The Association Between Intra-abdominal Pressure and Diuretic Response in Heart Failure.

PURPOSE OF THE REVIEW: An efficient diuretic response is vital during cardiac decompensation in heart failure (HF) patients. The increase in intra-abdominal pressure (IAP) could be one of the keys for understanding cardiorenal syndrome and guiding diuretic treatment during hospitalization. In this review, we analyze the relationship between IAP and diuretic response in HF patients. RECENT FINDINGS: Increased IAP is associated with worsening renal function (WRF) in patients with advanced HF. Furthermore, the persistence of a rise in IAP after the first 72 h of intravenous diuretic treatment has been correlated with a worse diuretic response, a higher degree of congestion, and an impaired prognosis. The rise in IAP in HF patients has been associated with impaired renal function and a lower diuretic response. Nonetheless, more studies are needed to elucidate the actual role of IAP in congestive nephropathy and whether it may help guide diuretic therapy during acute decompensations.

Variación de la presión intraabdominal en los pacientes con insuficiencia cardíaca aguda según la fracción de eyección ventricular izquierda. Resultados del estudio PIA / Variation in intraabdominal pressure in patients with acute heart failure according to left ventricular ejection fraction. Results of an intraabdominal pressure study

Antecedentes El aumento de la presión intraabdominal (PIA) se ha correlacionado con elevación de la creatinina en pacientes con insuficiencia cardíaca con fracción de eyección ventricular izquierda gravemente deprimida (ICFEr). Sin embargo, dicha variable no se ha explorado en pacientes más estables o con insuficiencia cardíaca y fracción de eyección preservada (ICFEp). Pacientes y método Estudio observacional, prospectivo y descriptivo consistente en la medición de la PIA en pacientes ingresados por insuficiencia cardíaca (IC) descompensada. Se estratificó la muestra según la fracción de eyección ventricular izquierda (FEVI) con un punto de corte del 50%, con el objetivo de analizar la PIA, así como las características basales y el grado de congestión empleando la ecografía clínica y la impedanciometría. Resultados Se incluyeron un total de 56 pacientes, 22 con ICFEr y 34 con ICFEp. Los pacientes con ICFEr presentaron una mayor prevalencia de cardiopatía isquémica (11 vs. 6; p = 0,010) y EPOC/asma (6 vs. 2%; p = 0,025). La PIA fue más alta en pacientes con ICFEr (17,2 mmHg vs. 13,3 mmHg; p = 0,004), sin diferencias en la función renal al ingreso según la FEVI (CKD-EPI creatinina) (ICFEr 55,0 mL/min/1,73 m2 [32,6-83,6] vs. ICFEp 55,0 mL/min/1,73 m2 [44,0-74,9]; p = 0,485). Los pacientes con ICFEr presentaron un perfil más congestivo estimado por ecografía (colapso de la cava inferior [26% vs. 50%; p = 0,001]), impedanciometría (agua corporal total al ingreso: 46 L vs. 41 L; p = 0,052 y a las 72 horas 50,2 L vs. 39,1 L; p = 0,038) y concentración de CA125 (68 U/mL vs. 39 U/mL; p = 0,037). Conclusiones Durante los episodios de descompensación los pacientes con ICFEr tienen mayor elevación de la PIA y un mayor grado de congestión sistémica (AU)

Background The increase in intraabdominal pressure (IAP) has been correlated with increased creatinine levels in patients with heart failure with severely reduced left ventricular ejection fraction (HFrEF). However, IAP has not been examined in more stable patients or those with heart failure with preserved ejection fraction (HFpEF). Patients and method We conducted an observational, prospective descriptive study that measured the IAP of patients hospitalised for decompensated heart failure (HF). The sample was stratified according to left ventricular ejection fraction (LVEF), with a cut-off of 50%. The objective was to analyse the IAP, the baseline characteristics and degree of congestion using clinical ultrasonography and impedance audiometry. Results The study included 56 patients, 22 with HFrEF and 34 with HFpEF. The patients with HFrEF presented a higher prevalence of ischaemic heart disease (11% vs. 6%; p = 0.010) and chronic obstructive pulmonary disease/asthma (6% vs. 2%; p = 0.025). The IAP was higher in the patients with HFrEF (17.2 vs. 13.3 mmHg; p = 0.004), with no differences in renal function at admission according to the LVEF (CKD-EPI creatinine) (HFrEF 55.0 mL/min/1.73 m2 [32.6-83.6] vs. HFpEF 55.0 mL/min/1.73 m2 [44.0-74.9]; p = 0.485). The patients with HFrEF presented a more congestive profile determined through ultrasonography (inferior vena cava collapse [26% vs. 50%; p = 0.001]), impedance audiometry (total body water at admission, 46 L vs. 41 L; p = 0.052; and at 72 h, 50.2 L vs. 39.1 L; p = 0.038) and CA125 concentration (68 U/mL vs. 39 U/mL; p = 0.037). Conclusions During the decompensation episodes, the patients with HFrEF had a greater increase in IAP and a higher degree of systemic congestion (AU)

Variation in intraabdominal pressure in patients with acute heart failure according to left ventricular ejection fraction. Results of an intraabdominal pressure study.

