Clinical suspicion, diagnosis and management of cardiac amyloidosis: update document and executive summary.

In recent years, the interest in cardiac amyloidosis has grown exponentially. However, there is a need to improve our understanding of amyloidosis in order to optimise early detection systems. Therefore, it is crucial to incorporate solutions to improve the suspicion, diagnosis and follow-up of cardiac amyloidosis. In this sense, we designed a tool following the different phases to reach the diagnosis of cardiac amyloidosis, as well as an optimal follow-up: a) clinical suspicion, where the importance of the "red flags" to suspect it and activate the diagnostic process is highlighted; 2) diagnosis, where the diagnostic algorithm is mainly outlined; and 3) follow-up of confirmed patients. This is a practical resource that will be of great use to all professionals caring for patients with suspected or confirmed cardiac amyloidosis, to improve its early detection, as well as to optimise its accurate diagnosis and optimal follow-up.

Diferencias en función del sexo en las características clínicas y resultados del ensayo clínico CLOROTIC (combinación de diuréticos de asa con tiazidas en la insuficiencia cardiaca descompensada) / Sex differences in clinical characteristics and outcomes in the CLOROTIC (combining loop with thiazide diuretics for decompensated heart failure) trial

ObjetivoEvaluar si existen diferencias en los resultados del ensayo clínico CLOROTIC según el sexo. Métodos Subanálisis del ensayo CLOROTIC, que evaluó la eficacia y la seguridad de añadir hidroclorotiazida (HCTZ) o placebo a furosemida intravenosa en pacientes con insuficiencia cardiaca aguda (ICA). Los resultados primarios y secundarios incluyeron cambios en el peso y la disnea a las 72 y 96horas, medidas de la respuesta diurética y la mortalidad y reingresos a los 30 y 90días. Se evaluó la influencia del sexo en los resultados primarios y secundarios y de seguridad. Resultados De los 230 pacientes incluidos, 111 (48%) eran mujeres, que tenían más edad y valores más elevados de fracción de eyección ventricular izquierda. Los hombres tenían más cardiopatía isquémica, enfermedad pulmonar obstructiva crónica y mayor valor de péptidos natriuréticos. La adición de HCTZ a furosemida se asoció con una mayor pérdida de peso a las 72/96horas y mejor respuesta diurética a las 24horas en comparación con el placebo, sin diferencias significativas según el sexo (ningún valor de p para la interacción fue significativo). El deterioro de la función renal fue más frecuente en mujeres (OR: 8,68; IC95%: 3,41-24,63) que en varones (OR: 2,5; IC95%: 0,99-4,87), p=0,027. No hubo diferencias en la mortalidad ni en los reingresos a los 30/90días. Conclusión La adición de HCTZ a furosemida intravenosa es una estrategia eficaz para mejorar la respuesta diurética en la ICA sin diferencias según el sexo. Sin embargo, el deterioro de la función renal es más frecuente en las mujeres. (AU)

Aims The addition of hydrochlorothiazide (HCTZ) to furosemide improved the diuretic response in patients with acute heart failure (AHF) in the CLOROTIC trial. Our aim was to evaluate if there were differences in clinical characteristics and outcomes according to sex. Methods This is a post hoc analysis of the CLOROTIC trial, including 230 patients with AHF randomized to receive HCTZ or placebo in addition to an intravenous furosemide regimen. The primary and secondary outcomes included changes in weight and patient-reported dyspnoea 72 and 96h after randomization, metrics of diuretic response and mortality/rehospitalizations at 30 and 90days. The influence of sex on primary, secondary and safety outcomes was evaluated. Results One hundred and eleven (48%) women were included in the study. Women were older and had higher values of left ventricular ejection fraction. Men had more ischemic cardiomyopathy and chronic obstructive pulmonary disease and higher values of natriuretic peptides. The addition of HCTZ to furosemide was associated to a greatest weight loss at 72/96h, better metrics of diuretic response and higher 24-h diuresis compared to placebo without significant differences according to sex (all P-values for interaction were not significant). Worsening renal function occurred more frequently in women (OR: 8.68; 95%CI: 3.41-24.63) than men (OR: 2.5; 95%CI: 0.99-4.87), P=.027. There were no differences in mortality or rehospitalizations at 30/90days. Conclusion Adding HCTZ to intravenous furosemide is an effective strategy to improve diuretic response in AHF with no difference according to sex, but worsening renal function was more frequent in women. (AU)

Diferencias en función del sexo en las características clínicas y resultados del ensayo clínico CLOROTIC (combinación de diuréticos de asa con tiazidas en la insuficiencia cardiaca descompensada) / Sex differences in clinical characteristics and outcomes in the CLOROTIC (combining loop with thiazide diuretics for decompensated heart failure) trial

