Biomarkers of stable and decompensated phases of heart failure with preserved ejection fraction.

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) is a disorder related to patient comorbidities and aging. Whether mitochondrial dysfunction is present during HFpEF decompensation versus the stable phase is largely unknown. The aim of the present study was to identify mitochondrial and cell metabolism blood biomarkers in older patients with acute and stable HFpEF. METHODS: Peripheral blood biomarkers were investigated in a group of eight to 12 patients aged 80-96 years and diagnosed with HFpEF first when they were in decompensated phase and then at least three months later in stable phase. Their data were compared to two control groups with an equal number of participants and sex proportions. One group was age matched and the other included individuals aged between 22 and 44 years. RESULTS: Decompensated patients experienced an increased mitochondrial superoxide production and mitochondrial mass, lower mitochondrial DNA copy number and LDHB expression, and higher lactate level compared to the stable stage. The stable phase was characterized by a sharp reduction in formate level. Multivariate analysis indicated that formate, lactate, and histidine can distinguish both of the HFpEF phases. Many of these parameters, including LDHB, lactate, formate, and mitochondrial mass, followed an age-related pattern, with acute HFpEF at its apex or nadir, suggesting that it represents an exacerbation of an aging-related process. CONCLUSIONS: We identified distinct blood biomarkers of chronic and decompensated HFpEF phases. The data underlined the relationship between HFpEF and aging. These findings could be used to monitor patients and might be therapeutically targeted.

Resultados a 30 días en los pacientes mayores frágiles con insuficiencia cardiaca aguda dados de alta desde urgencias o sus unidades vinculadas que cumplen los criterios de alto riesgo del estudio DEED FRAIL-AHF / Thirty-day outcomes in frail older patients discharged home from the emergency department with acute heart failure: effects of high-risk criteria identified by the DEED FRAIL-AHF trial

Objetivos: Estudiar el efecto a 30 días de los criterios de alto riesgo (CAR) en los mayores frágiles con insuficiencia cardiaca aguda (ICA) dados de alta desde urgencias o unidades vinculadas (URG_UV). Método: Análisis secundario del registro OAK-Discharge. Se seleccionaron pacientes frágiles $ 70 años con ICA dados de alta desde URG_UV. Los CAR se clasificaron en modificables (CAR_M) y no modificables (CAR_NM). Las variables de resultado fueron la compuesta cardiovascular (VC_CV) (revisita u hospitalización por ICA o mortalidad cardiovascular) y días vivos fuera del hospital (DVFH) a 30 días del alta. Resultados: Se incluyeron 380 pacientes con una edad media de 86 (DE 5,5) años, 61,2% mujeres. Un 65,1% tuvo CAR_M, 47,8% CAR_NM y 81,6% ambos. Ochenta y tres pacientes (21,8%) presentaron la VC_CV a 30 días. La media de DVFH a 30 días fue de 27,6 (DE 6,1) días. La presencia de CAR modificable, no modificable o ambos, se asoció más frecuentemente a la VC_CV a 30 días (25,0% vs 17,2%, p = 0,092; 27,6% vs 16,7%, p = 0,010; 24,7% vs15,2%, p = 0,098) y a menos DVFH a 30 días [26,9 (7,0) vs 28,4 (4,4), p = 0,011; 27,1 (7,0) vs 28,0 (5,0), p = 0,127; 27,1 (6,7) vs 28,8 (3,4), p = 0,005], respectivamente. Tras el análisis multivariante, los CAR_M se asociaron de forma independiente con menos DVFH a 30 días (diferencia absoluta ajustada –1,3 días; IC 95% –2,7 a –0,1) y los CAR_NM con más eventos en la VC_CV a 30 días (diferencia absoluta ajustada 10,4%; IC 95% 2,1% a 18,7%). (AU)