BACKGROUND: The increase in intraabdominal pressure (IAP) has been correlated with increased creatinine levels in patients with heart failure with severely reduced left ventricular ejection fraction (HFrEF). However, IAP has not been examined in more stable patients or those with heart failure with preserved ejection fraction (HFpEF). PATIENTS AND METHOD: We conducted an observational, prospective descriptive study that measured the IAP of patients hospitalised for decompensated heart failure (HF). The sample was stratified according to left ventricular ejection fraction (LVEF), with a cut-off of 50%. The objective was to analyse the IAP, the baseline characteristics and degree of congestion using clinical ultrasonography and impedance audiometry. RESULTS: The study included 56 patients, 22 with HFrEF and 34 with HFpEF. The patients with HFrEF presented a higher prevalence of ischaemic heart disease (11% vs. 6%; p = 0.010) and chronic obstructive pulmonary disease/asthma (6% vs. 2%; p = 0.025). The IAP was higher in the patients with HFrEF (17.2 vs. 13.3 mmHg; p = 0.004), with no differences in renal function at admission according to the LVEF (CKD-EPI creatinine) (HFrEF 55.0 mL/min/1.73 m2 [32.6-83.6] vs. HFpEF 55.0 mL/min/1.73 m2 [44.0-74.9]; p = 0.485). The patients with HFrEF presented a more congestive profile determined through ultrasonography (inferior vena cava collapse [26% vs. 50%; p = 0.001]), impedance audiometry (total body water at admission, 46 L vs. 41 L; p = 0.052; and at 72 h, 50.2 L vs. 39.1 L; p = 0.038) and CA125 concentration (68 U/mL vs. 39 U/mL; p = 0.037). CONCLUSIONS: During the decompensation episodes, the patients with HFrEF had a greater increase in IAP and a higher degree of systemic congestion.

Prognostic value of multimodal assessment of congestion in acute heart failure.

BACKGROUND: A physical examination has limited performance in estimating systemic venous congestion and predicting mortality in patients with heart failure. We have evaluated the usefulness of the N-terminal prohormone of brain natriuretic peptide (NT-proBNP), cancer antigen 125 (CA125), lung ultrasound findings, relative plasma volume (rPV) estimation, and the urea/creatinine ratio as surrogate parameters of venous congestion and predictors of mortality. METHODS: This work is a retrospective study of 203 patients admitted for acute heart failure in a tertiary hospital's internal medicine department with follow-up in a specialized outpatient clinic between 2013 and 2018. Clinical data were collected from hospital records. Treatment was decided upon according to the clinical judgment of each patient's attending physician. The main outcome measure was all-cause mortality at one year of follow-up. RESULTS: Patients' mean age was 78.8 years and 47% were male. A total of 130 (65%) patients had chronic heart failure, 51 (26.2%) patients were in New York Heart Association class III-IV, and 116 (60%) patients had preserved left ventricular ejection fraction. During follow-up, 42 (22%) patients died. Values of NT-proBNP≥3804pg/mL (HR 2.78 [1.27-6.08]; p=.010) and rPV≥-4.54% (HR 2.74 [1.18-6.38]; p=.019) were independent predictors of all-cause mortality after one year of follow-up. CONCLUSIONS: NT-proBNP and rPV are independent predictors of one-year mortality among patients hospitalized for decompensated heart failure.

Valor pronóstico de la valoración multimodal de la congestión en la insuficiencia cardiaca aguda / Prognostic value of multimodal assessment of congestion in acute heart failure

Fundamento El examen físico presenta una rentabilidad limitada en la estimación de la congestión venosa sistémica y en la predicción de la mortalidad de los pacientes con insuficiencia cardiaca. Hemos evaluado la utilidad del fragmento amino terminal del péptido natriurético cerebral (NT-proBNP), del antígeno de cáncer 125 (CA125), los hallazgos de la ecografía pulmonar, la estimación del volumen plasmático relativo (VPr) y el cociente urea/creatinina, como parámetros subrogados de congestión venosa y predictores de mortalidad. Material y métodos Estudio retrospectivo de 203 pacientes ingresados por insuficiencia cardiaca aguda en el servicio de medicina interna de un hospital terciario, con seguimiento monográfico en consultas externas entre los años 2013 y 2018. Los datos clínicos se recogieron de los registros hospitalarios. Las intervenciones terapéuticas se guiaron por el criterio clínico del médico responsable de cada paciente. El desenlace principal fue mortalidad general tras un año de seguimiento. Resultados La edad media de los pacientes fue 78,8 años, 47% eran varones. Un total de 130 (65%) pacientes presentaban insuficiencia cardiaca crónica, 51 (26,2%) pacientes se encontraban en clase III-IV de la New York Heart Association y 116 (60%) pacientes presentaban fracción de eyección de ventrículo izquierdo preservada. Durante el seguimiento fallecieron 42 (22%) pacientes. Los valores de NT-proBNP≥3.804pg/mL (HR 2,78 [1,27-6,08]; p=0,010) y el VPr≥–4,54% (HR 2,74 [1,18-6,38]; p=0,019) fueron predictores independientes de mortalidad general tras un año de seguimiento. Conclusiones El NT-proBNP y el VPr son predictores independientes de mortalidad a un año entre los pacientes ingresados por insuficiencia cardiaca descompensada (AU)