ObjetivoEvaluar si existen diferencias en los resultados del ensayo clínico CLOROTIC según el sexo. Métodos Subanálisis del ensayo CLOROTIC, que evaluó la eficacia y la seguridad de añadir hidroclorotiazida (HCTZ) o placebo a furosemida intravenosa en pacientes con insuficiencia cardiaca aguda (ICA). Los resultados primarios y secundarios incluyeron cambios en el peso y la disnea a las 72 y 96horas, medidas de la respuesta diurética y la mortalidad y reingresos a los 30 y 90días. Se evaluó la influencia del sexo en los resultados primarios y secundarios y de seguridad. Resultados De los 230 pacientes incluidos, 111 (48%) eran mujeres, que tenían más edad y valores más elevados de fracción de eyección ventricular izquierda. Los hombres tenían más cardiopatía isquémica, enfermedad pulmonar obstructiva crónica y mayor valor de péptidos natriuréticos. La adición de HCTZ a furosemida se asoció con una mayor pérdida de peso a las 72/96horas y mejor respuesta diurética a las 24horas en comparación con el placebo, sin diferencias significativas según el sexo (ningún valor de p para la interacción fue significativo). El deterioro de la función renal fue más frecuente en mujeres (OR: 8,68; IC95%: 3,41-24,63) que en varones (OR: 2,5; IC95%: 0,99-4,87), p=0,027. No hubo diferencias en la mortalidad ni en los reingresos a los 30/90días. Conclusión La adición de HCTZ a furosemida intravenosa es una estrategia eficaz para mejorar la respuesta diurética en la ICA sin diferencias según el sexo. Sin embargo, el deterioro de la función renal es más frecuente en las mujeres. (AU)

Aims The addition of hydrochlorothiazide (HCTZ) to furosemide improved the diuretic response in patients with acute heart failure (AHF) in the CLOROTIC trial. Our aim was to evaluate if there were differences in clinical characteristics and outcomes according to sex. Methods This is a post hoc analysis of the CLOROTIC trial, including 230 patients with AHF randomized to receive HCTZ or placebo in addition to an intravenous furosemide regimen. The primary and secondary outcomes included changes in weight and patient-reported dyspnoea 72 and 96h after randomization, metrics of diuretic response and mortality/rehospitalizations at 30 and 90days. The influence of sex on primary, secondary and safety outcomes was evaluated. Results One hundred and eleven (48%) women were included in the study. Women were older and had higher values of left ventricular ejection fraction. Men had more ischemic cardiomyopathy and chronic obstructive pulmonary disease and higher values of natriuretic peptides. The addition of HCTZ to furosemide was associated to a greatest weight loss at 72/96h, better metrics of diuretic response and higher 24-h diuresis compared to placebo without significant differences according to sex (all P-values for interaction were not significant). Worsening renal function occurred more frequently in women (OR: 8.68; 95%CI: 3.41-24.63) than men (OR: 2.5; 95%CI: 0.99-4.87), P=.027. There were no differences in mortality or rehospitalizations at 30/90days. Conclusion Adding HCTZ to intravenous furosemide is an effective strategy to improve diuretic response in AHF with no difference according to sex, but worsening renal function was more frequent in women. (AU)

Sex differences in clinical characteristics and outcomes in the CLOROTIC (combining loop with thiazide diuretics for decompensated heart failure) trial.

AIMS: The addition of hydrochlorothiazide (HCTZ) to furosemide improved the diuretic response in patients with acute heart failure (AHF) in the CLOROTIC trial. Our aim was to evaluate if there were differences in clinical characteristics and outcomes according to sex. METHODS: This is a post-hoc analysis of the CLOROTIC trial, including 230 patients with AHF randomized to receive HCTZ or placebo in addition to an intravenous furosemide regimen. The primary and secondary outcomes included changes in weight and patient-reported dyspnoea 72 and 96 h after randomization, metrics of diuretic response and mortality/rehospitalizations at 30 and 90 days. The influence of sex on primary, secondary and safety outcomes was evaluated. RESULTS: One hundred and eleven (48%) women were included in the study. Women were older and had higher values of left ventricular ejection fraction. Men had more ischemic cardiomyopathy and chronic obstructive pulmonary disease and higher values of natriuretic peptides. The addition of HCTZ to furosemide was associated to a greatest weight loss at 72/96 h, better metrics of diuretic response and higher 24-h diuresis compared to placebo without significant differences according to sex (all p-values for interaction were not significant). Worsening renal function occurred more frequently in women (OR [95%CI]: 8.68 [3.41-24.63]) than men (OR [95%CI]: 2.5 [0.99-4.87]), p = 0.027. There were no differences in mortality or rehospitalizations at 30/90 days. CONCLUSION: Adding HCTZ to intravenous furosemide is an effective strategy to improve diuretic response in AHF with no difference according to sex, but worsening renal function was more frequent in women. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov: NCT01647932; EudraCT Number: 2013-001852-36.

