Francisco Javier Martín-Sánchez

Factores pronósticos a corto plazo en los ancianos atendidos en urgencias por insuficiencia cardiaca aguda

Introduccion y objetivos Investigar los factores asociados a la mortalidad a corto plazo en los pacientes ancianos que acuden a urgencias por un episodio de insuficiencia cardiaca aguda. Metodos Estudio de cohortes, analitico-prospectivo, multicentrico y sin intervencion. Se incluyo a pacientes de 65 o mas anos atendidos en ocho servicios de urgencias de hospitales terciarios espanoles. Se analizaron 28 variables independientes (epidemiologicas, clinicas y funcionales) que pudieran influir en la mortalidad a 30 dias. Los datos se obtuvieron mediante la consulta de la historia clinica o la entrevista con el paciente o su familia. Se realizo un estudio multivariable mediante regresion logistica. Resultados Se incluyo a 623 pacientes, de los que 42 (6,7%) habian fallecido a los 30 dias de la consulta en urgencias. Cuatro variables se asociaron de forma significativa con la mortalidad: la dependencia funcional basal (indice de Barthel ≤ 60, odds ratio [OR] = 2,9; intervalo de confianza [IC] del 95%, 1,2-6,5), clases III y IV de la NYHA (OR = 3; IC del 95%, 1,3-7), presion arterial sistolica Conclusiones Existen diversos factores disponibles tras una primera valoracion en urgencias, entre ellos la dependencia funcional del paciente, que determinan un mal pronostico a corto plazo del paciente anciano que consulta por un episodio de insuficiencia cardiaca aguda.

Differential clinical characteristics and outcome predictors of acute heart failure in elderly patients

OBJECTIVE We determined the clinical-epidemiological characteristics and prognostic factors of early mortality and re-consultation in an elderly population attending the hospital emergency department (HED) for acute heart failure (AHF). PATIENTS AND METHODS A prospective, observational, non interventional study including all the patients with AHF attended in the Spanishs HED. Two groups were defined: elderly (≥ 80 years) and controls (< 80 years). VARIABLES demographic characteristics, comorbidity, degree of cardiac involvement, previous treatment, symptoms and signs of the AHF episode, precipitating factors, treatment in the HED and outcome. OUTCOME VARIABLES mortality and re-consultation within 30 days. RESULTS Of the 942 patients included, 455 of whom were elderly (48.3%). In this elderly population female sex, auricular fibrillation and a history of ictus and a poor functional status predominated. The type of ventricular dysfunction was unknown in 70%. No main differences in the presentation of AHF were found between the two groups. Mortality and re-consultation to the HED within 30 days were similar in both groups. While several factors were identified to be related to mortality or re-consultation in control group, in the elderly group it was more difficult to identify patients who will die or re-consult to the HED within the following 30 days. Only respiratory insufficiency on arrival to the HED was found to predict a greater probability of death (OR 3.55; CI95% 1.39-9.11). CONCLUSIONS AHF in elderly patients presents some differential characteristics and, most importantly, it is more difficult to identify which of these patients will die or re-consult in the short-term.

Predicting 30-Day Mortality for Patients With Acute Heart Failure in the Emergency Department: A Cohort Study

