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.

Neuropatía femoral: hematoma en músculo ilíaco y fractura vertebral lumbar / Femoral neuropathy: haematoma in iliac muscle and a lumbar vertebral fracture

Paciente de 75 años con antecedentes de fibrilación auricular anticoagulada con acenocumarol, que presenta dolor, impotencia funcional e parestesias de extremidad inferior derecha tras caída sobre región sacro-coccigea. En pruebas complementarias se evidencia fractura vertebral L5 y hematoma sobre músculo ilíaco derecho, procediéndose a drenaje quirúrgico, suspensión de acenocumarol, e inicio de apixaban. Tras el tratamiento persiste neuropatía femoral, que ha impedido la completa recuperación funcional. DISCUSIÓN: Neuropatía femoral de posible causa por compresiva por hematoma del iliopsoas o radicular por estenosis de canal lumbar y contacto con raíz L4, observando en ambos casos debilidad de musculatura proximal de extremidad inferior. Sospecha hematoma ante dolor lumbar, masa en flanco o hipovolemia. Manejo controvertido e individualizado en función de la severidad de la sintomatología, desde conservador a drenaje quirúrgico para reducir secuelas y complicaciones hemorrágicas. Apixaban ha mostrado mayor perfil de seguridad. La estabilización de fractura lumbar permitió recuperación funcional parcial

75-year-old patient with a history of acenocumarol anticoagulated atrial fibrillation, which shows pain, functional impotence and right lower limb paresthesias after fall. Studies evidenc evertebral fracture L5 and haematoma on right iliac muscle, proceeding to surgical drainage, suspension of acenocumarol, and onset of apixaban. After treatment persisted femoral neuropathy, which not allowed complete functional recovery. DISCUSSION: Femoral neuropathy as possible cause of compressive hematoma over iliopsoas muscle or secundary to lumbar canal stenosis and contact with L4 root. In both of the misit posible to observe weakness of proximal lower limb musculature. Haematoma was suspected due to lower back pain, flank mass and hypovolemia. Handlingis based on the severity of the symptomatology, from conservative to surgical drainage to reduce sequelae and bleeding complications. Apixaban has shown a higher safety profile. Stabilization of lumbar fracture allowed partial functional recovery

[Femoral neuropathy: Haematoma in iliac muscle and a lumbar vertebral fracture]. / Neuropatía femoral: hematoma en músculo ilíaco y fractura vertebral lumbar.

75-year-old patient with a history of acenocumarol anticoagulated atrial fibrillation, which shows pain, functional impotence and right lower limb paresthesias after fall. Studies evidenc evertebral fracture L5 and haematoma on right iliac muscle, proceeding to surgical drainage, suspension of acenocumarol, and onset of apixaban. After treatment persisted femoral neuropathy, which not allowed complete functional recovery. DISCUSSION: Femoral neuropathy as possible cause of compressive hematoma over iliopsoas muscle or secundary to lumbar canal stenosis and contact with L4 root. In both of the misit posible to observe weakness of proximal lower limb musculature. Haematoma was suspected due to lower back pain, flank mass and hypovolemia. Handlingis based on the severity of the symptomatology, from conservative to surgical drainage to reduce sequelae and bleeding complications. Apixaban has shown a higher safety profile. Stabilization of lumbar fracture allowed partial functional recovery.

Comparación de los índices PROFUND y PALIAR en pacientes pluripatológicos con enfermedad crónica no oncológica en fase avanzada / Comparison between PROFUND and PALIAR indexes in polypathological patients with advanced non-oncologic chronic diseases

