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.

Influence of the length of hospitalisation in post-discharge outcomes in patients with acute heart failure: Results of the LOHRCA study.

OBJECTIVE: To investigate the relationship between length of hospitalisation (LOH) and post-discharge outcomes in acute heart failure (AHF) patients and to ascertain whether there are different patterns according to department of initial hospitalisation. METHODS: Consecutive AHF patients hospitalised in 41 Spanish centres were grouped based on the LOH (<6/6-10/11-15/>15 days). Outcomes were defined as 90-day post-discharge all-cause mortality, AHF readmissions, and the combination of both. Hazard ratios (HRs), adjusted by chronic conditions and severity of decompensation, were calculated for groups with LOH >6 days vs. LOH <6 days (reference), and stratified by hospitalisation in cardiology, internal medicine, geriatrics, or short-stay units. RESULTS: We included 8563 patients (mean age: 80 (SD = 10) years, 55.5% women), with a median LOH of 7 days (IQR 4-11): 2934 (34.3%) had a LOH <6 days, 3184 (37.2%) 6-10 days, 1287 (15.0%) 11-15 days, and 1158 (13.5%) >15 days. The 90-day post-discharge mortality was 11.4%, readmission 32.2%, and combined endpoint 37.4%. Mortality was increased by 36.5% (95%CI = 13.0-64.9) when LOH was 11-15 days, and by 72.0% (95%CI = 42.6-107.5) when >15 days. Conversely, no differences were found in readmission risk, and the combined endpoint only increased 21.6% (95%CI = 8.4-36.4) for LOH >15 days. Stratified analysis by hospitalisation departments rendered similar post-discharge outcomes, with all exhibiting increased mortality for LOH >15 days and no significant increments in readmission risk. CONCLUSIONS: Short hospitalisations are not associated with worse outcomes. While post-discharge readmissions are not affected by LOH, mortality risk increases as the LOH lengthens. These findings were similar across hospitalisation departments.

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.

Utilidad de la escala MEESSI para la estratificación del riesgo de pacientes con insuficiencia cardiaca aguda en servicios de urgencias / The usefulness of the MEESSI score for risk stratification of patients with acute heart failure at the emergency department

Introducción y objetivos: En los servicios de urgencias hospitalarios(SUH), la escala MEESSI estratifica a los pacientes diagnosticados de insuficiencia cardiaca aguda(ICA) según su riesgo de mortalidad a 30 días. Se valida la escala de riesgo MEESSI en una nueva cohorte de pacientes para evaluar su precisión al estratificar el riesgo y compararla en diferentes entornos. Métodos: Se incluyó a los pacientes consecutivos diagnosticados de ICA en 30 SUH durante enero y febrero de 2016. Se calculó la puntuación MEESSI de cada paciente. El estadístico C midió la capacidad discriminatoria para predecir la mortalidad a 30 días del modelo MEESSI completo y los modelos secundarios. Se realizaron comparaciones entre los subgrupos de pacientes de hospitales universitarios y comunitarios, de SUH con actividad alta, media o baja y de SUH que reclutaron o que no reclutaron a pacientes de la cohorte original de derivación de la escala MEESSI. Resultados: Se analizó a 4.711 pacientes (hospitales universitarios/comunitarios: 3.811/900; SUH alta/media/baja actividad: 2.695/1.479/537; SUH participantes/no participantes en el estudio de derivación original:3.892/819). La distribución de pacientes según las categorías de riesgo de la escala MEESSI fue: 1.673 (35,5%) de bajo riesgo, 2.023 (42,9%) de riesgo intermedio, 530 (11,3%) de alto riesgo y 485 (10,3%) de muy alto riesgo, con mortalidades a 30 días del 2,0, el 7,8, el 17,9 y el 41,4% respectivamente. El estadístico C para el modelo completo fue 0,810 (IC95%, 0,790-0,830) y varió de 0,731 a 0,785 para los modelos secundarios. La capacidad discriminatoria de la escala de riesgo MEESSI fue similar entre los subgrupos de hospitales, entre SUH de distinta actividad y entre hospitales reclutadores originales y nuevos. Conclusiones: La escala MEESSI estratifica con éxito a los pacientes con ICA en los SUH según el riesgo de muerte a 30días, lo cual puede ayudar en urgencias a la toma de decisiones sobre el destino de estos pacientes

Introduction and objectives: The MEESSI scale stratifies acute heart failure (AHF) patients at the emergency department (ED) according to the 30-day mortality risk. We validated the MEESSI risk score in a new cohort of Spanish patients to assess its accuracy in stratifying patients by risk and to compare its performance in different settings. Methods: We included consecutive patients diagnosed with AHF in 30 EDs during January and February 2016. The MEESSI score was calculated for each patient. The c-statistic measured the discriminatory capacity to predict 30-day mortality of the full MEESSI model and secondary models. Further comparisons were made among subgroups of patients from university and community hospitals, EDs with high-, medium-or low-activity and EDs that recruited or not patients in the original MEESSI derivation cohort. Results: We analyzed 4711 patients (university/community hospitals: 3811/900; high-/medium-/low-activity EDs: 2695/1479/537; EDs participating/not participating in the previous MEESSI derivation study: 3892/819). The distribution of patients according to the MEESSI risk categories was: 1673 (35.5%) low risk, 2023 (42.9%) intermediate risk, 530 (11.3%) high risk and 485 (10.3%) very high risk, with 30-day mortality of 2.0%, 7.8%, 17.9%, and 41.4%, respectively. The c-statistic for the full model was 0.810 (95%CI, 0.790-0.830), ranging from 0.731 to 0.785 for the subsequent secondary models. The discriminatory capacity of the MEESSI risk score was similar among subgroups of hospital type, ED activity, and original recruiter EDs. Conclusions: The MEESSI risk score successfully stratifies AHF patients at the ED according to the 30-day mortality risk, potentially helping clinicians in the decision-making process for hospitalizing patients

The Usefulness of the MEESSI Score for Risk Stratification of Patients With Acute Heart Failure at the Emergency Department.

