The two different profiles in heart failure with preserved ejection fraction and type 2 diabetes mellitus: ischemic and diabetic.

OBJECTIVE: Two profiles of patients with heart failure with preserved ejection fraction (HFpEF) and type 2 diabetes mellitus (T2DM) can be discerned: those with ischemic and those with diabetic cardiomyopathy (DMC). We aim to analyze clinical differences and prognosis between patients of these two profiles. MATERIAL AND METHODS: This cohort study analyzes data from the Spanish Heart Failure Registry, a multicenter, prospective registry that enrolled patients admitted for decompensated heart failure and followed them for one year. Three groups were created according to the presence of T2DM and heart disease depending on the etiology (ischemic when coronary artery disease was present, or DMC when no coronary, valvular, or congenital heart disease; no hypertension; nor infiltrative cardiovascular disease observed on an endomyocardial biopsy). The groups and outcomes were compared. RESULTS: A total of 466 patients were analyzed. Group 1 (n = 210) included patients with ischemic etiology and T2DM. Group 2 (n = 112) included patients with DMC etiology and T2DM. Group 3 (n = 144), a control group, included patients with ischemic etiology and without T2DM. Group 1 had more hypertension and dyslipidemia; group 2 had more atrial fibrillation (AF) and higher body mass index; group 3 had more chronic kidney disease and were older. In the regression analysis, group 3 had a better prognosis than group 1 (reference group) for cardiovascular mortality and HF readmissions (HR 0.44;95%CI 0.2-1; p = .049). CONCLUSIONS: Patients with T2DM and HFpEF, who had the poorest prognosis, were of two different profiles: either ischemic or DMC etiology. The first had a higher burden of cardiovascular disease and inflammation whereas the second had a higher prevalence of obesity and AF. The first had a slightly poorer prognosis than the second, though this finding was not significant.

Safety of benzodiazepines in patients with acute heart failure: A propensity score-matching study.

AIM: Benzodiazepines (BZDs) are one of the most used drugs to control symptoms in patients with acute heart failure (HF). However, the evidence on its safety is inconclusive. The objective was to describe the characteristics of patients admitted for HF and treated with BZDs and to assess the relationship of this treatment and mortality. PATIENTS AND METHODS: We performed a cross-sectional, multicentre (74 Spanish hospitals), cohort study. Patients admitted for HF were divided depending on whether they were treated with BZDs or not. Propensity score analysis matched patients in both groups in a 1:1 manner according to different factors. The primary outcome was mortality at day 7. Secondary outcomes were mortality at days 30 and 180, as well as readmissions and emergency room visits at 180 days. RESULTS: We included 1855 patients: 639 (34.4%) had prescribed BZDs treatment versus 1216 (65.6%) who had not been treated. Patients receiving BZDs had advanced heart disease, severe symptoms, need more HF intensive treatment and higher mortality. After propensity matching 381 balanced paired cases were included in each group. Treatment with BZDs was not associated with greater risk of mortality at day 7 of index hospitalization (7.6% vs 5.2%, adjusted OR 1.49, 95% CI 0.83-2.68, p = 0.186). There were also no differences between groups in terms of mortality at day 30 and 180, readmissions or visits to the emergency room. CONCLUSIONS: Our data support that benzodiazepines could be safely used for improving symptoms. in patients admitted for acute HF in terms of short-medium term mortality.

Estimating the Prevalence of Cardiac Amyloidosis in Old Patients with Heart Failure-Barriers and Opportunities for Improvement: The PREVAMIC Study.

