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)

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.

Prognostic value of multimodal assessment of congestion in acute heart failure.

BACKGROUND: A physical examination has limited performance in estimating systemic venous congestion and predicting mortality in patients with heart failure. We have evaluated the usefulness of the N-terminal prohormone of brain natriuretic peptide (NT-proBNP), cancer antigen 125 (CA125), lung ultrasound findings, relative plasma volume (rPV) estimation, and the urea/creatinine ratio as surrogate parameters of venous congestion and predictors of mortality. METHODS: This work is a retrospective study of 203 patients admitted for acute heart failure in a tertiary hospital's internal medicine department with follow-up in a specialized outpatient clinic between 2013 and 2018. Clinical data were collected from hospital records. Treatment was decided upon according to the clinical judgment of each patient's attending physician. The main outcome measure was all-cause mortality at one year of follow-up. RESULTS: Patients' mean age was 78.8 years and 47% were male. A total of 130 (65%) patients had chronic heart failure, 51 (26.2%) patients were in New York Heart Association class III-IV, and 116 (60%) patients had preserved left ventricular ejection fraction. During follow-up, 42 (22%) patients died. Values of NT-proBNP≥3804pg/mL (HR 2.78 [1.27-6.08]; p=.010) and rPV≥-4.54% (HR 2.74 [1.18-6.38]; p=.019) were independent predictors of all-cause mortality after one year of follow-up. CONCLUSIONS: NT-proBNP and rPV are independent predictors of one-year mortality among patients hospitalized for decompensated heart failure.

Valor pronóstico de la valoración multimodal de la congestión en la insuficiencia cardiaca aguda / Prognostic value of multimodal assessment of congestion in acute heart failure

Fundamento El examen físico presenta una rentabilidad limitada en la estimación de la congestión venosa sistémica y en la predicción de la mortalidad de los pacientes con insuficiencia cardiaca. Hemos evaluado la utilidad del fragmento amino terminal del péptido natriurético cerebral (NT-proBNP), del antígeno de cáncer 125 (CA125), los hallazgos de la ecografía pulmonar, la estimación del volumen plasmático relativo (VPr) y el cociente urea/creatinina, como parámetros subrogados de congestión venosa y predictores de mortalidad. Material y métodos Estudio retrospectivo de 203 pacientes ingresados por insuficiencia cardiaca aguda en el servicio de medicina interna de un hospital terciario, con seguimiento monográfico en consultas externas entre los años 2013 y 2018. Los datos clínicos se recogieron de los registros hospitalarios. Las intervenciones terapéuticas se guiaron por el criterio clínico del médico responsable de cada paciente. El desenlace principal fue mortalidad general tras un año de seguimiento. Resultados La edad media de los pacientes fue 78,8 años, 47% eran varones. Un total de 130 (65%) pacientes presentaban insuficiencia cardiaca crónica, 51 (26,2%) pacientes se encontraban en clase III-IV de la New York Heart Association y 116 (60%) pacientes presentaban fracción de eyección de ventrículo izquierdo preservada. Durante el seguimiento fallecieron 42 (22%) pacientes. Los valores de NT-proBNP≥3.804pg/mL (HR 2,78 [1,27-6,08]; p=0,010) y el VPr≥–4,54% (HR 2,74 [1,18-6,38]; p=0,019) fueron predictores independientes de mortalidad general tras un año de seguimiento. Conclusiones El NT-proBNP y el VPr son predictores independientes de mortalidad a un año entre los pacientes ingresados por insuficiencia cardiaca descompensada (AU)