Background A physical examination has limited performance in estimating systemic venous congestion and predicting mortality in patients with heart failure. We have evaluated the usefulness of the N-terminal prohormone of brain natriuretic peptide (NT-proBNP), cancer antigen 125 (CA125), lung ultrasound findings, relative plasma volume (rPV) estimation, and the urea/creatinine ratio as surrogate parameters of venous congestion and predictors of mortality. Methods This work is a retrospective study of 203 patients admitted for acute heart failure in a tertiary hospital's internal medicine department with follow-up in a specialized outpatient clinic between 2013 and 2018. Clinical data were collected from hospital records. Treatment was decided upon according to the clinical judgment of each patient's attending physician. The main outcome measure was all-cause mortality at one year of follow-up. Results Patients’ mean age was 78.8 years and 47% were male. A total of 130 (65%) patients had chronic heart failure, 51 (26.2%) patients were in New York Heart Association class III-IV, and 116 (60%) patients had preserved left ventricular ejection fraction. During follow-up, 42 (22%) patients died. Values ??of NT-proBNP≥3,804pg/mL (HR 2.78 [1.27-6.08]; p=.010) and rPV ≥–4.54% (HR 2.74 [1.18-6.38]; p=.019) were independent predictors of all-cause mortality after one year of follow-up. Conclusions NT-proBNP and rPV are independent predictors of one-year mortality among patients hospitalized for decompensated heart failure (AU)

Importancia pronóstica del daño renal agudo y de los pequeños aumentos de la concentración de creatinina durante la descompensación aguda de la insuficiencia cardiaca / Prognostic significance of acute kidney injury and small increases in creatinine concentration during acute decompensation of heart failure

ANTECEDENTES: El diagnóstico de daño renal agudo (DRA) durante los episodios de insuficiencia cardiaca aguda (ICA) sigue siendo un desafío. Analizamos la incidencia y el pronóstico del DRA y la importancia de los aumentos pequeños de creatinina durante los episodios de ICA y tras su estabilización. PACIENTES Y MÉTODOS: Se incluyeron prospectivamente pacientes ingresados por ICA. La creatinina se midió al ingreso, a las 48h de este y 24h antes del alta. El DRA se diagnosticó cuando la creatinina aumentó≥50% en 7 días (criterio RIFLE) o≥0,3mg/dL en 48h (criterio AKIN) durante el ingreso. Se evaluaron los cambios entre la creatinina basal (medida dentro de los 3 meses previos al ingreso) y un mes después del alta, para buscar el deterioro residual de la función renal y su importancia. RESULTADOS: Se incluyeron 204 pacientes. La incidencia de DRA fue del 28,4% (n=58). La creatinina alcanzó su máxima concentración al quinto día en pacientes con DRA vs. no DRA (1,9 vs. 1,1mg/dL; p < 0,000) y 3 meses después del alta permaneció significativamente más alta entre los pacientes con DRA (aumento del 20 vs. 4%; p = 0,013). La mortalidad a los 12 meses se asoció con aumentos en la cistatina C, el NT-proBNP y la presencia de DRA (15,5 vs. 44,8%, p < 0,0001), siendo este último el predictor independiente de muerte más potente ?Exp(B)=5,34; p = 0,009?. Aumentos menores de creatinina (20% o 0,2mg/dL) durante el ingreso asociaron una menor supervivencia a los 12 meses (p = 0,033 y p = 0,019, respectivamente). Los aumentos de creatinina≥10% entre la basal y un mes después del alta también se asociaron con una mayor mortalidad (12,6 vs. 22,5%, p = 0,044). CONCLUSIONES: La presencia de DRA es un potente predictor de mortalidad en las ICA. Pequeños incrementos en las concentraciones de creatinina, por debajo del umbral aceptado para la definición de DRA, tienen un pronóstico significativo

BACKGROUND: Diagnosis of acute kidney injury (AKI) during acute decompensations of heart failure (ADHF) remain challenging. We analysed the incidence and prognosis of AKI, and the significance of small increases of creatinine, during ADHF and after stabilization. PATIENTS AND METHODS: Patients admitted for ADHF were prospectively included. Creatinine was measured at admission, 48h thereafter and 24h before discharge. AKI was diagnosed when creatinine increased≥50% in 7 days (RIFLE criteria) or≥0.3mg/dL in 48h (AKIN criteria) during admission. Changes between baseline creatinine (measured within 3-month before admission) and one month after discharge were assessed, to seek for residual impairment of renal function and its significance. RESULTS: Two hundred and four patients were included. Incidence of AKI was 28.4% (n=58). Creatinine peaked by day 5 in patients with AKI vs. non-AKI (1.9 vs. 1.1mg/dL; P<.000) and remained significantly higher among patients with AKI 3 months after discharge (increase of 20 vs. 4%; P=.013). Twelve-months mortality was associated with increases in cystatin C, NT-proBNP and AKI (15.5 vs. 44.8%, P<.000), being the latter the most powerful independent predictor of death ?Exp(B)=5.34; P=.009?. Minor increases in creatinine (20% or 0.2mg/dL) during admission associated lesser 12-months survival (P=.033 and P=.019, respectively). Increases in creatinine≥10% between baseline and one month after discharge are associated with higher mortality (12.6 vs. 22.5%, P=.044). CONCLUSIONS: AKI is a strong predictor of mortality after ADHF. Minor increments in creatinine concentrations, below the accepted threshold for AKI definition, are prognostically meaningful