Objectives: To study the effect of high-risk criteria on 30-day outcomes in frail older patients with acute heart failure (AHF) discharged from an emergency department (ED) or an ED’s observation and short-stay areas. Methods.:Secondary analysis of discharge records in the Older AHF Key Data registry. We selected frail patients (aged > 70 years) discharged with AHF from EDs. Risk factors were categorized as modifiable or nonmodifiable. The outcomes were a composite endpoint for a cardiovascular event (revisits for AHF, hospitalization for AHF, or cardiovascular death) and the number of days alive out-of-hospital (DAOH) within 30 days of discharge. Results: We included 380 patients with a mean (SD) age of 86 (5.5) years (61.2% women). Modifiable risk factors were identified in 65.1%, nonmodifiable ones in 47.8%, and both types in 81.6%. The 30-day cardiovascular composite endpoint occurred in 83 patients (21.8%). The mean 30-day DAOH observed was 27.6 (6.1) days. High-risk factors were present more often in patients who developed the cardiovascular event composite endpoint: the rates for patients with modifiable, nonmodifiable, or both types of risk were, respectively, as follows in comparison with patients not at high risk: 25.0% vs 17.2%, P = .092; 27.6% vs 16.7%, P = .010; and 24.7% vs 15.2%, P = .098). The 30-day DAOH outcome was also lower for at-risk patients, according to type of risk factor present: modifiable, 26.9 (7.0) vs 28.4 (4.4) days, P = .011; nonmodifiable, 27.1 (7.0) vs 28.0 (5.0) days, P = .127; and both, 27.1 (6.7) vs28.8 (3.4) days, P = .005). After multivariate analysis, modifiable risk remained independently associated with fewer days alive (adjusted absolute difference in 30-day DAOH, –1.3 days (95% CI, –2.7 to –0.1 days). Nonmodifiable factors were associated with increased risk for the 30-day cardiovascular composite endpoint (adjusted absolute difference, 10.4%; 95% CI, –2.1% to 18.7%). (AU)

Thirty-day outcomes in frail older patients discharged home from the emergency department with acute heart failure: effects of high-risk criteria identified by the DEED FRAIL-AHF trial. / Resultados a 30 días en los pacientes mayores frágiles con insuficiencia cardiaca aguda dados de alta desde urgencias o sus unidades vinculadas que cumplen los criterios de alto riesgo del estudio DEED FRAIL-AHF.

OBJECTIVES: To study the effect of high-risk criteria on 30-day outcomes in frail older patients with acute heart failure (AHF) discharged from an emergency department (ED) or an ED's observation and short-stay areas. MATERIAL AND METHODS: Secondary analysis of discharge records in the Older AHF Key Data registry. We selected frail patients (aged > 70 years) discharged with AHF from EDs. Risk factors were categorized as modifiable or nonmodifiable. The outcomes were a composite endpoint for a cardiovascular event (revisits for AHF, hospitalization for AHF, or cardiovascular death) and the number of days alive out-of-hospital (DAOH) within 30 days of discharge. RESULTS: We included 380 patients with a mean (SD) age of 86 (5.5) years (61.2% women). Modifiable risk factors were identified in 65.1%, nonmodifiable ones in 47.8%, and both types in 81.6%. The 30-day cardiovascular composite endpoint occurred in 83 patients (21.8%). The mean 30-day DAOH observed was 27.6 (6.1) days. Highrisk factors were present more often in patients who developed the cardiovascular event composite endpoint: the rates for patients with modifiable, nonmodifiable, or both types of risk were, respectively, as follows in comparison with patients not at high risk: 25.0% vs 17.2%, P = .092; 27.6% vs 16.7%, P = .010; and 24.7% vs 15.2%, P = .098). The 30-day DAOH outcome was also lower for at-risk patients, according to type of risk factor present: modifiable, 26.9 (7.0) vs 28.4 (4.4) days, P = .011; nonmodifiable, 27.1 (7.0) vs 28.0 (5.0) days, P = .127; and both, 27.1 (6.7) vs 28.8 (3.4) days, P = .005). After multivariate analysis, modifiable risk remained independently associated with fewer days alive (adjusted absolute difference in 30-day DAOH, -1.3 days (95% CI, -2.7 to -0.1 days). Nonmodifiable factors were associated with increased risk for the 30-day cardiovascular composite endpoint (adjusted absolute difference, 10.4%; 95% CI, -2.1% to 18.7%). CONCLUSION: Risk factors are common in frail elderly patients with AHF discharged home from hospital ED areas. Their presence is associated with a worse 30-day prognosis.

