The Effects of a Therapeutic Strategy Guided by Lung Ultrasound on 6-Month Outcomes in Patients with Heart Failure: Results from the EPICC Randomized Controlled Trial.

Background: Pulmonary congestion (PC) is associated with an increased risk of hospitalization and death in patients with heart failure (HF). Lung ultrasound is highly sensitive for detecting PC. The aim of this study is to evaluate whether lung ultrasound-guided therapy improves 6-month outcomes in patients with HF. Methods: A randomized, multicenter, single-blind clinical trial in patients discharged after hospitalization for decompensated HF. Participants were assigned 1:1 to receive treatment guided according to the presence of lung ultrasound signs of congestion (semi-quantitative evaluation of B lines and the presence of pleural effusion) versus standard of care (SOC). The primary endpoint was the combination of cardiovascular death, readmission, or emergency department or day hospital visit due to worsening HF at 6 months. In September 2020, after an interim analysis, patient recruitment was stopped. Results: A total of 79 patients were randomized (mean age 81.2 +/− 9 years) and 41 patients (51.8%) showed a left ventricular ejection fraction >50%. The primary endpoint occurred in 11 patients (29.7%) in the SOC group and in 11 patients (26.1%) in the LUS group (log-rank = 0.83). Regarding nonserious adverse events, no significant differences were found. Conclusions: LUS-guided diuretic therapy after hospital discharge due to ADHF did not show any benefit in survival or a need for intravenous diuretics compared with SOC.

Prognostic Significance of the PROFUND Index on One Year Mortality in Acute Heart Failure: Results from the RICA Registry.

Background: Heart failure (HF) is a syndrome with high prevalence, mainly affecting elderly patients, where the presence of associated comorbidities is of great importance. Methods: An observational study from a prospective registry was conducted. Patients identified from the National Registry of Heart Failure (RICA), which belongs to the Working Group on Heart Failure and Atrial Fibrillation of the Spanish Society of Internal Medicine (SEMI), were included. The latter is a prospective, multicenter registry that has been active since 2008. It includes individual consecutive patients over 50 years of age with a diagnosis of HF at hospital discharge (acute decompensated or new-onset HF). Results: In total, 5424 patients were identified from the registry. Forty-seven percent were men and mean left ventricular ejection fraction (LVEF) was 51.4%; 1132 had a score of 0 to 2 according to the PROFUND index, 3087 had a score of 3 to 6, and 952 patients had a score of 7 to 10 points. In the sample, 252 patients had a score above 11 points. At the end of the year of follow-up, 61% of the patients died. This mortality increased proportionally as the PROFUND index increased, specifically 75% for patients with PROFUND greater than 11. The Kaplan-Meier survival curve shows that survival at one year progressively decreases as the PROFUND index value increases. Thus, subjects with scores greater than seven (intermediate-high and high-risk) presented the worst survival with a log rank of 0.96 and a p < 0.05. In the regression analysis, we found a higher risk of death from any cause at one year in the group with the highest risk according to the PROFUND index (score greater than 11 points (HR 1.838 (1.410−2.396)). Conclusions: The PROFUND index is a good index for predicting mortality in patients admitted for acute HF, especially in those subjects at intermediate to high risk with scores above seven. Future studies should seek to determine whether the PROFUND index score is simply a prognostic marker or whether it can also be used to make therapeutic decisions for those subjects with very high short-term mortality.

Epidemiología de la insuficiencia cardiaca con fracción de eyección preservada: resultados del Registro RICA / Epidemiology of heart failure with preserved ejection fraction: Results from the RICA Registry

