Prevalence, Related Factors and Association of Left Bundle Branch Block With Prognosis in Patients With Acute Heart Failure: a Simultaneous Analysis in 3 Independent Cohorts.

OBJECTIVES: To determine the prevalence, characteristics and association with prognosis of left bundle branch block (LBBB) in 3 different cohorts of patients with acute heart failure (AHF). METHODS AND RESULTS: We retrospectively analyzed 12,950 patients with AHF who were included in the EAHFE (Epidemiology Acute Heart Failure Emergency), RICA (National Heart Failure Registry of the Spanish Internal Medicine Society), and BASEL-V (Basics in Acute Shortness of Breath Evaluation of Switzerland) registries. We independently analyzed the relationship between baseline and clinical characteristics and the presence of LBBB and the potential association of LBBB with 1-year all-cause mortality and a 90-day postdischarge combined endpoint (Emergency Department reconsultation, hospitalization or death). The prevalence of LBBB was 13.5% (95% confidence interval: 12.9%-14.0%). In all registries, patients with LBBB more commonly had coronary artery disease and previous episodes of AHF, were taking chronic spironolactone treatment, had lower left ventricular ejection fraction and systolic blood pressure values and higher NT-proBNP levels. There were no differences in risk for patients with LBBB in any cohort, with adjusted hazard ratios (95% confidence interval) for 1-year mortality in EAHFE/RICA/BASEL-V cohorts of 1.02 (0.89-1.17), 1.15 (0.95-1.38) and 1.32 (0.94-1.86), respectively, and for 90-day postdischarge combined endpoint of 1.00 (0.88-1.14), 1.14 (0.92-1.40) and 1.26 (0.84-1.89). These results were consistent in sensitivity analyses. CONCLUSIONS: Less than 20% of patients with AHF present LBBB, which is consistently associated with cardiovascular comorbidities, reduced left ventricular ejection fraction and more severe decompensations. Nonetheless, after taking these factors into account, LBBB in patients with AHF is not associated with worse outcomes.

Utilidad pronóstica de la ecografía a pie de cama previa al alta en pacientes con insuficiencia cardíaca aguda y fracción de eyección preservada / Prognostic utility of bedside lung ultrasound before discharge in patients with acute heart failure with preserved ejection fraction

Antecedentes y objetivo: La utilidad de la ecografía como herramienta pronóstica en pacientes con insuficiencia cardíaca aguda es conocida, pero la mayoría de estudios han sido realizados en grupos mixtos de pacientes con fracción de eyección preservada y reducida. Si bien algunos análisis de subgrupos sugieren ausencia de diferencias en función de la fracción de eyección, no existen estudios específicos que lo confirmen. Nuestro objetivo es determinar la utilidad pronóstica de la ecografía a pie de cama en pacientes ingresados por insuficiencia cardíaca y fracción de eyección preservada.Material y métodoEstudio de cohortes prospectivo con seguimiento a 3meses tras realización de ecografía pulmonar previa al alta en pacientes ingresados por insuficiencia cardíaca aguda y fracción de eyección preservada. Se determinan las líneasB presentes al alta. Se constituyen dos grupos: con menos de 15líneasB (no expuestos) y con 15 o más (expuestos). Se comparan en términos de reingreso y muerte debidos a insuficiencia cardíaca.ResultadosEl grupo expuesto tiene mayor riesgo de reingreso (HR: 2,39; IC95%: 1,12-5,12; p=0,024), incluso tras ajuste multivariable (HR: 2,46; IC95%: 1,11-5,46; p=0,03). No se ha encontrado asociación con mortalidad por insuficiencia cardíaca (HR: 1,28; IC95%: 0,23-6,98).ConclusiónLa congestión subclínica evaluada con ecografía pulmonar al alta se asocia con peor pronóstico en pacientes con insuficiencia cardíaca aguda y fracción de eyección preservada. Los pacientes con 15 o más líneasB tienen un riesgo 2,5 mayor de reingreso que los pacientes menos congestivos. (AU)

