Utilidad pronóstica de la presión de pulso en pacientes con insuficiencia cardiaca con fracción de eyección preservada: Registro RICA / Prognostic utility of pulse pressure in patients with heart failure with preserved ejection fraction: The RICA Registry

Background and aims The prognostic role of pulse pressure (PP) in heart failure (HF) patients with preserved left ventricular ejection fraction (LVEF) is not well understood. Our aim was to evaluate it in acute and stable HF. Material and methods This work is a retrospective observational study of patients included in the RICA registry between 2008 and 2021. Blood pressure was collected on admission (decompensation) and 3 months later on an outpatient basis (stability). Patients were categorized according to whether the PP was greater or less than 50mmHg. All-cause mortality was assessed at 1year after admission. Results A total of 2291 patients were included, with mean age 80.1±7.7 years. 62.9% were women and 16.7% had a history of coronary heart disease. In the acute phase, there was no difference in mortality according to PP values, but in the stable phase PP<50mmHg was independently associated with all-cause mortality at 1-year follow-up (HR 1.57, 95% CI 1.21−2.05, p=0.001), after adjusting for age, sex, New York Heart Association functional class, previous HF, chronic kidney disease, valvular heart disease, cerebrovascular disease, score on the Barthel and Pfeiffer scales, hemoglobin and sodium levels. Conclusion Low stable-phase PP was associated with increased all-cause mortality in HF patients with preserved LVEF. However, PP was not useful as a prognostic marker of mortality in acute HF. Further studies are needed to assess the relationship of this variable with mortality in HF patients (AU)

Antecedentes y objetivo El papel pronóstico de la presión de pulso (PP) en pacientes con insuficiencia cardiaca (IC) con fracción de eyección de ventrículo izquierdo (FEVI) preservada no es bien conocido. Nuestro objetivo fue evaluarlo en fases de descompensación y de estabilidad. Material y métodos Estudio observacional retrospectivo de pacientes incluidos en registro RICA entre 2008 y 2021. La presión arterial se recogió al ingreso (descompensación) y a los 3 meses (estabilidad). Se calculó la PP y los pacientes se categorizaron según PP mayor/igual vs menor de 50mmHg. Se evaluó la mortalidad por todas las causas al año del ingreso. Resultados Se incluyeron 2.291 pacientes, con edad media 80,1±7,7 años. El 62,9% eran mujeres y un 16,7% tenían antecedentes de cardiopatía isquémica. En fase aguda, no hubo diferencias en la mortalidad según los valores de PP, pero en fase estable una PP<50mmHg se asoció de forma independiente con mortalidad por todas las causas al año de seguimiento (HR 1,57, IC 95% 1,21-2,05; p=0,001), una vez controlado por edad, sexo, NYHA, IC previa, enfermedad renal crónica, valvulopatía, enfermedad cerebrovascular, Barthel, Pfeiffer, hemoglobina y sodio. Conclusione Una PP baja en fase estable se asoció con mayor mortalidad por todas las causas en pacientes con IC con FEVI preservada. Sin embargo, la PP no demostró ser un factor pronóstico en fase de descompensación. Se necesitan más estudios que valoren la relación de esta variable con la mortalidad en los pacientes con IC (AU)

Prognostic utility of pulse pressure in patients with heart failure with preserved ejection fraction: The RICA Registry.

BACKGROUND AND AIMS: The prognostic role of pulse pressure (PP) in heart failure (HF) patients with preserved left ventricular ejection fraction (LVEF) is not well understood. Our aim was to evaluate it in acute and stable HF. MATERIAL AND METHODS: This work is a retrospective observational study of patients included in the RICA registry between 2008 and 2021. Blood pressure was collected on admission (decompensation) and 3 months later on an outpatient basis (stability). Patients were categorized according to whether the PP was greater or less than 50mmHg. All-cause mortality was assessed at 1year after admission. RESULTS: A total of 2291 patients were included, with mean age 80.1±7.7 years. 62.9% were women and 16.7% had a history of coronary heart disease. In the acute phase, there was no difference in mortality according to PP values, but in the stable phase PP<50mmHg was independently associated with all-cause mortality at 1-year follow-up (HR 1.57, 95% CI 1.21-2.05, p=0.001), after adjusting for age, sex, New York Heart Association functional class, previous HF, chronic kidney disease, valvular heart disease, cerebrovascular disease, score on the Barthel and Pfeiffer scales, hemoglobin and sodium levels. CONCLUSIONS: Low stable-phase PP was associated with increased all-cause mortality in HF patients with preserved LVEF. However, PP was not useful as a prognostic marker of mortality in acute HF. Further studies are needed to assess the relationship of this variable with mortality in HF patients.

