Juan Jorge González-Armengol

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.

Conocimiento de la enfermedad y del testamento vital en pacientes con insuficiencia cardiaca

Introduccion y objetivos Investigar en pacientes con insuficiencia cardiaca atendidos en urgencias su conocimiento de las posibilidades evolutivas y del testamento vital (TV) y su predisposicion a redactarlo. Metodos Estudio transversal con inclusion prospectiva y consecutiva, multicentrico, sin intervencion. Se consignaron caracteristicas clinico-demograficas de cada paciente y, tras el control de sus sintomas, se realizo una encuesta acerca de aspectos de conocimiento y opinion de su enfermedad. Como variables dependientes, se consideraron tener buen conocimiento objetivo de su enfermedad y la predisposicion a redactar un TV. Se investigaron los factores asociados. Resultados Se incluyo a 309 pacientes: el 79% se consideraba subjetivamente bien informado, el 51,5% lo estaba realmente, el 39,8% desearia mas informacion y el 54,7%, participar mas en la toma de decisiones; el 13,3% sabia en que consistia un TV; al 4,9% su medico le habia informado y el 28,8% se mostraba partidario de redactarlo. Estar objetivamente bien informado y estar dispuesto a redactar un TV se asociaron de forma reciproca e independiente; ademas, con la primera variable se asociaron el ingreso en intensivos, considerarse bien informado y haber participado suficientemente en la toma de decisiones, y con la segunda, tener menos de 75 anos, desear mas informacion, saber en que consiste el TV y el centro de procedencia. Conclusiones El conocimiento de los pacientes con insuficiencia cardiaca respecto a sus posibilidades evolutivas es suboptimo, como tambien lo es su conocimiento del TV y su predisposicion a redactarlo. Debe mejorarse la informacion de estos aspectos como parte esencial de la relacion medico-paciente.

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.

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.