INTRODUCTION AND OBJECTIVES: The MEESSI scale stratifies acute heart failure (AHF) patients at the emergency department (ED) according to the 30-day mortality risk. We validated the MEESSI risk score in a new cohort of Spanish patients to assess its accuracy in stratifying patients by risk and to compare its performance in different settings. METHODS: We included consecutive patients diagnosed with AHF in 30 EDs during January and February 2016. The MEESSI score was calculated for each patient. The c-statistic measured the discriminatory capacity to predict 30-day mortality of the full MEESSI model and secondary models. Further comparisons were made among subgroups of patients from university and community hospitals, EDs with high-, medium- or low-activity and EDs that recruited or not patients in the original MEESSI derivation cohort. RESULTS: We analyzed 4711 patients (university/community hospitals: 3811/900; high-/medium-/low-activity EDs: 2695/1479/537; EDs participating/not participating in the previous MEESSI derivation study: 3892/819). The distribution of patients according to the MEESSI risk categories was: 1673 (35.5%) low risk, 2023 (42.9%) intermediate risk, 530 (11.3%) high risk and 485 (10.3%) very high risk, with 30-day mortality of 2.0%, 7.8%, 17.9%, and 41.4%, respectively. The c-statistic for the full model was 0.810 (95%CI, 0.790-0.830), ranging from 0.731 to 0.785 for the subsequent secondary models. The discriminatory capacity of the MEESSI risk score was similar among subgroups of hospital type, ED activity, and original recruiter EDs. CONCLUSIONS: The MEESSI risk score successfully stratifies AHF patients at the ED according to the 30-day mortality risk, potentially helping clinicians in the decision-making process for hospitalizing patients.

The role of atrial fibrillation in the short-term outcomes of patients with acute heart failure.

AIMS: To investigate whether the presence of atrial fibrillation (AF) is independently associated with adverse short-term outcomes in patients diagnosed with acute heart failure (AHF) in the emergency department (ED). METHODS: We performed a secondary analysis of patients included in the EAHFE registries 4&5. Patients were divided by the presence of sinus rhythm (SR) or AF at ED arrival. The primary outcome was 30-day all-cause mortality. Secondary outcomes included the 30-day post-discharge combined endpoint of ED revisit or hospitalisation due to AHF and all-cause mortality. We recorded 54 independent variables that can affect outcomes. Cox regression was used to investigate adjusted significant associations between AF and outcomes. Analyses were repeated according to whether AF was previously known and whether AF was considered responsible for the AHF episode. RESULTS: We analysed 6045 ED visits (mean age 80.4 years, 55.9% women), 3644 (60.3%) with AF. The cumulative 30-day mortality was 9.4%, and the adverse combined endpoint (ACE) was 25.9% (ED revisit with and without hospitalisation were 16.5 and 8.9% and death occurred in 4.7%). No differences were found in outcomes of AHF patients with SR and AF, and among the latter group, no differences were found depending on whether AF was considered responsible for the AHF episode. Patients with previously known AF had significantly lower 30-day mortality and higher post-discharge ACE rates, although these differences disappeared after adjustment for confounders HR 0.782, 95% CI 0.590-1.037, p = 0.087; and HR 1.131, 95% CI 0.924-1.385, p = 0.234). CONCLUSION: The coexistence of AF does not impact the short-term outcomes of patients diagnosed with AHF in the ED.

[Vernakalant in hospital emergency practice: safety and effectiveness]. / Seguridad y eficacia de vernakalant en la práctica clínica de los servicios de urgencias.

OBJECTIVES: To study the effectiveness and safety of vernakalant for restoration of sinus rhythm in patients with atrial fibrillation (AF) in routine hospital emergency department care, and to evaluate factors associated with a more effective response. MATERIAL AND METHODS: Prospective multicenter cohort study enrolling consecutive patients who were administered vernakalant for medical cardioversion of AF between September 2014 through March 2016 in 5 hospitals in the Spanish autonomous community of Valencia. RESULTS: We studied 165 cases. The median (interquartile range) was 68 years (56-77) years. Cardioversion with vernakalant was effective in 77.6% (95% CI, 71.1%-84%). The median time to conversion was 8 ( 6-12) minutes after a first dose and 34 (22-62) minutes after a second dose. A prior history of cardiac insufficiency was nonsignificantly less common in patients who converted with vernakalant (6.3%) than in those who did not (18.9%) (adjusted odds ratio [OR], 0.45 [95% CI, 0.13-1.56]; P=.208). Having no prior history of AF was nonsignificantly related to greater effectiveness (in 54.7% vs in 35.1% with prior AF). Duration less than 12 hours was significantly associated with greater effectiveness (83.6% vs 59.5%; adjusted OR, 2.76 [95% CI, 1.12-6.80]; P=.028). Adverse events were reported for 30 patients. None of the events had clinically important consequences, and in only 2 cases (1.2%) was it necessary to suspend treatment. CONCLUSION: Vernakalant is effective and safe for restoring sinus rhythm in the hospital emergency department.