Resultados del seguimiento en una consulta monográfica tras el alta por insuficiencia cardiaca / Follow-up results in a specialised consultation after discharge for heart failure

INTRODUCCIÓN: A pesar de los avances en el diagnóstico y el tratamiento, la insuficiencia cardiaca (IC) sigue teniendo una alta morbimortalidad. El tratamiento de las comorbilidades y la educación sanitaria se han demostrado eficaces, así como la atención multidisciplinar, en unidades especializadas, aunque ello implica un esfuerzo organizativo y estructural no siempre disponible. Presentamos los resultados de una consulta ambulatoria simple, centrada en la atención monográfica a la IC. PACIENTES Y MÉTODOS: La consulta incluyó a pacientes dados de alta tras una hospitalización (ingreso índice) por descompensación de IC en el servicio de Medicina Interna. El seguimiento se realizó por internistas con especial dedicación (no exclusiva) en IC y una enfermera con dedicación compartida. El seguimiento consistió en visitas fijas 1, 3, 6 y 12 meses tras el alta, más visitas a demanda en caso de necesidad. RESULTADOS: Se incluyó a 250 pacientes con un seguimiento mínimo de un año. La disminución de los ingresos y las visitas a Urgencias por IC fue del 56 y el 61% (p < 0,05), respectivamente, y del 46 y el 40% (p < 0,05) por cualquier causa. Además, se consiguió una optimización del tratamiento, con un aumento significativo en el porcentaje de prescripción de fármacos basados en la evidencia y reducción de otros, como calcioantagonistas. CONCLUSIÓN: Un modelo sencillo basado en la atención monográfica a la IC es eficaz en la reducción de reingresos y la optimización del tratamiento. La carencia de recursos asistenciales no debería suponer un obstáculo para una atención monográfica a pacientes con IC

BACKGROUND: Despite advances in the diagnosis and treatment of heart failure (HF), the condition still has high morbidity and mortality. Health education and the treatment of comorbidities have been shown to be effective, as has multidisciplinary care in specialised units, although this involves organisational and structural efforts that are not always feasible. We present the results of a simple outpatient consultation, focused on the specialised care of HF. PATIENTS AND METHODS: The consultation included patients discharged after hospitalisation (index hospitalisation) for decompensated HF from an internal medicine department. The follow-up was conducted by internists especially dedicated (not exclusively) to HF and a nurse partially dedicated to HF. The follow-up consisted of fixed visits 1, 3, 6 and 12 months after the discharge, with more visits on demand if needed. RESULTS: A total of 250 patients were included with a minimum follow-up of 1 year. The reduction in hospitalisations and emergency department visits was 56% and 61% (P<.05), respectively, for HF and 46% and 40% (P<.05), respectively, for any cause. Treatment optimisation was also achieved, with a significant increase in the evidence-based drug prescription rate and the reduction of other drugs, such as calcium antagonists. CONCLUSION: A simple model based on a specialised care consultation for HF is effective in reducing readmissions and optimising the treatment. The lack of healthcare resources should not be an obstacle for specialised care for patients with HF

Variation in intraabdominal pressure in patients with acute heart failure according to left ventricular ejection fraction. Results of an intraabdominal pressure study. / Variación de la presión intraabdominal en los pacientes con insuficiencia cardíaca aguda según la fracción de eyección ventricular izquierda. Resultados del estudio PIA.

BACKGROUND: The increase in intraabdominal pressure (IAP) has been correlated with increased creatinine levels in patients with heart failure with severely reduced left ventricular ejection fraction (HFrEF). However, IAP has not been examined in more stable patients or those with heart failure with preserved ejection fraction (HFpEF). PATIENTS AND METHOD: We conducted an observational, prospective descriptive study that measured the IAP of patients hospitalised for decompensated heart failure (HF). The sample was stratified according to left ventricular ejection fraction (LVEF), with a cut-off of 50%. The objective was to analyse the IAP, the baseline characteristics and degree of congestion using clinical ultrasonography and impedance audiometry. RESULTS: The study included 56 patients, 22 with HFrEF and 34 with HFpEF. The patients with HFrEF presented a higher prevalence of ischaemic heart disease (11% vs. 6%; p = 0.010) and chronic obstructive pulmonary disease/asthma (6% vs. 2%; p = 0.025). The IAP was higher in the patients with HFrEF (17.2 vs. 13.3 mmHg; p = 0.004), with no differences in renal function at admission according to the LVEF (CKD-EPI creatinine) (HFrEF 55.0 mL/min/1.73 m2 [32.6-83.6] vs. HFpEF 55.0 mL/min/1.73 m2 [44.0-74.9]; p = 0.485). The patients with HFrEF presented a more congestive profile determined through ultrasonography (inferior vena cava collapse [26% vs. 50%; p = 0.001]), impedance audiometry (total body water at admission, 46 L vs. 41 L; p = 0.052; and at 72 h, 50.2 L vs. 39.1 L; p = 0.038) and CA125 concentration (68 U/mL vs. 39 U/mL; p = 0.037). CONCLUSIONS: During the decompensation episodes, the patients with HFrEF had a greater increase in IAP and a higher degree of systemic congestion.

Intra-abdominal pressure and its relationship with markers of congestion in patients admitted for acute decompensated heart failure.

