Comorbilidad en pacientes con diabetes mellitus tipo 2 e insuficiencia cardíaca con fracción de eyección preservada. Análisis de clusters del registro RICA. Oportunidades de mejora / Comorbidity in patients with type 2 diabetes mellitus and heart failure with preserved ejection fraction. Cluster analysis of the RICA registry. Opportunities for improvement

ANTECEDENTES Y OBJETIVOS: La heterogeneidad de los pacientes con insuficiencia cardíaca y fracción de eyección preservada (ICFEP) es elevada, por lo que se tiende a agrupar en fenotipos para intervenir con precisión. Dentro de estos, los pacientes con diabetes mellitus (DM) mantienen esta heterogeneidad. Nuestro objetivo es describir grupos de pacientes con ICFEP y DM basados en otras comorbilidades. MATERIAL Y MÉTODOS: Los pacientes se reclutan desde el registro nacional de insuficiencia cardíaca (RICA). Se incluyen pacientes con fracción de eyección mayor o igual al 50% sin valvulopatía y con DM. Se realiza un análisis aglomerativo jerárquico con el método de Ward incluyendo las siguientes variables: dislipemia, hepatopatía, EPOC, demencia, enfermedad cerebrovascular, arritmia, presión arterial sistólica, índice de masa corporal (IMC), estimación del filtrado glomerular y hemoglobina. RESULTADOS: Se incluyen 1.934 pacientes con ICFEP, de los que 907 (46,9%) tenían DM, con predominio de mujeres (60,9%) y con un IMC de 31,1 (5,9) kg/m2. Se obtienen 4 grupos: dos con elevado riesgo vascular (uno con arritmia y otro no), con 263 pacientes el primero y 201 el segundo, otro con predominio de EPOC (140 pacientes) y un último grupo de 303 pacientes con más edad pero menos comorbilidad. CONCLUSIONES: En nuestros pacientes con ICFEP y DM predomina la obesidad y el sexo femenino. Los cuatro grupos ofrecen oportunidades de tratamiento para mejorar su pronóstico no solo basadas en la utilización de nuevos fármacos antidiabéticos sino por otras opciones que pueden suponer un punto de partida para nuevas investigaciones

AIM: The heterogeneity of patients with heart failure and preserved ejection fraction (HFpEF) is high, thusthis entity tends to be grouped into phenotypes to act with precision. Within these groups, patients with type 2 diabetes mellitus (T2DM) hold this heterogeneity. Our aim is to describe subgroups of patients with HFpEF and T2DM based on other comorbidities. MATERIAL AND METHODS: Patients were recruited from the national registry of heart failure (RCIA). Patients with ejection fraction greater than or equal to 50% without valvular disease and with T2DM were included. A hierarchical agglomerative analysis was performed with Ward's method including the following variables: dyslipidemia, liver disease, Chronic obstructive pulmonary disease (COPD), dementia, cerebrovascular disease, arrhythmia, systolic blood pressure, body mass index (BMI), estimation of glomerular filtration and hemoglobin. RESULTS: 1934 patients with ICFEP were included, of which 907 (46.9%) had T2DM with a predominance of women (60.9%) and with a BMI of 31.1 (5.9) Kg / m2. Four groups were obtained, two with high vascular risk (one with arrhythmia and the other without it) with 263 patients the first and 201 the second. A third group had a predominance of COPD (140 patients) and a last group with 303 patients older but with less comorbidity. CONCLUSIONS: In our patients with ICFEP and T2DM, obesity and female sex predominated. All four groups offered treatment chances to improve their prognosis not only based on the use of new antidiabetic drugs but also on other options that may be a starting point for further research

Comorbidity in patients with type 2 diabetes mellitus and heart failure with preserved ejection fraction. Cluster analysis of the RICA registry. Opportunities for improvement. / Comorbilidad en pacientes con diabetes mellitus tipo 2 e insuficiencia cardíaca con fracción de eyección preservada. Análisis de clusters del registro RICA. Oportunidades de mejora.

AIM: The heterogeneity of patients with heart failure and preserved ejection fraction (HFpEF) is high, thusthis entity tends to be grouped into phenotypes to act with precision. Within these groups, patients with type 2 diabetes mellitus (T2DM) hold this heterogeneity. Our aim is to describe subgroups of patients with HFpEF and T2DM based on other comorbidities. MATERIAL AND METHODS: Patients were recruited from the national registry of heart failure (RCIA). Patients with ejection fraction greater than or equal to 50% without valvular disease and with T2DM were included. A hierarchical agglomerative analysis was performed with Ward's method including the following variables: dyslipidemia, liver disease, Chronic obstructive pulmonary disease (COPD), dementia, cerebrovascular disease, arrhythmia, systolic blood pressure, body mass index (BMI), estimation of glomerular filtration and hemoglobin. RESULTS: 1934 patients with ICFEP were included, of which 907 (46.9%) had T2DM with a predominance of women (60.9%) and with a BMI of 31.1 (5.9) Kg / m2. Four groups were obtained, two with high vascular risk (one with arrhythmia and the other without it) with 263 patients the first and 201 the second. A third group had a predominance of COPD (140 patients) and a last group with 303 patients older but with less comorbidity. CONCLUSIONS: In our patients with ICFEP and T2DM, obesity and female sex predominated. All four groups offered treatment chances to improve their prognosis not only based on the use of new antidiabetic drugs but also on other options that may be a starting point for further research.