OBJETIVO: Estudiar el efecto a 30 días de los criterios de alto riesgo (CAR) en los mayores frágiles con insuficiencia cardiaca aguda (ICA) dados de alta desde urgencias o unidades vinculadas (URG_UV). METODO: Análisis secundario del registro OAK-Discharge. Se seleccionaron pacientes frágiles 70 años con ICA dados de alta desde URG_UV. Los CAR se clasificaron en modificables (CAR_M) y no modificables (CAR_NM). Las variables de resultado fueron la compuesta cardiovascular (VC_CV) (revisita u hospitalización por ICA o mortalidad cardiovascular) y días vivos fuera del hospital (DVFH) a 30 días del alta. RESULTADOS: Se incluyeron 380 pacientes con una edad media de 86 (DE 5,5) años, 61,2% mujeres. Un 65,1% tuvo CAR_M, 47,8% CAR_NM y 81,6% ambos. Ochenta y tres pacientes (21,8%) presentaron la VC_CV a 30 días. La media de DVFH a 30 días fue de 27,6 (DE 6,1) días. La presencia de CAR modificable, no modificable o ambos, se asoció más frecuentemente a la VC_CV a 30 días (25,0% vs 17,2%, p = 0,092; 27,6% vs 16,7%, p = 0,010; 24,7% vs 15,2%, p = 0,098) y a menos DVFH a 30 días [26,9 (7,0) vs 28,4 (4,4), p = 0,011; 27,1 (7,0) vs 28,0 (5,0), p = 0,127; 27,1 (6,7) vs 28,8 (3,4), p = 0,005], respectivamente. Tras el análisis multivariante, los CAR_M se asociaron de forma independiente con menos DVFH a 30 días (diferencia absoluta ajustada ­1,3 días; IC 95% ­2,7 a ­0,1) y los CAR_NM con más eventos en la VC_CV a 30 días (diferencia absoluta ajustada 10,4%; IC 95% 2,1% a 18,7%). CONCLUSIONES: Los CAR son frecuentes en los mayores frágiles con ICA dados de alta desde URG_UV y su presencia se asocia a peores resultados a 30 días tras alta.

Iron deficiency and safety of ferric carboxymaltose in patients with acute heart failure. AHF-ID study.

INTRODUCTION: The presence of iron deficiency (ID) in patients with acute heart failure (AHF) is high. There are few studies on the characteristics of these patients and the safety of ferric carboxymaltose administration (FCM). OBJECTIVE: Study the differences among patients with AHF based on the presence and type of ID as well as the safety of FCM administration in these patients. METHOD: The AHF-ID study is a multicentre, analytical, prospective follow-up cohort including patients admitted to six Spanish hospitals for AHF. ID was defined as serum ferritin <100 µg/L (group A) or ferritin 100-299 µg/L with a TSAT <20% (group B). In cases receiving FCM the appearance of adverse events was analysed. Adjusted Cox regression was used to determine the association with 30-days reattendance for AHF after discharge. RESULTS: A total of 221 patients were recruited; 191 (86.4%) presented ID, 121 (63.4%) group A and 70 (36.6%) group B. There were scarce differences between the groups analysed. No differences were found in 30-days reattendance for AHF. FCM was administered to 158 (71.5%) patients, with 8 (5.1%) presenting adverse events, the most frequent being digestive alterations. Treatment was not discontinued in any case. CONCLUSIONS: There are scarce differences between the presence and the type of ID in patients with AHF. The administration of FCM in patients with ID and AHF is safe.

Respuesta de los autores: Importancia de la fragilidad física en el momento del ingreso en el pronóstico de la insuficiencia cardiaca / Author's reply: Prognosis in heart failure: importance of physical frailty at the time of admission

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El efecto de la fragilidad física en el pronóstico a largo plazo en los pacientes mayores con insuficiencia cardiaca aguda dados de alta desde un servicio de urgencias / Physical frailty and its impact on long-term outcomes in older patients with acute heart failure after discharge from an emergency department

Objetivo. Estudiar la frecuencia de fragilidad física y si su presencia se asocia con la presencia de resultados adversos en el primer año en los pacientes mayores con insuficiencia cardiaca aguda (ICA) dados de alta desde urgencias. Método. Estudio observacional de cohortes prospectivo que incluyó a los pacientes de 75 o más años con ICA dados de alta desde un servicio de urgencias. Se definió la fragilidad física como la presencia de 7 puntos en el Short Physical Performance Battery. La variable de resultado fue la aparición de un evento compuesto (revisita o reingreso por insuficiencia cardiaca y mortalidad por cualquier causa) en los primeros 365 días tras el alta de urgencias. Resultados. Se incluyeron 86 pacientes [edad media: 84 (DE 6 años); 59,3% mujeres]. La presencia de fragilidad se documentó en 49 (57%) pacientes. La frecuencia de la variable de resultado compuesta a los 365 días tras el alta de urgencias fue de un 46,5%. La fragilidad física fue un factor pronóstico independiente de presentar la variable resultado (OR ajustada = 3,6; IC 95% 1,0-12,9; p = 0,047). Conclusiones. La presencia de fragilidad física en los pacientes mayores con ICA dados de alta desde urgencias podría ser un factor pronóstico de malos resultados durante el primer año