Beneficios de un modelo asistencial integral en pacientes con insuficiencia cardíaca y fracción de eyección preservada: Programa UMIPIC / Benefits of a comprehensive care model in patients with heart failure and preserved ejection fraction: The UMIPIC program

Antecedentes Los pacientes con insuficiencia cardíaca (IC) y fracción de eyección preservada (ICFEp), a diferencia de aquellos con fracción de eyección reducida, son más ancianos, presentan más comorbilidades y no son candidatos a medidas terapéuticas eficaces. Por todo ello presentan un riesgo elevado de ingreso hospitalario y mortalidad. En este estudio se evaluó el beneficio de un modelo asistencial, caracterizado por una atención integral y continuada (programa UMIPIC) en pacientes con ICFEp. Métodos Se analizaron prospectivamente los datos de 2.401 pacientes con ICFEp atendidos en servicios de medicina interna, procedentes del registro RICA. Se dividieron en 2 grupos, uno en seguimiento en el programa UMIPIC (grupo UMIPIC, n: 1.011) y otro atendido de forma convencional (grupo RICA, n: 1.390). Se seleccionaron por emparejamiento (propensity score matching) 753 pacientes en cada grupo y se evaluaron los ingresos y la mortalidad durante 12 meses de seguimiento, tras un episodio de hospitalización por IC. Resultados El grupo UMIPIC, con respecto al RICA, en la cohorte emparejada, tuvo una menor tasa de ingresos por IC (19,2% frente a 36,5% respectivamente; hazard ratio [HR]=0,56; intervalo de confianza del 95% [IC 95%]: 0,45-0,68; p<0,001) y de mortalidad (12,6% frente a 28%, respectivamente; HR=0,40; IC 95%: 0,31-0,51; p<0,001). No se observaron diferencias en cuanto a ingresos por causas distintas a la IC. Conclusiones La implementación del programa asistencial UMIPIC a pacientes con ICFEp y elevada comorbilidad, basado en una atención integral y continuada, reduce tanto los ingresos como la mortalidad al año de seguimiento (AU)

Background Patients with heart failure (HF) and preserved ejection fraction (HFpEF), in contrast to those with reduced ejection fraction, are older, have more comorbidities, and are not candidates for effective therapeutic measures. Therefore, they are at high risk for hospital admission and mortality. This study evaluated the benefit of a comprehensive continuous care program (UMIPIC program) in patients with HFpEF. Methods We prospectively analyzed data on 2,401 patients with HFpEF attended to in internal medicine departments who form part of the RICA registry. They were divided into 2 groups: one was followed-up on in the UMIPIC program (UMIPIC group, n: 1,011) and another received conventional care (RICA group, n: 1,390). A total of 753 patients in each group were selected by propensity score matching and admissions and mortality were assessed during 12 months of follow-up after an episode of hospitalization due to HF. Results Compared to the RICA group, the UMIPIC group had a lower rate of HF admissions (19.2% versus 36.5%, respectively; hazard ratio [HR]=0.56; 95% confidence interval [CI]: 0.45-0.68; p<.001) and mortality (12.6% versus 28%, respectively; HR=0.40; 95% CI: 0.31-0.51; p<.001). There were no differences in hospitalizations for non-HF causes. Conclusions Implementation of the UMIPIC program, which is based on comprehensive continuous care, for patients with HFpEF and a high degree of comorbidity reduces both admissions and mortality in the first year of follow-up (AU)

Benefits of a comprehensive care model in patients with heart failure and preserved ejection fraction: The UMIPIC program.

BACKGROUND: Patients with heart failure (HF) and preserved ejection fraction (HFpEF), in contrast to those with reduced ejection fraction, are older, have more comorbidities, and are not candidates for effective therapeutic measures. Therefore, they are at high risk for hospital admission and mortality. This study evaluated the benefit of a comprehensive continuous care program (UMIPIC program) in patients with HFpEF. METHODS: We prospectively analyzed data on 2401 patients with HFpEF attended to in internal medicine departments who form part of the RICA registry. They were divided into 2 groups: one was followed-up on in the UMIPIC program (UMIPIC group, n: 1011) and another received conventional care (RICA group, n: 1390). A total of 753 patients in each group were selected by propensity score matching and admissions and mortality were assessed during 12 months of follow-up after an episode of hospitalization due to HF. RESULTS: Compared to the RICA group, the UMIPIC group had a lower rate of HF admissions (19.2% versus 36.5%, respectively; hazard ratio [HR] = 0.56; 95% confidence interval [CI]: 0.45-0.68; p < 0.001) and mortality (12.6% versus 28%, respectively; HR = 0.40; 95% CI: 0.31-0.51; p < 0.001). There were no differences in hospitalizations for non-HF causes. CONCLUSIONS: Implementation of the UMIPIC program, which is based on comprehensive continuous care, for patients with HFpEF and a high degree of comorbidity reduces both admissions and mortality in the first year of follow-up.