Resumen ejecutivo de la actualización 2023 del consenso de actuación básica durante el ingreso hospitalario por insuficiencia cardiaca aguda / Executive summary of the 2023 update on the consensus regarding basic conduct during hospital admission for patients with acute heart failure

La insuficiencia cardiaca aguda (ICA) está asociada a una importante morbimortalidad, constituyendo la primera causa de hospitalización en mayores de 65 años en nuestro país. Las principales recomendaciones recogidas son: 1) al ingreso, se recomienda realizar una evaluación integral, considerando el tratamiento habitual y comorbilidades, ya que condicionan el pronóstico; 2) en las primeras horas de atención hospitalaria, el tratamiento descongestivo es prioritario, y se recomienda un abordaje terapéutico diurético precoz y escalonado en función de la respuesta; 3) durante la fase estable, se recomienda considerar el inicio y/o titulación del tratamiento con fármacos basados en la evidencia, es decir, sacubitrilo/valsartán o inhibidores de la enzima convertidora de angiotensina/antagonistas de los receptores de angiotensina II, betabloqueantes, antialdosterónicos e inhibidores SGLT2, y 4) en el momento del alta hospitalaria, es recomendable utilizar un listado —tipo check-list— para optimizar el manejo del paciente hospitalizado e identificar las opciones más eficientes para mantener la continuidad de cuidados tras el alta (AU)

Acute heart failure (AHF) is associated with significant morbidity and mortality and it stands as the primary cause of hospitalization for individuals over the age of 65 in Spain. This document outlines the main recommendations as follows: (1) upon admission, it is crucial to conduct a comprehensive assessment, taking into account the patient's standard treatment and comorbidities, as these factors determine the prognosis of the disease; (2) During the initial hours of hospital care, prioritizing decongestive treatment is essential. It is recommended to adopt an early staged diuretic therapeutic approach based on the patient's response; (3) In order to manage patients in the stable phase, it is advisable to consider initiating and/or adjusting evidence-based drug treatments such as sacubitril/valsartan or angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta blockers, aldosterone antagonists, and SGLT2 inhibitors; (4) Upon hospital discharge, utilizing a checklist is recommended to optimize the patient's management and identify the most efficient options for ensuring continuity of care post-discharge (AU)

Manejo y tratamiento actual de la insuficiencia cardiaca en unidades acreditadas de cardiología y medicina interna en España / Current heart failure disease management and treatment in accredited units from cardiology and internal medicine in Spain

Antecedentes y objetivos La insuficiencia cardiaca (IC) es una patología compleja con una alta prevalencia, incidencia y mortalidad que conlleva un importante coste sanitario. En España existen unidades de IC (UIC) multidisciplinares, lideradas por cardiología y medicina interna. Nuestro objetivo era conocer su organización actual y adherencia a las últimas recomendaciones científicas. Materiales y métodos Un comité científico formado por cardiólogos e internistas elaboró una encuesta a finales de 2021, que fue enviada a 110 UIC. Setenta y tres de cardiología, acreditadas por SEC-Excelente, y 37 de medicina interna, integradas en el programa UMIPIC. Resultados Se recibieron 83 encuestas cumplimentadas (75,5%); 49 de cardiología y 34 de medicina interna. Los resultados mostraron que las UIC están integradas mayoritariamente por un cardiólogo, internista y enfermería especializada (34,9%). El perfil de paciente atendido en las UIC cardiológicas es muy diferente al paciente de las UMIPIC, siendo estos últimos mayores, con fracción de eyección ventricular izquierda conservada y más carga de comorbilidad. La mayoría de UIC actualmente realizan seguimiento mixto, presencial y telemático (73,5%). Los péptidos natriuréticos son los biomarcadores más utilizados (90%). Se titulan los cuatro grupos farmacológicos fundamentales de tratamiento de la IC a la vez mayoritariamente (85%). Solo 24% de las unidades mantienen una comunicación fluida con atención primaria. Conclusiones Los dos modelos de UIC liderados por cardiología y medicina interna son complementarios, disponen de enfermería especializada, y siguen al paciente de forma mixta, con una adherencia farmacológica muy alta a las últimas recomendaciones científicas. El principal punto de mejora es la coordinación con atención primaria (AU)

Background and objectives Heart failure (HF) is a complex disease with high prevalence, incidence and mortality rates leading to high healthcare burden. In Spain, there are multidisciplinary HF units coordinated by cardiology and internal medicine. Our objective was to describe its current organizational model and their adherence to the latest scientific recommendations. Materials and methods In late 2021, a scientific committee (with cardiology and internal medicine specialists) developed a questionnaire that was sent as an online survey to 110 HF units [73 from cardiology (accredited by SEC-Excelente) and 37 from internal medicine (integrated in UMIPIC program)]. Results We received 83 answers (75.5% total: 49 from cardiology and 34 from internal medicine). The results showed that HF units are mostly integrated by specialists from cardiology, internal medicine and specialized nurse practitioners (34.9%). Patient characteristics from HF units are widely different when comparing those in cardiology to UMIPIC, being the latter older, more frequently with preserved ejection fraction and higher comorbidity burden. Most HF units (73.5%) currently use a hybrid face-to-face/virtual model to perform patient follow-up. Natriuretic peptides are the biomarkers most commonly used (90%). All four disease-modifying drug classes are mainly implemented at the same time (85%). Only 24% of HF units hold fluent communication with primary care. Conclusions Both models from cardiology and internal medicine HF units are complementary, they include specialized nursing, they use hybrid approach for patient follow-up and they display a high adherence to the latest guideline recommendations. Coordination with primary care remains as the major improvement area (AU)

Executive summary of the 2023 update on the consensus regarding basic conduct during hospital admission for patients with acute heart failure.