BACKGROUND: Cardiac amyloidosis (CA) could be a common cause of heart failure (HF). The objective of the study was to estimate the prevalence of CA in patients with HF. METHODS: Observational, prospective, and multicenter study involving 30 Spanish hospitals. A total of 453 patients ≥ 65 years with HF and an interventricular septum or posterior wall thickness > 12 mm were included. All patients underwent a 99mTc-DPD/PYP/HMDP scintigraphy and monoclonal bands were studied, following the current criteria for non-invasive diagnosis. In inconclusive cases, biopsies were performed. RESULTS: The vast majority of CA were diagnosed non-invasively. The prevalence was 20.1%. Most of the CA were transthyretin (ATTR-CM, 84.6%), with a minority of cardiac light-chain amyloidosis (AL-CM, 2.2%). The remaining (13.2%) was untyped. The prevalence was significantly higher in men (60.1% vs 39.9%, p = 0.019). Of the patients with CA, 26.5% had a left ventricular ejection fraction less than 50%. CONCLUSIONS: CA was the cause of HF in one out of five patients and should be screened in the elderly with HF and myocardial thickening, regardless of sex and LVEF. Few transthyretin-gene-sequencing studies were performed in older patients. In many patients, it was not possible to determine the amyloid subtype.

Chronic Obstructive Pulmonary Disease in Elderly Patients with Acute and Advanced Heart Failure: Palliative Care Needs-Analysis of the EPICTER Study.

Introduction: There are studies that evaluate the association between chronic obstructive pulmonary disease (COPD) and heart failure (HF) but there is little evidence regarding the prognosis of this comorbidity in older patients admitted for acute HF. In addition, little attention has been given to the extracardiac and extrapulmonary symptoms presented by patients with HF and COPD in more advanced stages. The aim of this study was to evaluate the prognostic impact of COPD on mortality in elderly patients with acute and advanced HF and the clinical manifestations and management from a palliative point of view. Methods: The EPICTER study ("Epidemiological survey of advanced heart failure") is a cross-sectional, multicenter project that consecutively collected patients admitted for HF in 74 Spanish hospitals. Demographic, clinical, treatment, organ-dependent terminal criteria (NYHA III-IV, LVEF <20%, intractable angina, HF despite optimal treatment), and general terminal criteria (estimated survival <6 months, patient/family acceptance of palliative approach, and one of the following: evidence of HF progression, multiple Emergency Room visits or admissions in the last six months, 10% weight loss in the last six months, and functional impairment) were collected. Terminal HF was considered if the patient met at least one organ-dependent criterion and all the general criteria. Both groups (HF with COPD and without COPD) were compared. A Kaplan−Meier survival analysis was performed to evaluate the presence of COPD on the vital prognosis of patients with HF. Results: A total of 3100 patients were included of which 812 had COPD. In the COPD group, dyspnea and anxiety were more frequently observed (86.2% vs. 75.3%, p = 0.001 and 35.4% vs. 31.2%, p = 0.043, respectively). In patients with a history of COPD, presentation of HF was in the form of acute pulmonary edema (21% vs. 14.4% in patients without COPD, p = 0.0001). Patients with COPD more frequently suffered from advanced HF (28.9% vs. 19.4%; p < 0.001). Consultation with the hospital palliative care service during admission was more frequent when patients with HF presented with associated COPD (94% vs. 6.8%; p = 0.036). In-hospital and six-month follow-up mortality was 36.5% in patients with COPD vs. 30.7% in patients without COPD, p = 0.005. The mean number of hospital admissions during follow-up was higher in patients with HF and COPD than in those with isolated HF (0.63 ± 0.98 vs. 0.51 ± 0.84; p < 0.002). Survival analysis showed that patients with a history of COPD had fewer survival days during follow-up than those without COPD (log Rank chi-squared 4.895 and p = 0.027). Conclusions: patients with HF and COPD had more severe symptoms (dyspnea and anxiety) and also a worse prognosis than patients without COPD. However, the prognosis of patients admitted to our setting is poor and many patients with HF and COPD may not receive the assessment and palliative care support they need. Palliative care is necessary in chronic non-oncologic diseases, especially in multipathologic and symptom-intensive patients. This is a clinical care aspect to be improved and evaluated in future research studies.

Cancer Impacts Prognosis on Mortality in Patients with Acute Heart Failure: Analysis of the EPICTER Study.