Background Physicians in the emergency department (ED) need additional tools to stratify patients with acute heart failure (AHF) according to risk. Objective To predict mortality using data that are readily available at ED admission. Design Prospective cohort study. Setting 34 Spanish EDs. Participants The derivation cohort included 4867 consecutive ED patients admitted during 2009 to 2011. The validation cohort comprised 3229 patients admitted in 2014. Measurements 88 candidate risk factors and 30-day mortality. Results Thirteen independent risk factors were identified in the derivation cohort and were combined into an overall score, the MEESSI-AHF (Multiple Estimation of risk based on the Emergency department Spanish Score In patients with AHF) score. This score predicted 30-day mortality with excellent discrimination (c-statistic, 0.836) and calibration (Hosmer-Lemeshow P = 0.99) and provided a steep gradient in 30-day mortality across risk groups (<2% for patients in the 2 lowest risk quintiles and 45% in the highest risk decile). These characteristics were confirmed in the validation cohort (c-statistic, 0.828). Multiple sensitivity analyses did not find important amounts of confounding or bias. Limitations The study was confined to a single country. Participating EDs were not selected randomly. Many patients had missing data. Measurement of some risk factors was subjective. Conclusion This tool has excellent discrimination and calibration and was validated in a different cohort from the one that was used to develop it. Physicians can consider using this tool to inform clinical decisions as further studies are done to determine whether the tool enhances physician decision making and improves patient outcomes. Primary Funding Source Instituto de Salud Carlos III, Spanish Ministry of Health; Fundació La Marató de TV3; and Catalonia Govern.

Clinical effects and safety of different strategies for administering intravenous diuretics in acutely decompensated heart failure: a randomised clinical trial

Background The mainstay of treatment for acutely decompensated heart failure (ADHF) is intravenous diuretic therapy either as a bolus or via continuous infusion. Objectives We evaluated the clinical effects and safety of three strategies of intravenous furosemide administration used in emergency departments (EDs) for ADHF. Methods We performed a multicentre, randomised, parallel-group study. Patients with ADHF were randomised within 2 h of ED arrival to receive furosemide by continuous infusion (10 mg/h, group 1) or boluses (20 mg/6 h, group 2; or 20 mg/8 h, group 3). The primary end point was total diuresis, and secondary end points were dyspnoea, orthopnoea, extension of rales and peripheral oedema, blood pressure, respiratory and heart rates, and pulse oximetry, which were measured at arrival and 3, 6, 12 and 24 h after treatment onset. We also measured serum creatinine, sodium and potassium levels at arrival and after 24 h. Results Group 1 patients (n=36) showed greater 24 h diuresis (3705 mL) than those in groups 2 (n=37) and 3 (n=36) (3093 and 2670 mL, respectively; p<0.01), and this greater diuretic effect was observed earlier. However, no differences were observed among groups in the nine secondary clinical end points evaluated. Creatinine deterioration developed in 15.6% of patients, hyponatraemia in 9.2%, and hypokalaemia in 19.3%, with the only difference among groups observed in hypokalaemia (group 1, 36.3%; group 2, 13.5%; group 3, 8.3%; p<0.01). Conclusions In patients with ADHF attending the ED, boluses of furosemide have a smaller diuretic effect but provide similar clinical relief, similar preservation of renal function, and a lower incidence of hypokalaemia than continuous infusion. Trial registration number This randomised trial was registered in the European Clinical Trial Database (EudraCT) with the reference number 2008-004488-20.

Puntos clave en la asistencia al anciano frágil en Urgencias

Patients older than 65 years are increasingly attended in the Emergency Department (ED). This means that internists working in ED are responsible for improving their geriatric training. The frail elders are the one who have the higher probability to suffer an adverse event. The detection of this profile is very important for making a decision in ED. A possible geriatric emergency model would be the one that screens frailty among all patients older than 65 years old in ED by nurses, and, in those triaged as of high risk, a geriatric assessment must be done by a geriatric trained doctor or nurse. All this information will be helpful for the final location and discharge follow-up plan.