Background A physical examination has limited performance in estimating systemic venous congestion and predicting mortality in patients with heart failure. We have evaluated the usefulness of the N-terminal prohormone of brain natriuretic peptide (NT-proBNP), cancer antigen 125 (CA125), lung ultrasound findings, relative plasma volume (rPV) estimation, and the urea/creatinine ratio as surrogate parameters of venous congestion and predictors of mortality. Methods This work is a retrospective study of 203 patients admitted for acute heart failure in a tertiary hospital's internal medicine department with follow-up in a specialized outpatient clinic between 2013 and 2018. Clinical data were collected from hospital records. Treatment was decided upon according to the clinical judgment of each patient's attending physician. The main outcome measure was all-cause mortality at one year of follow-up. Results Patients’ mean age was 78.8 years and 47% were male. A total of 130 (65%) patients had chronic heart failure, 51 (26.2%) patients were in New York Heart Association class III-IV, and 116 (60%) patients had preserved left ventricular ejection fraction. During follow-up, 42 (22%) patients died. Values ??of NT-proBNP≥3,804pg/mL (HR 2.78 [1.27-6.08]; p=.010) and rPV ≥–4.54% (HR 2.74 [1.18-6.38]; p=.019) were independent predictors of all-cause mortality after one year of follow-up. Conclusions NT-proBNP and rPV are independent predictors of one-year mortality among patients hospitalized for decompensated heart failure (AU)

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

Resultados del seguimiento en una consulta monográfica tras el alta por insuficiencia cardiaca / Follow-up results in a specialised consultation after discharge for heart failure

INTRODUCCIÓN: A pesar de los avances en el diagnóstico y el tratamiento, la insuficiencia cardiaca (IC) sigue teniendo una alta morbimortalidad. El tratamiento de las comorbilidades y la educación sanitaria se han demostrado eficaces, así como la atención multidisciplinar, en unidades especializadas, aunque ello implica un esfuerzo organizativo y estructural no siempre disponible. Presentamos los resultados de una consulta ambulatoria simple, centrada en la atención monográfica a la IC. PACIENTES Y MÉTODOS: La consulta incluyó a pacientes dados de alta tras una hospitalización (ingreso índice) por descompensación de IC en el servicio de Medicina Interna. El seguimiento se realizó por internistas con especial dedicación (no exclusiva) en IC y una enfermera con dedicación compartida. El seguimiento consistió en visitas fijas 1, 3, 6 y 12 meses tras el alta, más visitas a demanda en caso de necesidad. RESULTADOS: Se incluyó a 250 pacientes con un seguimiento mínimo de un año. La disminución de los ingresos y las visitas a Urgencias por IC fue del 56 y el 61% (p < 0,05), respectivamente, y del 46 y el 40% (p < 0,05) por cualquier causa. Además, se consiguió una optimización del tratamiento, con un aumento significativo en el porcentaje de prescripción de fármacos basados en la evidencia y reducción de otros, como calcioantagonistas. CONCLUSIÓN: Un modelo sencillo basado en la atención monográfica a la IC es eficaz en la reducción de reingresos y la optimización del tratamiento. La carencia de recursos asistenciales no debería suponer un obstáculo para una atención monográfica a pacientes con IC

BACKGROUND: Despite advances in the diagnosis and treatment of heart failure (HF), the condition still has high morbidity and mortality. Health education and the treatment of comorbidities have been shown to be effective, as has multidisciplinary care in specialised units, although this involves organisational and structural efforts that are not always feasible. We present the results of a simple outpatient consultation, focused on the specialised care of HF. PATIENTS AND METHODS: The consultation included patients discharged after hospitalisation (index hospitalisation) for decompensated HF from an internal medicine department. The follow-up was conducted by internists especially dedicated (not exclusively) to HF and a nurse partially dedicated to HF. The follow-up consisted of fixed visits 1, 3, 6 and 12 months after the discharge, with more visits on demand if needed. RESULTS: A total of 250 patients were included with a minimum follow-up of 1 year. The reduction in hospitalisations and emergency department visits was 56% and 61% (P<.05), respectively, for HF and 46% and 40% (P<.05), respectively, for any cause. Treatment optimisation was also achieved, with a significant increase in the evidence-based drug prescription rate and the reduction of other drugs, such as calcium antagonists. CONCLUSION: A simple model based on a specialised care consultation for HF is effective in reducing readmissions and optimising the treatment. The lack of healthcare resources should not be an obstacle for specialised care for patients with HF

Prognostic value of multimodal assessment of congestion in acute heart failure. / Valor pronóstico de la valoración multimodal de la congestión en la insuficiencia cardiaca aguda.

