Factors related to early readmissions after acute heart failure: a nested case-control study.

AIMS: To describe the main characteristics of patients who were readmitted to hospital within 1 month after an index episode for acute decompensated heart failure (ADHF). METHODS AND RESULTS: This is a nested case-control study in the ReIC cohort, cases being consecutive patients readmitted after hospitalization for an episode of ADHF and matched controls selected from those who were not readmitted. We collected clinical data and also patient-reported outcome measures, including dyspnea, Minnesota Living with Heart Failure Questionnaire (MLHFQ), Tilburg Frailty Indicator (TFI) and Hospital Anxiety and Depression Scale scores, as well as symptoms during a transition period of 1 month after discharge. We created a multivariable conditional logistic regression model. Despite cases consulted more than controls, there were no statistically significant differences in changes in treatment during this first month. Patients with chronic decompensated heart failure were 2.25 [1.25, 4.05] more likely to be readmitted than de novo patients. Previous diagnosis of arrhythmia and time since diagnosis ≥ 3 years, worsening in dyspnea, and changes in MLWHF and TFI scores were significant in the final model. CONCLUSION: We present a model with explanatory variables for readmission in the short term for ADHF. Our study shows that in addition to variables classically related to readmission, there are others related to the presence of residual congestion, quality of life and frailty that are determining factors for readmission for heart failure in the first month after discharge. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03300791. First registration: 03/10/2017.

Impact of sex differences and network systems on the in-hospital mortality of patients with ST-segment elevation acute myocardial infarction.

INTRODUCTION AND OBJECTIVES: Network systems have achieved reductions in both time to reperfusion and in-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI). However, the data have not been disaggregated by sex. The aim of this study was to analyze the influence of network systems on sex differences in primary percutaneous coronary intervention (pPCI) and in-hospital mortality from 2005 to 2015. METHODS: The Minimum Data Set of the Spanish National Health System was used to identify patients with STEMI. Logistic multilevel regression models and Poisson regression analysis were used to calculate risk-standardized in-hospital mortality ratios and incidence rate ratios (IRRs). RESULTS: Of 324 998 STEMI patients, 277 281 were selected after exclusions (29% women). Even when STEMI networks were established, the use of reperfusion therapy (PCI, fibrinolysis, and CABG) was lower in women than in men from 2005 to 2015: 56.6% vs 75.6% in men and 36.4% vs 57.0% in women, respectively (both P<.001). pPCI use increased from 34.9% to 68.1% in men (IRR, 1.07) and from 21.7% to 51.7% in women (IRR, 1.08). The crude in-hospital mortality rate was higher in women (9.3% vs 18.7%; P<.001) but decreased from 2005 to 2015 (IRRs, 0.97 for men and 0.98 for women; both P < .001). Female sex was an independent risk factor for mortality (adjusted OR, 1.23; P<.001). The risk-standardized in-hospital mortality ratio was lower in women when STEMI networks were in place (16.9% vs 19.1%, P<.001). pPCI and the presence of STEMI networks were associated with lower in-hospital mortality in women (adjusted ORs, 0.30 and 0.75, respectively; both P<.001). CONCLUSIONS: Women were less likely to receive pPCI and had higher in-hospital mortality than men throughout the 11-year study period, even with the presence of a network system for STEMI.

Short-term mortality risk score for de novo acute heart failure (ESSIC-FEHF).

BACKGROUND: Different variables are playing a role in prognosis of acute heart failure. OBJECTIVES: Our purpose was to create and validate a risk score to predict mortality in patients with a first episode of acute heart failure during the first 2 months after the first hospitalization. DESIGN: This was a prospective cohort study. PARTICIPANTS: We recruited patients diagnosed with a first episode of acute heart failure. MAIN MEASURES: We collected data on sociodemographic characteristics; medical history; symptoms; precipitating factors; signs and symptoms of congestion; echocardiographic parameters; aetiology; vital signs and laboratory findings; and response to initial treatment (yes/no). A Cox proportional hazard regression model was built with mortality during the first 2 months after the index episode as the dependent variable. A risk score is presented. KEY RESULTS: The mortality rate during the first 2 months after a first episode of heart failure was 5%. Age, systolic blood pressure, serum sodium, ejection fraction and blood urea nitrogen were selected in the internal validation, as was right ventricular failure. A risk score was developed. Both the model and the score showed good discrimination and calibration properties when applied to an independent cohort. CONCLUSIONS: Our ESSIC-FEHF risk score showed excellent properties in the derivation cohort and also in a cohort from a different time period. This score is expected to help decision making in patients diagnosed with heart failure for the first time.