Acute heart failure (AHF) is associated with significant morbidity and mortality and it stands as the primary cause of hospitalization for individuals over the age of 65 in Spain. This document outlines the main recommendations as follows: (1) Upon admission, it is crucial to conduct a comprehensive assessment, taking into account the patient's standard treatment and comorbidities, as these factors determine the prognosis of the disease. (2) During the initial hours of hospital care, prioritizing decongestive treatment is essential. It is recommended to adopt an early staged diuretic therapeutic approach based on the patient's response. (3) In order to manage patients in the stable phase, it is advisable to consider initiating and/or adjusting evidence-based drug treatments such as sacubitril/valsartan or angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta blockers, aldosterone antagonists, and SGLT2 inhibitors. (4) Upon hospital discharge, utilizing a checklist is recommended to optimize the patient's management and identify the most efficient options for ensuring continuity of care post-discharge.

Current heart failure disease management and treatment in accredited units from cardiology and internal medicine in Spain.

BACKGROUND AND OBJECTIVES: Heart failure (HF) is a complex disease with high prevalence, incidence and mortality rates leading to high healthcare burden. In Spain, there are multidisciplinary HF units coordinated by cardiology and internal medicine. Our objective is to describe its current organizational model and their adherence to the latest scientific recommendations. MATERIALS AND METHODS: In late 2021, a scientific committee (with cardiology and internal medicine specialists) developed a questionnaire that was sent as an online survey to 110 HF units. 73 from cardiology (accredited by SEC-Excelente) and 37 from internal medicine, (integrated in UMIPIC program). RESULTS: We received 83 answers (75.5% total: 49 from cardiology and 34 from internal medicine). The results showed that HF units are mostly integrated by specialists from cardiology, internal medicine and specialized nurse practitioners (34.9%). Patient characteristics from HF units are widely different when comparing those in cardiology to UMIPIC, being the latter older, more frequently with preserved ejection fraction and higher comorbidity burden. Most HF units (73.5%) currently use a hybrid face-to-face/virtual model to perform patient follow-up. Natriuretic peptides are the biomarkers most commonly used (90%). All four disease-modifying drug classes are mainly implemented at the same time (85%). Only 24% of HF units hold fluent communication with primary care. CONCLUSIONS: Both models from cardiology and internal medicine HF units are complementary, they include specialized nursing, they use hybrid approach for patient follow-up and they display a high adherence to the latest guideline recommendations. Coordination with primary care remains as the major improvement area.

Beneficios de un modelo asistencial integral en pacientes con insuficiencia cardíaca y fracción de eyección preservada: Programa UMIPIC / Benefits of a comprehensive care model in patients with heart failure and preserved ejection fraction: The UMIPIC program

Antecedentes Los pacientes con insuficiencia cardíaca (IC) y fracción de eyección preservada (ICFEp), a diferencia de aquellos con fracción de eyección reducida, son más ancianos, presentan más comorbilidades y no son candidatos a medidas terapéuticas eficaces. Por todo ello presentan un riesgo elevado de ingreso hospitalario y mortalidad. En este estudio se evaluó el beneficio de un modelo asistencial, caracterizado por una atención integral y continuada (programa UMIPIC) en pacientes con ICFEp. Métodos Se analizaron prospectivamente los datos de 2.401 pacientes con ICFEp atendidos en servicios de medicina interna, procedentes del registro RICA. Se dividieron en 2 grupos, uno en seguimiento en el programa UMIPIC (grupo UMIPIC, n: 1.011) y otro atendido de forma convencional (grupo RICA, n: 1.390). Se seleccionaron por emparejamiento (propensity score matching) 753 pacientes en cada grupo y se evaluaron los ingresos y la mortalidad durante 12 meses de seguimiento, tras un episodio de hospitalización por IC. Resultados El grupo UMIPIC, con respecto al RICA, en la cohorte emparejada, tuvo una menor tasa de ingresos por IC (19,2% frente a 36,5% respectivamente; hazard ratio [HR]=0,56; intervalo de confianza del 95% [IC 95%]: 0,45-0,68; p<0,001) y de mortalidad (12,6% frente a 28%, respectivamente; HR=0,40; IC 95%: 0,31-0,51; p<0,001). No se observaron diferencias en cuanto a ingresos por causas distintas a la IC. Conclusiones La implementación del programa asistencial UMIPIC a pacientes con ICFEp y elevada comorbilidad, basado en una atención integral y continuada, reduce tanto los ingresos como la mortalidad al año de seguimiento (AU)