Systemic venous congestion is present in most cases of acute decompensated heart failure (ADHF). An accurate assessment of congestion is key to improve outcomes and avoid residual congestion. Physical examination has limitations for grading congestion; hence, new methods for assessing congestion have been developed. A multimodal approach, combining surrogate markers of congestion, may be a suitable strategy. The aim of this study was to compare the prognostic value of Amino terminal fragment of pro-Brain Natriuretic Peptide (NT-proBNP), Carbohydrate cancer antigen 125 (CA125), lung ultrasound, relative plasma volume status (rPVS) and urea/Creatinine ratio (U/C ratio), to predict one-year all-cause mortality. MATERIAL AND METHODS: Retrospective, observational analysis of 203 patients admitted at the Internal Medicine ward of a tertiary teaching Hospital due to ADHF, followed in monographic outclinic. Clinical data were obtained from hospital records. Therapeutic interventions followed exclusively the clinical judgement of the physician responsible for each patient. RESULTS: 203 patients were included for the final analysis between 2013 and 2018. Chronic heart failure (CHF) was present in 130 patients (65%); 51 patients (26.2%) had class III-IV of New York Heart Association (NYHA); 116 patients (60%) had HF with preserved ejection fraction (HFpEF). Forty-two patients (21.6%) died during follow-up. NT-proBNP≥3804 pg/mL (HR 2.78 [1.27 - 6.08]; P=.010) and rPVS≥-4.54% (HR 2.74 [1.18 - 6.38]; P=.019), were independent predictors for 1-year all-cause mortality on top of CA125, lung ultrasound and U/C ratio. CONCLUSIONS: NT-proBNP and rPVS are independent predictors of one-year mortality among patients admitted for ADHF.

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.

Follow-up results in a specialised consultation after discharge for heart failure. / Resultados del seguimiento en una consulta monográfica tras el alta por insuficiencia cardiaca.

BACKGROUND: Despite advances in the diagnosis and treatment of heart failure (HF), the condition still has high morbidity and mortality. Health education and the treatment of comorbidities have been shown to be effective, as has multidisciplinary care in specialised units, although this involves organisational and structural efforts that are not always feasible. We present the results of a simple outpatient consultation, focused on the specialised care of HF. PATIENTS AND METHODS: The consultation included patients discharged after hospitalisation (index hospitalisation) for decompensated HF from an internal medicine department. The follow-up was conducted by internists especially dedicated (not exclusively) to HF and a nurse partially dedicated to HF. The follow-up consisted of fixed visits 1, 3, 6 and 12 months after the discharge, with more visits on demand if needed. RESULTS: A total of 250 patients were included with a minimum follow-up of 1 year. The reduction in hospitalisations and emergency department visits was 56% and 61% (P<.05), respectively, for HF and 46% and 40% (P<.05), respectively, for any cause. Treatment optimisation was also achieved, with a significant increase in the evidence-based drug prescription rate and the reduction of other drugs, such as calcium antagonists. CONCLUSION: A simple model based on a specialised care consultation for HF is effective in reducing readmissions and optimising the treatment. The lack of healthcare resources should not be an obstacle for specialised care for patients with HF.