Objective. To study the frequency of physical frailty and explore whether its presence in older patients with acute heart failure (AHF) is associated with adverse outcomes in the year after discharge from a emergency department (ED). Methods. Prospective observational cohort study in patients with AHF aged 75 years or older who were discharged from our ED. Physical frailty was defined by a score of 7 or less on the Short Physical Performance Battery. The outcome was the development of a composite event (ED revisit for AHF, hospital readmission for AHF, or all-cause mortality) within 365 days of discharge from the ED. Results. Eighty-six patients with a mean (SD) age of 84 (6) years were included; 59.3% were women. Frailty was identified in 49 patients (57%). The composite outcome was observed in 46.5% within 365 days. Physical fragility was an independent predictor of the outcome (adjusted odds ratio, 3.6; 95% CI, 1.0-12.9; P=.047). Conclusions. Frailty in older patients with AHF may predict a poor outcome during the year following discharge from an emergency department

Physical frailty and its impact on long-term outcomes in older patients with acute heart failure after discharge from an emergency department. / El efecto de la fragilidad física en el pronóstico a largo plazo en los pacientes mayores con insuficiencia cardiaca aguda dados de alta desde un servicio de urgencias.

OBJECTIVES: To study the frequency of physical frailty and explore whether its presence in older patients with acute heart failure (AHF) is associated with adverse outcomes in the year after discharge from a emergency department (ED). MATERIAL AND METHODS: Prospective observational cohort study in patients with AHF aged 75 years or older who were discharged from our ED. Physical frailty was defined by a score of 7 or less on the Short Physical Performance Battery. The outcome was the development of a composite event (ED revisit for AHF, hospital readmission for AHF, or all-cause mortality) within 365 days of discharge from the ED. RESULTS: Eighty-six patients with a mean (SD) age of 84 (6) years were included; 59.3% were women. Frailty was identified in 49 patients (57%). The composite outcome was observed in 46.5% within 365 days. Physical fragility was an independent predictor of the outcome (adjusted odds ratio, 3.6; 95% CI, 1.0-12.9; P=.047). CONCLUSION: Frailty in older patients with AHF may predict a poor outcome during the year following discharge from an emergency department.

OBJETIVO: Estudiar la frecuencia de fragilidad física y si su presencia se asocia con la presencia de resultados adversos en el primer año en los pacientes mayores con insuficiencia cardiaca aguda (ICA) dados de alta desde urgencias. METODO: Estudio observacional de cohortes prospectivo que incluyó a los pacientes de 75 o más años con ICA dados de alta desde un servicio de urgencias. Se definió la fragilidad física como la presencia de 7 puntos en el Short Physical Performance Battery. La variable de resultado fue la aparición de un evento compuesto (revisita o reingreso por insuficiencia cardiaca y mortalidad por cualquier causa) en los primeros 365 días tras el alta de urgencias. RESULTADOS: Se incluyeron 86 pacientes [edad media: 84 (DE 6 años); 59,3% mujeres]. La presencia de fragilidad se documentó en 49 (57%) pacientes. La frecuencia de la variable de resultado compuesta a los 365 días tras el alta de urgencias fue de un 46,5%. La fragilidad física fue un factor pronóstico independiente de presentar la variable resultado (OR ajustada = 3,6; IC 95% 1,0-12,9; p = 0,047). CONCLUSIONES: La presencia de fragilidad física en los pacientes mayores con ICA dados de alta desde urgencias podría ser un factor pronóstico de malos resultados durante el primer año.

Clinical phenotypes of acute heart failure based on signs and symptoms of perfusion and congestion at emergency department presentation and their relationship with patient management and outcomes.

OBJECTIVE: To compare the clinical characteristics and outcomes of patients with acute heart failure (AHF) according to clinical profiles based on congestion and perfusion determined in the emergency department (ED). METHODS AND RESULTS: Overall, 11 261 unselected AHF patients from 41 Spanish EDs were classified according to perfusion (normoperfusion = warm; hypoperfusion = cold) and congestion (not = dry; yes = wet). Baseline and decompensation characteristics were recorded as were the main wards to which patients were admitted. The primary outcome was 1-year all-cause mortality; secondary outcomes were need for hospitalisation during the index AHF event, in-hospital all-cause mortality, prolonged hospitalisation, 7-day post-discharge ED revisit for AHF and 30-day post-discharge rehospitalisation for AHF. A total of 8558 patients (76.0%) were warm + wet, 1929 (17.1%) cold + wet, 675 (6.0%) warm + dry, and 99 (0.9%) cold + dry; hypoperfused (cold) patients were more frequently admitted to intensive care units and geriatrics departments, and warm + wet patients were discharged home without admission. The four phenotypes differed in most of the baseline and decompensation characteristics. The 1-year mortality was 30.8%, and compared to warm + dry, the adjusted hazard ratios were significantly increased for cold + wet (1.660; 95% confidence interval 1.400-1.968) and cold + dry (1.672; 95% confidence interval 1.189-2.351). Hypoperfused (cold) phenotypes also showed higher rates of index episode hospitalisation and in-hospital mortality, while congestive (wet) phenotypes had a higher risk of prolonged hospitalisation but decreased risk of rehospitalisation. No differences were observed among phenotypes in ED revisit risk. CONCLUSIONS: Bedside clinical evaluation of congestion and perfusion of AHF patients upon ED arrival and classification according to phenotypic profiles proposed by the latest European Society of Cardiology guidelines provide useful complementary information and help to rapidly predict patient outcomes shortly after ED patient arrival.