INTRODUCTION: Heart failure (HF) and cancer are currently the leading causes of death worldwide, with an increasing incidence with age. Little is known about the treatment received and the prognosis of patients with acute HF and a prior cancer diagnosis. OBJECTIVE: to determine the clinical characteristics, palliative treatment received, and prognostic impact of patients with acute HF and a history of solid tumor. METHODS: The EPICTER study ("Epidemiological survey of advanced heart failure") is a cross-sectional, multicenter project that consecutively collected patients admitted for acute HF in 74 Spanish hospitals. Patients were classified into two groups according to whether they met criteria for acute HF with and without solid cancer, and the groups were subsequently compared. A multivariable logistic regression analysis was conducted, using the forward stepwise method. A Kaplan-Meier survival analysis was performed to evaluate the impact of solid tumor on prognosis in patients with acute HF. RESULTS: A total of 3127 patients were included, of which 394 patients (13%) had a prior diagnosis of some type of solid cancer. Patients with a history of cancer presented a greater frequency of weight loss at admission: 18% vs. 12% (p = 0.030). In the cancer group, functional impairment was noted more frequently: 43% vs. 35%, p = 0.039). Patients with a history of solid cancer more frequently presented with acute HF with preserved ejection fraction (65% vs. 58%, p = 0.048) than reduced or mildly reduced. In-hospital and 6-month follow-up mortality was 31% (110/357) in patients with solid cancer vs. 26% (637/2466), p = 0.046. CONCLUSION: Our investigation demonstrates that in-hospital mortality and mortality during 6-month follow-up in patients with acute HF were higher in those subjects with a history of concomitant solid tumor cancer diagnosis.

Causas de muerte en pacientes hospitalizados en servicios de medicina interna por insuficiencia cardíaca según la fracción de eyección. Registro RICA / Causes of death in hospitalized patients in internal medicine departments with heart failure according to ejection fraction. RICA registry

IntroducciónLos datos disponibles de las causas de muerte en pacientes ingresados por insuficiencia cardíaca en servicios de medicina interna y en población española según fracción de eyección reducida (FER), preservada (FEP) e intermedia (FEI) son escasos. Su estudio puede mejorar el conocimiento de estos pacientes y su pronóstico.MétodosEstudio de cohortes multicéntrico y prospectivo de 4.144 pacientes que ingresaron por insuficiencia cardíaca en unidades de medicina interna. Se registraron sus características clínicas, tasa de fallecimientos y sus causas agrupadas según FEP (≥ 50%), FEI (40-49%) y FER (<40%) durante una mediana de seguimiento de un año.ResultadosSe registraron 1.198 fallecimientos (29%), de los que 833 fallecieron por causas cardiovasculares (69,5%), fundamentalmente por insuficiencia cardíaca (50%) y por muerte súbita (7,5%) y 365 por causas no cardiovasculares (NoCV) (30,5%), sobre todo por infecciones (13%). La causa más frecuente y temprana en todos los grupos fue la insuficiencia cardíaca. Los pacientes con FEP tenían menor tasa de muerte súbita y mayor de infecciones (p <0,05). Las causas de muerte en FEI fueron más parecidas a las de FEP.ConclusionesLas causas de muerte en pacientes con insuficiencia cardíaca fueron diferentes dependiendo del tipo de fracción de eyección. Los pacientes con FEI y FEP, por su elevada comorbilidad y mayor frecuencia de muerte NoCV, son los que más se beneficiarían de un manejo integral por parte de medicina interna.

Causes of death in hospitalized patients in internal medicine departments with heart failure according to ejection fraction. RICA registry. / Causas de muerte en pacientes hospitalizados en servicios de medicina interna por insuficiencia cardíaca según la fracción de eyección. Registro RICA.