Background and objective: The utility of lung ultrasound as a prognostic tool for patients with acute heart failure is well known, but most studies have been conducted in mixed groups of patients with preserved and reduced ejection fraction. While some subgroup analysis suggests that lung ultrasound is useful regardless of ejection fraction, no specific studies have addressed this question. Our objective is to determine the utility of bedside lung ultrasound as a prognostic tool for patients with preserved ejection fraction, acute heart failure.Material and methodsProspective cohort study with 3-month follow-up after bedside lung ultrasound before discharge in patients hospitalized for acute heart failure with preserved ejection fraction. The number of Blines was determined. Two groups were formed: less than 15Blines (unexposed) and 15Blines or more (exposed). They were compared in terms of readmission and death attributable to worsening heart failure.ResultsThe exposed group was at higher risk of readmission (HR: 2.39; 95%CI: 1.12-5.12; P=.024), even after multivariable adjustment (HR: 2.46; 95%CI: 1.11-5.46, P=.03). Differences between groups in terms of mortality were not statistically significant (HR: 1.28; 95%CI: .23-6.98).ConclusionSubclinical congestion evaluated with lung ultrasound before discharge is associated with worse prognosis in patients with acute heart failure and preserved ejection fraction. Patients with 15Blines are 2.5times more likely to be readmitted for acute heart failure than less congestive patients. (AU)

Prognostic utility of bedside lung ultrasound before discharge in patients with acute heart failure with preserved ejection fraction. / Utilidad pronóstica de la ecografía a pie de cama previa al alta en pacientes con insuficiencia cardíaca aguda y fracción de eyección preservada.

BACKGROUND AND OBJECTIVE: The utility of lung ultrasound as a prognostic tool for patients with acute heart failure is well known, but most studies have been conducted in mixed groups of patients with preserved and reduced ejection fraction. While some subgroup analysis suggests that lung ultrasound is useful regardless of ejection fraction, no specific studies have addressed this question. Our objective is to determine the utility of bedside lung ultrasound as a prognostic tool for patients with preserved ejection fraction, acute heart failure. MATERIAL AND METHODS: Prospective cohort study with 3-month follow-up after bedside lung ultrasound before discharge in patients hospitalized for acute heart failure with preserved ejection fraction. The number of Blines was determined. Two groups were formed: less than 15Blines (unexposed) and 15Blines or more (exposed). They were compared in terms of readmission and death attributable to worsening heart failure. RESULTS: The exposed group was at higher risk of readmission (HR: 2.39; 95%CI: 1.12-5.12; P=.024), even after multivariable adjustment (HR: 2.46; 95%CI: 1.11-5.46, P=.03). Differences between groups in terms of mortality were not statistically significant (HR: 1.28; 95%CI: .23-6.98). CONCLUSION: Subclinical congestion evaluated with lung ultrasound before discharge is associated with worse prognosis in patients with acute heart failure and preserved ejection fraction. Patients with 15Blines are 2.5times more likely to be readmitted for acute heart failure than less congestive patients.

Utilidad pronóstica de la ecografía pulmonar en el seguimiento ambulatorio de pacientes con insuficiencia cardiaca / Use of lung ultrasound as a prognostic tool in outpatients with heart failure

Objetivo: Valorar la utilidad pronóstica de la ecografía pulmonar en pacientes con insuficiencia cardiaca. Métodos: Estudio observacional de cohortes prospectivo, en el que se realizó una ecografía pulmonar a 54 pacientes en seguimiento ambulatorio por insuficiencia cardiaca. La ecografía se clasificó como positiva o negativa para síndrome intersticial ecográfico según el número de líneas B observadas. Se realizó un seguimiento durante 6 meses, considerando eventos indicativos de mal pronóstico las visitas a urgencias, reingresos y fallecimientos debidos a insuficiencia cardiaca. Resultados: El 53,7% (29) de los enfermos presentaban síndrome intersticial ecográfico. De ellos, reingresaron el 48,3% (14) frente al 16% (4) de los que no tenían dicho síndrome (p = 0,012). Considerando como variable final conjunta la necesidad de reingreso, las urgencias y fallecimientos por insuficiencia cardiaca, el 55,2% (16) de los pacientes con síndrome intersticial presentaron al menos una de estas complicaciones, frente al 20% (5) de los participantes sin el síndrome (p = 0,008). Conclusiones: La ecografía en el ámbito ambulatorio es útil para predecir qué enfermos tienen mayor riesgo de descompensación de insuficiencia cardiaca a medio plazo (AU)