Effect of risk of malnutrition on 30-day mortality among older patients with acute heart failure in Emergency Departments.

BACKGROUND: Little is known about the prevalence and impact of risk of malnutrition on short-term mortality among seniors presenting with acute heart failure (AHF) in emergency setting. The objective was to determine the impact of risk of malnutrition on 30-day mortality risk among older patients who attended in Emergency Departments (EDs) for AHF. MATERIAL AND METHODS: We performed a secondary analysis of the OAK-3 Registry including all consecutive patients ≥65 years attending in 16 Spanish EDs for AHF. Risk of malnutrition was defined by the Mini Nutritional Assessment Short Form (MNA-SF) < 12 points. Unadjusted and adjusted logistic regression models were used to assess the association between risk of malnutrition and 30-day mortality. RESULTS: We included 749 patients (mean age: 85 (SD 6); 55.8% females). Risk of malnutrition was observed in 594 (79.3%) patients. The rate of 30-day mortality was 8.8%. After adjusting for MEESSI-AHF risk score clinical categories (model 1) and after adding all variables showing a significantly different distribution among groups (model 2), the risk of malnutrition was an independent factor associated with 30-day mortality (adjusted OR by model 1 = 3.4; 95%CI 1.2-9.7; p = .020 and adjusted OR by model 2 = 3.1; 95%CI 1.1-9.0; p = .033) compared to normal nutritional status. CONCLUSIONS: The risk of malnutrition assessed by the MNA-SF is associated with 30-day mortality in older patients with AHF who were attended in EDs. Routine screening of risk of malnutrition may help emergency physicians in decision-making and establishing a care plan.

Planificación del alta desde urgencias para reducir eventos adversos a 30 días en pacientes mayores frágiles con insuficiencia cardiaca aguda: diseño y justificación del ensayo clínico DEED FRAIL-AHF / Planning to reduce 30-day adverse events after discharge of frail elderly patients with acute heart failure: design and rationale for the DEED FRAIL-AHF trial

Objetivos: Demostrar la eficacia de una intervención integral en la transición de cuidados (Plan de Alta Guiado Multinivel, PAGM) para disminuir eventos adversos a 30 días en ancianos frágiles con insuficiencia cardiaca aguda (ICA) dados de alta desde servicios de urgencias (SU) y validar los resultados de dicha intervención en condiciones reales. Método: Se seleccionarán pacientes mayores de 70 años frágiles con diagnóstico principal de ICA dados del alta a su domicilio desde SU. La intervención consistirá en aplicar un PAGM: 1) lista de verificación sobre recomendaciones clínicas y activación de recursos; 2) programación de visita precoz; 3) transmisión de información a atención primaria; 4) hoja de instrucciones al paciente por escrito. Fase 1: ensayo clínico con asignación al azar por conglomerados emparejado. Se asignará de forma aleatoria 10 SU (N = 480) al grupo de intervención y 10 SU (N = 480) al grupo de control. Se compararán los resultados entre grupo de intervención y control. Fase 2: estudio cuasi-experimental. Se realizará la intervención en los 20 SU (N = 300). Se comparará los resultados entre la fase 1 y 2 del grupo de intervención y entre la fase 1 y 2 del grupo de control. La variable principal de resultado es compuesta (revisita a urgencias u hospitalización por ICA o mortalidad de origen cardiovascular) a los 30 días del alta. Conclusiones: El estudio valorará la eficacia y factibilidad de una intervención integral en la transición de cuidados para reducir resultados adversos a 30 días en ancianos frágiles con ICA dados de alta desde los SU