Current analysis of the results of the COURAGE trial: has an optimal treatment been reached in clinical practice?

The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial was designed to evaluate the benefits of percutaneous coronary intervention in reducing the risk of cardiovascular events in patients with chronic stable coronary artery disease. The results reinforce the prior evidence regarding the importance of medical treatment which should be a universal goal. The study population enrolled was quite average for a routine cardiology clinic. However, the results of cardiac intervention are center-dependent and therefore need to be analyzed as such. Patients should initially receive the optimal medical treatment. Patients with symptom persistence, intolerance to medical treatment, and moderate to severe ischemia should be considered candidates for combined treatment. Treatment needs to be individualized and discussed with the patient. New studies, without the limitations of the COURAGE trial, enrolling high-risk patients treated with new interventional technologies, are needed to assess the impact of ischemia in long-term prognosis.

Clinical profile and management of hypertensive patients with chronic ischemic heart disease and renal dysfunction attended by cardiologists in daily clinical practice.

OBJECTIVE: The present study was designed to assess the influence of renal function on the clinical profile and management of the hypertensive outpatients with chronic ischemic heart disease. METHODS: A total of 112 investigators, all cardiologists, were asked to consecutively enrol outpatients of at least 18 years of age, both sexes, with an established diagnosis of hypertension and chronic ischemic heart disease. Renal function was assessed by serum creatinine levels and estimated glomerular filtration rate using the Modification of Diet in Renal Disease formula. Renal impairment was considered a serum creatinine of at least 1.2/1.3 mg/dl (women/men) or an estimated glomerular filtration rate less than 60 ml/min/1.73 m2. Blood pressure was considered controlled when it was less than 140/90 mmHg and less than 130/80 mmHg in diabetic patients or patients with chronic kidney disease. RESULTS: A total of 2024 patients (66.8+/-10.1 years; 31.7% women) were included. A total of 666 (32.9%) and 498 (24.6%) patients exhibited renal function impairment assessed by estimated glomerular filtration rate and serum creatinine, respectively. The subgroup of patients with renal dysfunction was older, with a higher proportion of women with atrial fibrillation, diabetes, organ damage, associated clinical conditions and a worse blood pressure control. No differences were found in clinical profile when the two subgroups of patients with impaired renal function [serum creatinine >or=1.2/>or=1.3 mg/dl (women/men) vs. estimated glomerular filtration rate <60 ml/min per 1.73 m2] were compared. CONCLUSION: Renal function impairment is frequent in the hypertensive population with coronary artery disease. Patients with renal dysfunction represent a subgroup of very high-risk population with more risk factors and comorbidities and worse blood pressure control. The clinical profiles of hypertensive patients with renal function impairment are similar whether renal dysfunction is detected by high serum creatinine or by low estimated glomerular filtration rate.

Sex differences in the hypertensive population with chronic ischemic heart disease.

Cardiopatía Isquémica Crónica e Hipertensión Arterial en la Práctica Clínica en España (CINHTIA) was a survey designed to assess the clinical management of hypertensive outpatients with chronic ischemic heart disease. Sex differences were examined. Blood pressures (BP) was considered controlled at levels of <140/90 or <130/80 mm Hg in diabetics (European Society of Hypertension/European Society of Cardiology 2003); low-density lipoprotein cholesterol (LDL-C) was considered controlled at levels <100 mg/dL (National Cholesterol Education Program Adult Treatment Panel III). In total, 2024 patients were included in the study. Women were older, with a higher body mass index and an increased prevalence of atrial fibrillation. Dyslipidemia, smoking, sedentary lifestyle, and peripheral arterial disease were more frequent in men. In contrast, diabetes, left ventricular hypertrophy, and heart failure were more common in women. BP and LDL-C control rates, although poor in both groups, were better in men (44.9% vs 30.5%, P<.001 and 33.0% vs 25.0%, P<.001, respectively). Stress testing and coronary angiography were more frequently performed in men.

Creation and validation of the acute heart failure risk score: AHFRS.