Objectives: To assess the prognostic value of lung ultrasound for patients with chronic heart failure. Methods: Prospective observational cohort study, in which a lung ultrasound was performed on 54 patients at a heart failure outpatient consultation. Ultrasonography was classified as positive or negative for ultrasound interstitial syndrome depending on the number of B lines observed. Patients were followed up for six months; considering emergency visits, readmissions and deaths due to heart failure as markers of poor prognosis. Results: 53.7% (29) of the patients had ultrasound interstitial syndrome. Among them, 48.3% (14) were readmitted, compared to 16% (4) of those without the syndrome (P = .012). Considering any of the events previously described as end points (readmissions, emergencies and deaths), we found that in the group of patients with ultrasound interstitial syndrome, 55.2% (16) had at least one of these complications, compared to 20% (5) of participants without the syndrome (P = .008). Conclusions: Lung ultrasound in the outpatient setting is useful in predicting which patients are at increased risk of heart failure decompensation in the mid-term (AU)

[Use of lung ultrasound as a prognostic tool in outpatients with heart failure]. / Utilidad pronóstica de la ecografía pulmonar en el seguimiento ambulatorio de pacientes con insuficiencia cardiaca.

OBJECTIVES: To assess the prognostic value of lung ultrasound for patients with chronic heart failure. METHODS: Prospective observational cohort study, in which a lung ultrasound was performed on 54 patients at a heart failure outpatient consultation. Ultrasonography was classified as positive or negative for ultrasound interstitial syndrome depending on the number of B lines observed. Patients were followed up for six months; considering emergency visits, readmissions and deaths due to heart failure as markers of poor prognosis. RESULTS: 53.7% (29) of the patients had ultrasound interstitial syndrome. Among them, 48.3% (14) were readmitted, compared to 16% (4) of those without the syndrome (P=.012). Considering any of the events previously described as end points (readmissions, emergencies and deaths), we found that in the group of patients with ultrasound interstitial syndrome, 55.2% (16) had at least one of these complications, compared to 20% (5) of participants without the syndrome (P=.008). CONCLUSIONS: Lung ultrasound in the outpatient setting is useful in predicting which patients are at increased risk of heart failure decompensation in the mid-term.

Ancho de distribución eritrocitario como predictor de mortalidad tras el alta hospitalaria en mayores de 70 años / Red cell distribution width and mortality following hospital discharge in patients over 70 years of age

Fundamento y objetivo: Analizar si el ancho de distribución eritrocitario (ADE) se comporta como factor pronóstico de mortalidad tras el alta hospitalaria en pacientes mayores de 70 años y si su capacidad pronóstica es superior a la de otros parámetros de laboratorio. Pacientes y método: Estudio longitudinal prospectivo en 426 pacientes ingresados en el Servicio de Medicina Interna que sobrevivieron a un ingreso hospitalario. Se recogieron variables sociodemográficas, comorbilidad, situación funcional, situación cognitiva y parámetros de la enfermedad que origina el ingreso (diagnóstico, parámetros analíticos, estancia). El seguimiento se realizó durante un año mediante entrevista telefónica, en la que se recogieron datos sobre la situación vital y, si procedía, fecha de fallecimiento. El efecto del ADE sobre la mortalidad se evaluó mediante regresión logística y su capacidad pronóstica mediante el área bajo la curva ROC. Resultados: Cada punto porcentual de incremento del ADE se asoció con una mayor mortalidad al año, con una odds ratio de 1,19 (intervalo de confianza del 95% [IC 95%] 1,08-1,31). La mortalidad en cada tercil del ADE fue 15,6% en el inferior, 21,5% en el intermedio y 30,5% en el más elevado. Un modelo clínico suplementado con el ADE mejora su capacidad predictora de mortalidad evaluada mediante curva ROC. La mejora de reclasificación neta de dicha predicción es del 1,71% (IC 95% 0,07-3,35) (p = 0,04). Conclusión: El presente estudio aporta nuevas evidencias de asociación del ADE con mortalidad en una cohorte de pacientes ancianos que sobreviven a un ingreso hospitalario. El ADE fue el único parámetro de laboratorio analizado que mejoraba la capacidad pronóstica de mortalidad a un año (AU)

