La insuficiencia cardíaca en los servicios de medicina interna (estudio SEMI-IC)

Predictive risk factors for death in elderly patients after hospitalization for acute heart failure in an internal medicine unit

To determine the predictive factors of mortality after hospitalization for acute heart failure (AHF) in an internal medicine department. Retrospective observational analysis conducted on 164 patients hospitalized for AHF in 2016-2017. Demographic, clinical and biological characteristics were assessed during hospitalization. The primary endpoint was the occurrence of all-cause death. Multivariate analysis was performed using the Cox model adjusted for age and renal function. The study population was mostly female (n = 106, 64.6%), elderly (82.9 years ± 10.0), with a preserved LVEF (86%). Mean Charlson comorbidity index was 6.5 ± 2.5. After a median follow-up of 17.5 months (IQR 6-38), 109 patients (65%) had died with a median time to death of 14 months (IQR 3-29). In univariate analysis, patients who died were significantly older, had lower BMI and renal function, and higher CCI and NT-proBNP levels (median of 4944 ng/l [2370-14403] versus 1740 ng/l [1119-3503], p < 0.001). In multivariate analysis, risk factors for death were lower BMI (HR 0.69, CI [0.53-0.90], p = 0.005), lower albuminemia (HR 0.77 [0.63-0.94], p = 0.009), higher ferritinemia (HR 1.38 [1.08-1.76], p = 0.010), higher uricemia (HR 1.28 [1.02-1.59], p = 0.030), higher NT-proBNP (HR 2.46 [1.65-3.67], p < 0.001) and longer hospital stay (HR 1.25 [1.05-1.49] p = 0.013). In elderly multimorbid patients, AHF prognosis appears to be influenced by nutritional criteria, including lower BMI, hypoalbuminemia, and hyperuricemia (independently of renal function). These results underline the importance of nutritional status, especially as therapeutic options are available. This consideration paves the way for further research in this field.

Palliative medicine for patients with advanced heart failure: New evidence

Although heart failure is one of the most common clinical syndromes in medicine and has a high mortality rate, few patients have access to adequate palliative care for their clinical situation. Several trials have recently been published on the usefulness of starting palliative treatment along with cardiac treatment for patients with advanced heart failure. In this review, we analyse the aspects of diagnosing and controlling the symptoms of patients with advanced heart failure and provide a collection of clinical trials that have analysed the efficacy of a palliative intervention in this patient group. Physicians need to be equipped with strategies for recognizing the need for this type of intervention without it resulting in neglecting the active treatment of the patient's heart failure.

[Prevalence and prognostic meaning of comorbidity in heart failure]

Heart failure (HF) predominantly affects elderly individuals and has a significant impact on the health systems of developed countries. Comorbidities are present in most patients with HF by acting as the cause, the consequence or a mere coincidence. In addition to their high prevalence, they have considerable relevance because they can mask symptoms, impede the diagnosis and treatment, contribute to progression and negatively influence the prognosis of HF. Most of the associated comorbidities result in a greater number of hospitalisations, poorer quality of life and increased mortality. Given that many of these comorbidities are underdiagnosed, their detection could improve the outcome and quality of life of patients with HF. This article reviews the prevalence and prognostic meaning of the most prevalent comorbidities associated with HF.

[Predictive variables for mortality in elderly patients hospitalized due to heart failure with preserved ejection fraction]

BACKGROUND AND OBJECTIVES

The prevalence of heart failure (HF) increases with age. Even though the mortality of patients ≥ 80 years of age with HF and preserved left ventricle ejection fraction (LVEF) is very high, the predictor variables are not well-known. The main goal of this study was to evaluate the mortality predictor factors in this subgroup of the elderly population.

PATIENTS AND METHODS

An observational and prospective study of patients hospitalized due to HF with preserved LVEF has been conducted. The demographic, clinical, functional and analytic factors were evaluated when the patients were admitted with special attention to the co-morbidities. The primary endpoint was the total mortality in the subgroup of patients ≥ 80 years of age after a year of follow-up. The predictor variables were studied by means of a multivariate Cox regression model.

RESULTS

From a total of 218 patients with an average age of 75.6 (±8.7) years of age, 75 patients (34.4%) were ≥ 80 years. The mortality rate of patients ≥ 80 years of age totaled 42.7%, in relation to 26.6% for the lower age group (log-rank<.001). After a multivariate analysis using the Cox regression model in patients ≥ 80, the serum urea levels above the average (hazard ratio [HR] 3.93; 95% confidence interval [95% CI] 1.58-9.75; P = .003), the age (HR 1.17; 95% CI 1.07-1.28; P<.001), the hyponatremia (HR 3.19; 95% CI 1.51-6.74; P = .002) and a lower score on the Barthel index (BI) (HR 1.016; 95% CI 1.002-1.031; P = .034) were independent mortality predictors after an one-year follow-up.

CONCLUSIONS

Serum urea levels, age, hyponatremia and a low BI score could be proposed as independent mortality predictors in patients ≥ 80 of age hospitalized for HF with preserved LVEF.