Validation of the PROFUND index to predict early post-hospital discharge mortality.

BACKGROUND: The PROFUND index (PI) is a prognostic scale for polypathological patients at 12 months. The objective of the study was to validate the PI as a predictor of 1-year mortality in a current cohort of polypathological patients and analyse its prognostic usefulness in the short-term (1 month and 3 months) after discharge from Internal Medicine. DESIGN: We conducted a prospective observational study and all polypathological patients discharged from an Internal Medicine Department between 01 March 2016 and 28 February 2017 were enrolled. METHODS: The variables recorded for each patient were age, sex, diseases and diagnostic categories defining patients as polypathological patients, PI at discharge, number of hospital admissions, length of stay, vital status at 1 year, and date and place of death if applicable. Follow-up lasted 1 year from the time of enrolment. RESULTS: Six hundred and ten polypathological patients were enrolled. Mortality was 41% and the patients who died were older, their length of stay was longer and their PI was higher compared with those who survived. The discrimination of the PI for predicting mortality was good, with a C-statistic of 0.718 [95% confidence interval (CI) 0.67-0.76]. In addition, a subgroup of patients with early mortality after discharge was identified, with a C-statistic of 0.74 (95% CI 0.67-0.80) at 30 days and 0.73 (95% CI 0.68-0.78) at 90 days. CONCLUSIONS: The PI is a valid tool for predicting early and 1-year mortality in polypathological patients after discharge from Internal Medicine.

External validation of the CACE-HF risk score for mortality in patients with heart failure.

AIMS: To validate externally the CACE-HF clinical prediction rule, which predicts 1-year mortality in patients with heart failure (HF). METHODS: We performed an external validation of the CACE-HF risk score in patients included in the RICA heart failure registry who had completed 1 year of follow-up, comparing the characteristics of the derivation and validation cohorts. The performance of the risk score was evaluated in terms of calibration, using calibration-in-the-large (a), calibration slope (b), and the Hosmer-Lemeshow test, and in terms of discrimination, using the area under the ROC curve. RESULTS: In total, 3337 patients were included in the validation cohort. There were no significant differences between the derivation and validation cohorts in 1-year mortality (24.63% vs. 22.98%) or in the risk score and risk classes. The discrimination capacity in the validation cohort was slightly lower, 0.67 (95% CI: 0.65, 0.69), compared to that of the derivation cohort. Calibration results were a -0.05 (95% CI: -0.14, 0.03), indicating that the average predictions did not differ from the average outcome frequency, and b = 0.75 (95% CI: 0.64, 0.86), indicating a modest inconsistency in predictor effects. Observed mortality versus predicted mortality according to the deciles and risk classes were very similar in both cases, indicating good calibration. CONCLUSIONS: The results of the external validation of the CACE-HF risk score show that although the capacity for discrimination was slightly lower than in the derivation cohort, the calibration was excellent. This tool, therefore, can assist in decision-making in the management of these patients.

Supervivencia a largo plazo del ictus isquémico / Long-term survival of ischemic stroke

Objetivo. El ictus isquémico es una enfermedad vascular grave, cuyo pronóstico a largo plazo no conocemos en toda su dimensión. Hemos estudiado la supervivencia a largo plazo y sus factores pronósticos tras un primer episodio de ictus agudo de origen isquémico (cardioembólico y aterotrombótico). Pacientes y métodos. Estudio de cohortes retrospectivo de pacientes que han requerido ingreso por un primer episodio de ictus isquémico. El ictus se clasificó en aterotrombótico, cardioembólico, lacunar e indeterminado. Los enfermos fueron seguidos durante 10 años. Resultados. Se incluyeron 415 pacientes (varones: 60%), con una edad media de 68,4 años. La media de seguimiento fue de 66 meses (IC del 95%: 24-108 meses). La supervivencia global a los 10 años fue del 55,4% (54,9-55,9) (aterotrombótico, 57,5% vs cardioembólico, 43,7%; p=0,002). En el análisis multivariante las variables relacionadas con la mortalidad fueron la mayor edad, presencia de insuficiencia renal crónica, dislipemia, antecedentes de insuficiencia cardiaca, fibrilación auricular, presentación con hemiplejía, y los signos de isquemia aguda y de edema perilesional en el TAC realizado en el ingreso hospitalario. Se asociaron a un mejor pronóstico la afectación del territorio de la arteria cerebral media derecha y el tratamiento con estatinas. Conclusiones. La supervivencia tras un ictus isquémico a los 10 años es algo superior al 40%, y tiene mejor pronóstico el ictus aterotrombótico que el cardioembólico(AU)