OBJETIVO: Describir la eficacia y seguridad de vernakalant para la reversión de la fibrilación auricular (FA) a ritmo sinusal en la práctica clínica habitual de los servicios de urgencias hospitalarios (SUH), así como evaluar las características asociadas a mayor respuesta eficaz. METODO: Estudio de cohortes multicéntrico, analítico, prospectivo, con inclusión consecutiva de pacientes en los que se administra vernakalant para realizar cardioversión farmacológica de una FA, llevado a cabo desde Septiembre 2014 hasta Marzo 2016 en 5 hospitales de la Comunidad Valenciana. RESULTADOS: Se analizaron 165 casos con una mediana de edad de 68 años [rango intercuartil (RIC): 56-77]. La reversión eficaz fue de 77,6% (IC 95%: 71,1%-84,0%). La mediana del tiempo de reversión fue de 8 minutos (RIC: 6-12) con la primera dosis y de 34 minutos (RIC: 22-62) con la segunda. La presencia de insuficiencia cardiaca previa fue menos frecuente en el grupo que revirtió con vernakalant, 6,3% frente a 18,9%, con una OR ajustada de 0,45 (IC 95%: 0,13-1,56), p = 0,208. Ser un primer episodio de FA y tener una duración de menos de 12 horas se relacionó con mayores tasas de reversión, 54,7% frente a 35,1% y de 83,6% frente a 59,5%, respectivamente, pero solo la segunda fue significativa con una OR ajustada de 2,76 (IC 95%: 1,12-6,80), p = 0,028. Se notificaron eventos adversos en 30 pacientes. Ninguno de ellos tuvo consecuencias relevantes y sólo dos (1,2%) motivaron la suspensión del fármaco. CONCLUSIONES: Vernakalant es un fármaco eficaz y seguro para la restauración del ritmo sinusal en los SUH.

Seguridad y eficacia de vernakalant en la práctica clínica de los servicios de urgencias / Vernakalant in hospital emergency practice: safety and effectiveness

Objetivo. Describir la eficacia y seguridad de vernakalant para la reversión de la fibrilación auricular (FA) a ritmo sinusal en la práctica clínica habitual de los servicios de urgencias hospitalarios (SUH), así como evaluar las características asociadas a mayor respuesta eficaz. Método. Estudio de cohortes multicéntrico, analítico, prospectivo, con inclusión consecutiva de pacientes en los que se administra vernakalant para realizar cardioversión farmacológica de una FA, llevado a cabo desde Septiembre 2014 hasta Marzo 2016 en 5 hospitales de la Comunidad Valenciana. Resultados. Se analizaron 165 casos con una mediana de edad de 68 anos [rango intercuartil (RIC): 56-77]. La reversión eficaz fue de 77,6% (IC 95%: 71,1%-84,0%). La mediana del tiempo de reversión fue de 8 minutos (RIC: 6-12) con la primera dosis y de 34 minutos (RIC: 22-62) con la segunda. La presencia de insuficiencia cardiaca previa fue menos frecuente en el grupo que revirtió con vernakalant, 6,3% frente a 18,9%, con una OR ajustada de 0,45 (IC 95%: 0,13-1,56), p = 0,208. Ser un primer episodio de FA y tener una duración de menos de 12 horas se relacionó con mayores tasas de reversión, 54,7% frente a 35,1% y de 83,6% frente a 59,5%, respectivamente, pero solo la segunda fue significativa con una OR ajustada de 2,76 (IC 95%: 1,12-6,80), p = 0,028. Se notificaron eventos adversos en 30 pacientes. Ninguno de ellos tuvo consecuencias relevantes y solo dos (1,2%) motivaron la suspensión del fármaco. Conclusiones. Vernakalant es un fármaco eficaz y seguro para la restauración del ritmo sinusal en los SUH (AU))

Objectives. To study the effectiveness and safety of vernakalant for restoration of sinus rhythm in patients with atrial fibrillation (AF) in routine hospital emergency department care, and to evaluate factors associated with a more effective response. Methods. Prospective multicenter cohort study enrolling consecutive patients who were administered vernakalant for medical cardioversion of AF between September 2014 through March 2016 in 5 hospitals in the Spanish autonomous community of Valencia. Results. We studied 165 cases. The median (interquartile range) was 68 years (56-77) years. Cardioversion with vernakalant was effective in 77.6% (95% CI, 71.1%-84%). The median time to conversion was 8 ( 6-12) minutes after a first dose and 34 (22-62) minutes after a second dose. A prior history of cardiac insufficiency was nonsignificantly less common in patients who converted with vernakalant (6.3%) than in those who did not (18.9%) (adjusted odds ratio [OR], 0.45 [95% CI, 0.13-1.56]; P=.208). Having no prior history of AF was nonsignificantly related to greater effectiveness (in 54.7% vs in 35.1% with prior AF). Duration less than 12 hours was significantly associated with greater effectiveness (83.6% vs 59.5%; adjusted OR, 2.76 [95% CI, 1.12-6.80]; P=.028). Adverse events were reported for 30 patients. None of the events had clinically important consequences, and in only 2 cases (1.2%) was it necessary to suspend treatment. Conclusion. Vernakalant is effective and safe for restoring sinus rhythm in the hospital emergency department (AU)