Objectives: To demonstrate the efficacy of a system for comprehensive care transfer (Multilevel Guided Discharge Plan [MGDP]) for frail older patients diagnosed with acute heart failure (AHF) and to validate the results of MGDP implementation under real clinical conditions. The MGDP seeks to reduce the number of adverse outcomes within 30 days of emergency department (ED) discharge. Method: We will enroll frail patients over the age of 70 years discharged home from the ED with a main diagnosis of AHF. The MGDP includes the following components: 1) a checklist of clinical recommendations and resource activations, 2) scheduling of an early follow-up visit, 3) transfer of information to the primary care doctor, and 4) written instructions for the patient. Phase 1 of the study will be a matched-pair cluster-randomized controlled trial. Ten EDs will be randomly assigned to the intervention group and 10 to the control group. Each group will enroll 480 patients, and the outcomes will be compared between groups. Phase 2 will be a quasi-experimental study of the intervention in 300 new patients enrolled by the same 20 EDs. The outcomes will be compared to those for each Phase-1 group. The main endpoint at 30 days will be a composite of 2 outcomes: revisits to an ED and/for hospitalization for AHF or cardiovascular death. Conclusions: The study will assess the efficacy and feasibility of comprehensive MGDP transfer of care for frail older AHF patients discharged home

Planning to reduce 30-day adverse events after discharge of frail elderly patients with acute heart failure: design and rationale for the DEED FRAIL-AHF trial. / Planificación del alta desde urgencias para reducir eventos adversos a 30 días en pacientes mayores frágiles con insuficiencia cardiaca aguda: diseño y justificación del ensayo clínico DEED FRAIL-AHF.

OBJECTIVES: To demonstrate the efficacy of a system for comprehensive care transfer (Multilevel Guided Discharge Plan [MGDP]) for frail older patients diagnosed with acute heart failure (AHF) and to validate the results of MGDP implementation under real clinical conditions. The MGDP seeks to reduce the number of adverse outcomes within 30 days of emergency department (ED) discharge. MATERIAL AND METHODS: We will enroll frail patients over the age of 70 years discharged home from the ED with a main diagnosis of AHF. The MGDP includes the following components: 1) a checklist of clinical recommendations and resource activations, 2) scheduling of an early follow-up visit, 3) transfer of information to the primary care doctor, and 4) written instructions for the patient. Phase 1 of the study will be a matched-pair cluster-randomized controlled trial. Ten EDs will be randomly assigned to the intervention group and 10 to the control group. Each group will enroll 480 patients, and the outcomes will be compared between groups. Phase 2 will be a quasi-experimental study of the intervention in 300 new patients enrolled by the same 20 EDs. The outcomes will be compared to those for each Phase-1 group. The main endpoint at 30 days will be a composite of 2 outcomes: revisits to an ED and/for hospitalization for AHF or cardiovascular death. CONCLUSION: The study will assess the efficacy and feasibility of comprehensive MGDP transfer of care for frail older AHF patients discharged home.

OBJETIVO: Demostrar la eficacia de una intervención integral en la transición de cuidados (Plan de Alta Guiado Multinivel, PAGM) para disminuir eventos adversos a 30 días en ancianos frágiles con insuficiencia cardiaca aguda (ICA) dados de alta desde servicios de urgencias (SU) y validar los resultados de dicha intervención en condiciones reales. METODO: Se seleccionarán pacientes 70 años frágiles con diagnóstico principal de ICA dados del alta a su domicilio desde SU. La intervención consistirá en aplicar un PAGM: 1) lista de verificación sobre recomendaciones clínicas y activación de recursos; 2) programación de visita precoz; 3) transmisión de información a atención primaria; 4) hoja de instrucciones al paciente por escrito. Fase 1: ensayo clínico con asignación al azar por conglomerados emparejado. Se asignará de forma aleatoria 10 SU (N = 480) al grupo de intervención y 10 SU (N = 480) al grupo de control. Se compararán los resultados entre grupo de intervención y control. Fase 2: estudio cuasi-experimental. Se realizará la intervención en los 20 SU (N = 300). Se comparará los resultados entre la fase 1 y 2 del grupo de intervención y entre la fase 1 y 2 del grupo de control. La variable principal de resultado es compuesta (revisita a urgencias u hospitalización por ICA o mortalidad de origen cardiovascular) a los 30 días del alta. CONCLUSIONES: El estudio valorará la eficacia y factibilidad de una intervención integral en la transición de cuidados para reducir resultados adversos a 30 días en ancianos frágiles con ICA dados de alta desde los SU.