Background and objective: To examine whether red cell distribution width (RDW) performs as a mortality predictor after hospital discharge in patients over 70 years of age and if its prognostic power is superior to other laboratory parameters. Patients and methods: Longitudinal and prospective study of 426 patients admitted to the Internal Medicine Department who survived hospitalization. Sociodemographic and comorbidity factors, functional and cognitive status as well as disease parameters causing admission (diagnosis, analytical parameters, length of stay) were collected. Patients were followed for one year by telephone interview and data were collected regarding vital status and, if appropriate, death date. RDW effect on mortality was assessed using logistic regression and prognostic capability by the area under the ROC curve. Results: Each percentage point rise in RDW was associated with increased mortality at one year with an odds ratio of 1.19 (95% confidence interval [95% CI] 1.08 to 1.31). Mortality in each tertile of RDW was 15.6% in the lowest, 21.5% in the middle and 30.5% in the highest. A clinical model supplemented with RDW improved mortality predictive ability assessed by ROC curve. Net reclassification improvement of the prediction rule was 1.71% (95% CI 0.07 to 3.35) p = 0.04. Conclusion: This study provides new evidence of the RDW association with mortality in a cohort of elderly patients who survived hospitalization. RDW was the only laboratory parameter that improved the one-year prognostic mortality ability (AU)

[Red cell distribution width and mortality following hospital discharge in patients over 70 years of age]. / Ancho de distribución eritrocitario como predictor de mortalidad tras el alta hospitalaria en mayores de 70 años.

BACKGROUND AND OBJECTIVE: To examine whether red cell distribution width (RDW) performs as a mortality predictor after hospital discharge in patients over 70 years of age and if its prognostic power is superior to other laboratory parameters. PATIENTS AND METHODS: Longitudinal and prospective study of 426 patients admitted to the Internal Medicine Department who survived hospitalization. Sociodemographic and comorbidity factors, functional and cognitive status as well as disease parameters causing admission (diagnosis, analytical parameters, length of stay) were collected. Patients were followed for one year by telephone interview and data were collected regarding vital status and, if appropriate, death date. RDW effect on mortality was assessed using logistic regression and prognostic capability by the area under the ROC curve. RESULTS: Each percentage point rise in RDW was associated with increased mortality at one year with an odds ratio of 1.19 (95% confidence interval [95% CI] 1.08 to 1.31). Mortality in each tertile of RDW was 15.6% in the lowest, 21.5% in the middle and 30.5% in the highest. A clinical model supplemented with RDW improved mortality predictive ability assessed by ROC curve. Net reclassification improvement of the prediction rule was 1.71% (95% CI 0.07 to 3.35) p=0.04. CONCLUSION: This study provides new evidence of the RDW association with mortality in a cohort of elderly patients who survived hospitalization. RDW was the only laboratory parameter that improved the one-year prognostic mortality ability.

Place of residence before hospital admission and mortality at 12-months in Spanish patients aged 70 years or older.

AIM: Hospitalization of elderly people is often followed by high mortality rates. The aim of this study was to analyze the influence of prior residence on 1-year mortality after hospital discharge in patients aged 70 years and over. METHODS: This was a prospective observational cohort study. Participants were 426 patients discharged from the Internal Medicine Department at a Spanish Hospital who were followed for a 12-month period. Data collection was carried out during hospitalization and included sociodemographic characteristics, comorbidity (Charlson index), functional (Barthel index and Lawton scale) and cognitive conditions (Short Portable Mental Status Questionnaire), together with parameters related to the disease causing admission (diagnosis related group, laboratory tests, length of hospital stay). Mortality was carried out using telephone interviews. RESULTS: A total of 420 (98.6%) patients were located at the end of follow up. Of these, 95 patients had died, giving an overall 1-year mortality of 22.6%. The mortality rate for patients living in their private homes was 15.6% versus 24.7% for those living with relatives and 60% for those living in institutions. After adjustment for potential confounders, prior residence was associated with mortality with a hazard ratio of 3.98 (95% CI 1.94-8.17) for those institutionalized and a hazard ration of 1.68 (95% CI 0.99-2.16) for those living with relatives, as compared with patients living in their private homes. CONCLUSIONS: Prior residence is associated with 1-year-mortality following discharge after controlling for several multidimensional factors.