Valor pronóstico a corto plazo de la proteína C reactiva en ancianos con insuficiencia cardíaca aguda / The short-term prognostic value of C-reactive protein in elderly patients with acute heart failure

Introducción y objetivos: la proteína C reactiva (PCR) plasmática ha sido evaluada como marcador pronóstico en insuficiencia cardíaca aguda (ICA). Sin embargo, no está confirmado que posea validez pronóstica cuando la población de ICA analizada está constituida por pacientes de edad avanzada. Métodos: analizamos los valores plasmáticos de PCR en todos los pacientes ingresados en servicios de medicina interna por ICA de cualquier tipo. Evaluamos la asociación existente entre dichos valores, las características clínicas basales de los pacientes y las tasas de mortalidad y reingreso por cualquier causa a los 3 meses del alta. Para las comparaciones se estratificó a los pacientes en terciles de valor de PCR bajo, medio y alto (< 2,24mg/l, 2,25-11,8mg/l y>11,8mg/l, respectivamente). Resultados: se incluyó a 1.443 pacientes, con una mediana de edad de 80 años (rango intercuartílico 73-85); de ellos, 680 (47%) eran hombres, con una carga de comorbilidad moderada; el 60,1% presentaba fracción de eyección del ventrículo izquierdo preservada (> 50%). El análisis multivariante confirmó la existencia de una asociación independiente entre valores elevados de PCR al ingreso y la presencia de infección respiratoria, presión sistólica baja y función renal alterada. Tres meses después del ingreso índice, un total de 142 pacientes (9,8%) habían fallecido y 268 (18,6%) habían reingresado o habían muerto. Los valores de la PCR en el momento del ingreso no se correlacionaron con la tasa de mortalidad por cualquier causa a los 3 meses (p=0,79), ni con la tasa a los 3 meses de reingreso por cualquier causa (p=0,96) o con la combinación de ambos acontecimientos (p=0,96). Sin embargo, los valores altos de la PCR se asociaron a estancias hospitalarias más prolongadas (p<0,001). Conclusión: nuestro estudio no confirma la existencia de una asociación entre los valores de PCR plasmáticos presentes en el ingreso en los ancianos con ICA con un mayor riesgo de mortalidad o reingreso a los 3 meses

Introduction and objectives: plasma c-reactive protein (crp) has been tested as a prognostic marker in acute heart failure (ahf). Whether its measurement really provides significant prognostic information when applied to elderly patients with ahf episodes remains unclear. Methods: we measured the plasma crp values of patients admitted because of any type of ahf to internal medicine services. We evaluated the association of these values with the patients' baseline clinical characteristics and their 3-month posdischarge all-cause mortality or readmission rates. For comparison purposes, we divided the sample in tertiles of low, medium and high crp values (<2,24mg/l, 2,25-11,8mg/l and>11,8mg/l). Results: we included 1443 patients with a median age of 80 years (interquartile range 73-85); 680 (47%) were men, with a moderate comorbid burden. 60.1% had preserved left ventricular ejection fraction (> 50%). Multivariate analysis confirmed an independent association between higher crp values and the presence of respiratory infection, lower systolic blood pressure and deteriorated renal function upon admission. Three months after the index admission, a total of 142 patients (9.8%) had died, and 268 (18.6%) had either been readmitted or died. admission crp values did not correlate with 3-month all-cause mortality (P=0.79), 3-month all-cause readmission (P=0.96) or the combination of both events (P=0.96). However, higher crp values were associated with a longer length of stay (P<0.001). Conclusion: our study does not confirm an association between admission plasma crp values in elderly ahf patients and subsequent higher 3-month mortality or readmission risks

The short-term prognostic value of C-reactive protein in elderly patients with acute heart failure. / Valor pronóstico a corto plazo de la proteína C reactiva en ancianos con insuficiencia cardíaca aguda.

INTRODUCTION AND OBJECTIVES: Plasma c-reactive protein (crp) has been tested as a prognostic marker in acute heart failure (ahf). Whether its measurement really provides significant prognostic information when applied to elderly patients with ahf episodes remains unclear. METHODS: We measured the plasma crp values of patients admitted because of any type of ahf to internal medicine services. We evaluated the association of these values with the patients' baseline clinical characteristics and their 3-month posdischarge all-cause mortality or readmission rates. For comparison purposes, we divided the sample in tertiles of low, medium and high crp values (<2,24mg/l, 2,25-11,8mg/l and>11,8mg/l). RESULTS: We included 1443 patients with a median age of 80 years (interquartile range 73-85); 680 (47%) were men, with a moderate comorbid burden. 60.1% had preserved left ventricular ejection fraction (> 50%). Multivariate analysis confirmed an independent association between higher crp values and the presence of respiratory infection, lower systolic blood pressure and deteriorated renal function upon admission. Three months after the index admission, a total of 142 patients (9.8%) had died, and 268 (18.6%) had either been readmitted or died. admission crp values did not correlate with 3-month all-cause mortality (P=0.79), 3-month all-cause readmission (P=0.96) or the combination of both events (P=0.96). However, higher crp values were associated with a longer length of stay (P<0.001). CONCLUSION: Our study does not confirm an association between admission plasma crp values in elderly ahf patients and subsequent higher 3-month mortality or readmission risks.