Valor pronóstico de la medición del diámetro y colapso inspiratorio de la vena cava inferior en la insuficiencia cardiaca aguda / Prognostic value of measuring the diameter and inspiratory collapse of the inferior vena cava in acute heart failure

Objetivos. Valorar la utilidad de la medición del diámetro y colapso de la vena cava inferior (VCI) en la insuficiencia cardiaca aguda (ICA), su relación con el pronóstico y con biomarcadores séricos de congestión. Pacientes y métodos. Estudio prospectivo observacional que incluyó 85 pacientes con ICA, clasificándolos en 4 grupos según el diámetro de la VCI (≤ o >20mm) y su colapso inspiratorio (< o ≥50%) al ingreso. Las variables de valoración fueron la mortalidad por IC y el evento combinado de mortalidad y reingreso por IC a los 180días. Resultados. El 24,7% de los pacientes presentó una VCI no dilatada y colapso ≥50% (grupo 1); el 20% VCI no dilatada y colapso <50% (grupo 2); el 5,9% VCI dilatada y colapso ≥50% (grupo 3); el 49,4% VCI dilatada y colapso <50% (grupo 4). La ausencia de colapso inspiratorio, pero no la dilatación de la VCI, se relacionó con concentraciones más elevadas de urea (p=0,007), creatinina (p=0,004), ácido úrico (p=0,008), NT-proBNP (p=0,009) y CA125 (p=0,005). La supervivencia libre de evento combinado a los 180días fue inferior en aquellos pacientes sin colapso de la VCI. Conclusiones. La dilatación y la ausencia de colapso inspiratorio de la VCI es frecuente en el contexto de la ICA. La ausencia de colapso inspiratorio de la VCI durante la fase de descompensación identifica un subgrupo de pacientes con peor pronóstico a los 6 meses (AU)

Objectives. To assess the utility of measuring the diameter and collapse of the inferior vena cava (IVC) in acute heart failure (AHF), its relationship with the prognosis and serum biomarkers of congestion. Patients and methods. An observational prospective study was conducted that included 85 patients with AHF, classifying them into 4 groups according to IVC diameter (≤ or >20mm) and inspiratory collapse (< or ≥50%) at admission. The endpoints were mortality due to HF and the combined event of mortality and readmission for HF at 180 days. Results. Some 24.7% of the patients had an undilated IVC and ≥50% collapse (group 1); 20% had an undilated IVC and <50% collapse (group 2), 5.9% had a dilated IVC and ≥50% collapse (group 3); and 49.4% had a dilated IVC and <50% collapse (group 4). The lack of inspiratory collapse but not IVC dilation was related to higher concentrations of urea (P=.007), creatinine (P=.004), uric acid (P=.008), NT-proBNP (P=.009) and CA125 (P=.005). Survival free of the combined event at 180 days was lower in those patients with no IVC collapse. Conclusions. Dilation and the absence of the inspiratory collapse of the IVC are common in the context of AHF. The lack of inspiratory collapse of the IVC during the decompensation phase identifies a subgroup of patients with poorer prognosis at 6 months (AU)

[Prognostic value of measuring the diameter and inspiratory collapse of the inferior vena cava in acute heart failure]. / Valor pronóstico de la medición del diámetro y colapso inspiratorio de la vena cava inferior en la insuficiencia cardiaca aguda.

OBJECTIVES: To assess the utility of measuring the diameter and collapse of the inferior vena cava (IVC) in acute heart failure (AHF), its relationship with the prognosis and serum biomarkers of congestion. PATIENTS AND METHODS: An observational prospective study was conducted that included 85 patients with AHF, classifying them into 4 groups according to IVC diameter (≤ or >20mm) and inspiratory collapse (< or ≥50%) at admission. The endpoints were mortality due to HF and the combined event of mortality and readmission for HF at 180 days. RESULTS: Some 24.7% of the patients had an undilated IVC and ≥50% collapse (group 1); 20% had an undilated IVC and <50% collapse (group 2), 5.9% had a dilated IVC and ≥50% collapse (group 3); and 49.4% had a dilated IVC and <50% collapse (group 4). The lack of inspiratory collapse but not IVC dilation was related to higher concentrations of urea (P=.007), creatinine (P=.004), uric acid (P=.008), NT-proBNP (P=.009) and CA125 (P=.005). Survival free of the combined event at 180 days was lower in those patients with no IVC collapse. CONCLUSIONS: Dilation and the absence of the inspiratory collapse of the IVC are common in the context of AHF. The lack of inspiratory collapse of the IVC during the decompensation phase identifies a subgroup of patients with poorer prognosis at 6 months.