Systemic congestion is one of the mechanisms involved in acute decompensated heart failure (ADHF). Increased intra-abdominal pressure (IAP), elicited by abdominal congestion, has been related to acute kidney injury and prognosis. Nonetheless, the link between diuretic response, surrogate markers of congestion and renal function remains poorly understood. We measured IAP in 43 patients from a non-interventional, exploratory, prospective, single center study carried out in patients admitted for ADHF. IAP was measured with a calibrated electronic manometer through a catheter inserted in the bladder. Normal IAP was defined as < 12 mmHg. At baseline, median IAP was 15 mmHg, with a reduction over the next 72 h to a median of 12 mmHg. A higher IAP at admission was associated with higher baseline blood urea (83 mg/dL [62-138] vs. 50 mg/dL [35-65]; p = 0.007) and creatinine (1.30 mg/dL vs. 0.95 mg/dL; p = 0.027), and with poorer diuretic response 72 h after admission, either measured by diuresis (14.4 mL/mg vs. 21.6 mL/mg; [p = 0.005]) or natriuresis (1.2 mEqNa/mg vs. 2.0 mEqNa/mg; [p = 0.008]). A higher incidence for 1-year all-cause mortality (45.0% vs. 16.7%; log-rank test = 0.041) was observed among those patients with IAP > 12 mmHg at 72 h. In patients with ADHF, higher IAP at admission is associated with poorer baseline renal function and impaired diuretic response. The persistence of IAP at 72 h above 12 mmHg associates to longer length of hospital stay and higher 1-year all-cause mortality.

Prognostic value of multimodal assessment of congestion in acute heart failure. / Valor pronóstico de la valoración multimodal de la congestión en la insuficiencia cardiaca aguda.

Systemic venous congestion is present in most cases of acute decompensated heart failure (ADHF). An accurate assessment of congestion is key to improve outcomes and avoid residual congestion. Physical examination has limitations for grading congestion; hence, new methods for assessing congestion have been developed. A multimodal approach, combining surrogate markers of congestion, may be a suitable strategy. The aim of this study was to compare the prognostic value of Amino terminal fragment of pro-Brain Natriuretic Peptide (NT-proBNP), Carbohydrate cancer antigen 125 (CA125), lung ultrasound, relative plasma volume status (rPVS) and urea/Creatinine ratio (U/C ratio), to predict one-year all-cause mortality. MATERIAL AND METHODS: Retrospective, observational analysis of 203 patients admitted at the Internal Medicine ward of a tertiary teaching Hospital due to ADHF, followed in monographic outclinic. Clinical data were obtained from hospital records. Therapeutic interventions followed exclusively the clinical judgement of the physician responsible for each patient. RESULTS: 203 patients were included for the final analysis between 2013 and 2018. Chronic heart failure (CHF) was present in 130 patients (65%); 51 patients (26.2%) had class III-IV of New York Heart Association (NYHA); 116 patients (60%) had HF with preserved ejection fraction (HFpEF). Forty-two patients (21.6%) died during follow-up. NT-proBNP≥3804 pg/mL (HR 2.78 [1.27 - 6.08]; P=.010) and rPVS≥-4.54% (HR 2.74 [1.18 - 6.38]; P=.019), were independent predictors for 1-year all-cause mortality on top of CA125, lung ultrasound and U/C ratio. CONCLUSIONS: NT-proBNP and rPVS are independent predictors of one-year mortality among patients admitted for ADHF.

Follow-up results in a specialised consultation after discharge for heart failure. / Resultados del seguimiento en una consulta monográfica tras el alta por insuficiencia cardiaca.

BACKGROUND: Despite advances in the diagnosis and treatment of heart failure (HF), the condition still has high morbidity and mortality. Health education and the treatment of comorbidities have been shown to be effective, as has multidisciplinary care in specialised units, although this involves organisational and structural efforts that are not always feasible. We present the results of a simple outpatient consultation, focused on the specialised care of HF. PATIENTS AND METHODS: The consultation included patients discharged after hospitalisation (index hospitalisation) for decompensated HF from an internal medicine department. The follow-up was conducted by internists especially dedicated (not exclusively) to HF and a nurse partially dedicated to HF. The follow-up consisted of fixed visits 1, 3, 6 and 12 months after the discharge, with more visits on demand if needed. RESULTS: A total of 250 patients were included with a minimum follow-up of 1 year. The reduction in hospitalisations and emergency department visits was 56% and 61% (P<.05), respectively, for HF and 46% and 40% (P<.05), respectively, for any cause. Treatment optimisation was also achieved, with a significant increase in the evidence-based drug prescription rate and the reduction of other drugs, such as calcium antagonists. CONCLUSION: A simple model based on a specialised care consultation for HF is effective in reducing readmissions and optimising the treatment. The lack of healthcare resources should not be an obstacle for specialised care for patients with HF.

Prognostic significance of acute kidney injury and small increases in creatinine concentration during acute decompensation of heart failure. / Importancia pronóstica del daño renal agudo y de los pequeños aumentos de la concentración de creatinina durante la descompensación aguda de la insuficiencia cardiaca.