INTRODUCTION: There are few data in the Spanish population about the causes of death in patients admitted to internal medicine departments for heart failure. Their study according to left ventricular ejection fraction (reduced: rEF, mid-range: mEF, and preserved: pEF) could improve the knowledge of patients and their prognosis. METHODS: Prospective multicentre cohort study of 4144 patients admitted with heart failure to internal medicine departments. Their clinical characteristics, mortality rate and causes were classified according to pEF (≥ 50%), mEF (40%-49%) and rEF (<40%). Patients were followed-up for a median of one year. RESULTS: There were 1198 deaths (29%). The cause of death was cardiovascular (CV) in 833 patients (69.5%), mainly heart failure (50%) and sudden cardiac death (7.5%). Non-cardiovascular (NoCV) causes were responsible for 365 deaths (30.5%). The most common NoCV causes were infections (13%). The most frequent and early cause in all groups was heart failure. Patients with pEF, compared to the other groups, had lower risk of sudden cardiac death and higher risk of infections (P <.05). The causes of death in patients with mrEF were closer to those with pEF. CONCLUSIONS: The causes of death in patients with heart failure were different depending on ejection fraction strata. Patients with mEF and pEF, due to their high comorbidity and higher frequency of NoCV death, would require comprehensive management by internal medicine.

Modes of death in heart failure according to age, sex and left ventricular ejection fraction.

Modes of death in patients with heart failure (HF) have been well characterized in randomized studies, but data from real-life are scarce, especially in the elderly, women and in HF with mid-range or preserved left ventricular ejection fraction (LVEF). Our purpose was to examine modes of death in HF patients according to age, sex and LVEF. We analysed the mode of death of HF patients from two prospective multicentre contemporary Spanish registries conducted by cardiologists (REDINSCOR, n = 2150) and by internists (RICA, n = 1396). Mode of death was pre-specified. Out of 3546 patients, 485 (13.7%) died during the 9-month follow-up. Cardiovascular (CV) causes were the most frequent, regardless of the age, sex and LVEF. More than half of patients died due to worsening HF in both groups of patients, followed by other non-CV causes in those attended by internists, and sudden cardiac death in those cared by cardiologists. Stroke was more common among elderly patients, women and HF with preserved LVEF. Non-CV causes, particularly infectious diseases, accounted for a remarkable proportion of deaths, especially in the elderly and in HF patients with preserved LVEF. Functional class, age and anaemia had a strong influence on both CV and non-CV death. CV death due to refractory HF was the most prevalent among our population, irrespective of age, sex or LVEF. However, a significant proportion of HF patients died from non-CV causes, particularly elderly with mid-range and preserved LVEF. These patients could benefit significantly from a multidisciplinary follow-up.

Prevalence of advanced heart failure and use of palliative care in admitted patients: Findings from the EPICTER study.

INTRODUCTION AND AIM: Palliative care in patients with advanced heart failure is strongly recommended by Clinical Practice Guidelines. We aimed to calculate the prevalence of advanced heart failure in admitted patients, to describe their management, and to analyse the factors that influence their referral to specialised palliative care. PATIENTS AND METHODS: Cross-sectional, multicentre study that consecutively included patients admitted for heart failure in 74 Spanish hospitals. If they met criteria for advanced heart failure, their treatment, complications and procedures were recorded. RESULTS: A total of 3153 patients were included. Of them, 739 (23%) met criteria for advanced heart failure. They were more likely to be women, older and to have a history of anaemia, chronic kidney disease and cognitive impairment. For their management, furosemide infusions (30%) and vasodilators (21%) were used. Refractory symptoms were treated with opioids (47%) and benzodiazepines (44%). Palliative care was only provided in the last hours of life in 48% of them. A multidisciplinary approach, involving palliative care specialists was sought in 15% of these patients. Treatment with furosemide infusions, an advanced New York Heart Association functional class, to meet advanced HF criteria and the presence of cancer were associated with the referral to specialised palliative care. CONCLUSIONS: Almost one in four patients admitted with HF met criteria of advanced disease. They were older and had more comorbidities. Specialist palliative care services were involved in only a minority of patients, mainly those who were highly symptomatic or had cancer.