Background Patients with heart failure (HF) and preserved ejection fraction (HFpEF), in contrast to those with reduced ejection fraction, are older, have more comorbidities, and are not candidates for effective therapeutic measures. Therefore, they are at high risk for hospital admission and mortality. This study evaluated the benefit of a comprehensive continuous care program (UMIPIC program) in patients with HFpEF. Methods We prospectively analyzed data on 2,401 patients with HFpEF attended to in internal medicine departments who form part of the RICA registry. They were divided into 2 groups: one was followed-up on in the UMIPIC program (UMIPIC group, n: 1,011) and another received conventional care (RICA group, n: 1,390). A total of 753 patients in each group were selected by propensity score matching and admissions and mortality were assessed during 12 months of follow-up after an episode of hospitalization due to HF. Results Compared to the RICA group, the UMIPIC group had a lower rate of HF admissions (19.2% versus 36.5%, respectively; hazard ratio [HR]=0.56; 95% confidence interval [CI]: 0.45-0.68; p<.001) and mortality (12.6% versus 28%, respectively; HR=0.40; 95% CI: 0.31-0.51; p<.001). There were no differences in hospitalizations for non-HF causes. Conclusions Implementation of the UMIPIC program, which is based on comprehensive continuous care, for patients with HFpEF and a high degree of comorbidity reduces both admissions and mortality in the first year of follow-up (AU)

Vericiguat en insuficiencia cardíaca: de la evidencia científica a la práctica clínica / Vericiguat in heart failure: from scientific evidence to clinical practice

A pesar de los tratamientos actuales, el riesgo de muerte y hospitalizaciones en pacientes con insuficiencia cardíaca con fracción de eyección reducida (IC-FEr) sigue siendo elevado. La fisiopatología de la IC-FEr incluye activación neurohormonal caracterizada por la estimulación de las vías deletéreas (sistemas simpático y renina-angiotensina-aldosterona) y la supresión de las vías protectoras como las dependientes del óxido nítrico. La inhibición o estimulación de algunas de estas vías, pero no de todas, es insuficiente. En la IC-FEr existe una menor actividad de óxido nítrico, guanilato ciclasa soluble y GMPc que provoca efectos deletéreos a nivel miocárdico, vascular y renal. Vericiguat estimula la actividad de esta vía protectora. El estudio VICTORIA demostró, en pacientes con IC-FEr y descompensación reciente, que la adición de vericiguat al tratamiento médico óptimo reducía de forma significativa la incidencia del objetivo primario compuesto de muerte cardiovascular u hospitalización por IC, con un número de 24 pacientes que es necesario tratar, y una excelente tolerabilidad (AU)

Despite currently available treatments, risk of death and hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF) remains high. The pathophysiology of HFrEF includes neurohormonal activation characterized by stimulation of deleterious pathways (i.e., sympathetic nervous and renin-angiotensin-aldosterone systems) and suppression of protective pathways such as nitric oxide-dependent pathways. Inhibition or stimulation of some, but not all, of these pathways is insufficient. In HFrEF, there is reduced nitric oxide, soluble guanylate cyclase, and cGMP activity, leading to deleterious effects in the myocardial, vascular, and renal systems. Vericiguat is able to stimulate the activity of this protective pathway. The VICTORIA study demonstrated that the addition of vericiguat to optimal medical treatment in patients with HFrEF and recent decompensation significantly reduced the incidence of the primary endpoint, a composite of cardiovascular death or HF hospitalization, with a number needed to treat of 24 patients and excellent tolerability (AU)

Vericiguat in heart failure: From scientific evidence to clinical practice.

Despite currently available treatments, risk of death and hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF) remains high. The pathophysiology of HFrEF includes neurohormonal activation characterized by stimulation of deleterious pathways (i.e., sympathetic nervous and renin-angiotensin-aldosterone systems) and suppression of protective pathways such as nitric oxide-dependent pathways. Inhibition or stimulation of some, but not all, of these pathways is insufficient. In HFrEF, there is reduced nitric oxide, soluble guanylate cyclase, and cGMP activity, leading to deleterious effects in the myocardial, vascular, and renal systems. Vericiguat is able to stimulate the activity of this protective pathway. The VICTORIA study demonstrated that the addition of vericiguat to optimal medical treatment in patients with HFrEF and recent decompensation significantly reduced the incidence of the primary endpoint, a composite of cardiovascular death or HF hospitalization, with a number needed to treat of 24 patients and excellent tolerability.

Benefits of a comprehensive care model in patients with heart failure and preserved ejection fraction: The UMIPIC program.

BACKGROUND: Patients with heart failure (HF) and preserved ejection fraction (HFpEF), in contrast to those with reduced ejection fraction, are older, have more comorbidities, and are not candidates for effective therapeutic measures. Therefore, they are at high risk for hospital admission and mortality. This study evaluated the benefit of a comprehensive continuous care program (UMIPIC program) in patients with HFpEF. METHODS: We prospectively analyzed data on 2401 patients with HFpEF attended to in internal medicine departments who form part of the RICA registry. They were divided into 2 groups: one was followed-up on in the UMIPIC program (UMIPIC group, n: 1011) and another received conventional care (RICA group, n: 1390). A total of 753 patients in each group were selected by propensity score matching and admissions and mortality were assessed during 12 months of follow-up after an episode of hospitalization due to HF. RESULTS: Compared to the RICA group, the UMIPIC group had a lower rate of HF admissions (19.2% versus 36.5%, respectively; hazard ratio [HR] = 0.56; 95% confidence interval [CI]: 0.45-0.68; p < 0.001) and mortality (12.6% versus 28%, respectively; HR = 0.40; 95% CI: 0.31-0.51; p < 0.001). There were no differences in hospitalizations for non-HF causes. CONCLUSIONS: Implementation of the UMIPIC program, which is based on comprehensive continuous care, for patients with HFpEF and a high degree of comorbidity reduces both admissions and mortality in the first year of follow-up.