BACKGROUND: Diagnosis of acute kidney injury (AKI) during acute decompensations of heart failure (ADHF) remain challenging. We analysed the incidence and prognosis of AKI, and the significance of small increases of creatinine, during ADHF and after stabilization. PATIENTS AND METHODS: Patients admitted for ADHF were prospectively included. Creatinine was measured at admission, 48h thereafter and 24h before discharge. AKI was diagnosed when creatinine increased≥50% in 7 days (RIFLE criteria) or≥0.3mg/dL in 48h (AKIN criteria) during admission. Changes between baseline creatinine (measured within 3-month before admission) and one month after discharge were assessed, to seek for residual impairment of renal function and its significance. RESULTS: Two hundred and four patients were included. Incidence of AKI was 28.4% (n=58). Creatinine peaked by day 5 in patients with AKI vs. non-AKI (1.9 vs. 1.1mg/dL; P<.000) and remained significantly higher among patients with AKI 3 months after discharge (increase of 20 vs. 4%; P=.013). Twelve-months mortality was associated with increases in cystatin C, NT-proBNP and AKI (15.5 vs. 44.8%, P<.000), being the latter the most powerful independent predictor of death ?Exp(B)=5.34; P=.009?. Minor increases in creatinine (20% or 0.2mg/dL) during admission associated lesser 12-months survival (P=.033 and P=.019, respectively). Increases in creatinine≥10% between baseline and one month after discharge are associated with higher mortality (12.6 vs. 22.5%, P=.044). CONCLUSIONS: AKI is a strong predictor of mortality after ADHF. Minor increments in creatinine concentrations, below the accepted threshold for AKI definition, are prognostically meaningful.

La congestión residual y la intuición clínica en la insuficiencia cardiaca descompensada / Residual congestion and clinical intuition in decompensated heart failure

Los síntomas congestivos son la clave para reconocer las descompensaciones de la insuficiencia cardiaca. Su tratamiento se basa en la reducción de la congestión hasta alcanzar una situación clínica que permita el alta del paciente para continuar el tratamiento ambulatoriamente. Lo importante, no obstante, no es el grado de congestión al ingreso, sino la que persiste después de un tratamiento diurético enérgico. A la persistencia de signos congestivos después de un tratamiento aparentemente correcto y eficaz, se le ha denominado «congestión residual» y se asocia con mal pronóstico. Las herramientas para su estimación son todavía rudimentarias, por lo que deben desarrollarse métodos que permitan una valoración más precisa

Congestive symptoms are the key to recognising decompensated heart failure, whose treatment is based on reducing the congestion until a clinical situation has been reached that allows the patient to be discharged to continue outpatient treatment. The important aspect is not the degree of congestion at admission but rather the congestion that persists after energetic diuretic therapy. The persistence of congestive signs following an apparently correct and effective therapy has been called residual congestion and is associated with a poor prognosis. The tools for determining this condition are still rudimentary. Methods therefore need to be developed that enable a more accurate assessment

Presión intraabdominal y empeoramiento de la función renal durante las descompensaciones de la insuficiencia cardiaca. Un informe preliminar del estudio PIA / Intraabdominal pressure and worsening renal function during decompensations of heart failure. A preliminary report from the PIA study

Antecedentes: El aumento de la presión intraabdominal (PIA) que tiene lugar durante la insuficiencia cardiaca aguda parece estar directamente relacionado con un empeoramiento de la función renal, lo que conduce a peores resultados clínicos. Nuestro objetivo fue analizar la relación entre la PIA y los determinantes de la función renal para la insuficiencia cardiaca aguda descompensada (ICAD) durante el ingreso en un pabellón de medicina interna convencional. Pacientes y métodos: Estudio descriptivo y prospectivo. Se incluyó a aquellos pacientes con una tasa de filtración glomerular > 30mL/min/1,73 m2, dispuestos a participar en el estudio y que otorgaron su consentimiento informado. El protocolo (PI 15 0227) fue aprobado por el Comité de Ética de Aragón. Resultados: Presentamos los resultados de un análisis preliminar llevado a cabo con los primeros 28 pacientes incluidos en el estudio. Los pacientes se segregaron en 2grupos según la mediana de la PIA, alta (PIA > 15mmHg) y baja (PIA < 15mmHg), medida durante las primeras 24 h tras el ingreso por ICAD. Cada grupo estuvo integrado por 14pacientes. No hubo diferencias entre los grupos en cuanto a características clínicas de referencia, comorbilidades ni tratamiento. Los pacientes con PIA superior a los 15mmHg presentaron una tasa de filtración glomerular basal significativamente baja (70,7 vs. 44,4mL/min/1,73 m2 con p = 0,004; urea en sangre 36 vs. 83mg/dL con p = 0,002; creatinina sérica 0,87 vs. 1,3mg/dL con p = 0,004 y cistatina C 1,2 vs. 1,94mg/dL con p = 0,002). Además, estos pacientes mostraron las concentraciones de ácido úrico más altas (5,7 vs. 8,0; p = 0,046), las de hemoglobina resultaron más bajas (11,7 vs. 10,5g/L; p = 0,04) y la estancia hospitalaria más larga (6,5 vs. 9,6 días; p = 0,017). Conclusiones: El aumento de la PIA parece ser un hallazgo frecuente en pacientes ingresados por ICAD. Independientemente de la PIA, los pacientes comparten un perfil clínico similar, si bien el aumento de la PIA se asoció con un empeoramiento significativo de la función renal de referencia