Pleural effusions in acute decompensated heart failure: Prevalence and prognostic implications.

BACKGROUND: The incidence of pleural effusions (PEs) in acute decompensated heart failure (ADHF) is not well established. We aimed to determine their prevalence, clinical characteristics and prognostic implications. METHODS: Retrospective review of 3245 consecutive patients with ADHF from the Spanish RICA Registry. The clinical characteristics of those with or without PEs on chest radiographs were compared and a predictive PE model was generated. RESULTS: Patient's median age was 80 years and 60% had a left ventricular ejection fraction (LVEF) >50%. PEs were seen in 46% of the cases, and their distribution was as follows: 58% bilateral, 27% right-sided and 14% left-sided. Male gender (OR 2.18; 95%CI 1.23-3.87), serum amino-terminal fraction of the pro-brain natriuretic peptide (NT-pro-BNP) levels >3500 pg/ml (OR 2.2; 95%CI 1.25-3.77), estimated systolic pulmonary artery pressure (sPAP) >55 mm Hg by echocardiography (OR 2.05; 95%CI 1.12-3.75), and serum prealbumin <15 mg/l (OR 1.96; 95%CI 1.08-3.52) were associated with PE development in a multivariate analysis. Serum NT-proBNP >8000 pg/ml, and systolic arterial pressure <110 mm Hg, but not PEs, independently predicted overall 1-year mortality. CONCLUSIONS: PEs are present on chest radiographs in nearly half of ADHF patients. They are mainly bilateral or right-sided and predominate in males with elevated sPAP on echocardiography and high serum levels of NT-proBNP. PEs do not independently predict 1-year mortality.

Heart failure with mid-range ejection fraction in patients admitted to internal medicine departments: Findings from the RICA Registry.

AIM: To improve the knowledge on characteristics, treatment and prognosis in patients with heart failure (HF) and mid-range ejection fraction discharged after an acute HF episode. METHODS: We prospectively included and followed 2753 patients admitted with HF to Internal Medicine units. Patients were classified according to ejection fraction (EF) into three strata: reduced, EF <40% (HFrEF); mid-range EF 40-49% (HFmrEF); and preserved EF ≥50% (HFpEF). Clinical, echocardiographic, laboratory data and treatment at discharge were recorded and the groups were compared. A multivariable analysis was performed to evaluate the association of EF with outcomes in these three groups. RESULTS: A total of 10.2% of patients had HFmrEF. They were more likely to be men and to have a history of chronic kidney disease and higher levels of NT-proBNP than those with HFpEF. Compared to patients with HFrEF, these patients had less frequently ischaemic aetiology and chronic obstructive pulmonary disease, and a higher proportion of atrial fibrillation and hypertension. In HFmrEF, the use of beta-blockers, aldosterone antagonists and antiplatelet drugs was lower than in HFrEF, but the use of calcium channel blockers and anticoagulants was higher. There were no differences between groups in 30-day and 1-year readmission rates. However, patients with HFrEF had significantly higher 1-year mortality (28%) than patients with HFmrEF and HFpEF (20% and 22%, p<0.001). CONCLUSIONS: Clinical characteristics and treatment among patients with HF differ depending on EF strata. Prognosis of patients with HFmrEF is closer to that of HFpEF, being medium term survival better than in HFrEF.

Insuficiencia cardiaca: ¿importa la especialidad que la trate? / Heart failure: does it matter which speciality treats it?