Our aims were to create and validate a clinical decision rule to assess severity in acute heart failure. We conducted a prospective cohort study of patients with symptoms of acute heart failure who attended the emergency departments (EDs) of three hospitals between April 2011 and April 2013. The following data were collected on arrival to or during the stay in the ED: baseline severity of symptoms; presence of decompensated comorbidities; number of hospital admissions/visits to EDs for acute heart failure during the previous 24 months; triggers of the exacerbation; clinical signs and symptoms; results of ancillary tests requested in the ED; treatments prescribed; and response to the initial treatment in the ED. The main outcome was poor course during the acute phase, in-hospital for admitted patients and during the first week following the ED visit for discharged patients, this being a composite endpoint that included death, admission to an intensive care unit, need for invasive mechanical ventilation, cardiac arrest and use of non-invasive mechanical ventilation. Multivariate logistic regression models were developed. Predictors of poor course in acute heart failure were oedema on chest radiography, visits to the ED and/or admissions in the previous two years, and levels of glycemia and blood urea nitrogen (areas under the curve of 0.83 in the derivation sample, and 0.82 in the validation sample). Four clinical predictors available in the ED can be used to create a simple score to predict poor course in acute heart failure.Clinical Trials.gov ID: NCT02437058.

[Patient's care and management of dyslipidemia at discharge after an acute coronary syndrome in the clinical practice in Spain: The SINCOPA study]. / Atención al alta en pacientes con síndrome coronario agudo y control de la dislipidemia en la práctica clínica en España: Estudio SINCOPA.

INTRODUCTION: European guidelines acknowledge that patients with an acute coronary syndrome (ACS) should have LDLc levels below 70mg/dL or reduced a 50% respect to their basal levels. However, some studies demonstrated that this goal is achieved in a small number of patients. The aim of this study was to determine how cardiologists (MC) and primary care specialist (GPs) from Spain manage LDLc in ACS patients during their daily practice. METHODS: An observational, cross-sectional, multicentric study was conducted. Information about daily practice was obtained from 291 MC and 564 GPs across Spain. RESULTS: 68% of MC and 67% of GPs considered ACS patients to be high-risk. Most consider the cLDL targets based on European guidelines. The statins most widely used for MC are atorvastatin and rosuvastatina and for GPs are atorvastatin and simvastatin. 66.4% of GPs follow the prescription of MC. 42% of MC and 19.9% of GPs considered that 75-100% of their patients achieved the LDLc target. The main reason of not achieving this target was lack of treatment adherence. CONCLUSIONS: The lack of adherence and poor perception of real LDLc control may contribute to the failure in achieving lipid targets in ACS patients.

[Advances in clinical cardiology: new approaches to old challenges]. / Novedades en cardiología clínica: nuevos enfoques de viejos retos.

This article provides cardiologists with a broad overview of recent advances in clinical cardiology that could affect their daily practice in the near future. It discusses new ways of interacting with primary care physicians, the most recent findings on the remote monitoring of chronic disease, and the latest publications on the drugs used in routine clinical practice. The article ends with a summary of the work carried out by the Clinical Cardiology Section of the Spanish Society of Cardiology during the last year.

Clinical profile and management of patients with chronic ischemic heart disease according to age in the population daily attended by cardiologists in Spain The ELDERCIC study.

OBJECTIVES: This study was aimed to evaluate the differences according to age in the clinical profile and management of outpatients with chronic ischemic heart disease attended by cardiologists in Spain. METHODS: Patients with an established diagnosis of chronic ischemic heart disease were included in this cross-sectional multicenter study. The age of 65 years was considered as the cut-off point for the present analysis. RESULTS: A total of 1038 subjects were included, 524 of them (50.5%) >65 years. Patients >65 years had a lesser prevalence of smoking, a longer history of hypertension, a worse left ventricular ejection fraction and a higher prevalence of heart failure and renal insufficiency than younger subjects. The number of prescribed drugs was higher in patients >65 years (6.1+/-1.9 vs 5.7+/-2.1, p=0.004). Blood pressure control rate was lower in older patients (38.1% vs 46.5%, p=0.008). No significant differences were found either in LDL-cholesterol (42.4% vs 46.5%), or glycemic control rates (42.4% vs 41.4%), both p=NS. Diagnostic and therapeutic procedures were also compared in >65 vs < or =65 years, exercise test was performed in 51.5% vs 62.8% (p<0.0001); stress echocardiography in 18.3% vs 13.2% (p=0.027); coronary angiography in 38.6% vs 53.5% (p<0.0001); and coronary revascularization in 37.2% vs 46.9% (p=0.002), without significant differences in electrocardiogram, echocardiogram, or isotopic exams. CONCLUSIONS: Older patients exhibited a worse clinical profile and a worse blood pressure control rate than the younger. However, diagnostic and therapeutic procedures appear to be frequently underused in the old patients.