Factores asociados a estancias cortas en los pacientes ingresados por insuficiencia cardiaca aguda / Factors associated with short stays for patients admitted with acute heart failure

OBJETIVO: Identificar factores asociados a un tiempo de estancia hospitalaria (TDEH) corto en pacientes ingresados por insuficiencia cardiaca aguda (ICA) en hospitales con unidad de corta estancia (UCE). MÉTODO: Estudio de cohorte multipropósito y multicéntrico no intervencionista, con seguimiento prospectivo de pacientes con ICA ingresados en 10 hospitales españoles con UCE. Se recogieron variables demográficas, antecedentes personales, situación basal cardiorrespiratoria y funcional, de urgencias, del ingreso y de seguimiento a 30 días. La variable resultado fue un TDEH corto (_ 4 días). Se realizaron curvas de rendimiento diagnóstico (ROC) de modelos simples y mixtos predictivos de TDEH corto y se calculó el área bajo la curva (ABC) de la característica operativa del receptor (COR). RESULTADOS: Se incluyeron 1.359 pacientes con una edad 78,7 (DE: 9,9) años, el 53,9% mujeres, 568 (41,8%) tuvieron un TDE de 4 o menos días. Ingresaron 590 pacientes (43,4%) en UCE y 769 (56,6%) en salas de hospitalización convencional. En el modelo de regresión mixto ajustado al centro, la crisis hipertensiva (OR 1,79, IC 95%: 1,17-2,73; p = 0,007) y el ingresar en UCE (OR 16,6, IC95%: 10,0-33,3; p < 0,001) se asociaron a TDEH corto, y la ICA hipotensiva (OR 0,49, IC 95%: 0,26-0,91; p = 0,025), la hipoxemia, (OR 0,68, IC 95%: 0,53-0,88; p = 0,004) e ingresar en miércoles, jueves o viernes (OR 0,62, IC 95%: 0,49-0,77; p < 0,001) a TDEH largo. El ABC COR del modelo mixto ajustada al centro fue 0,827 (IC 95%: 0,80-0,85; p < 0,001). La mortalidad a 30 días y el reingreso a 30 días no difirieron entre ambos grupos (0,5% frente a 0,5%, p = 0,959; y 22,9% frente a 27,7%, p = 0,059, respectivamente). CONCLUSIONES: En pacientes con ICA existen factores clínicos y organizativos en cada centro que se relacionan de forma independiente con un TDEH corto, entre los que destaca el tener una UCE

OBJECTIVE: To identify factors associated with short hospital stays for patients admitted with acute heart failure (AHF) admitted to hospitals with short-stay units (SSU). METHODS: Multicenter nonintervention study in a multipurpose cohort of patients with AHF to 10 Spanish hospitals with short-stay units; patients were followed prospectively. We recorded demographic data, medical histories, baseline cardiorespiratory and function variables on arrival in the emergency department, on admission, and at 30 days. The outcome variable was a short hospital stay (_ 4 days). We built receiver operating characteristic curves of simple and mixed predictive models for short stays and calculated the area under the curves. RESULTS: A total of 1359 patients with a mean (SD) age of 78.7 (9.9) years (53.9% women) were included; 568 (41.8%) had short stays. Five hundred ninety patients (43.4%) were admitted to SSU and 769 (56.6%) were admitted to conventional wards. The variables associated with a short-stay according to the mixed regression model were hypertensive crisis (odds ratio [OR], 1.79; 95% CI, 1.17-2.73; P=.007) and admission to a SSU (OR, 16.6; 95% CI, 10.0-33.3; P<.001). Hypotensive AHF (OR, 0.49; 95% CI, 0.26-0.91; P=.025), hypoxemia (OR, 0.68; 95% CI, 0.53-0.88; P=.004); and admission on a Wednesday, Thursday, or Friday (OR, 0.62; 95% CI, 0.49-0.77; P<.001) were associated with a long stay. The area under the receiver operating characteristic curve was 0.827 (95% CI, 0.80-0.85; P<.001). Thirty-day mortality and readmission rates did not differ between patients with short vs long stays (mortality, 0.5% in both cases, P=.959; and readmission, 22.9% vs 27.7%, respectively; P=.059). CONCLUSION: Both clinical and administrative factors are independently related to whether patients with AHF have short stays in the hospitals studied, and among therapy, it is remarkable the existence of a SSU

[Factors associated with short stays for patients admitted with acute heart failure]. / Factores asociados a estancias cortas en los pacientes ingresados por insuficiencia cardiaca aguda.

OBJECTIVES: To identify factors associated with short hospital stays for patients admitted with acute heart failure (AHF) admitted to hospitals with short-stay units (SSU). MATERIAL AND METHODS: Multicenter nonintervention study in a multipurpose cohort of patients with AHF to 10 Spanish hospitals with short-stay units; patients were followed prospectively. We recorded demographic data, medical histories, baseline cardiorespiratory and function variables on arrival in the emergency department, on admission, and at 30 days. The outcome variable was a short hospital stay (<= 4 days). We built receiver operating characteristic curves of simple and mixed predictive models for short stays and calculated the area under the curves. RESULTS: A total of 1359 patients with a mean (SD) age of 78.7 (9.9) years (53.9% women) were included; 568 (41.8%) had short stays. Five hundred ninety patients (43.4%) were admitted to SSU and 769 (56.6%) were admitted to conventional wards. The variables associated with a short-stay according to the mixed regression model were hypertensive crisis (odds ratio [OR], 1.79; 95% CI, 1.17-2.73; P=.007) and admission to a SSU (OR, 16.6; 95% CI, 10.0-33.3; P<.001). Hypotensive AHF (OR, 0.49; 95% CI, 0.26-0.91; P=.025), hypoxemia (OR, 0.68; 95% CI, 0.53-0.88; P=.004); and admission on a Wednesday, Thursday, or Friday (OR, 0.62; 95% CI, 0.49-0.77; P<.001) were associated with a long stay. The area under the receiver operating characteristic curve was 0.827 (95% CI, 0.80-0.85; P<.001). Thirty-day mortality and readmission rates did not differ between patients with short vs long stays (mortality, 0.5% in both cases, P=.959; and readmission, 22.9% vs 27.7%, respectively; P=.059). CONCLUSION: Both clinical and administrative factors are independently related to whether patients with AHF have short stays in the hospitals studied, and among therapy, it is remaslcasle the existence of a SSU.

