La pluripatología, un fenómeno no exclusivo de la Medicina Interna / Comorbidities: a phenomenon that is not unique to Internal Medicine

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Seguridad del paciente: contribución de un farmacéutico a un equipo multidisciplinar en la atención al paciente de Medicina Interna / Patient safety: the pharmacist's contribution to a multidisciplinary Internal Medicine patient-care team

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

La prevalencia de insuficiencia cardiaca aumenta con la edad y se acompaña de otras enfermedades, englobadas en un 'fenotipo cardiometabólico'. Su interrelación modifica la evolución y tratamiento que cada una tendría aisladamente. El paciente con insuficiencia cardiaca y comorbilidad es un enfermo frágil y complejo. Precisa una valoración integral, no solo biomédica, que incluya aspectos funcionales, cognitivos, afectivos y psicosociales. El tratamiento global, no recogido en las guías de práctica clínica, ha de adaptarse a todas y cada unas de las comorbilidades. Debe evitarse, en lo posible, la polifarmacia, por sus interacciones y la disminución de adherencia. Es necesario optimizar y adaptar el tratamiento a la fase evolutiva de la enfermedad y las necesidades específicas de cada paciente. La complejidad del proceso asistencial del paciente con insuficiencia cardiaca y comorbilidades exige la coordinación de los proveedores de salud, el apoyo familiar y del entorno (AU)

The prevalence of heart failure increases with age and is accompanied by other diseases, which are encompassed within a 'cardiometabolic phenotype'. 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 (AU)

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.

Influencia de la edad en la mortalidad de pacientes con insuficiencia cardiaca / Influence of age in mortality of patients with heart failure

Objetivo: La insuficiencia cardiaca (IC) representa uno de los motivos de ingreso más frecuentes en los Servicios de Medicina Interna. La elevada edad de los pacientes es una de las principales características de este tipo de ingreso. Nuestro objetivo fue estudiar la influencia de la edad en la mortalidad, a medio plazo, de la IC tras un episodio de descompensación.Metodo: Se revisaron las historias clínicas de los pacientes dados de alta, con diagnóstico de IC, durante el periodo comprendido entre septiembre de 2000 y agosto de 2001, y se registró su situación a fecha 1 de enero de 2003. Un total de 215 pacientes fueron revisados.Resultados: El número total de defunciones durante el periodo de seguimiento fue de 60 (27,9% del total de pacientes). Según aumentaba la edad de los pacientes se observó un mayor número de mujeres y un menor empleo de la ecocardiografía y del tratamiento con beta bloqueantes y anticoagulación oral en pacientes con fibrilación auricular. Aplicando el modelo de riesgos proporcionales de Cox, la edad (OR 1,043 IC 95% 1,002-1,085), la estancia media (OR 1,04, IC 95% 1,003-1,078), la presencia de diabetes mellitus (OR 2,51, IC 95% 1,37-4,60) y la ausencia de anticoagulación oral en caso de fibrilación auricular (OR 2,71, IC 95% 1,10-6,60) fueron factores pronósticos independientes.Conclusión: La edad constituye un importante factor pronóstico en pacientes con IC. Por ello deberían realizarse estudios clínicos que incluyeran pacientes con estas características, lo que permitiría conocer mejor la evolución de la IC en este grupo de población

Objective: Heart failure (HF) is one of the most frequent diagnosis in Internal Medicine Units. High age of patients is an important characteristic in these admissions. Our objective was to evaluate how age interact with mortality, to medium-term, in HF after a decompensated episode. Method: Through the patient medical record we obtained data about patients hospitalised in a Internal Medicine Unit, with HF diagnosis, for a year (from September 2000 to August 2001) and their survival at 1st January 2003. 215 patients were reviewed. Results: During follow-up, 60 patients died (27.9% of overall). In elderly patients, we observed a higher number of women and less use of echocardiography and treatment with beta-blockers and warfarin (in patients with atrial fibrillation). In Cox proportional-hazards model, age (OR 1.043 IC 95% 1.002-1.085), days of hospitalization (OR 1.04 IC 95% 1.003-1.078), diabetes mellitus (OR 2.51 IC 95% 1.37-4.60) and do not prescribe warfarin in patients with atrial fibrillation (OR 2.71 IC 95% 1.10-6.60) were independent prognostic factors. Conclusions: Age was an important prognostic factor in patients with HF. Clinical trials should be done in patients with these characteristics. So, we can know better clinical evolution of HF in this population

Manifestaciones sistémicas y respuesta al tratamiento en la arteritis temporal / Systemic manifestations and answer to the management of temporal arteritis

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