, is a poor predictor of 7-day or 30-day revisiting in these low-risk patients. We identified other factors related to these events

Patients with acute heart failure discharged from the emergency department and classified as low risk by the MEESSI score (multiple risk estimate based on the Spanish emergency department scale): prevalence of adverse events and predictability. / Eventos adversos en pacientes con insuficiencia cardiaca aguda clasificados de bajo riesgo por la escala MEESSI y dados de alta desde urgencias: cuantificación y predictibilidad.

OBJECTIVES: To determine the rate of adverse events in patients with acute heart failure (AHF) who were discharged from the emergency department (ED) after classification as low risk according to MEESSI score (multiple risk estimate based on the Spanish ED scale), to analyze the ability of the score to predict events, and to explore variables associated with adverse events. METHODS: Patients in the EAHFE registry (Epidemiology of Acute Heart Failure in EDs) were stratified according to risk indicated by MEESSI score in order to identify those considered at low risk on discharge. All-cause 30-day mortality and revisits related to AHF within 7 days and 30 days were recorded. The area under the receiver operating characteristic curve (AUC) was calculated for the MEESSI score's ability to predict these events. Associations between 42 variables and 7-day and 30-day revisits to the ED were analyzed by multivariable logistic regression. RESULTS: A total of 1028 patients were included. The 30-day mortality rate was 1.6% (95% CI, 0.9%-2.5%). The 7-day and 30-day revisit rates were 8.0% (95% CI, 6.4%-9.8%) and 24.7% (95% CI, 22.1%-25.7%), respectively. The AUCs for MEESSI score discrimination between patients with and without these outcomes were as follows: 30-day mortality, 0.69 (95% CI, 0.58-0.80); 7-day revisiting, 0.56 (95% CI, 0.49-0.63); and 30-day revisiting, 0.54 (95% CI, 0.50-0.59). Variables associated with 7-day revisits were long-term diuretic treatment (odds ratio [OR], 2.45; 95% CI, 1.01-5.98), hemoglobin concentration less than 110 g/L (OR, 1.68; 95% CI, 1.02-2.75), and intravenous diuretic treatment in the ED (OR, 0.53; 95% CI, 0.31-0.90). Variables associated with 30-day revisits were peripheral artery disease (OR, 1.74; 95% CI, 1.01-3.00), prior history of an AHF episode (OR, 1.42; 95% CI, 1.02-1.98), long-term mineralocorticoid receptor antagonist treatment (OR, 1.71; 95% CI, 1.09-2.67), Barthel index less than 90 points in the ED (OR, 1.48; 95% CI, 1.07-2.06), and intravenous diuretic treatment in the ED (OR, 0.58; 95% CI, 0.40-0.84). CONCLUSION: Patients with AHF who are at low risk for adverse events on discharge from our EDs have event rates that are near internationally recommended targets. The MEESSI score, which was designed to predict 30-day mortality, is a poor predictor of 7-day or 30-day revisiting in these low-risk patients. We identified other factors related to these events.

OBJETIVO: Investigar la tasa de eventos adversos en pacientes con insuficiencia cardiaca aguda (ICA) clasificados de bajo riesgo por la escala MEESSI y dados de alta desde urgencias, la capacidad discriminativa de dicha escala para estos eventos en dichos pacientes y las variables asociadas. METODO: Se estratificó el riesgo de los pacientes del Registro EAHFE (cohortes 2-5) mediante la escala MEESSI y se analizaron los clasificados de bajo riesgo dados de alta desde urgencias. Se investigó la mortalidad por cualquier causa a 30 días (M-30d), la revisita a urgencias por ICA a 7 días (REV-7d) y la revisita a urgencias u hospitalización por ICA a 30 días (REV-H-30d). Se calculó el área bajo la curva (ABC) de la característica operativa del receptor (COR) de la escala MEESSI para estos eventos. Se analizó la relación entre 42 variables y RV-7d y RV-H-30d mediante regresión logística multivariable. RESULTADOS: Se incluyeron 1028 pacientes. La M-30d fue 1,6% (IC 95%: 0,9-2,5), la REV-7d fue 8,0% (6,4-9,8) y la REV-H-30d fue 24,7% (22,1-25,7). El ABC ROC de la puntuación MEESSI para discriminar estos eventos adversos fue 0,69 (0,58-0,80), 0,56 (0,49-0,63) y 0,54 (0,50-0,59), respectivamente. Se asociaron con RV-7d: tratamiento diurético crónico (OR 2,45; 1,01-5,98), hemoglobina < 110 g/L (1,68; 1,02-2,75) y tratamiento diurético intravenoso en urgencias (0,53; 0,31-0,90). Se asociaron con REV-H-30d: arteriopatía periférica (1,74; 1,01-3,00), episodios previos de ICA (1,42; 1,02-1,98), tratamiento crónico con inhibidores de receptores mineralocorticoides (1,71; 1,09-2,67), índice de Barthel en urgencias < 90 puntos (1,48; 1,07-2,06) y tratamiento diurético intravenoso en urgencias (0,58; 0,40-0,84). CONCLUSIONES: Los pacientes con ICA de bajo riesgo dados de alta desde urgencias presentan tasas de eventos adversos cercanas a los estándares recomendados internacionalmente. La escala MEESSI, diseñada para predecir M-30d, tiene escasa capacidad predictiva para REV-7d y REV-H-30d en los pacientes de bajo riesgo. Este estudio describe otros factores asociados a tales eventos.