OBJETIVO: Identificar factores asociados a un tiempo de estancia hospitalaria (TDEH) corto en pacientes ingresados por insuficiencia cardiaca aguda (ICA) en hospitales con unidad de corta estancia (UCE). METODO: Estudio de cohorte multipropósito y multicéntrico no intervencionista, con seguimiento prospectivo de pacientes con ICA ingresados en 10 hospitales españoles con UCE. Se recogieron variables demográficas, antecedentes personales, situación basal cardiorrespiratoria y funcional, de urgencias, del ingreso y de seguimiento a 30 días. La variable resultado fue un TDEH corto (<= 4 días). Se realizaron curvas de rendimiento diagnóstico (ROC) de modelos simples y mixtos predictivos de TDEH corto y se calculó el área bajo la curva (ABC) de la característica operativa del receptor (COR). RESULTADOS: Se incluyeron 1.359 pacientes con una edad 78,7 (DE: 9,9) años, el 53,9% mujeres, 568 (41,8%) tuvieron un TDE de 4 o menos días. Ingresaron 590 pacientes (43,4%) en UCE y 769 (56,6%) en salas de hospitalización convencional. En el modelo de regresión mixto ajustado al centro, la crisis hipertensiva (OR 1,79, IC 95%: 1,17-2,73; p = 0,007) y el ingresar en UCE (OR 16,6, IC95%: 10,0-33,3; p < 0,001) se asociaron a TDEH corto, y la ICA hipotensiva (OR 0,49, IC 95%: 0,26-0,91; p = 0,025), la hipoxemia, (OR 0,68, IC 95%: 0,53-0,88; p = 0,004) e ingresar en miércoles, jueves o viernes (OR 0,62, IC 95%: 0,49-0,77; p < 0,001) a TDEH largo. El ABC COR del modelo mixto ajustada al centro fue 0,827 (IC 95%: 0,80-0,85; p < 0,001). La mortalidad a 30 días y el reingreso a 30 días no difirieron entre ambos grupos (0,5% frente a 0,5%, p = 0,959; y 22,9% frente a 27,7%, p = 0,059, respectivamente). CONCLUSIONES: En pacientes con ICA existen factores clínicos y organizativos en cada centro que se relacionan de forma independiente con un TDEH corto, entre los que destaca el tener una UCE.

[Characteristics and clinical course of patients with acute heart failure and the therapeutic measures applied in Spanish emergency departments: based on the EAHFE registry (Epidemiology of Acute Heart Failure in Emergency Departments)]. / Características clínicas, terapéuticas y evolutivas de los pacientes con insuficiencia cardiaca aguda atendidos en servicios de urgencias españoles: Registro EAHFE (Epidemiology of Acute Heart Failure in Spanish Emergency Departments).

OBJECTIVES: To analyze data recorded in the EAHFE registry (Epidemiology of Acute Heart Failure in Emergency Departments), which collects information on the clinical characteristics and laboratory findings of patients with acute heart failure (AHF) treated in 29 Spanish hospital emergency departments (EDs) as well as therapies used and clinical course. We analyzed changes in management observed over time and compared the results with data recorded in other AHF registries. MATERIAL AND METHODS: Prospective multicenter cohort study of consecutive patients treated in 3 different years: 2007, 2009, and 2011. We collected demographic, clinical, and laboratory data; medications taken prior to the emergency and in the ED; and outcome variables (in-hospital and 30-day and 1-year mortality rates, readmissions within 30 days). Changes in therapy and course in the 3 years were analyzed. The literature was reviewed to find other national and international AHF registries. RESULTS: A total of 5845 patients were included (2007, 948; 2009, 1483; 2011, 3414). The mean age was 79 years and 56% were women. The AHF episode registered was the first experienced by 34.6% of the patients. Comorbidity was high: 82% had hypertension, 42.3% had diabetes mellitus, and 47.7% had atrial fibrillation. Severe or total functional dependence was observed in 21.9%, and 57.3% had systolic dysfunction (left ventricular ejection fraction, 38.3%). The main treatments administered consisted in diuretics (96.8%), endovenous nitroglycerine (20.7%), noninvasive ventilation (6.4%), and inotropic agents or vasopressors (3.6%). The glomerular filtration rate was low in 57%. Troponin and natriuretic peptide levels were measured in the EDs in 49.1% and 42.4% of the cases, respectively. Patients presented as normotensive in 66.4% of the cases, hypertensive in 23.5%, and hypotensive in 4.6% (0.7% in shock); 76.1% were admitted (1.9% to the ICU). The median hospital stay was 7 days and 23.9% were discharged from the ED. In-hospital mortality was 7.6%; 30-day mortality was 9.4% and 1-year mortality 29.5%. Orders for troponin and natriuretic peptide determinations increased over the 3 study periods, and the intravenous infusion of diuretics and inotropic agents and vasoconstrictors decreased (P < 0.001, all comparisons). Revisits within 30 days also decreased (P = 0.004). No changes were observed in in-hospital or 30-day mortality rates between 2007 and 2011. We reviewed 14 previously published registry reports (8 compiled prospectively); only 2 of the registries included ED patients. CONCLUSION: The EAHFE registry describes the characteristics of AHF in a cohort that resembles the universe of our patients with AHF. Significant changes were observed over time in some aspects of AHF management. Revisits decreased, but mortality rates remained unchanged. Only 2 other previously analyzed registries included patients with AHF treated in hospital EDs.