Short-term Prognostic Factors in Elderly Patients Seen in Emergency Departments for Acute Heart Failure

INTRODUCTION AND OBJECTIVES To investigate factors associated with short-term mortality in elderly patients seen in emergency departments for an episode of acute heart failure. METHODS A prospective, non-interventional, multicenter, cohort study was carried out in patients aged 65 years and older who were treated in the emergency department of one of eight tertiary hospitals in Spain. Twenty-eight independent variables that could influence mortality at 30 days were assessed. They covered epidemiological and clinical factors and daily functioning. Data were obtained by reviewing medical records or by interviewing the patient or a relative. Multivariate logistic regression analysis was performed. RESULTS The study included 623 patients, 42 of whom (6.7%) died within 30 days of visiting the emergency department. Four variables were significantly associated with higher mortality: functional dependence at baseline (i.e., Barthel index=60; odds ratio [OR]=2.9; 95% confidence interval [CI], 1.2-6.5), New York Heart Association class III-IV (OR=3; 95% CI, 1.3-7), systolic blood pressure <100 mmHg (OR=4.8; 95% CI, 1.6-14.5) and blood sodium <135 mEq/l (OR=4.2; 95% CI, 1.8-9.6). CONCLUSIONS Several factors evaluated on initial assessment in the emergency department, including the level of functional dependence, were found to determine a poor short-term prognosis in elderly patients who present with an episode of acute heart failure.

Multicentric investigation of survival after Spanish emergency department discharge for acute heart failure.

Objective Ideally, discharges from the emergency department (ED) should be as safe as discharges after hospitalization. We have ascertained this hypothesis in patients with acute heart failure (AHF) directly discharged from EDs, analyzing their short-term outcome. Patients and methods A prospective, cohort, multicentric, noninterventional study of consecutive patients with AHF who visited in 20 Spanish EDs was conducted. Patients were grouped according to whether discharge had been from the ED (maximum 24-h ED stay) or after hospitalization. We collected baseline and current AHF episode data. Short-term outcome (30-day mortality and revisit rates) of both groups was compared by univariate crude analysis and stratified by predicted risk of 30-day mortality as well as by logistic regression adjustment for the differences found between ED and hospital groups. Results A total of 1669 patients were analysed: 546 (32.7%) discharged from ED and 1123 (67.3%) after hospitalisation; 75 (4.5%) died and 420 (25.2%) revisited the ED. Crude 30-day mortality rates of ED and hospital discharges were 2.9 and 5.3%, respectively (odds ratio for ED discharge: 0.56; 95% confidence interval: 0.33–0.96), whereas 30-day revisit rates were 23.8 and 26.4% (odds ratio: 0.96; 95% confidence interval: 0.77–1.19). Stratified analysis according to predicted risk of mortality and multivariate analysis adjusted for the discrepancy in baseline and current AHF episode characteristics in ED and hospital discharges confirmed the lack of short-term outcome differences between the two groups. Conclusion Direct ED discharge of patients with AHF after treatment and a short observation period is as safe as discharge after a longer time of inpatient hospitalization in general wards.

Predicting the risk of reattendance for acute heart failure patients discharged from Spanish Emergency Department observation units.

Background Patients with acute heart failure (AHF) are frequently evaluated in the Emergency Departments (ED) and discharged from their observation units (OU) without hospital admission. We examined direct discharge rates from the ED OU, risk factors for returning to the ED, and returning and mortality rates. Patients and methods This prospective, longitudinal, noninterventional, population-based cohort study included all the patients with AHF consecutively attended in seven Spanish EDs who were directly discharged without hospital admission. Reattendance (dependent variable) was accepted if occurred during the next 30 days after discharge. Twenty-nine independent variables were recorded, covering epidemiological, clinical, and functional data. Results Two hundred and fifty-nine of 740 patients (35%) diagnosed with AHF were entirely managed in the ED OU and discharged home (mean stay: 18.8 h); 26.7% of them were reattended. Only three variables were independently associated with the chance of reattendance: functional impairment predicted adverse outcomes [odds ratio (OR): 4.0, 95% confidence interval (95% CI): 1.7–9.1], while past history of hypertension and a systolic blood pressure greater than 160 mmHg at ED arrival decreased the risk of ED return (OR: 0.4, 95% CI: 0.2–0.9; and OR: 0.3; 95% CI: 0.1–0.9; respectively). An overall mortality of 4.7% was recorded during the next 30 days. Conclusion One-third of the patients consulting at the ED for an episode of AHF can be directly discharged from the OU of ED, with relatively low rates of reattendance (26.7%) and mortality (4.7%). Emergency physicians should be especially cautious discharging patients with functional dependence because they are at increased risk of returning.