Aspectos por dilucidar sobre el papel pronóstico de la presión arterial sistólica en la insuficiencia cardiaca / Aspects to be clarified on the prognostic role of the systolic arterial pressure in heart failure

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Impacto de las variables geriátricas en la mortalidad a 30 días de los ancianos atendidos por insuficiencia cardiaca aguda / Impact of geriatric assessment variables on 30-day mortality among older patients with acute heart failure

OBJETIVOS: Estudiar el impacto de las variables geriátricas en la mortalidad a 30 días entre los ancianos con insuficiencia cardiaca aguda (ICA). MÉTODO: Análisis retrospectivo del registro Older Acute heart failure Key data (OAK) que incluye prospectivamente a pacientes consecutivos 65 años con ICA en 3 servicios de urgencias españoles durante 4 meses (noviembre-diciembre 2011 y enero-febrero 2014). Se realizó una valoración geriátrica adaptada a urgencias durante los días laborales de 8 am a 10 pm. Se recogieron variables demográficas, clínicas, analíticas y geriátricas (comorbilidad, polifarmacia, fragilidad, situación basal funcional, cognitiva y social, despistaje de síndrome confusional, deterioro cognitivo y depresión, y situación nutricional). La variable de resultado fue la mortalidad por cualquier causa a los 30 días. RESULTADOS: Se incluyeron 565 pacientes con edad media 83 años (DE 7,1), 346 mujeres (61,6%). Sesenta y cinco sujetos (11,5%) fallecieron a los 30 días. La presencia de síndrome confusional agudo (OR ajustada = 2,2; IC95% 1,0-4,8; p = 0,04), de enfermedad aguda (OR ajustada = 1,8; IC95% 0,9-3,4; p = 0,05) o pérdida de apetito (OR ajustada = 1,8; IC95% 1-3,4; p = 0,04) en los últimos 3 meses, y de fragilidad (OR ajustada = 2,0; IC95% 1,0-4,1; p = 0,05) o dependencia funcional grave (OR ajustada = 4,4; IC95% 1,9-11,4; p = 0,01) fueron factores independientes asociados con mortalidad a los 30 días. CONCLUSIONES: Existen ciertas variables geriátricas que debieran contemplarse en la estratificación de riesgo a corto plazo de los pacientes ancianos con ICA

OBJECTIVE: To study the impact of geriatric assessment variables on 30-day mortality among older patients with acute heart failure (AHF). METHODS: Retrospective analysis of cases in the OAK Registry (Older Acute Heart Failure Key Data), a prospectively compiled database of consecutive patients aged 65 years or older treated for AHF in 3 Spanish emergency departments over a 4-month period (November-December 2011 and January-February 2014). The patients underwent a geriatric assessment adapted for emergency department use on weekdays between 8 AM and 10 PM. Demographic, clinical, laboratory, and geriatric assessment variables were recorded. The geriatric variables were concurrent diseases; polypharmacy; frailty; functional, social, and cognitive status at baseline; results of screening for confusional state, cognitive impairment, and depression; and nutritional status. The primary outcome was all-cause mortality at 30 days. RESULTS: We included 565 patients with a mean (SD) age of 83 (7.1) years; 346 (61.6%) were women. Sixty-five (11.5%) died within 30 days. Independent factors associated with 30-day mortality were acute confusional state (adjusted odds ratio [aOR], 2.2; 95% CI, 1.0-4.8; P=.04), acute illness (aOR, 1.8; 95% CI, 0.9-3.4; P=.05), loss of appetite in the past 3 months (aOR, 1.8; 95% CI, 1.0-3.4; P=.04), frailty (aOR, 2.0, 95% CI, 1.0-4.1; P=.05), and severe disability (aOR, 4.4; 95% CI, 1.9-11.4; P=.01). CONCLUSIONS: Certain geriatric variables should be considered when assessing short-term risk in older patients with AHF

Impact of geriatric assessment variables on 30-day mortality among older patients with acute heart failure. / Impacto de las variables geriátricas en la mortalidad a 30 días de los ancianos atendidos por insuficiencia cardiaca aguda?

OBJETIVE: To study the impact of geriatric assessment variables on 30-day mortality among older patients with acute heart failure (AHF). METHODS: Retrospective analysis of cases in the OAK Registry (Older Acute Heart Failure Key Data), a prospectively compiled database of consecutive patients aged 65 years or older treated for AHF in 3 Spanish emergency departments over a 4-month period (November-December 2011 and January-February 2014). The patients underwent a geriatric assessment adapted for emergency department use on weekdays between 8 AM and 10 PM. Demographic, clinical, laboratory, and geriatric assessment variables were recorded. The geriatric variables were concurrent diseases; polypharmacy; frailty; functional, social, and cognitive status at baseline; results of screening for confusional state, cognitive impairment, and depression; and nutritional status. The primary outcome was all-cause mortality at 30 days. RESULTS: We included 565 patients with a mean (SD) age of 83 (7.1) years; 346 (61.6%) were women. Sixty-five (11.5%) died within 30 days. Independent factors associated with 30-day mortality were acute confusional state (adjusted odds ratio [aOR], 2.2; 95% CI, 1.0­4.8; P=.04), acute illness (aOR, 1.8; 95% CI, 0.9­3.4; P=.05), loss of appetite in the past 3 months (aOR, 1.8; 95% CI, 1.0­3.4; P=.04), frailty (aOR, 2.0, 95% CI, 1.0­4.1; P=.05), and severe disability (aOR, 4.4; 95% CI, 1.9­11.4; P=.01). CONCLUSIONS: Certain geriatric variables should be considered when assessing short-term risk in older patients with AHF.

