Timing of previous heart failure hospitalization as a prognostic factor for emergency department heart failure patients.

To investigate whether the timing of a previous hospital admission for acute heart failure (AHF) is a prognostic factor for AHF patients revisiting the emergency department (ED) in the subsequent 12-month follow-up. All ED AHF patients enrolled in the previously described EAHFE registry were stratified by the presence or absence of an AHF hospitalization admission in the prior 12 months. The primary outcome was 12-month all-cause mortality post ED visit. Secondary end points were hospital admission, prolonged hospitalization (> 7 days), mortality during hospitalization and a 90-day post-discharge adverse composite event (ACE) rate, defined as ED revisits due to AHF, hospitalizations due to AHF, or all-cause mortality. Outcomes were adjusted for baseline and AHF episode characteristics.Of 5,757 patients included, the median age was 84 years (IQR 77-88); 57% were women, and 3,759 (65.3%) had an AHF hospitalization in the previous 12 months. The 12-month mortality was 37% (41.7% vs. 28.3% p < 0.001), hospital admission was 76.1% (78.8% vs. 71.1% p < 0.001) ACE was 60.2% (65.1% vs. 50.5% p < 0.001). In the adjusted analysis, patients with AHF hospitalization in the prior 12 months had a higher mortality (HR = 1.41; 95% CI 1.27-1.56), 90-day ACE rate (HR = 1.45: 95% CI 1.32-1.59), and more hospital admissions (OR = 1.32; 95% CI 1.16-1.51), with shorter times since the previous hospitalization being related to the outcomes analyzed. One-year mortality, adverse events at 90 days, and readmission rates are increased in ED AHF patients previously admitted within the last 12 months.

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

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

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

Calidad percibida por los pacientes con insuficiencia cardiaca aguda respecto a la atención recibida en urgencias: estudio CALPERICA / Patients’ perception of quality of emergency department care for acute heart failure: the CALPERICA study

Objetivo: Constatar la calidad percibida de los pacientes con insuficiencia cardiaca aguda (ICA) dados de alta desde urgencias, compararla con la de los ingresados, e investigar las variables asociadas con la calidad percibida. Método: Estudio diseñado prospectivamente, transversal, tipo caso-control, realizado en 7 servicios de urgencias en pacientes consecutivamente diagnosticados de ICA que valoraron mediante encuesta telefónica la atención médica, atención enfermera, trato global y grado de resolución del problema en urgencias. También se solicitó el grado de acuerdo con la decisión de alta directa desde urgencias. Se compararon los pacientes dados de alta e ingresados, y se investigó si estos resultados diferían en función de la existencia de eventos adversos los 30 días siguientes. Resultados: Se incluyeron 1.147 casos y se entrevistaron 1.003 (87,4%): 253 pacientes (25,2%) fueron dados de alta. No hubo diferencias significativas en la valoración que dieron a la asistencia médica, de enfermería, atención global y resolución del problema entre pacientes dados de alta e ingresados. La puntuación global (entre 0 y 10) fue de 7,34 (1,38) y 7,38 (1,52), respectivamente (p = 0,66). Más del 90% estuvieron de acuerdo o muy de acuerdo con la decisión de alta. No hubo diferencias de valoración en función de si habían existido acontecimientos adversos posteriores. Conclusiones: Los pacientes con ICA califican bien los distintos componentes de la atención que reciben en urgencias, sin diferencias entre pacientes ingresados y dados de alta. Entre estos últimos, su grado de acuerdo con la decisión médica de alta es elevado y su valoración se mantiene estable indistintamente de si con posterioridad se producen eventos adversos (AU)