Introducción y objetivos: La caracterización de los pacientes con insuficiencia cardiaca (IC) con fracción de eyección preservada (IC-FEp) sigue teniendo interés. El objetivo fue conocer la prevalencia, las características clínicas y epidemiológicas de la IC-FEp, y sus cambios en los últimos años.MétodosAnalizamos el Registro RICA, de la Sociedad Española de Medicina Interna; estudio de cohorte multicéntrico y prospectivo de pacientes ingresados por IC, consecutivamente en servicios de medicina interna, durante un periodo de 11 años (2008-2018).ResultadosSe incluyeron 4.752 pacientes, 2957 (62,2%) con IC-FEp, proporción que se mantuvo constante durante todo el periodo. En comparación con los pacientes con IC y fracción de eyección reducida (IC-FEr), los pacientes con IC-FEp tienen: mayor edad, predominio de sexo femenino, etiología hipertensiva y valvular, distinto perfil de comorbilidades y peor capacidad funcional (menor índice de Barthel). La mayoría de pacientes recibía un tratamiento similar al de la IC-FEr (inhibidores del sistema renina-angiotensina-aldosterona y betabloqueantes). La mortalidad global al año de seguimiento fue del 24% en la IC-FEp y del 30% en la IC-FEr. En el análisis multivariante el riesgo de muerte fue superior en los pacientes con IC-FEr (HR: 1,84; IC 95%: [1,43-2,36]); la estancia hospitalaria fue inferior en la IC-FEp y no hubo diferencias en las re-hospitalizaciones. (AU)

Introduction and objectives: There is great interest in better characterizing patients with heart failure (HF) with preserved ejection fraction (HF-PEF). The objective of this study is to determine the prevalence, progression over time and to describe the clinical and epidemiological characteristics of patients with HF-PEF.MethodsFrom the National Registry of Heart Failure (RICA, prospective multicentre cohort study) we analysed patients consecutively admitted for HF in Internal Medicine wards over a period of 11 years (2008-2018).Results4752 patients were included, 2957 (62.2%) with preserved ejection fraction. This prevalence remained constant from 2008 to 2019. Compared to patients with HF and reduced ejection fraction (HF-REF) patients with HF-PEF are older, more are female, there is a higher prevalence of hypertensive and valvular aetiology, they have a profile of different comorbidities and worse functional status. A high proportion of patients receive disease-modifying treatment for IC-REF (renin-angiotensin-aldosterone system inhibitors and beta-blockers). The overall mortality after one-year follow-up was 24% and 30% in the HF-PEF and the HF-REF, respectively. In the multivariate analysis, the risk of death was higher in patients with HF-REF compared to HF-PEF (OR: 1.84; 95% CI: [1.43-2.36]). The length of hospital stay was also lower in the HF-PEF patients but there were no differences in re-hospitalizations. (AU)

Epidemiology of heart failure with preserved ejection fraction: Results from the RICA Registry. / Epidemiología de la insuficiencia cardiaca con fracción de eyección preservada: resultados del Registro RICA.

INTRODUCTION AND OBJECTIVES: There is great interest in better characterizing patients with heart failure (HF) with preserved ejection fraction (HF-PEF). The objective of this study is to determine the prevalence, progression over time and to describe the clinical and epidemiological characteristics of patients with HF-PEF. METHODS: From the National Registry of Heart Failure (RICA, prospective multicentre cohort study) we analysed patients consecutively admitted for HF in Internal Medicine wards over a period of 11 years (2008-2018). RESULTS: 4752 patients were included, 2957 (62.2%) with preserved ejection fraction. This prevalence remained constant from 2008 to 2019. Compared to patients with HF and reduced ejection fraction (HF-REF) patients with HF-PEF are older, more are female, there is a higher prevalence of hypertensive and valvular aetiology, they have a profile of different comorbidities and worse functional status. A high proportion of patients receive disease-modifying treatment for IC-REF (renin-angiotensin-aldosterone system inhibitors and beta-blockers). The overall mortality after one-year follow-up was 24% and 30% in the HF-PEF and the HF-REF, respectively. In the multivariate analysis, the risk of death was higher in patients with HF-REF compared to HF-PEF (OR: 1.84; 95% CI: [1.43-2.36]). The length of hospital stay was also lower in the HF-PEF patients but there were no differences in re-hospitalizations. CONCLUSIONS: Sixty percent of patients in the RICA registry have preserved ejection fraction. These patients have a higher comorbidity burden and a worse functional status, but lower mortality compared with HF-REF patients.

Differential characteristics of acute heart failure in very elderly patients: the prospective RICA study.