OBJETIVO: Presentación de los resultados del Registro EAHFE (Epidemiology of Acute Heart Failure in Emergency Departments) que recoge las características clínicas, de laboratorio, terapéuticas y la evolución de los pacientes con insuficiencia cardiaca aguda (ICA) atendidos en 29 servicios de urgencias hospitalarios (SUH) españoles. Se analizan los cambios de manejo a lo largo del tiempo; y se comparan los resultados con los de otros registros de ICA. METODO: Estudio multicéntrico, de cohortes, prospectivo, de inclusión consecutiva, realizado en tres periodos (2007, 2009 y 2011). Se recogieron datos demográficos, clínicos, de laboratorio, del tratamiento farmacológico previo y el administrado en SUH y variables evolutivas (mortalidad intrahospitalaria y a los 30 días y al año, reingreso a 30 días). Se analizaron los cambios terapéuticos y evolutivos a lo largo de estos 3 periodos. Se revisó la literatura para identificar registros previos de ICA de carácter nacional o internacional. RESULTADOS: Se incluyeron 5.845 pacientes (2007: 948, 2009: 1.483, 2011: 3.414), con edad media de 79 años y 56% mujeres. Un 34,6% era un primer episodio de ICA. Presentaron elevada comorbilidad (82% hipertensión, 42,3% diabetes mellitus, 47,7% fibrilación auricular). Un 21,9% tenía dependencia funcional grave o total. El 57,3% tenía una disfunción sistólica (FEVI 38,3%). Los principales tratamientos administrados en urgencias consistieron en diuréticos (96,8%), nitroglicerina endovenosa (20,7%), ventilación no invasiva (6,4%) y fármacos inotrópicos o vasopresores (3,6%). El 57% presentaba una tasa de filtrado glomerular disminuida. Las troponinas y los péptidos natriuréticos se determinaron en urgencias en un 49,1% y 42,4% de casos, respectivamente. Las formas de presentación se clasificaron como: normotensiva (66,4%), hipertensiva (23,5%), hipotensiva (4,6%, 0,7% con shock). El 76,1% fue ingresado (1,9% en intensivos), con una mediana de estancia hospitalaria de 7 días, y el 23,9% dado de alta desde urgencias. La mortalidad intrahospitalaria fue 7,6%, a 30 días 9,4% y al año 29,5%. A lo largo del periodo estudiado, ha aumentado la solicitud de troponinas (p < 0,001) y péptidos natriuréticos (p <0,001) en urgencias, ha disminuido el uso de diuréticos en perfusión (p < 0,001) y de inotropos/vasoconstrictores (p < 0,001) y ha disminuido el porcentaje de reconsulta a 30 días (p = 0,004). No se observaron cambios en la mortalidad intrahospitalaria y a los 30 días entre el periodo 2007-2011. Se han revisado 14 registros anteriores (8 prospectivos), y solo en 2 la inclusión de pacientes se hizo desde el SUH. CONCLUSIONES: El Registro EAHFE describe las características de la ICA a partir de una cohorte que se aproxima al universo de pacientes con ICA. Con el paso del tiempo se observan cambios significativos en el manejo de la ICA: las revisitas han disminuido aunque la mortalidad no se ha modificado. Aparte del Registro EAHFE, solo existen otros 2 registros en el mundo que incluyan a los pacientes con ICA atendidos en urgencias.

Estancia prolongada en pacientes ingresados por insuficiencia cardiaca aguda en la Unidad de Corta Estancia (estudio EPICA-UCE): factores asociados / Prolonged hospitalization in patients admitted for acute heart failure in the short stay unit (EPICA-UCE study): Study of associated factors