Objectives: To determine perception of quality of care for acute heart failure (AHF) of patients discharged from the emergency department in comparison with the perception of admitted patients; to explore the variables associated with perception of quality. Methods: Prospective, cross-sectional case–control study in 7 emergency departments. Consecutive patients diagnosed with AHF were recruited to answer a telephone survey assessing their view of quality of physician c are, nurse care, overall treatment, and degree of resolution of their problem in the emergency department. Discharged patients were also asked to state their level of agreement with the decision to send them home from the emergency department. The answers of patients who were discharged home were compared with patients who were admitted to the ward. The results were analyzed according to whether or not adverse events occurred within 30 days. Results: A total of 1147 patients were enrolled and 1003 (87.4%) were interviewed; 253 of the patients (25.2%) were discharged home. We found no significant differences in any of the assessments (on physician or nurse care, overall treatment, or degree of resolution) between patients who were discharged home and those who were admitted. The mean (SD) overall satisfaction assessments (on a scale of 0 to 10) were 7.34 (1.38) and 7.38 (1.52), respectively, in the 2 groups (P=.66). Over 90% of those discharged home agreed with or strongly agreed with the decision. Evaluations were unrelated to whether or not adverse events occurred in the next 30 dyas. Conclusions: Patients with AHF have high opinions of the different components of care received in the emergency department, and their evaluations are unrelated to whether they were admitted or discharged home. Those discharged home agree with the decision and their opinion remains firm regardless of whether adverse events occur later (AU)

Efecto de una intervención formativa en urgencias en la mejora del manejo y el tratamiento de la insuficiencia cardiaca aguda / Emergency-department training course on improving the management of acute heart failure: evaluation of effectiveness

Introducción y objetivos: Existe un escaso seguimiento de las recomendaciones de las guías de manejo diagnóstico y terapéutico de los pacientes con insuficiencia cardiaca aguda (ICA) en los servicios de urgencias hospitalarios (SUH). Se evalúa si un programa de intervención sobre urgenciólogos permite mejorar el cumplimiento de estas guías. Método: Se diseñó un estudio de intervención cuasi-experimental sin grupo control y con una comparación pre y post-intervención. En una primera fase, se incluyeron de forma consecutiva a 708 pacientes que acudieron al SUH de 6 hospitales españoles durante un mes con el diagnóstico principal de ICA. En una segunda fase, se realizaron diferentes programas de formación sobre el manejo de la ICA según las guías vigentes. Tras la intervención, se volvió a incluir, siguiendo la misma metodología, a 613 pacientes que acudieron de ICA. Las variables principales fueron aquéllas que estudios previos habían detectado una mayor desviación de las recomendaciones de las principales guías (determinación de troponinas plasmáticas y BNP o pro-BNP, uso de furosemida en perfusión continua o nitroglicerina endovenosa y utilización de ventilación no invasiva-VNI). Resultados: Hubo escasas diferencias entre los grupos pre y postintervención en sus características demográficas, clínicas o en el tratamiento (en el grupo postintervención, existía un mayor porcentaje de pacientes con enfermedad cerebrovascular, neumopatíacrónica, disfunción sistólica y tratamiento ambulatorio con bloqueadores beta-adrenérgicos; p < 0,05 para todos ellos). Se detectó un aumento significativo en (..) (AU)

Background and objective: Current guidelines on the diagnostic and therapeutic management of acute heart failure have not been strictly followed in hospital emergency departments. This study aimed to assess whether a training course for emergency physicians improved compliance with recommended practices. Methods: A quasi-experimental study, without a control group, was designed to compare compliance pre- and posttraining. In the first phase, we included data for 708 consecutive patients who received a principal diagnosis of acute heart failure at 6 Spanish hospitals within 1 month. In the second phase, we organized guidelines-based training on the management of acute heart failure. After the intervention, we included data for 613 consecutive patients following the same methodology. The main outcome variables were the ones that previous studies had identified as deviating most from current guidelines (determination of serum levels of troponin, brain natriuretic peptide [BNP], and N-terminal prohormone-BNP [NT-pro-BNP]; use of furosemide in continuous perfusion or intravenous nitroglycerin; and use of noninvasive ventilation). Results: Few statistically significant differences in patient, clinical, or outpatient treatment characteristics were detected between the pre- and post-training patient groups, although there was a slightly greater percentage of cerebrovascular disease, chronic respiratory disease, systolic dysfunction, and outpatient treatment with â-blockers in the postintervention group. BNP or NT-pro-BNP determinations were performed significantly more often after training (absolute increased in score, 44.7%; 95% confidence interval [CI], 39.9-49.5; (..) (AU)