Objective. Ischemic stroke is a serious vascular disease whose long term prognosis in all of its dimensions is not known. We have studied the long-term survival and its predictors after a first episode of acute ischemic stroke (atherothrombotic and cardioembolic). Patients and methods. A retrospective cohort study was made of patients with a first episode of ischemic stroke. The ictus was classified into atherothrombotic, cardioembolic, lacunar and undetermined. Patients were followed up for 10 years. Results. A total of 415 cases (60% men) with mean age of 68.4 years, were included. Mean follow-up was 66 months (95% CI: 24-108 months). Overall survival at 10 years was 55.4% (54.9-55.9) (atherothrombotic, 57.7% vs cardioembolic, 43.7%, P=.002). In the multivariate analysis, variables related to mortality in acute ischemic stroke were age, chronic renal failure, dyslipidemia, history of heart failure, atrial fibrillation (AF), presenting as hemiplegia, signs of acute ischemia and perilesional edema in the brain scan on hospital admission. Involvement of the territory of right middle cerebral artery and treatment with statins were associated to a better prognosis. Conclusions. Survival of patients after ischemic stroke at ten year is over 40%, and atherothrombotic stroke as a better prognosis than cardioembolic one(AU)

[Long-term survival of ischemic stroke]. / Supervivencia a largo plazo del ictus isquémico.

OBJECTIVE: Ischemic stroke is a serious vascular disease whose long term prognosis in all of its dimensions is not known. We have studied the long-term survival and its predictors after a first episode of acute ischemic stroke (atherothrombotic and cardioembolic). PATIENTS AND METHODS: A retrospective cohort study was made of patients with a first episode of ischemic stroke. The ictus was classified into atherothrombotic, cardioembolic, lacunar and undetermined. Patients were followed up for 10 years. RESULTS: A total of 415 cases (60% men) with mean age of 68.4 years, were included. Mean follow-up was 66 months (95% CI: 24-108 months). Overall survival at 10 years was 55.4% (54.9-55.9) (atherothrombotic, 57.7% vs cardioembolic, 43.7%, P=.002). In the multivariate analysis, variables related to mortality in acute ischemic stroke were age, chronic renal failure, dyslipidemia, history of heart failure, atrial fibrillation (AF), presenting as hemiplegia, signs of acute ischemia and perilesional edema in the brain scan on hospital admission. Involvement of the territory of right middle cerebral artery and treatment with statins were associated to a better prognosis. CONCLUSIONS: Survival of patients after ischemic stroke at ten year is over 40%, and atherothrombotic stroke as a better prognosis than cardioembolic one.

[The role of radiologists in the management of thyroid nodules]. / Papel del radiólogo en el manejo del nódulo tiroideo.

We review the different techniques in the diagnostic of thyroid nodule. The ultrasound and, especially, sonographically guided fine-needle aspiration (US-FNA), are the most accurate diagnostics tests to achieve a correct diagnosis of thyroid nodule, which is only done better by the surgery treatment and the pathology study of all lesion. We review the situations in which US-FNA is necessary and the different diagnostic and therapeutics options. Finally, we propose algorithms for the management of a solitary thyroid nodule, multinodular goiter and casually discovered nodule.

Papel del radiólogo en el manejo del nódulo tiroideo / The role of radiologists in the management of thyroid nodules

Se revisan las diferentes herramientas existentes para el diagnóstico del nódulo tiroideo. Dentro de ellas la ecografía, y sobre todo la punción-aspiración con aguja fina mediante guía ecográfica (ECO-PAAF), constituyen hoy en día las pruebas más fiables para determinar la naturaleza de un nódulo tiroideo, sólo superadas por la extirpación quirúrgica y el estudio anatomopatológico de la pieza completa. Se revisan las situaciones en las que se debe realizar ECO-PAAF, los diagnósticos posibles y las alternativas terapéuticas en función del diagnóstico obtenido. Por último, se proponen algoritmos de manejo diagnóstico y terapéutico para el nódulo solitario, el bocio multinodular y el nódulo asintomático descubierto casualmente

We review the differents techniques in the diagnostic of thyroid nodule. The ultrasound and, especially, sonographically guided fine-needle aspiration (US-FNA), are the most accurate diagnostics tests to achieve a correct diagnosis of thyroid nodule, which is only done better by the surgery treatment and the pathology study of all lesion. We review the situations in which US-FNA is necessary and the differents diagnostic andtherapeutics options. Finally, we propose algorithms for the management of a solitary thyroid nodule, multinodular goiter and casually discovered nodule