Comprehensive therapeutic approach for patients with heart failure and comorbidity. / Abordaje terapéutico integral del paciente con insuficiencia cardiaca y comorbilidad.

The prevalence of heart failure increases with age and is accompanied by other diseases, which are encompassed within a «cardiometabolic phenotype¼. Their interrelation changes the evolution and treatment that each disease would have in isolation. Patients with heart failure and comorbidity are frail and complex. They require a comprehensive assessment (not just biomedical), which includes functional, cognitive, affective and psychosocial aspects. The overall treatment, which is not covered in the clinical practice guidelines, should adapt to each and every one of the comorbidities. Polypharmacy should be avoided as much as possible, due to its interactions and reduced adherence. Treatment needs to be optimised and adapted to the evolutionary phase of the disease and the specific needs of each patient. The complexity of the care process for patients with heart failure and comorbidities requires the coordination of healthcare providers and support from family and others involved in the patient's care.

Resultados tras la implementación de un programa de mejora de la calidad del contenido de los informes de alta hospitalaria en insuficiencia cardiaca / Results of implementing a programme to improve the quality of the contents in hospital discharge reports in cases of heart failure

Objetivos: Analizar la información recogida en los informes de alta hospitalaria (IAH) que se entregan a los pacientes con diagnóstico principal de insuficiencia cardiaca (IC), y demostrar la mejora en el contenido de estos informes después de la intervención realizada. Material y métodos: Se incluyeron los IAH con diagnóstico de IC emitidos por el servicio de Medicina Interna y se comparó la presencia de datos diagnósticos, pronósticos y terapéuticos en estos IAH, en una muestra anterior y otra posterior a una intervención, consistente en la comunicación de los resultados obtenidos del análisis de la muestra inicial a los facultativos del servicio. Resultados: Se analizaron 651 IAH (371 preintervención y 280 postintervención). La mayoría de los IAH (> 70%) no recogían la clase funcional. La mayor parte de los IAH no contenían información sobre la realización de un ecocardiograma previo al ingreso analizado, y de los IAH que recogieron información ecocardiográfica previa la mayoría no permitían determinar si la IC era diastólica o sistólica. En la muestra posterior hubo un menor porcentaje de IAH que prescribían inhibidores de la enzima convertidora de angiotensina o antagonistas de los receptores de angiotensina ii (26% vs. 32%; p < 0,001). En el 30% de la muestra previa y en el 38% de la posterior había indicación de betabloqueantes (p = 0,027). Conclusiones: La realización de una pequeña intervención informativa a los facultativos responsables de los pacientes con IC mejora la recogida de datos importantes diagnósticos, pronósticos y terapéuticos en los IAH (AU)

Objectives: To analyse the information collected in hospital discharge reports (HDR) that are given to patients with a diagnosis of heart failure (HF), and demonstrate the improvement in the content of these reports after the introduction of an intervention. Material and methods: HDR with HF as the main diagnosis issued by the Department of Internal Medicine were analysed, and the presence of the diagnosis, prognosis and therapeutic data in these HDR was compared in a sample before and after the intervention, which consisted of reporting the results of analysis of the initial sample to the physicians. Results: A total of 651 HDR (371 pre-intervention and 280 post-intervention) were analysed. Most of the HDR (over 70%) did not include the functional class. Most of the HDR did not include information about echocardiogram performed before the hospitalization period analysed, and most of the HDR that collected this information did not determine if the HF was diastolic or systolic. In the post-intervention sample there was a lower percentage of HDR that prescribed angiotensin-converting enzyme inhibitors or angiotensin receptor blocker ii (26% vs 32%, P < .001). In 30% of the pre-intervention sample and 38% of the post-intervention sample there was indication of beta-blockers (P = .027). Conclusions: A short discussion with the physicians responsible for patients with HF improves the inclusion of important data on the diagnosis, prognosis and treatment in the HDR (AU)

[Results of implementing a programme to improve the quality of the contents in hospital discharge reports in cases of heart failure]. / Resultados tras la implementación de un programa de mejora de la calidad del contenido de los informes de alta hospitalaria en insuficiencia cardiaca.