Fundamento y objetivo: Estudiar los factores asociados con una estancia prolongada de los pacientes ingresados por insuficiencia cardiaca aguda (ICA) en las unidades de corta estancia (UCE) españolas. Pacientes y método: Estudio de cohorte multipropósito y multicéntrico, con seguimiento prospectivo, que incluyó a todos los pacientes ingresados por ICA en las 11 UCE del registro EAHFE. Se recogieron variables demográficas, antecedentes personales, situación basal cardiorrespiratoria y funcional, datos del episodio de urgencias, del ingreso y del seguimiento a 60 días. La variable resultado fue la estancia prolongada en la UCE (mayor de 72 h). Se utilizó un modelo de regresión logística para controlar los efectos de los factores de confusión. Resultados: Se incluyeron 819 pacientes, con una edad media (DE) de 80,9 (8,4) años; 483 (59,0%) eran mujeres. La mediana de estancia fue de 3 días (intervalo intercuartílico 2,0-5,0), y la mortalidad intrahospitalaria del 2,7%. Fueron factores independientes asociados a una estancia prolongada, la coexistencia de enfermedad pulmonar obstructiva crónica (odds ratio [OR] 1,56, intervalo de confianza del 95% [IC 95%] 1,02-2,38; p = 0,040) y anemia (OR 1,72, IC 95% 1,21-2,44; p = 0,002), una saturación de oxígeno basal a la llegada a urgencias < 90% (OR 2,21, IC 95% 1,51-3,23; p < 0,001), una crisis hipertensiva como factor precipitante de la ICA (factor protector, OR 0,49, IC 95% 0,26-0,93; p = 0,028) e ingresar en jueves (OR 1,90, IC 95% 1,19-3,05; p = 0,008). No hubo diferencias significativas entre ambos grupos respecto a la mortalidad intrahospitalaria (2,4 frente a 3,0%), mortalidad (4,1 frente a 4,2%) ni revisita a 60 días (18,4 frente a 21,6%). Conclusiones: En los pacientes con ICA que ingresan en la UCE, se tienen que considerar factores como la presencia de crisis hipertensiva, insuficiencia respiratoria, anemia, antecedente de enfermedad pulmonar obstructiva crónica, e ingresar un jueves para evitar hospitalizaciones prolongadas (AU)

Background and objective: To study the factors associated with prolonged hospitalization in patients admitted for acute heart failure (AHF) in Spanish short-stay units (SSUs). Patients and methods: This was a multicentre, multipurpose cohort study with prospective follow-up including all patients admitted for AHF in the 11 SSUs of the EAHFE registry. Demographic data, previous illness, baseline cardiorespiratory and functional status, acute episode and admission and follow up variables at 60 days were recorded. The primary outcome was prolonged hospitalization in the SSU (> 72 h). A logistic regression model was used to control the effects of confounding factors. Results: Eight-hundred and nineteen patients were included with a mean age of 80.9 (SD 8.4) years, 483 (59.0%) being women. The median length stay was 3.0 (IQR 2.0-5.0) days with an in-hospital mortality of 2.7%. The independent factors associated with prolonged hospitalization were the coexistence of chronic obstructive pulmonary disease (odds ratio [OR] 1.56; 95% IC 1.02-2.38; P = .040) and anaemia (OR 1.72; 95% CI 1.21-2.44; P = .002), basal oxygen saturation < 90% on arrival to the Emergency Department (OR2.21, 95% CI 1.51-3.23; P < .001), hypertensive episode as the precipitating factor of the AHF (protective factor OR 0.49; 95% CI 0.26-0.93; P = .028) and admission on Thursday (OR 1.90; 95% CI 1.19-3.05; P = .008). There were no significant differences between both groups regarding to in-hospital mortality (2.4 vs. 3.0%), mortality (4.1 vs. 4.2%) or revisit at 60 days (18.4 vs. 21.6%).Conclusions: Several factors including hypertensive episode, insufficiency respiratory, anaemia, chronic obstructive pulmonary disease, and admission on Thursday should be taken into account in patients with AHF admitted in SSU stay to avoid prolonged hospitalization (AU)

Characteristics of acute heart failure in very elderly patients - EVE study (EAHFE very elderly).

OBJECTIVES: To determine the characteristics and prognostic factors of early death in the very elderly with acute heart failure (AHF). PATIENTS AND METHODS: We performed a prospective, observational study of AHF patients attended in Emergency Departments (ED), analyzing 45 variables collected in ED and studying troponin, natriuretic peptides and echocardiographies, not always available in the ED. The patients were divided into 2 groups: nonagenarian (age ≥ 90 years) and controls (age < 90 years). The study variables were mortality and death or reconsultation to the ED for AHF within 30 days after inclusion. RESULTS: We included 4700 patients (nonagenarians: 520, 11.1%). The 30-day mortality was 21.5% and 8.7% (p<0.01), respectively with a combined event of 33.3% and 26.7% (p=0.001). Age ≥ 90 years was maintained in all the models associated with death (OR: 1.94, CI 95%: 1.40-2.70). In nonagenarians, chronic kidney insufficiency (OR: 2.07, CI95%: 1.16-3.69), severe functional dependence (OR: 2.18, CI95%; 1.30-3.64) and basal oxygen saturation <90% (OR: 1.97, CI95%: 1.17-3.32) and hyponatremia <135 mEq/L (OR: 1.89, CI95%: 1.05-3.42) were predictive variables of mortality. We observed an association between elevated troponin levels and natriuretic peptide values > 5,180 pg/mL and mortality (OR: 4.26, CI95%: 1.83-9.89; and OR: 3.51, CI95%: 1.45-8.48; respectively). CONCLUSIONS: The profile of nonagenarians with AHF differs from that of younger patients. Although very advanced age is an independent prognostic factor of mortality, these patients have fewer predictive factors of mortality, being only functional deterioration, basal kidney disease, hyponatremia and respiratory insufficiency on arrival at the ED and probably troponin values and elevated natriuretic peptides.

Clinical effects and safety of different strategies for administering intravenous diuretics in acutely decompensated heart failure: a randomised clinical trial.