Lesión de órganos diana en la insuficiencia cardiaca aguda / Target organ damage in acute heart failure

La insuficiencia cardiaca aguda es un condicionante pronóstico, tanto por su alta morbimortalidad durante el episodio agudo, como por el incremento de acontecimientos adversos a medio y largo plazo. Los mecanismos fisiopatológicos desencadenados durante la agudización podrían no cesar al alcanzarse la estabilidad clínica, manteniéndose una vez pasado el episodio agudo. De este modo, persistiría cierto grado de activación neurohormonal, estrés oxidativo, apoptosis e inflamación, entre otros, que conllevaría daño orgánico, no exclusivamente miocárdico, sino probablemente generalizado sobre el aparato cardiovascular. Esta nueva percepción de la persistencia de los mecanismos lesivos más allá de las agudizaciones puede ser el inicio de un cambio de perspectiva para el desarrollo de nuevas estrategias terapéuticas que persiguen un control global, tanto de los cambios hemodinámicos y congestivos que acontecen durante la descompensación cardiaca aguda, como de los remanentes tras alcanzarse la estabilidad clínica (AU)

Acute heart failure is a prognostic factor due to its high mortality during the acute phase and the increased frequency of medium to long-term adverse events. The pathophysiological mechanisms triggered during these exacerbations can persist after reaching clinical stability, remaining even after the acute episode has ended. A certain degree of neurohormonal activation, oxidative stress, apoptosis and inflammation (among other conditions) can therefore persist, resulting in organ damage, not just of the myocardium but likely the entire cardiovascular apparatus. This new insight into the persistence of harmful mechanisms that last beyond the exacerbations could be the start of a change in perspective for developing new therapeutic strategies that seek an overall control of hemodynamic and congestive changes that occur during acute decompensated heart failure and changes that remain after achieving clinical stability (AU)

Target organ damage in acute heart failure.

Acute heart failure is a prognostic factor due to its high mortality during the acute phase and the increased frequency of medium to long-term adverse events. The pathophysiological mechanisms triggered during these exacerbations can persist after reaching clinical stability, remaining even after the acute episode has ended. A certain degree of neurohormonal activation, oxidative stress, apoptosis and inflammation (among other conditions) can therefore persist, resulting in organ damage, not just of the myocardium but likely the entire cardiovascular apparatus. This new insight into the persistence of harmful mechanisms that last beyond the exacerbations could be the start of a change in perspective for developing new therapeutic strategies that seek an overall control of hemodynamic and congestive changes that occur during acute decompensated heart failure and changes that remain after achieving clinical stability.

Prognostic value of glomerular filtration rate estimation equations in acute heart failure with preserved versus reduced ejection fraction.

AIMS: Renal function is an important prognostic factor in heart failure. The aim of this study was to compare the predictive value of estimated renal function calculated by the Chronic Kidney Disease-Epidemiology Collaboration equation (CKD-EPI) and the abbreviated Modification of Diet in Renal Disease (MDRD-4) equation for long-term all-cause mortality in patients admitted for acute decompensated heart failure (ADHF) with both preserved ejection fraction (HF-PEF) and reduced ejection fraction (HF-REF). METHODS AND RESULTS: We evaluated patients included in the Spanish National Registry of Heart Failure (RICA). RICA is a multicentre, prospective, cohort study that included patients admitted to the Internal Medicine units with ADHF. Estimated glomerular filtration rate (eGFR) was calculated with CKD-EPI and MDRD-4 equations. A total of 1805 patients admitted for ADHF were studied (52% women; median age 80 years, interquartile range 73.9-84.6 years); of these, 1044 (58%) had HF-PEF. eGFR values were lower with the CKD-EPI formula than with the MDRD-4 formula (51 ml/min/1.73 m(2) vs. 55.7 ml/min/1.73 m(2) ; p < 0.001). The two formulas provided independent prognostic information over long-term follow-up, in both HF-PEF and HF-REF patients. However, in HF-PEF patients, CKD-EPI equation was associated with a significant improvement in reclassification analyses (net reclassification improvement 6.78%; p = 0.009). CONCLUSIONS: In this clinical cohort of ADHF patients, eGFR as calculated by both the CKD-EPI and the MDRD-4 formulas offered similar prognostic information, irrespective of ejection fraction status, but in HF-PEF patients specifically, the CKD-EPI formula seems to improve clinical risk stratification as compared with MDRD-4.