Beneficios de un modelo asistencial integral en pacientes ancianos con insuficiencia cardíaca y elevada comorbilidad: programa UMIPIC / Morbidity and mortality in elderly patients with heart failure managed with a comprehensive care model vs. usual care: The UMIPIC program

Antecedentes: Los pacientes ancianos con insuficiencia cardíaca (IC) presentan una elevada comorbilidad que conlleva una atención fragmentada, con frecuentes hospitalizaciones y alta mortalidad. En este estudio se evaluó el beneficio de un modelo asistencial caracterizado por una atención integral y continuada (programa UMIPIC), en pacientes con IC de edad avanzada. Métodos y resultados: Se analizaron prospectivamente 2.862 pacientes con IC atendidos en servicios de Medicina Interna, procedentes del registro RICA. Se dividieron en 2 grupos: uno en seguimiento en el programa UMIPIC (grupo UMIPIC, n: 809) y otro atendido de forma convencional (grupo RICA, n: 2053). Se evaluaron los reingresos por IC durante 12 meses de seguimiento y la mortalidad total tras un episodio de hospitalización por IC. Los pacientes del grupo UMIPIC tuvieron más edad, comorbilidades y fracción de eyección preservada que los del grupo RICA. Sin embargo, el grupo UMIPIC tuvo una menor tasa de reingresos por IC (17 frente a 26%, p<0,001) y de mortalidad (16 frente a 27%, respectivamente, p<0,001). Se seleccionaron por emparejamiento (propensity score matching) 370 pacientes de cada grupo, manteniéndose las diferencias en reingresos por IC (15% UMIPIC frente a 30% RICA; hazard ratio [HR]=0,44; intervalo de confianza del 95%: 0,32-0,60; p<0,001) y mortalidad (17% UMIPIC frente a 28% RICA; hazard ratio=0,58; intervalo de confianza del 95%: 0,42-0,79; p=0,001). Conclusiones: La implantación del programa UMIPIC, basado en una atención integral y continuada a pacientes ancianos con IC y elevada comorbilidad, disminuye significativamente los reingresos por IC y la mortalidad total (AU)

Background: Elderly patients with heart failure (HF) have a high degree of comorbidity which leads to fragmented care, with frequent hospitalizations and high mortality. This study evaluated the benefit of a comprehensive continuous care model (UMIPIC program) in elderly HF patients. Methods and results: We prospectively analyzed data from the RICA registry on 2,862 patients with HF treated in internal medicine departments. They were divided into two groups: one monitored in the UMIPIC program (UMIPIC group, n: 809) and another which received conventional care (RICA group, n: 2.053). We evaluated HF readmissions during 12 months of follow-up and total mortality after episodes of HF hospitalization. UMIPIC patients were older with higher rates of comorbidity and preserved ejection fraction than the RICA group. However, the UMIPIC group had a lower rate of HF readmissions (17% vs. 26%, p<.001) and mortality (16% vs. 27%, respectively; p<.001). In addition, we selected 370 propensity score-matched patients from each group and the differences in HF readmissions (15% UMIPIC vs. 30% RICA; hazard ratio [HR]=0.44; 95% confidence interval [CI] 0.32-0.60; p<.001) and mortality (17% UMIPIC vs. 28% RICA; hazard ratio=0.58; 95% CI 0.42-0.79; p=.001) were maintained. Conclusions: The implementation of the UMIPIC program, based on comprehensive continuous care of elderly patients with HF and high comorbidity, markedly reduce HF readmissions and total mortality (AU)

Morbidity and mortality in elderly patients with heart failure managed with a comprehensive care model vs. usual care: The UMIPIC program.

BACKGROUND: Elderly patients with heart failure (HF) have a high degree of comorbidity which leads to fragmented care, with frequent hospitalizations and high mortality. This study evaluated the benefit of a comprehensive continuous care model (UMIPIC program) in elderly HF patients. METHODS AND RESULTS: We prospectively analyzed data from the RICA registry on 2862 patients with HF treated in internal medicine departments. They were divided into two groups: one monitored in the UMIPIC program (UMIPIC group, n: 809) and another which received conventional care (RICA group, n: 2.053). We evaluated HF readmissions during 12 months of follow-up and total mortality after episodes of HF hospitalization. UMIPIC patients were older with higher rates of comorbidity and preserved ejection fraction than the RICA group. However, the UMIPIC group had a lower rate of HF readmissions (17% vs. 26%, p < .001) and mortality (16% vs. 27%, respectively; p < .001). In addition, we selected 370 propensity score-matched patients from each group and the differences in HF readmissions (15% UMIPIC vs. 30% RICA; hazard ratio [HR] = 0.44; 95% confidence interval [CI] 0.32-0.60; p < .001) and mortality (17% UMIPIC vs. 28% RICA; hazard ratio = 0.58; 95% CI 0.42-0.79; p = .001) were maintained. CONCLUSIONS: The implementation of the UMIPIC program, based on comprehensive continuous care of elderly patients with HF and high comorbidity, markedly reduce HF readmissions and total mortality.