Fundamento y objetivo: Comparar la rentabilidad de los índices PALIAR y PROFUND para predecir la mortalidad en pacientes pluripatológicos con enfermedad crónica no oncológica en fase avanzada. Material y métodos: Estudio de cohortes, prospectivo y multicéntrico con pacientes pluripatológicos con enfermedades crónicas no oncológicas en fase avanzada ingresados en departamentos de medicina interna entre el 1 de julio y el 31 de diciembre de 2014. Se recogieron datos de edad, género, categorías de pluripatología, enfermedad avanzada, comorbilidad, valoración funcional y cognitiva, síntomas de enfermedad terminal, necesidad de cuidador, ingresos en los 3 y 12 meses previos, número de fármacos, y se calcularon los índices PROFUND y PALIAR. Tras un seguimiento durante 12 meses la mortalidad se valoró con las curvas de supervivencia de Kaplan-Meier y la rentabilidad de los índices con las curvas ROC. Resultados: Se incluyeron 213 pacientes con edad media 83 (7) años y 106 (49,8%) eran mujeres. La mortalidad a los 6 meses fue del 40,4% y a los 12 del 50,2%. Los pacientes fallecidos puntuaban más alto en los índices PROFUND [11,2(4,2) frente a 8,5(3,9); p<0,001] y PALIAR [6,7 (4,6) frente a 3,6 (3,1); p<0,001]. La capacidad discriminativa del índice PALIAR a los 6 meses (área bajo la curva 0,734; IC95% 0,665-0,803) fue superior a la del índice PROFUND y no hubo diferencias a los 12 meses. Conclusiones: En pacientes pluripatológicos con enfermedad crónica en fase avanzada el índice PALIAR tiene un rendimiento mayor que el índice PROFUND para predecir la mortalidad a los 6 meses y similar a los 12 meses

Background and objective: To compare the discrimination power of PROFUND and PALIAR indexes for predicting mortality in polypathological patients with advanced non-oncologic chronic disease. Material and methods: Prospective multicentre cohort study. We included polypathological patients with advanced non-oncologic chronic disease, who were admitted to internal medicine departments between July 1st and December 31th, 2014. Data was collected from each patient on age, sex, categories of polypathology, advanced disease, comorbidity, functional and cognitive assessment, terminal illness symptoms, need for caregiver, hospitalisation in the past three and 12 months and number of drugs. We calculated the PROFUND and PALIAR indexes and conducted a 12-month follow-up. We assessed mortality with the Kaplan-Meier survival curves and the discrimination of indexes with the ROC curves. Results: We included 213 patients with a mean (standard deviation) age of 83.0 (7.0) years, 106 (49.8%) of whom were female. Mortality at six months was 40.4% and at 12 months 50.2%. Deceased patients scored higher scores on the PROFUND [11.2(4.2) vs 8.5(3.9); P<.001] and PALIAR [6.7 (4.6) vs 3.6(3.1); p<0,001] indexes. The discrimination of PALIAR index at six months (under the curve area 0.734 95%CI 0.665-0.803) was higher than of PROFUND, and there was no difference at 12 months. Conclusions: In polypathological patients with advanced non-oncologic chronic disease, the PALIAR index had better discrimination power than PROFUND index at 66 months and there were no differences at 12 months

Comparison between PROFUND and PALIAR indexes in polypathological patients with advanced non-oncologic chronic diseases. / Comparación de los índices PROFUND y PALIAR en pacientes pluripatológicos con enfermedad crónica no oncológica en fase avanzada.

BACKGROUND AND OBJECTIVE: To compare the discrimination power of PROFUND and PALIAR indexes for predicting mortality in polypathological patients with advanced non-oncologic chronic disease. MATERIAL AND METHODS: Prospective multicentre cohort study. We included polypathological patients with advanced non-oncologic chronic disease, who were admitted to internal medicine departments between July 1st and December 31th, 2014. Data was collected from each patient on age, sex, categories of polypathology, advanced disease, comorbidity, functional and cognitive assessment, terminal illness symptoms, need for caregiver, hospitalisation in the past three and 12 months and number of drugs. We calculated the PROFUND and PALIAR indexes and conducted a 12-month follow-up. We assessed mortality with the Kaplan-Meier survival curves and the discrimination of indexes with the ROC curves. RESULTS: We included 213 patients with a mean (standard deviation) age of 83.0 (7.0) years, 106 (49.8%) of whom were female. Mortality at six months was 40.4% and at 12 months 50.2%. Deceased patients scored higher scores on the PROFUND [11.2(4.2) vs 8.5(3.9); P<.001] and PALIAR [6.7 (4.6) vs 3.6(3.1); p<0,001] indexes. The discrimination of PALIAR index at six months (under the curve area 0.734 95%CI 0.665-0.803) was higher than of PROFUND, and there was no difference at 12 months. CONCLUSIONS: In polypathological patients with advanced non-oncologic chronic disease, the PALIAR index had better discrimination power than PROFUND index at 66 months and there were no differences at 12 months.

The nutritional risk and short-, medium- and long-term mortality of hospitalized patients with atrial fibrillation.