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Impacto pronóstico de la especialidad en el paciente ambulatorio con insuficiencia cardiaca: un análisis emparejado de los registros REDINSCOR y RICA / Prognostic impact of physician specialty on the prognosis of outpatients with heart failure: propensity matched analysis of the REDINSCOR and RICA registries

Introducción y objetivos: La especialidad responsable del paciente hospitalizado por insuficiencia cardiaca (IC) tiene impacto pronóstico, pero esta cuestión no está clara en el medio ambulatorio. Nuestro objetivo es comparar el perfil clínico y pronóstico de pacientes ambulatorios con IC tratados por cardiólogos o internistas. Métodos: Estudio retrospectivo en el que se analizan los datos de 2 registros multicéntricos nacionales, REDINSCOR (n = 2.150, cardiología) y RICA (n = 1.396, medicina interna). Para medir el efecto del especialista, se realizó un emparejamiento por puntuación de propensión que incluyó sus principales diferencias clínicas. Resultados: Los pacientes a cargo de cardiología fueron frecuentemente varones, jóvenes, con IC isquémica y fracción de eyección del ventrículo izquierdo (FEVI) reducida. Entre los seguidos por medicina interna predominó el sexo femenino, la edad avanzada, un mayor porcentaje con FEVI preservada y comorbilidades. La mortalidad a los 9 meses fue menor entre los pacientes del REDINSCOR (el 11,6 frente al 16,9%; p < 0,001), con una tasa de reingreso por IC similar (el 15,7 frente al 16,9%; p = 0,349). La puntuación de propensión seleccionó a 558 parejas comparables y continuó mostrando una mortalidad significativamente menor entre los pacientes tratados por cardiología (el 12,0 frente al 18,8%; riesgo relativo = 0,64; intervalo de confianza del 95%, 0,48-0,85; p = 0,002), sin diferencias en el reingreso (el 18,1 frente al 17,2%; riesgo relativo = 0,95; intervalo de confianza del 95%, 0,74-1,22; p = 0,695). Conclusiones: Edad, sexo, FEVI y comorbilidades contribuyen al distinto perfil de los pacientes con IC según especialidad. Después del emparejamiento por puntuación de propensión, la mortalidad a los 9 meses fue menor entre los pacientes a cargo de cardiología (AU)

Introduction and objectives: The specialty treating patients with heart failure (HF) has a prognostic impact in the hospital setting but this issue remains under debate in the ambulatory environment. We aimed to compare the clinical profile and outcomes of outpatients with HF treated by cardiologists or internists. Methods: We analyzed the clinical, electrocardiogram, laboratory, and echocardiographic data of 2 prospective multicenter Spanish cohorts of outpatients with HF treated by cardiologists (REDINSCOR, n = 2150) or by internists (RICA, n = 1396). Propensity score matching analysis was used to test the influence of physician specialty on outcome. Results: Cardiologist-treated patients were often men, were younger, and had ischemic etiology and reduced left ventricular ejection fraction (LVEF). Patients followed up by internists were predominantly women, were older, and a higher percentage had preserved LVEF and associated comorbidities. The 9-month mortality was lower in the REDINSCOR cohort (11.6% vs 16.9%; P < .001), but the 9-month HF-readmission rates were similar (15.7% vs 16.9%; P = .349). The propensity matching analysis selected 558 pairs of comparable patients and continued to show significantly lower 9-month mortality in the cardiology cohort (12.0% vs 18.8%; RR, 0.64; 95% confidence interval [95%CI], 0.48-0.85; P = .002), with no relevant differences in the 9-month HF-readmission rate (18.1% vs 17.2%; RR, 0.95; 95%CI, 0.74-1.22; P = .695). Conclusions: Age, sex, LVEF and comorbidities were major determinants of specialty-related referral in HF outpatients. An in-depth propensity matched analysis showed significantly lower 9-month mortality in the cardiologist cohort (AU)

Prognostic Impact of Physician Specialty on the Prognosis of Outpatients With Heart Failure: Propensity Matched Analysis of the REDINSCOR and RICA Registries.