OBJETIVOS: Estudiar el impacto de las variables geriátricas en la mortalidad a 30 días entre los ancianos con insuficiencia cardiaca aguda (ICA). MÉTODO: Análisis retrospectivo del registro Older Acute heart failure Key data (OAK) que incluye prospectivamente a pacientes consecutivos 65 años con ICA en 3 servicios de urgencias españoles durante 4 meses (noviembre-diciembre 2011 y enero-febrero 2014). Se realizó una valoración geriátrica adaptada a urgencias durante los días laborales de 8 am a 10 pm. Se recogieron variables demográficas, clínicas, analíticas y geriátricas (comorbilidad, polifarmacia, fragilidad, situación basal funcional, cognitiva y social, despistaje de síndrome confusional, deterioro cognitivo y depresión, y situación nutricional). La variable de resultado fue la mortalidad por cualquier causa a los 30 días. RESULTADOS: Se incluyeron 565 pacientes con edad media 83 años (DE 7,1), 346 mujeres (61,6%). Sesenta y cinco sujetos (11,5%) fallecieron a los 30 días. La presencia de síndrome confusional agudo (OR ajustada = 2,2; IC95% 1,0-4,8; p = 0,04), de enfermedad aguda (OR ajustada = 1,8; IC95% 0,9-3,4; p = 0,05) o pérdida de apetito (OR ajustada = 1,8; IC95% 1-3,4; p = 0,04) en los últimos 3 meses, y de fragilidad (OR ajustada = 2,0; IC95% 1,0-4,1; p = 0,05) o dependencia funcional grave (OR ajustada = 4,4; IC95% 1,9-11,4; p = 0,01) fueron factores independientes asociados con mortalidad a los 30 días. CONCLUSIONES: Existen ciertas variables geriátricas que debieran contemplarse en la estratificación de riesgo a corto plazo de los pacientes ancianos con ICA.

Impact of Frailty and Disability on 30-Day Mortality in Older Patients With Acute Heart Failure.

The objectives were to determine the impact of frailty and disability on 30-day mortality and whether the addition of these variables to HFRSS EFFECT risk score (FBI-EFFECT model) improves the short-term mortality predictive capacity of both HFRSS EFFECT and BI-EFFECT models in older patients with acute decompensated heart failure (ADHF) atended in the emergency department. We performed a retrospective analysis of OAK Registry including all consecutive patients ≥65 years old with ADHF attended in 3 Spanish emergency departments over 4 months. FBI-EFFECT model was developed by adjusting probabilities of HFRSS EFFECT risk categories according to the 6 groups (G1: non frail, no or mildly dependent; G2: frail, no or mildly dependent; G3: non frail, moderately dependent; G4: frail, moderately dependent; G5: severely dependent; G6: very severely dependent).We included 596 patients (mean age: 83 [SD7]; 61.2% females). The 30-day mortality was 11.6% with statistically significant differences in the 6 groups (p < 0.001). After adjusting for HFRSS EFFECT risk categories, we observed a progressive increase in hazard ratios from groups G2 to G6 compared with G1 (reference). FBI-EFFECT had a better prognostic accuracy than did HFRSS EFFECT (log-rank p < 0.001; Net Reclassification Improvement [NRI] = 0.355; p < 0.001; Integrated Discrimination Improvement [IDI] = 0.052; p ;< 0.001) and BI-EFFECT (log-rank p = 0.067; NRI = 0.210; p = 0.033; IDI = 0.017; p = 0.026). In conclusion, severe disability and frailty in patients with moderate disability are associated with 30-day mortality in ADHF, providing additional value to HFRSS EFFECT model in predicting short-term prognosis and establishing a care plan.

La acidosis láctica en pacientes en tratamiento con metformina no siempre se asocia al fármaco / Lactic acidosis in patients treated with metformin is not always drugrelated

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