Background: An increase in intraabdominal pressure (IAP) during acute heart failure, seems to be directly related to worsening renal function, which leads to worse clinical outcomes. We aimed to analyze the relationship between IAP and determinants of renal function during admission for acute decompensation of heart failure (ADHF) in a conventional Internal Medicine Ward. Patients and methods: Descriptive and prospective study. Patients admitted for ADHF with an estimated glomerular filtration rate > 30mL/min/1.73 m2, willing to participate and who gave their informed consent were included. Ethics Committee of Aragon approved the protocol (PI 15 0227). Results: We hereby report the results of an interim analysis of the first 28 patients included. Patients were divided in 2groups according to the median of IAP measured during the first 24h after admission for ADHF, namely high IAP (IAP>15mmHg) and low (IAP< 15mmHg). Fourteen patients were included in each group. No differences were found in baseline clinical characteristics, comorbidities or treatment between both groups. Patients with IAP above 15mmHg, showed a significant lower baseline estimated glomerular filtration rate (70.7 vs. 44.4mL/min/1.73 m2 with p=0.004], blood urea 36 vs. 83mg/dL with p=0.002]; serum creatinine 0.87 vs. 1.3mg/dL with p=0.004 and cystatin C 1.2 vs. 1.94mg/dL with p= 0.002. Additionally, these patients had higher uric acid (5.7 vs. 8.0, p=0.046), lower hemoglobin concentrations (11.7 vs. 10.5g/L, p=0.04) and longer length of hospital stay (6.5 vs. 9.6 days, p=0.017). Conclusions: The increase in IAP seems to be a frequent finding in patients admitted for ADHF. Patients share similar clinical profile irrespective of IAP, although the increase in IAP is associated with a significant baseline impairment of renal function

Residual congestion and clinical intuition in decompensated heart failure. / La congestión residual y la intuición clínica en la insuficiencia cardiaca descompensada.

Congestive symptoms are the key to recognising decompensated heart failure, whose treatment is based on reducing the congestion until a clinical situation has been reached that allows the patient to be discharged to continue outpatient treatment. The important aspect is not the degree of congestion at admission but rather the congestion that persists after energetic diuretic therapy. The persistence of congestive signs following an apparently correct and effective therapy has been called residual congestion and is associated with a poor prognosis. The tools for determining this condition are still rudimentary. Methods therefore need to be developed that enable a more accurate assessment.

Intraabdominal pressure and worsening renal function during decompensations of heart failure. A preliminary report from the PIA study. / Presión intraabdominal y empeoramiento de la función renal durante las descompensaciones de la insuficiencia cardiaca. Un informe preliminar del estudio PIA.

BACKGROUND: An increase in intraabdominal pressure (IAP) during acute heart failure, seems to be directly related to worsening renal function, which leads to worse clinical outcomes. We aimed to analyze the relationship between IAP and determinants of renal function during admission for acute decompensation of heart failure (ADHF) in a conventional Internal Medicine Ward. PATIENTS AND METHODS: Descriptive and prospective study. Patients admitted for ADHF with an estimated glomerular filtration rate > 30mL/min/1.73 m2, willing to participate and who gave their informed consent were included. Ethics Committee of Aragon approved the protocol (PI 15 0227). RESULTS: We hereby report the results of an interim analysis of the first 28 patients included. Patients were divided in 2groups according to the median of IAP measured during the first 24h after admission for ADHF, namely high IAP (IAP>15mmHg) and low (IAP< 15mmHg). Fourteen patients were included in each group. No differences were found in baseline clinical characteristics, comorbidities or treatment between both groups. Patients with IAP above 15mmHg, showed a significant lower baseline estimated glomerular filtration rate (70.7 vs. 44.4mL/min/1.73 m2 with p=0.004], blood urea 36 vs. 83mg/dL with p=0.002]; serum creatinine 0.87 vs. 1.3mg/dL with p=0.004 and cystatin C 1.2 vs. 1.94mg/dL with p= 0.002. Additionally, these patients had higher uric acid (5.7 vs. 8.0, p=0.046), lower hemoglobin concentrations (11.7 vs. 10.5g/L, p=0.04) and longer length of hospital stay (6.5 vs. 9.6 days, p=0.017). CONCLUSIONS: The increase in IAP seems to be a frequent finding in patients admitted for ADHF. Patients share similar clinical profile irrespective of IAP, although the increase in IAP is associated with a significant baseline impairment of renal function.

Valor pronóstico de la ratio urea / creatinina en la insuficiencia cardiaca descompensada y su relación con el daño renal agudo / Prognostic value of the urea: creatinine ratio in decompensated heart failure and its relationship with acute kidney damage