Utilidad pronóstica de las cifras ambulatorias de presión arterial en pacientes de edad avanzada con insuficiencia cardíaca. Resultados del estudio DICUMAP / Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study

Introducción La monitorización ambulatoria de la presión arterial (MAPA) ha demostrado la utilidad en la evaluación pronóstica de los pacientes hipertensos con insuficiencia cardíaca (IC) con o sin otras enfermedades cardiovasculares. El objetivo de este estudio consistió en determinar si la MAPA puede identificar a pacientes con IC con un peor pronóstico. Métodos y resultados Estudio multicéntrico prospectivo en el que se incluyeron pacientes ambulatorios y clínicamente estables con IC. Todos los pacientes se sometieron a una MAPA. Se incluyó un total de 154 pacientes de 17 centros. La edad media fue de 76,8 años (±8,3) y el 55,2% eran mujeres. En total, el 23,7% presentaba IC con fracción de eyección reducida (IC-FEr), el 68,2% se encontraba en la clase funcional II de la NYHA y el 19,5%, en la clase funcional III de la NYHA. Al cabo de un año de seguimiento se produjeron 13 (8,4%) muertes, 10 de ellas atribuidas a la IC. En 19 de los 29 pacientes que precisaron hospitalización, esta se debió a la IC. La presencia de un patrón no dipper de PA se asoció a un mayor riesgo de reingreso o muerte al año de seguimiento (25% frente al 5%; p=0,024). Según un análisis de regresión de Cox, una clase funcional más avanzada de la NYHA (razón de riesgos instantáneos, 3,51; IC del 95%, 1,70-7,26; p=0,001; comparación entre las clases III y II de la NYHA) y una mayor reducción nocturna proporcional de la PA diastólica (razón de riesgos instantáneos, 0,961; IC del 95%, 0,926-0,997; p=0,032 por cada reducción del 1% de la PA diastólica) se asociaron a muerte o reingreso al cabo de un año de manera independiente. Conclusiones En los pacientes de edad avanzada con IC crónica, un patrón no dipper de PA determinado mediante MAPA se asoció a un mayor riesgo de hospitalización y muerte por IC (AU)

Introduction Ambulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis. Methods and results Prospective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (±8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p=.024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95%CI 1.70-7.26; p=.001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926-0.997; p=.032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year. Conclusion In older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF (AU)

Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study.

INTRODUCTION: Ambulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis. METHODS AND RESULTS: Prospective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (± 8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p=.024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95% CI 1.70-7.26; p=.001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926-0.997; p=.032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year. CONCLUSION: In older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF.

Consensus on improving the comprehensive care of patients with acute heart failure.

The latest acute heart failure (AHF) consensus document from the Spanish Society of Cardiology (SEC, for its initials in Spanish), Spanish Society of Internal Medicine (SEMI), and Spanish Society of Emergency Medicine (SEMES) was published in 2015, which made an update covering the main novelties regarding AHF from the last few years necessary. These include publication of updated European guidelines on HF in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding AHF such as early treatment, intermittent treatment, advanced HF, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to AHF and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease.

Consensus on basic conduct during the hospital admission of patients with acute heart failure.

Acute heart failure (AHF) is a highly prevalent clinical entity in individuals older than 45 years in Spain. AHF is associated with significant morbidity and mortality and is the leading cause of hospitalisation for individuals older than 65 years in Spain, a quarter of whom die within 1 year of the hospitalisation. In recent years, there has been an upwards trend in hospitalisations for AHF, which increased 76.7% from 2003 to 2013. Readmissions at 30 days for AHF have also increased (from 17.6% to 22.1%), at a relative mean rate of 1.36% per year, with the consequent increase in the use of resources and the economic burden for the healthcare system. The aim of this document (developed by the Heart Failure and Atrial Fibrillation Group of the Spanish Society of Internal Medicine) is to guide specialists on the most important aspects of treatment and follow-up for patients with AHF during hospitalisation and the subsequent follow-up. The main recommendations listed in this document are as follows: 1) At admission, perform a comprehensive assessment, considering the patient's standard treatment and comorbidities, given that these determine the disease prognosis to a considerable measure. 2) During the first few hours of hospital care, decongestive treatment is a priority, and a staged diuretic therapeutic approach based on the patient's response is recommended. 3) To manage patients in the stable phase, consider starting and/or adjusting evidence-based drug treatment (e.g., sacubitril/valsartan or angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta blockers and aldosterone antagonists). 4) At hospital discharge, use a checklist to optimise the patient's management and identify the most efficient options for maintaining continuity of care after discharge.