[Progress in clinical cardiology: surface electrocardiography, cardiovascular disease in women, and novel therapies]. / Novedades en cardiología clínica: electrocardiografía de superficie, enfermedad vascular y mujer y novedades terapéuticas.

This review from the Clinical Cardiology and Outpatient Section of the Spanish Society of Cardiology details recent progress in the field of clinical cardiology. On this occasion, the emphasis is on advances in surface electrocardiography and cardiovascular disease in women. In addition, the review contains a brief overview of those major new developments in therapy that have had the greatest impact on daily clinical practice and summarizes the activities of the Clinical Cardiology and Outpatient Section.

Therapeutic inertia in the outpatient management of dyslipidemia in patients with ischemic heart disease. The inertia study.

INTRODUCTION AND OBJECTIVES: Studies indicate that dyslipidemia is undertreated. Numerous systematic reviews have shown that, even when therapeutic targets set by clinical practice guidelines have not been met, treatment remains unchanged despite the availability of alternatives approaches. The result is increased morbidity and mortality. Our aims were to investigate this phenomenon, known as therapeutic inertia, in patients with dyslipidemia and ischemic heart disease, and to determine its possible causes. DESIGN: national, multicenter, observational study of data obtained from physicians by questionnaire and from the clinical records of patients with ischemic heart disease. Main variable: therapeutic inertia during a consultation, defined as treatment remaining the same despite a change being indicated (e.g. low-density lipoprotein cholesterol >100 mg/dl or >70 mg/dl in diabetics). Covariates: physician, patient and consultation characteristics. STATISTICAL ANALYSIS: multivariate logistic regression analysis of factors associated with therapeutic inertia during a consultation. RESULTS: Overall, 43% of consultations involved therapeutic inertia, and an association with coronary risk factors, including diabetes, did not result in a change in treatment. Therapeutic inertia occurred more frequently when there was a long time between the diagnosis and treatment of dyslipidemia and that of ischemic heart disease. Undertreatment was particularly common in women despite a greater overall risk. The more experienced physicians treated younger patients more appropriately. Clinical practice was improved by educational sessions at conferences. CONCLUSIONS: Therapeutic inertia was common in patients with chronic ischemic heart disease and dyslipidemia, irrespective of overall cardiovascular risk. Factors associated with the patient, disease and physician had an influence.

High heart rate: more than a risk factor. Lessons from a clinical practice survey.

Several epidemiological studies have reported that an elevated heart rate (HR) is associated with coronary atherosclerosis independently of other risk factors. Nevertheless, it is still unclear whether HR is itself the cause or there is merely an association between HR and mortality in this population. A total of 1686 patients with hypertension and chronic ischemic heart disease were included in this study. According to the resting HR, the patients were distributed in 3 groups (group 1: HR<63 bpm; group 2: 63-82 bpm; group 3: >82 bpm). 580 patients (34.4%) belonged to group 1; 936 (55.5%) to group 2 and 170 (10.1%) to group 3. Patients with high HR exhibited a poorer prognosis not only due to a worse clinical profile (more concomitant cardiovascular risk factors and organ damage), but suggestively because despite the use of a similar number of drugs, patients with higher HR were associated with lesser risk control rates in daily clinical practice. Despite current guidelines that do not still recognize HR as a cardiovascular risk factor, it appears that physicians should pay more attention to it in clinical practice since high HR is warning about an increased risk.

[Clinical cardiology: update]. / Actualización en cardiología clínica.

Clinical cardiology encompasses all forms of heart disease and their more general characteristics, and its sphere of activity includes practical aspects of prevention, diagnosis, and inpatient and outpatient treatment as applied to patients on an everyday basis. Since certain areas of cardiology have become highly specialized, this review of new developments reported in the past year has attempted to bring together all those advances that are not the subject of research in some particular specialization within cardiology and that have such a wide range of application that they should be familiar to all clinical cardiologists, irrespective of their daily responsibilities. For the purposes of this review, articles were classified according to their origin as either English-language, European, or domestic publications. The review concludes with a summary of registry data collected in the last two years by the Clinical and Outpatient Cardiology Section of the Spanish Society of Cardiology.