BACKGROUND: The mainstay of treatment for acutely decompensated heart failure (ADHF) is intravenous diuretic therapy either as a bolus or via continuous infusion. OBJECTIVES: We evaluated the clinical effects and safety of three strategies of intravenous furosemide administration used in emergency departments (EDs) for ADHF. METHODS: We performed a multicentre, randomised, parallel-group study. Patients with ADHF were randomised within 2 h of ED arrival to receive furosemide by continuous infusion (10 mg/h, group 1) or boluses (20 mg/6 h, group 2; or 20 mg/8 h, group 3). The primary end point was total diuresis, and secondary end points were dyspnoea, orthopnoea, extension of rales and peripheral oedema, blood pressure, respiratory and heart rates, and pulse oximetry, which were measured at arrival and 3, 6, 12 and 24 h after treatment onset. We also measured serum creatinine, sodium and potassium levels at arrival and after 24 h. RESULTS: Group 1 patients (n=36) showed greater 24 h diuresis (3705 mL) than those in groups 2 (n=37) and 3 (n=36) (3093 and 2670 mL, respectively; p<0.01), and this greater diuretic effect was observed earlier. However, no differences were observed among groups in the nine secondary clinical end points evaluated. Creatinine deterioration developed in 15.6% of patients, hyponatraemia in 9.2%, and hypokalaemia in 19.3%, with the only difference among groups observed in hypokalaemia (group 1, 36.3%; group 2, 13.5%; group 3, 8.3%; p<0.01). CONCLUSIONS: In patients with ADHF attending the ED, boluses of furosemide have a smaller diuretic effect but provide similar clinical relief, similar preservation of renal function, and a lower incidence of hypokalaemia than continuous infusion. TRIAL REGISTRATION NUMBER: This randomised trial was registered in the European Clinical Trial Database (EudraCT) with the reference number 2008-004488-20.

[Prolonged hospitalization in patients admitted for acute heart failure in the short stay unit (EPICA-UCE study): study of associated factors]. / Estancia prolongada en pacientes ingresados por insuficiencia cardiaca aguda en la Unidad de Corta Estancia (estudio EPICA-UCE): factores asociados.

BACKGROUND AND OBJECTIVE: To study the factors associated with prolonged hospitalization in patients admitted for acute heart failure (AHF) in Spanish short-stay units (SSUs). PATIENTS AND METHODS: This was a multicentre, multipurpose cohort study with prospective follow-up including all patients admitted for AHF in the 11 SSUs of the EAHFE registry. Demographic data, previous illness, baseline cardiorespiratory and functional status, acute episode and admission and follow up variables at 60 days were recorded. The primary outcome was prolonged hospitalization in the SSU (>72h). A logistic regression model was used to control the effects of confounding factors. RESULTS: Eight-hundred and nineteen patients were included with a mean age of 80.9 (SD 8.4) years, 483 (59.0%) being women. The median length stay was 3.0 (IQR 2.0-5.0) days with an in-hospital mortality of 2.7%. The independent factors associated with prolonged hospitalization were the coexistence of chronic obstructive pulmonary disease (odds ratio [OR] 1.56; 95% IC 1.02-2.38; P=.040) and anaemia (OR 1.72; 95% CI 1.21-2.44; P=.002), basal oxygen saturation<90% on arrival to the Emergency Department (OR 2.21, 95% CI 1.51-3.23; P<.001), hypertensive episode as the precipitating factor of the AHF (protective factor OR 0.49; 95% CI 0.26-0.93; P=.028) and admission on Thursday (OR 1.90; 95% CI 1.19-3.05; P=.008). There were no significant differences between both groups regarding to in-hospital mortality (2.4 vs. 3.0%), mortality (4.1 vs. 4.2%) or revisit at 60 days (18.4 vs. 21.6%). CONCLUSIONS: Several factors including hypertensive episode, insufficiency respiratory, anaemia, chronic obstructive pulmonary disease, and admission on Thursday should be taken into account in patients with AHF admitted in SSU stay to avoid prolonged hospitalization.

Predicting the risk of reattendance for acute heart failure patients discharged from Spanish Emergency Department observation units.

BACKGROUND: Patients with acute heart failure (AHF) are frequently evaluated in the Emergency Departments (ED) and discharged from their observation units (OU) without hospital admission. We examined direct discharge rates from the ED OU, risk factors for returning to the ED, and returning and mortality rates. PATIENTS AND METHODS: This prospective, longitudinal, noninterventional, population-based cohort study included all the patients with AHF consecutively attended in seven Spanish EDs who were directly discharged without hospital admission. Reattendance (dependent variable) was accepted if occurred during the next 30 days after discharge. Twenty-nine independent variables were recorded, covering epidemiological, clinical, and functional data. RESULTS: Two hundred and fifty-nine of 740 patients (35%) diagnosed with AHF were entirely managed in the ED OU and discharged home (mean stay: 18.8 h); 26.7% of them were reattended. Only three variables were independently associated with the chance of reattendance: functional impairment predicted adverse outcomes [odds ratio (OR): 4.0, 95% confidence interval (95% CI): 1.7-9.1], while past history of hypertension and a systolic blood pressure greater than 160 mmHg at ED arrival decreased the risk of ED return (OR: 0.4, 95% CI: 0.2-0.9; and OR: 0.3; 95% CI: 0.1-0.9; respectively). An overall mortality of 4.7% was recorded during the next 30 days. CONCLUSION: One-third of the patients consulting at the ED for an episode of AHF can be directly discharged from the OU of ED, with relatively low rates of reattendance (26.7%) and mortality (4.7%). Emergency physicians should be especially cautious discharging patients with functional dependence because they are at increased risk of returning.