OBJECTIVES: To analyse the information collected in hospital discharge reports (HDR) that are given to patients with a diagnosis of heart failure (HF), and demonstrate the improvement in the content of these reports after the introduction of an intervention. MATERIAL AND METHODS: HDR with HF as the main diagnosis issued by the Department of Internal Medicine were analysed, and the presence of the diagnosis, prognosis and therapeutic data in these HDR was compared in a sample before and after the intervention, which consisted of reporting the results of analysis of the initial sample to the physicians. RESULTS: A total of 651 HDR (371 pre-intervention and 280 post-intervention) were analysed. Most of the HDR (over 70%) did not include the functional class. Most of the HDR did not include information about echocardiogram performed before the hospitalization period analysed, and most of the HDR that collected this information did not determine if the HF was diastolic or systolic. In the post-intervention sample there was a lower percentage of HDR that prescribed angiotensin-converting enzyme inhibitors or angiotensin receptor blocker ii (26% vs 32%, P<.001). In 30% of the pre-intervention sample and 38% of the post-intervention sample there was indication of beta-blockers (P=.027). CONCLUSIONS: A short discussion with the physicians responsible for patients with HF improves the inclusion of important data on the diagnosis, prognosis and treatment in the HDR.

Biliary ileus / Íleo biliar

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Comorbidity in heart failure. Results of the Spanish RICA Registry.

BACKGROUND: We sought to identify the comorbidities associated with heart failure (HF) in a non-selected cohort of patients, and its influence on mortality and rehospitalization. DESIGN AND METHODS: Data were obtained from the 'Registro de Insuficiencia Cardiaca' (RICA) of the Spanish Society of Internal Medicine. The registry includes patients prospectively admitted in Internal Medicine units for acute HF. Variables included in Charlson Index (ChI) were collected and analysed according to age, gender, left ventricular ejection fraction (LVEF) and Barthel Index. The primary end point of study was the likelihood of rehospitalization and death for any cause during the year after discharge. RESULTS: We included 2051 patients, mean age 78 and 53% females. LVEF was ⩾ 50% in 59.1% of the cohort. There was a high degree of dependency as measured by Barthel Index (14.8 % had an index ≤ 60). Mean ChI was 2.91 (SD ± 2.4). The most frequent comorbidities included in ChI were diabetes mellitus (44.3%), chronic renal impairment (30.8%) and chronic obstructive pulmonary disease (COPD) (27.4%). Age, myocardial infarction, peripheral artery disease, dementia, COPD, chronic renal impairment and diabetes with target-organ damage were all identified as independent prognostic factors for the combined end point of rehospitalization and death at 1 year. However, if multivariate analysis was done including ChI, only this remained as an independent prognostic factor for the combined end point (P < 0.001). CONCLUSIONS: HF is a comorbid condition. ChI is a simple and feasible tool for estimating the burden of comorbidities in such population. We believe that a holistic approach to HF would improve prognosis and the relief the pressure exerted on public health services.

[Diagnostic limitations of positron emission tomography. What are we seeking?]. / Limitaciones diagnósticas de la tomografía por emisión de positrones. ?Qué buscamos?

Positron emission tomography is an imaging technique based on the use of radiopharmaceuticals. The most extended one is the glucose analogue 18F fluorodeoxyglucose (FDG) that is deposited where there is an increase of glycolytic metabolism, whether this is caused by neoplastic, inflammatory or infectious diseases. It is used in oncology for the initial staging, to assess response to treatment, residual disease, recurrent diagnosis and restaging, but specifically among the different types of tumor. It also has a field in the study of large vessel vasculitis, in granulomatous diseases and in dementias.