[Incidence of pneumonia in HIV-infected patients in the highly active antiretroviral therapy era]. / Incidencia de neumonía en pacientes infectados por el virus de la inmunodeficiencia humana en la era del tratamiento antirretroviral de gran actividad.

BACKGROUND AND OBJECTIVE: There is scant data comparing the incidence of pneumonia in the community and in the human immunodeficiency virus (HIV) population in highly active antiretroviral therapy (HAART) era. PATIENTS AND METHOD: Prospective study during 18 months. Data were obtained by the means of the electronic clinical record. Incidence rate was compared between HIV positive and negative patients. RESULTS: There were 529 pneumonia episodes in global population (n = 220,000), 1.6 cases/1000 person-year. HIV-infected patients (n = 170) suffered 12 episodes of pneumonia; 46 cases/1000 person-year (relative risk = 29.3, 95% confidence interval, 16.34-51.4; p < 0.01). HIV infected patients with pneumonia have a lower CD4 count (mean 434 versus 230 cells/ml; p = 0.04), higher viral load (4.1 versus 3.2 log copies/ml; p = 0.07) and received antiretroviral treatment in a similar proportion compared to HIV without pneumonia (62 versus a 66.7%, p = 0.5). CONCLUSIONS: Pneumonia in HIV infected patients may be about 30 times more frequent than general population in HAART era. Prevention measures should be reinforced.

Incidencia de neumonía en pacientes infectados por el virus de la inmunodeficiencia humana en la era del tratamiento antirretroviral de gran actividad / Incidence of pneumonia in HIV-infected patients in the highly active antiretroviral therapy era

Fundamento y objetivo: Apenas hay datos sobre la incidencia de neumonía en los pacientes infectados por el virus de la inmunodeficiencia humana (VIH) respecto a la población general en la era del tratamiento antirretroviral de gran actividad (TARGA). Pacientes y método: Se ha realizado un registro prospectivo de las neumonías atendidas en un hospital de zona durante 18 meses. Se comparan las tasas de incidencia entre la población general y los pacientes infectados por el VIH. Resultados: En la población general (n = 220.000) la incidencia de neumonía fue de 1,6 casos/1.000 personas/año, frente a 46 casos/ 1.000 personas/año en pacientes infectados por el VIH (n = 170) (riesgo relativo = 29,3; intervalo de confianza del 95%, 16,34-51,4; p < 0,01). Los pacientes seropositivos con neumonía tenían una cifra inferior de linfocitos CD4 (media de 434 frente a 230 células/ml; p = 0,04), una carga viral más elevada (4,1 frente a 3,2 log copias/ml; p = 0,07) y recibían TARGA en un porcentaje similar a los que no presentaron neumonía (el 62 frente al 66,7%; p = 0,5). Conclusiones: En la era del TARGA, la incidencia de neumonía en la población infectada por el VIH puede ser unas 30 veces superior a la de la población general, por lo que es necesario reforzar las medidas de prevención en este tipo de pacientes

Background and objective: There is scant data comparing the incidence of pneumonia in the community and in the human immunodeficiency virus (HIV) population in highly active antiretroviral therapy (HAART) era. Patients and method: Prospective study during 18 months. Data were obtained by the means of the electronic clinical record. Incidence rate was compared between HIV positive and negative patients. Results: There were 529 pneumonia episodes in global population (n = 220,000), 1.6 cases/1000 person-year. HIV-infected patients (n = 170) suffered 12 episodes of pneumonia; 46 cases/1000 person-year (relative risk = 29.3, 95% confidence interval, 16.34-51.4; p < 0.01). HIV infected patients with pneumonia have a lower CD4 count (mean 434 versus 230 cells/ml; p = 0.04), higher viral load (4.1 versus 3.2 log copies/ml; p = 0.07) and received antiretroviral treatment in a similar proportion compared to HIV without pneumonia (62 versus a 66.7%, p = 0.5). Conclusions: Pneumonia in HIV infected patients may be about 30 times more frequent than general population in HAART era. Prevention measures should be reinforced