Pablo Herrero-Puente

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.

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.

Morphine Use in the ED and Outcomes of Patients With Acute Heart Failure: A Propensity Score-Matching Analysis Based on the EAHFE Registry

OBJECTIVE: The objective was to determine the relationship between short‐term mortality and intravenous morphine use in ED patients who received a diagnosis of acute heart failure (AHF). METHODS: Consecutive patients with AHF presenting to 34 Spanish EDs from 2011 to 2014 were eligible for inclusion. The subjects were divided into those with (M) or without IV morphine treatment (WOM) groups during ED stay. The primary outcome was 30‐day all‐cause mortality, and secondary outcomes were mortality at different intermediate time points, in‐hospital mortality, and length of hospital stay. We generated a propensity score to match the M and WOM groups that were 1:1 according to 46 different epidemiological, baseline, clinical, and therapeutic factors. We investigated independent risk factors for 30‐day mortality in patients receiving morphine. RESULTS: We included 6,516 patients (mean age, 81 [SD, 10] years; 56% women): 416 (6.4%) in the M and 6,100 (93.6%) in the WOM group. Overall, 635 (9.7%; M, 26.7%; WOM, 8.6%) died by day 30. After propensity score matching, 275 paired patients constituted each group. Patients receiving morphine had a higher 30‐day mortality (55 [20.0%] vs 35 [12.7%] deaths; hazard ratio, 1.66; 95% CI, 1.09–2.54; P = .017). In patients receiving morphine, death was directly related to glycemia (P = .013) and inversely related to the baseline Barthel index and systolic BP (P = .021) at ED arrival (P = .021). Mortality was increased at every intermediate time point, although the greatest risk was at the shortest time (at 3 days: 22 [8.0%] vs 7 [2.5%] deaths; OR, 3.33; 95% CI, 1.40–7.93; P = .014). In‐hospital mortality did not increase (39 [14.2%] vs 26 [9.1%] deaths; OR, 1.65; 95% CI, 0.97–2.82; P = .083) and LOS did not differ between groups (median [interquartile range] in M, 8 [7]; WOM, 8 [6]; P = .79). CONCLUSIONS: This propensity score‐matched analysis suggests that the use of IV morphine in AHF could be associated with increased 30‐day mortality.

The GALA study: relationship between galectin-3 serum levels and short- and long-term outcomes of patients with acute heart failure

Abstract Objective: We tested the hypothesis that early measurement of galectin-3 at the emergency department (ED) during an episode of acute heart failure (AHF) allows predicting short- and long-term outcomes. Methods: We performed an exploratory study including 115 patients consecutively diagnosed with AHF in a single ED. Clinical and analytical variables were recorded. The primary endpoint was 30-day all-cause mortality, and secondary endpoints were 30-day composite outcome (death, rehospitalization or ED reconsultation, whichever first) and 1-year mortality. Results: Seven patients (6.1%) died within 30 days and 43 (37.4%) within 1 year. The 30-day composite endpoint was observed in 21.1% of patients. Galectin-3 was correlated with NT-proBNP and the glomerular filtration rate but not with age and s-cTnI. Measured at time of ED arrival, galectin-3 showed good discriminatory capacity for 30-day mortality (AUC ROC: 0.732; 95% CI 0.512–0.953; p = 0.041) but not for 1-year mortality (0.521; 0.408–0.633; p = 0.722). Patients with galectin-3 concentrations >42 μg/L had an OR = 7.67(95%CI = 1.57-37.53; p = 0.012) for 30-day mortality. Conversely, NT-proBNP only showed predictive capacity for 1-year mortality (0.642; 0.537–0.748; p = 0.014). Patients with NT-proBNP concentrations >5400 ng/L had an OR = 4.34 (95%CI = 1.93-9.77; p < 0.001) for 1-year mortality. These increased short- (galectin-3) and long-term (NT-proBNP) risks remained significant after adjustment for age or renal function. s-cTnI failed in both short- and long term death prediction. No biomarker predicted the short-term composite endpoint. Conclusion: These results suggest that galectin-3 could help to monitor the risk of short-term mortality in unselected patients with AHF attended in the ED.