INTRODUCTION: Acute heart failure (AHF) is a frequent epidemic in geriatrics. The main aim of this study was to evaluate the clinical and prognostic differences of very elderly patients with AHF compared to the rest, and evaluate the factors associated with 90-day mortality. METHODS: We analyzed 3828 patients hospitalized for AHF with an age of ≥ 70 years. The population was divided into three groups: 70-79, 80-89 and ≥ 90 years old (nonagenarians). The baseline characteristics of patients nonagenarians were compared with the rest. In the group of nonagenarians, their clinical characteristics were analyzed according to the left ventricular ejection fraction (LVEF) and the factors associated with mortality at 90 days of follow-up. RESULTS: Nonagenarians showed higher comorbidity and cognitive deterioration, worse basal functional status, and preserved LVEF. Alternatively, they presented a lower rate of diabetes mellitus, lower incidence of de novo AHF, and lower prescription of angiotensin-converting-enzyme inhibitors, aldosterone blockers, anticoagulants, and statins at hospital discharge. Of the total, 334 patients (9.3%) had died by 90 days. The 90-day mortality rate was highest in nonagenarians (7.1% vs 9.8% vs 17%; p = 0.001). Multivariate analysis showed that renal failure, New York Heart Association (NYHA) functional classifications of III-IV, and a more advanced functional deterioration at baseline are predictors of mortality within 90 days. CONCLUSIONS: The AHF in patients nonagenarians has a different clinical profile compared to younger patients and a higher mortality. In this subgroup of patients having a worse baseline functional status, higher NYHA classification (III-IV), and renal failure are predictors of 90-day mortality.

Cortistatin regulates glucose-induced electrical activity and insulin secretion in mouse pancreatic beta-cells.

Although there is growing evidence that cortistatin regulates several functions in different tissues, its role in the endocrine pancreas is not totally known. Here, we aim to study the effect of cortistatin on pancreatic beta-cells and glucose-stimulated insulin secretion (GSIS). Exposure of isolated mouse islets to cortistatin inhibited GSIS. This effect was prevented using a somatostatin receptor antagonist. Additionally, cortistatin hyperpolarized the membrane potential and reduced glucose-induced action potentials in isolated pancreatic beta-cells. Cortistatin did not modify ATP-dependent K+ (KATP) channel activity. In contrast, cortistatin increased the activity of a small conductance channel with characteristics of G protein-coupled inwardly rectifying K+ (GIRK) channels. The cortistatin effects on membrane potential and GSIS were largely reduced in the presence of a GIRK channel antagonist and by down-regulation of GIRK2 with small interfering RNA. Thus, cortistatin acts as an inhibitory signal for glucose-induced electrical activity and insulin secretion in the mouse pancreatic beta-cell.

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.

Combining heart rate and systolic blood pressure to improve risk stratification in older patients with heart failure: Findings from the RICA Registry.

OBJECTIVES: Heart rate (HR) and systolic blood pressure (SBP) are independent prognostic variables in patients with heart failure (HF). We evaluated if combining HR and SBP could improve prognostic assessment in older patients. METHODS: Variables associated with all-cause mortality and readmission for HF during 9months of follow-up were analyzed from the Spanish Heart Failure Registry (RICA). HR and SBP values were stratified in three combined groups. RESULTS: We evaluated 1551 patients, 82years and 56% women. Using HR strata of <70 and ≥70bpm we found mortality rates of 9.8 and 13.6%, respectively (hazard ratio 1.0 and 1.35). For SBP≥140, 120-140 and <120mmHg, mortality rates were 8.2, 10.4 and 20.3%. respectively (hazard ratio 1.0, 1.34 and 2.76). Using combined strata of HR<70bpm and SBP≥140mmHg (n=176; low-risk), HR<70 and SBP<140+HR≥70 and SBP<120 (n=1089; moderate-risk) and HR≥70 and SBP<120 (n=286; high-risk) we found mortality rates of 4.5%, 11.0% and 24.0%, respectively. Multivariate Cox regression for all-cause mortality shows for low-, middle- and high-risk groups was 1 (reference), 1.93 (95% CI: 0.93-3.99, p=0.077) and 4.32 (95% CI: 2.04-9.14, p<0.001). BMI, NYHA, MDRD, hypertension and sodium were also independent prognostic factors. CONCLUSIONS: The combination provides better risk discrimination than use of HR and SBP alone and may provide a simple and reliable tool for risk assessment for older HF patients in clinical practice.