INTRODUCTION AND OBJECTIVES: The specialty treating patients with heart failure (HF) has a prognostic impact in the hospital setting but this issue remains under debate in the ambulatory environment. We aimed to compare the clinical profile and outcomes of outpatients with HF treated by cardiologists or internists. METHODS: We analyzed the clinical, electrocardiogram, laboratory, and echocardiographic data of 2 prospective multicenter Spanish cohorts of outpatients with HF treated by cardiologists (REDINSCOR, n=2150) or by internists (RICA, n=1396). Propensity score matching analysis was used to test the influence of physician specialty on outcome. RESULTS: Cardiologist-treated patients were often men, were younger, and had ischemic etiology and reduced left ventricular ejection fraction (LVEF). Patients followed up by internists were predominantly women, were older, and a higher percentage had preserved LVEF and associated comorbidities. The 9-month mortality was lower in the REDINSCOR cohort (11.6% vs 16.9%; P<.001), but the 9-month HF-readmission rates were similar (15.7% vs 16.9%; P=.349). The propensity matching analysis selected 558 pairs of comparable patients and continued to show significantly lower 9-month mortality in the cardiology cohort (12.0% vs 18.8%; RR, 0.64; 95% confidence interval [95%CI], 0.48-0.85; P=.002), with no relevant differences in the 9-month HF-readmission rate (18.1% vs 17.2%; RR, 0.95; 95%CI, 0.74-1.22; P=.695). CONCLUSIONS: Age, sex, LVEF and comorbidities were major determinants of specialty-related referral in HF outpatients. An in-depth propensity matched analysis showed significantly lower 9-month mortality in the cardiologist cohort.

Heart Failure with Recovered Ejection Fraction in a Cohort of Elderly Patients with Chronic Heart Failure.

OBJECTIVE: The aim of this study was to determine whether patients with heart failure (HF) who recover left ventricular ejection fraction (LVEF), termed here as 'Rec-HF', have a distinct clinical profile and prognosis compared with patients with HF and reduced LVEF (HF-REF) or HF and preserved LVEF (HF-PEF). METHODS: We evaluated and classified patients from the Spanish Heart Failure Registry into three categories based on enrollment/follow-up echocardiograms: HF-PEF (LVEF ≥50%), HF-REF (LVEF persistently <50%) and Rec-HF (LVEF on enrollment <50% but normalized during follow-up). RESULTS: A total of 1,202 patients were included, 1,094 with HF-PEF, 81 with HF-REF and 27 with Rec-HF. The three groups included patients of advanced age (mean age 75 years) with comorbidities. Rec-HF patients were younger, with a better functional status, lower prevalence of diabetes mellitus, dementia and cerebrovascular disease, and higher prevalence of COPD. The etiology of HF was more frequently ischemic and alcoholic and less frequently hypertensive. After a median follow-up of 367 days, the unadjusted hazard ratios for death in the Rec-HF versus HF-PEF and HF-REF groups were 0.11 (95% CI 0.02-080; p = 0.029) and 0.31 (95% CI 0.04-2.5; p = 0.274). Results were statistically nonsignificant in multivariate-adjusted models. CONCLUSION: Rec-HF is also present in elderly patients with HF but it is necessary to further investigate the natural history and optimal pharmacologic management of this 'new HF syndrome'.

Precipitating factors of heart failure admission: Differences related to age and left ventricular ejection fraction.

AIM: To evaluate precipitating factors (PF) of exacerbation in heart failure (HF) and their relationship with age, preserved vs. reduced left ventricular ejection fraction (LVEF) and short-term prognosis. METHODS: We included and followed 2962 patients admitted with acute HF to Internal Medicine Units. Several PF were identified. Differences in PF according to preserved vs. reduced LVEF and age (patients≥80years vs. younger) were analyzed. Primary endpoints were readmission due to worsening HF and all-cause mortality at 3months follow-up. Multivariable Cox models were conducted to identify the independent predictors of 3-months mortality and readmission. RESULTS: More than half of the patients were 80years and over, 47% were women and 61% had preserved LVEF. Atrial fibrillation (AF) and myocardial ischemia were the more common cause of decompensation among octogenarians. It was more frequent to find myocardial ischemia or non-adherence to treatment as precipitants in patients with systolic dysfunction. However, respiratory infections, AF and poor control of blood pressure were more usual in patients with preserved LVEF compared to those with LVEF <50%. Patients admitted for HF precipitated by myocardial ischemia had a higher risk of readmission at 3months (HR 1.49; CI 95%: 1.12-1.99, p=0.006) and the longest hospital stay (12days). PF showed no predictive value for mortality. CONCLUSION: Myocardial ischemia as a PF was an independent marker for HF readmissions at 3-months follow-up. Precipitants are different depending on the age and LVEF of patients. Their identification could improve risk stratification and prevention strategies.