Gym score: 30-day mortality predictive model in elderly patients attended in the emergency department with infection

Objective To determine the validity of the classic sepsis criteria or systemic inflammatory response syndrome (heart rate, respiratory rate, temperature, and leukocyte count) and the modified sepsis criteria (systemic inflammatory response syndrome criteria plus glycemia and altered mental status), and the validity of each of these variables individually to predict 30-day mortality, as well as develop a predictive model of 30-day mortality in elderly patients attended for infection in emergency departments (ED). Methods A prospective cohort study including patients at least 75 years old attended in three Spanish university ED for infection during 2013 was carried out. Demographic variables and data on comorbidities, functional status, hemodynamic sepsis diagnosis variables, site of infection, and 30-day mortality were collected. Results A total of 293 patients were finally included, mean age 84.0 (SD 5.5) years, and 158 (53.9%) were men. Overall, 185 patients (64%) fulfilled the classic sepsis criteria and 224 patients (76.5%) fulfilled the modified sepsis criteria. The all-cause 30-day mortality was 13.0%. The area under the curve of the classic sepsis criteria was 0.585 [95% confidence interval (CI) 0.488–0.681; P=0.106], 0.594 for modified sepsis criteria (95% CI: 0.502–0.685; P=0.075), and 0.751 (95% CI: 0.660–0.841; P<0.001) for the GYM score (Glasgow <15; tachYpnea>20 bpm; Morbidity–Charlson index ≥3) to predict 30-day mortality, with statistically significant differences (P=0.004 and P<0.001, respectively). The GYM score showed good calibration after bootstrap correction, with an area under the curve of 0.710 (95% CI: 0.605–0.815). Conclusion The GYM score showed better capacity than the classic and the modified sepsis criteria to predict 30-day mortality in elderly patients attended for infection in the ED.

Emergency Heart Failure Mortality Risk Grade score performance for 7-day mortality prediction in patients with heart failure attended at the emergency department: validation in a Spanish cohort.

Objective The Emergency Heart Failure Mortality Risk Grade (EHMRG) scale, derived in 86 Canadian emergency departments (EDs), stratifies patients with acute-decompensated heart failure (ADHF) according to their 7-day mortality risk. We evaluated its external validity in a Spanish cohort. Patients and methods We applied the EHMRG scale to ADHF patients consecutively included in the Epidemiology of Acute Heart Failure in Emergency departments (EAHFE) registry (29 Spanish EDs) and measured its performance. Patients were distributed into quintiles according to the original and their self-defined score cutoffs. The 7-day mortality rates were compared internally among different categories and with categories of Canadian cohorts. Results The EAHFE group [n: 1553 patients; 80 (10) years; 55.6% women] had a 5.5% 7-day mortality rate and the EHMRG scale c-statistic was 0.741 (95% confidence interval: 0.688–0.793) compared with 0.807 (0.761–0.842) and 0.804 (0.763–0.840) obtained in the Canadian derivation and validation cohorts. The mortality rate of the EAHFE group mortality increased progressively as the quintile categories increased using intervals defined by either the Canadian or the Spanish EHMRG score cutoffs, although with more regular increments with the EAHFE-defined intervals; using the latter, patients at quintiles 2, 3, 4, 5a and 5b had (compared with quintile 1) odds ratios of 1.77, 3.36, 4.44, 9.39 and 16.19, respectively. Conclusion The EHMRG scale stratified risk in an ADHF cohort that included both palliative and nonpalliative patients in Spanish EDs, showing an extrapolation to a higher mortality risk cohort than the original derivation sample. Stratification improved when the score was recalibrated in the Spanish cohort.