Predictive capacity of a multimarker strategy to determine short-term mortality in patients attending a hospital emergency Department for acute heart failure. BIO-EAHFE study.

OBJECTIVE: A multimarker strategy may help determine the prognosis of patients with acute heart failure (AHF). The aim of this study was to evaluate the capacity of mid-regional pro-adrenomedullin (MRproADM), copeptin and interleukin-6 (IL-6) combined with conventional clinical and biochemical markers to predict the 30-day mortality of patients with AHF. METHODS: We performed an observational, multicenter, prospective study of patients attended in the emergency department (ED) for AHF. We collected clinical and biochemical data as well as comorbidities and biomarker values. The endpoint variable was mortality at 7, 14, 30, 90 and 180days. The clinical model included: gender, age, blood pressure values, hemoglobin, sodium <135mmol/L and estimated glomerular filtration <60mL/min/1.73m2. We made receiver operating curves (ROC) curves, and areas under the curve (AUC) and survival analysis for each model and calculated the hazard ratio (HR) and its 95% confidence interval. RESULTS: A total of 547 individuals were included: 55.6% were women with a mean age of 79.9 (9.5) years. Copeptin alone showed greater discriminatory power for 30-mortality [AUC 0.70 (0.62-0.78)]. The AUC for 30-day mortality of the clinical model plus copeptin and NTproBNP was 0.75 (0.67-0.83), being better than the clinical model alone with 0.67 (0.58-0.76; p=0.19). The discriminatory power of the different biomarkers alone, in combination or together with the clinical model decreased over time. CONCLUSIONS: The combination of a clinical model with copeptin and NTproBNP, which are available in the ED, is able to prognose early mortality in patients with an episode of AHF.

Influence of Intravenous Nitrate Treatment on Early Mortality Among Patients With Acute Heart Failure. NITRO-EAHFE Study.

INTRODUCTION AND OBJECTIVES: There is little evidence on the prognostic influence of intravenous nitrates in patients with acute heart failure. Our purpose was to determine the influence of this treatment on early mortality and new visits. METHODS: Prospective, multicenter cohort study of patients with acute heart failure in an emergency room during 2 periods (May 2009 and November-December 2011). Patients with systolic blood pressure > 110mmHg were included, grouped according to whether they received intravenous nitroglycerin or not. Endpoints were mortality at 3, 7, 14, and 30 days and new visits at 30 days. The propensity score was estimated by logistic regression to determine the prognostic influence of the treatment. RESULTS: We included 3178 of 4897 individuals. A total of 308 (9.7%) had died within 30 days and 465 (17%) attended new visits. The mean (standard deviation) age was 79.5 (10.0) years, and 796 (25%) patients received intravenous nitrates. After matching, there were 685 individuals in each group. The hazard ratio for 30-day mortality with nitrates was 1.21 (95% confidence interval, 0.87-1.70) and was 0.93 for new visits (95% confidence interval, 0.71-1.22). The results were similar for mortality at 3, 7, and 14 days (hazard ratio = 1.05 [95% confidence interval, 0.56-1.96], hazard ratio = 1.20 [95% confidence interval, 0.74-1.94], and hazard ratio = 1.23 [95% confidence interval, 0.82-1.84], respectively). In the presence of hypertensive pulmonary edema, the nitrates group showed a hazard ratio of 0.88 (95% confidence interval, 0.47-1.63) for 30-day mortality. CONCLUSIONS: Intravenous nitrates do not influence early mortality or new visits in patients with acute heart failure.

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.

Influencia del tratamiento con nitratos intravenosos en la mortalidad precoz de pacientes con insuficiencia cardiaca aguda. Estudio NITRO-EAHFE / Influence of intravenous nitrate treatment on early mortality among patients with acute heart failure. NITRO-EAHFE Study

Introducción y objetivos. La evidencia sobre la influencia pronóstica de los nitratos intravenosos en pacientes con insuficiencia cardiaca aguda es escasa. El objetivo del estudio es determinar la influencia de este tratamiento en mortalidad precoz y reconsulta. Métodos. Estudio de cohortes, multicéntrico, prospectivo de pacientes con insuficiencia cardiaca aguda en servicios de urgencias en 2 periodos (mayo de 2009 y noviembre-diciembre de 2011). Se incluyó pacientes con presión arterial sistólica > 110 mmHg agrupados en función de si recibieron nitroglicerina intravenosa o no. Las variables objetivo fueron mortalidad a 3, 7, 14 y 30 días y reconsulta a 30 días. Para determinar la influencia pronóstica del tratamiento se realizó un propensity score mediante regresión logística. Resultados. De 4.897 individuos se incluyeron 3.178. Fallecieron a 30 días 308 (9,7%) y reconsultaron 465 (17%). La edad media era de 79,5 ± 10,0 años y 796 (25%) recibieron nitratos intravenosos. Tras emparejarlos quedaron 685 individuos en cada grupo. La hazard ratio de los nitratos para mortalidad a 30 días fue 1,21 (intervalo de confianza del 95%, 0,87-1,70) y para reconsulta 0,93 (intervalo de confianza del 95%, 0,71-1,22). Los resultados fueron similares para la mortalidad a 3, 7 y 14 días (hazard ratio = 1,05 [intervalo de confianza del 95%, 0,56-1,96], hazard ratio = 1,20 [intervalo de confianza del 95%, 0,74-1,94] y hazard ratio = 1,23 [intervalo de confianza del 95%, 0,82-1,84], respectivamente). En presencia de edema de pulmón hipertensivo, el grupo de nitratos mostró una hazard ratio de 0,88 (intervalo de confianza del 95%, 0,47-1,63) para mortalidad a 30 días. Conclusiones. Los nitratos intravenosos no influyen en mortalidad precoz ni en reconsulta en pacientes con insuficiencia cardiaca aguda (AU)

Introduction and objectives. There is little evidence on the prognostic influence of intravenous nitrates in patients with acute heart failure. Our purpose was to determine the influence of this treatment on early mortality and new visits. Methods. Prospective, multicenter cohort study of patients with acute heart failure in an emergency room during 2 periods (May 2009 and November-December 2011). Patients with systolic blood pressure > 110 mmHg were included, grouped according to whether they received intravenous nitroglycerin or not. Endpoints were mortality at 3, 7, 14, and 30 days and new visits at 30 days. The propensity score was estimated by logistic regression to determine the prognostic influence of the treatment. Results. We included 3178 of 4897 individuals. A total of 308 (9.7%) had died within 30 days and 465 (17%) attended new visits. The mean (standard deviation) age was 79.5 (10.0) years, and 796 (25%) patients received intravenous nitrates. After matching, there were 685 individuals in each group. The hazard ratio for 30-day mortality with nitrates was 1.21 (95% confidence interval, 0.87-1.70) and was 0.93 for new visits (95% confidence interval, 0.71-1.22). The results were similar for mortality at 3, 7, and 14 days (hazard ratio = 1.05 [95% confidence interval, 0.56-1.96], hazard ratio = 1.20 [95% confidence interval, 0.74-1.94], and hazard ratio = 1.23 [95% confidence interval, 0.82-1.84], respectively). In the presence of hypertensive pulmonary edema, the nitrates group showed a hazard ratio of 0.88 (95% confidence interval, 0.47-1.63) for 30-day mortality. Conclusions. Intravenous nitrates do not influence early mortality or new visits in patients with acute heart failure (AU)