Consenso de actuación básica durante el ingreso hospitalario por insuficiencia cardiaca aguda / Consensus on basic conduct during the hospital admission of patients with acute heart failure

La insuficiencia cardiaca aguda (ICA) es una entidad clínica con una elevada prevalencia en la población de más de 45años en España. Está asociada a una importante morbimortalidad, constituyendo la primera causa de hospitalización en mayores de 65años en nuestro país, de los cuales una cuarta parte fallecen al año del ingreso. En los últimos años se ha observado una tendencia al alza en las hospitalizaciones por ICA, que aumentaron un 76,7% en el período de 2003 a 2013. Los reingresos a los 30días por ICA también aumentaron (del 17,6 al 22,1%) a un ritmo medio relativo del 1,36% por año, con el consiguiente incremento en el uso de recursos y en la carga económica para el sistema sanitario. Este documento, elaborado por el grupo de Insuficiencia Cardiaca y Fibrilación Auricular de la Sociedad Española de Medicina Interna, tiene como objetivo orientar al especialista en los aspectos más importantes del tratamiento y seguimiento de los pacientes con ICA durante el ingreso y el seguimiento posterior. Las principales recomendaciones recogidas son: 1)en el momento del ingreso, realizar una evaluación integral, considerando el tratamiento habitual y comorbilidades del paciente, ya que condicionan en gran medida el pronóstico de la enfermedad; 2)en las primeras horas de atención hospitalaria, el tratamiento descongestivo es prioritario y se recomienda un abordaje terapéutico diurético escalonado en función de la respuesta; 3)en el manejo de la fase estable, considerar el inicio y/o ajustar el tratamiento con fármacos basados en la evidencia, es decir, sacubitrilo/valsartán o IECA/ARAII, betabloqueantes y antialdosterónicos; 4)en el momento del alta hospitalaria, utilizar un checklist para optimizar el manejo del paciente hospitalizado e identificar las opciones más eficientes para mantener la continuidad de cuidados tras el alta (AU)

Acute heart failure (AHF) is a highly prevalent clinical entity in individuals older than 45years in Spain. AHF is associated with significant morbidity and mortality and is the leading cause of hospitalisation for individuals older than 65years in Spain, a quarter of whom die within 1year of the hospitalisation. In recent years, there has been an upwards trend in hospitalisations for AHF, which increased 76.7% from 2003 to 2013. Readmissions at 30days for AHF have also increased (from 17.6% to 22.1%), at a relative mean rate of 1.36% per year, with the consequent increase in the use of resources and the economic burden for the healthcare system. The aim of this document (developed by the Heart Failure and Atrial Fibrillation Group of the Spanish Society of Internal Medicine) is to guide specialists on the most important aspects of treatment and follow-up for patients with AHF during hospitalisation and the subsequent follow-up. The main recommendations listed in this document are as follows: (1)At admission, perform a comprehensive assessment, considering the patient's standard treatment and comorbidities, given that these determine the disease prognosis to a considerable measure. (2)During the first few hours of hospital care, decongestive treatment is a priority, and a staged diuretic therapeutic approach based on the patient's response is recommended. (3)To manage patients in the stable phase, consider starting and/or adjusting evidence-based drug treatment (e.g., sacubitril/valsartan or angiotensin-converting enzyme inhibitors/angiotensinII receptor blockers, beta blockers and aldosterone antagonists). (4)At hospital discharge, use a checklist to optimise the patient's management and identify the most efficient options for maintaining continuity of care after discharge (AU)

Consenso para la mejora de la atención integral de los pacientes con insuficiencia cardíaca aguda / Consensus on improving the comprehensive care of patients with acute heart failure

El último consenso sobre insuficiencia cardíaca aguda de la Sociedad Española de Cardiología, la Sociedad Española de Medicina Interna y la Sociedad Española de Medicina de Urgencias y Emergencias se elaboró en 2015, por lo que era necesaria una actualización para revisar las diversas novedades relacionadas con la temática de insuficiencia cardíaca aguda que han ido apareciendo los últimos años. Entre ellas están la publicación de las nuevas guías europeas sobre insuficiencia cardíaca en el 2016, nuevos estudios sobre el manejo farmacológico de los pacientes durante la hospitalización y novedades sobre diversos aspectos relacionados con la insuficiencia cardíaca aguda, tales como el abordaje precoz, terapia intermitente, insuficiencia cardíaca avanzada y congestión refractaria. Por ello, este consenso se elaboró con la intención de actualizar todos los aspectos relacionados con la insuficiencia cardíaca aguda y proporcionar un documento que detallase de manera completa el diagnóstico, tratamiento y manejo de esta enfermedad (AU)

The latest acute heart failure consensus document from the Spanish Society of Cardiology, Spanish Society of Internal Medicine, and Spanish Society of Emergency Medicine was published in 2015, which made an update covering the main novelties regarding acute heart failure from the last few years necessary. These include publication of updated European guidelines on heart failure in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding acute heart failure such as early treatment, intermittent treatment, advanced heart failure, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to acute heart failure and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease (AU)