OBJECTIVE: To determine the association between the level of nutritional risk and the mortality of hospitalized patients with atrial fibrillation. METHODS: In a prospective cohort study, we included patients hospitalized with atrial fibrillation in an internal medicine department in 2007. We calculated the nutritional risk with the Controlling Nutritional Status (CONUT) score and conducted a 10-year follow-up. To determine the variables associated with mortality in the short (3 months), medium (1 year) and long term (10 years), we constructed a Cox proportional hazards regression model and calculated the Kaplan-Meier survival curves. RESULTS: The study included 282 patients with a mean (SD) age of 81.2 (7.9) years. The mean CONUT score was 4.7 (2.8) points. Thirty-six patients had zero nutritional risk, 110 had a low risk, 106 had a moderate risk, and 30 had a high risk. The median survival of the patients with zero, low, moderate and high risk was 33 months, 21 months, 10 months and 60 days, respectively. The CONUT score was independently associated with mortality at 3 months (HR 1.144; 95% CI 1.062-1.233), 12 months (HR 1.102; 95% CI 1.030-1.179) and 10 years (HR 1.051; 95% CI 1.000-1.103). CONCLUSIONS: Nutritional risk is associated with the short-, medium- and long-term mortality of hospitalized patients with atrial fibrillation.

External validation of the PALIAR index for patients with advanced, nononcologic chronic diseases.

OBJECTIVE: To externally validate the PALIAR index for patients with advanced, nononcologic chronic diseases. METHODS: We performed a prospective, multicenter cohort study that included patients with advanced, nononcologic chronic diseases hospitalized in internal medicine departments and treated consecutively by the researchers between July 1st and December 31st, 2014. Data were collected from each patient on age, sex, advanced disease, Charlson index, comorbidities, Barthel index, terminal illness symptoms, need for caregiver, hospitalization in the past 3 and 12 months and number of drugs. We calculated the PALIAR index and conducted a 6-month follow-up. To analyze the association between the variables and mortality, we constructed several multivariate logistic regression models. RESULTS: The study included 295 patients with a mean age of 82.7 (8.6) years, 148 (50.2%) of whom were women. Mortality at 6 months was associated with the albumin level (OR 0.52, 95% CI 0.30-0.85, p = 0.011), and the terminal illness (OR 2.75, 95% CI 1.55-4.89, p = 0.001). The PALIAR index showed good discrimination for predicting mortality (statistical C, 0.728, 95% CI 0.670-0.787). A reduced version of the PALIAR index showed similar mortality discriminatory power. CONCLUSIONS: The PALIAR index is a reliable tool for predicting mortality in patients with advanced, nononcologic chronic diseases.

Adherence to guidelines and mortality in atrial fibrillation.

OBJECTIVE: Determining the adherence to ACC/AHA/ESC 2006 guidelines and its influence on the survival of patients with atrial fibrillation. METHODS: Prospective observational study of patients discharged during 2007 from an Internal Medicine department with a main or secondary diagnose of atrial fibrillation. The stroke risk was estimated with the CHADS2 score. The follow-up was carried out in outpatient medical office or via telephone. RESULTS: We included 259 patients (mean age 80.9 years); 73% of them had a high risk of stroke. Oral anticoagulants were administered to 134 (51.7%), and antiplatelet drugs to 71 (27%) patients. A rate control strategy was chosen for 155 (59.8%) patients and a rhythm control one for 28 (10.8%). In 100 (38.6%) patients, treatment was adherent to the guidelines. Adherence to the guidelines was associated with age (0.95 95%CI 0.92-0.99; p=0.03), contraindication to the use of oral anticoagulants (0.38 95%CI 0.18-0.81; p=0.01) and mitral valve heart disease/valvular prosthesis (2.10 95%CI 1.04-4.25; p=0.04). The median follow-up was 727 days, and 191 patients died. Patients treated according to the guidelines had a higher rate of survival during the first three years (0.47 vs. 0.36; p=0.049). The use of oral anticoagulants was associated with a higher probability of survival over a 5 year period (0.34 vs 0.21; p=0.001) and the rate control strategy during the first year (0.69 vs 0.57; p=0.04). CONCLUSIONS: In the real world, the treatment of atrial fibrillation according to the guidelines is associated with improved survival for up to three years during follow-up.