Relationship between osteoprotegerin and mortality in decompensated heart failure with preserved ejection fraction.

AIM: The aim of this study was to evaluate whether osteoprotegerin - an emerging inflammatory biomarker in cardiovascular diseases - predicts outcomes in patients with acute heart failure and preserved ejection fraction. METHODS: We measured urea, creatinine, hemoglobin, high-sensitivity C-reactive protein, N-terminal pro-B-type natriuretic peptide and osteoprotegerin on admission in 177 patients admitted with decompensated heart failure and left ventricular ejection fraction at least 45%. The population was divided according to the median values of osteoprotegerin (158.6 ng/l). Primary and secondary endpoints were all-cause mortality and death/readmission at 1-year follow-up, respectively. Multivariable Cox models were generated for osteoprotegerin and common risk factors. We also evaluated the reclassification of patients into risk categories after adding this biomarker to the model. RESULTS: A total of 43 patients died during the follow-up and 84 had a combined event. Kaplan-Meier curves showed significantly increased primary and secondary endpoints according to the median of osteoprotegerin (log-rank, P < 0.0001 and 0.001, respectively). After adjustment for age, estimated glomerular filtration rate, hemoglobin, N-terminal pro-B-type natriuretic peptide, BMI and New York Heart Association III-IV, osteoprotegerin was a significant predictor of primary endpoint evaluated as continuous and categorized variable (relative risk 2.49, 95% confidence interval 1.18-5.24, P = 0.016 and relative risk 2.35, 95% confidence interval 1.11-4.96, P = 0.025, respectively). The clinical prediction model with osteoprotegerin evaluated with Net Reclassification Index was not significant. CONCLUSION: Osteoprotegerin is independently associated with all-cause mortality in patients hospitalized for heart failure with preserved ejection fraction. However, adding this biomarker into a risk model does not improve its prediction value.

Troponin T in acute heart failure: clinical implications and prognosis in the Spanish National Registry on Heart Failure.

BACKGROUND: Elevated troponin in heart failure has been associated with worse prognosis, but there are differences in the design and results of published studies. Our objective was to determine the association of troponin T with mortality and readmissions in patients with acute heart failure in clinical practice conditions. METHODS: We included patients from the RICA registry who were hospitalized for acute heart failure. They were classified into 3 groups according to troponin T levels: normal, intermediate and high (<0.02, 0.02-0.049 and ≥ 0.05 ng/mL, respectively). Survival was studied by Kaplan-Meier curves and the association of variables was tested by Cox regression analysis. RESULTS: A total of 406 patients was included. Average age was 76.9 (76.0-77.7) years. Hypertensive heart disease was the most common etiology. Left ventricular ejection fraction was <45% in 22.1% of the patients. The group with elevated troponin T had higher proportions of women, systolic dysfunction, renal failure and anemia, a lower body mass index and longer hospital stay. At one year, patients with elevated troponin T had higher mortality than patients with normal troponin (35.5 vs. 13.9%, p<0.001). The composite event (mortality and readmissions) was also more frequent (51.6 vs. 30.9%, p<0.001), but there were no differences in readmissions alone. Troponin T ≥ 0.02 ng/mL was independently associated with mortality. CONCLUSIONS: Elevated troponin T levels are common in patients with heart failure in clinical practice and are associated with increased mortality and events after one year of follow-up.