Introducción: El empeoramiento de la función renal es un índice de mal pronóstico en pacientes con insuficiencia cardiaca aguda (ICA). El cociente urea/creatinina (U/C) podría tener significación pronóstica en la ICA. Material y métodos: Estudio observacional, prospectivo, cuyo objetivo fue analizar el valor pronóstico del cociente U/C, determinado en las primeras 24-48h del ingreso, en pacientes hospitalizados por ICA, así como su relación con el filtrado glomerular estimado (FGe) y el daño renal agudo (DRA). Resultados: Se incluyeron un total de 204 pacientes, con edad media de 79,3 años. La mediana de FGe fue 55ml/min/1,73m2. En el análisis multivariante, un cociente U/C > 50 se asoció con una mayor probabilidad de DRA durante el ingreso (36,5% vs. 21,9%) y mortalidad por cualquier causa (odds ratio [OR] 2,75) y por IC (OR 3,50) durante el seguimiento. La elevación del cociente U/C fue pronóstica solo en los pacientes con FGe normales (mortalidad 4,4% vs. 22%; p=0,01). La combinación del cociente U/C con el FGe tuvo mayor capacidad predictiva de DRA que cada uno de ellos por separado (área bajo la curva 0,718, intervalo de confianza al 95% 0,643-0,793; p<0,001). Conclusiones: Un cociente U/C > 50 predice mortalidad a largo plazo en pacientes con FGe normal, y combinado con el FGe, mejora la identificación del riesgo de DRA, en pacientes ingresados por ICA. Dado lo simple de este biomarcador, sugerimos su uso sistemático en la clínica diaria

Background: Worsening renal function is associated with an adverse prognosis for patients with acute heart failure (AHF). Urea-creatinine ratio (U:C ratio) might be useful for measuring renal function and could help stratify patients with AHF. Material and methods: An observational and prospective study was conducted to analyse the prognostic value of the U:C ratio, measured during the first 24-28 hours of admission, for patients hospitalised for decompensated Heart failure, and its relationship with estimated glomerular filtration rate (eGFR) and acute kidney injury (AKI). Results: The study included 204 patients, with a mean age of 79.3 years, and a median eGFR of 55 mL/min/1.73m2. In the multivariate analysis, an U:C ratio above the median (50) was related to the development of AKI (36.5% vs. 21.9%) and to increased mortality, both overall (OR 2.75) and by HF (OR 3.50) in long term. In combination with eGFR, the U:C ratio showed prognostic value in patients with normal eGFR (mortality of 4.4% for an U:C ratio ≤ 50 vs. 22% for U:C ratio > 50; p=0.01), as well as a better predictive capacity for AKI than each of them separately (AUC, 0.718; 95% CI 0.643-0.793; p>.000). Conclusions: An U:C ratio > 50 is a predictor of increased long-term mortality for patients hospitalised for decompensated HF and with normal eGFR. Given the simplicity of this biomarker, its use in clinical practice should be more systematic

Prognostic value of the urea:creatinine ratio in decompensated heart failure and its relationship with acute kidney damage. / Valor pronóstico de la ratio urea / creatinina en la insuficiencia cardiaca descompensada y su relación con el daño renal agudo.

BACKGROUND: Worsening renal function is associated with an adverse prognosis for patients with acute heart failure (AHF). Urea-creatinine ratio (U:C ratio) might be useful for measuring renal function and could help stratify patients with AHF. MATERIAL AND METHODS: An observational and prospective study was conducted to analyse the prognostic value of the U:C ratio, measured during the first 24-28 hours of admission, for patients hospitalised for decompensated Heart failure, and its relationship with estimated glomerular filtration rate (eGFR) and acute kidney injury (AKI). RESULTS: The study included 204 patients, with a mean age of 79.3 years, and a median eGFR of 55 mL/min/1.73m2. In the multivariate analysis, an U:C ratio above the median (50) was related to the development of AKI (36.5% vs. 21.9%) and to increased mortality, both overall (OR 2.75) and by HF (OR 3.50) in long term. In combination with eGFR, the U:C ratio showed prognostic value in patients with normal eGFR (mortality of 4.4% for an U:C ratio ≤ 50 vs. 22% for U:C ratio > 50; p=0.01), as well as a better predictive capacity for AKI than each of them separately (AUC, 0.718; 95% CI 0.643-0.793; p>.000). CONCLUSIONS: An U:C ratio > 50 is a predictor of increased long-term mortality for patients hospitalised for decompensated HF and with normal eGFR. Given the simplicity of this biomarker, its use in clinical practice should be more systematic.

Fisiopatología de la enfermedad de Fabry / The pathophysiology of Fabry disease

La enfermedad de Fabry es una entidad lisosomal de expresión clínica sistémica, causada por el depósito tisular de globotriaosilceramida, debido a un déficit en su degradación. Como en la mayoría de las enfermedades lisosomales, la existencia de una mutación en un gen no explica las alteraciones fisiopatológicas que presentan los pacientes. Se realiza una revisión exhaustiva de los mecanismos patogénicos que acontecen en la enfermedad de Fabry (AU)

Fabry disease is a lysosomal condition with systemic clinical expression, caused by the tissue deposit of globotriaosylceramide, due to a deficit in its degradation. As with most lysosomal diseases, the presence of a mutation in a gene does not explain the pathophysiological disorders shown by patients. We conducted a comprehensive review of the pathogenic mechanisms that occur in Fabry disease (AU)

The pathophysiology of Fabry disease. / Fisiopatología de la enfermedad de Fabry.

Fabry disease is a lysosomal condition with systemic clinical expression, caused by the tissue deposit of globotriaosylceramide, due to a deficit in its degradation. As with most lysosomal diseases, the presence of a mutation in a gene does not explain the pathophysiological disorders shown by patients. We conducted a comprehensive review of the pathogenic mechanisms that occur in Fabry disease.