[Diagnosis of heart failure with preserved or reduced ejection fraction in a one-stop clinic]

OBJECTIVES

a) To assess the usefulness of a one-stop clinic for the diagnosis of outpatients with new onset heart failure; b) to characterize these patients comparing preserved (HF-PEF) versus reduced ejection fraction (HF-REF), and c) to determine brain natriuretic peptide (BNP) cut-off limit to identify HF in outpatients.

DESIGN

Observational descriptive study.

SETTING

Primary care.

PARTICIPANTS AND MEASUREMENTS

A total of 143 outpatients with new onset HF were assessed in a one-stop clinic. A cardiologist evaluation, electrocardiogram, chest X-ray, BNP, and echocardiography (diastolic and systolic study) were performed.

RESULTS

Almost two-thirds (65.7%) were diagnosed with HF: 67% with HF-PEF and 33% HF-REF. Women (71.4% versus 38.7%, P=.002), presence of swelling ankles (61.9% versus 35.5%, P=.016) and higher body mass index (29.8±5.1 versus 27.2±5.0 P=.021) were more frequent in the first group of patients. Echocardiographic signs of diastolic dysfunction and pulmonary hypertension were found in both groups, with higher values of BNP (153.3±123.1 versus 400.8±579.8 P=.025) and troponin I (0.024±0.019 versus 0.071±0.12, P=.037) in HF-REF patients. Female gender and swelling ankles were predictors of HF-PEF in the multivariate analysis, while Q waves and higher values of BNP and heart rate were predictors of HF-REF. A cut-off value of 60.12 pg/ml for BNP provided 83% sensitivity, 84% specificity (AUC=0.898; 95% CI; 0.848-0.948; P <.001).

CONCLUSIONS

The one-stop HF clinic has diagnosed and characterized outpatients with new onset HF and high prevalence of HF-PEF. The cut-off value of 60.12 pg/ml for BNP provides high sensitivity and specificity to identify HF in this population.

[Prognostic factors and long-term survival after initial diagnosis of heart failure]

BACKGROUND AND OBJECTIVE

To assess long-term mortality and prognostic factors after initial diagnosis of heart failure (HF), to analyze the differences in function of the left ventricular ejection fraction (preserved [HFPEF] vs. systolic dysfunction [HFSD]) and to compare the results with the main series of incident cases of HF published.

PATIENTS AND METHODS

Retrospective cohort study including patients first diagnosed of heart failure (Framingham criteria), between 1-01-1997 and 31-12-2001, classified according to a left ventricle ejection fraction (LVEF) above or equal to 50% (HFPEF) or below 50% (HFSD). Follow-up of patients was conducted during ten years.

RESULTS

Out of 400 incident cases of heart failure, 231 patients (57,7%) presented with HFPEF. At 10 years, mortality rates were higher in the HFSD group (64,5 vs. 55,4%, p=0,04). Following a multi-variant analysis, HFPEF mortality was related with age, diabetes mellitus, ischemic heart disease, and chronic renal failure. Treatment with statins and beta-blockers was associated with improved prognosis. Among patients with HFSD, mortality predictors were similar, although patients treated with statins did not show higher survival rates. For other series of incident cases, there were differences in variables related to prognosis and mortality of patients.

CONCLUSIONS

After an initial diagnosis of HF, more than half of patients die within 10 years of monitoring. Age, diabetes mellitus, ischemic heart disease and chronic renal failure are all associated with worse prognosis in these patients, whereas the use of beta-blockers and statins is associated with a better prognosis.

Influence of admission blood pressure on mortality in patients with acute decompensated heart failure

OBJECTIVES

To determine the relationship between admission blood pressure (BP) and prognosis in patients hospitalized for acute decompensated heart failure (HF).

BACKGROUND

The relationship between BP admission blood pressure and outcomes in decompensated HF is controversial. It has been suggested that this presentation may be a specific disorder, but their mechanisms and clinical relationships are poorly defined.

METHODS

We evaluated the association between initial BP (systolic, diastolic and mean BP) with readmission and mortality, as well as potential interactions with age, clinical characteristics, renal function, left ventricular dysfunction, comorbidities and treatment. By using Cox regression models the association between each outcome and BP was tested.

RESULTS

A total of 581 patients (77.5-years-old, range 51-100) were included. At admission, mean BP in quartiles was 77.09 mm Hg (53.3-85.0) (Q1); 91.46 mm Hg (85.0-96.7) (Q2); 103.41 mm Hg (96.7-109.9) (Q3) and 124.79 mm Hg (109.9-209.0) (Q4). Median duration of follow-up was 8 months [95% confidence interval (CI) 5.2-11.1]. Mortality was 15.5% (Q1), 9.2% (Q2), 12.6% (Q3) and 7.3% (Q4). Interquartile hazard ratio (95% CIs) for mortality was 0.40 (0.19-0.85) P=0.017. Body mass index (BMI) was higher in Q4 29.59 k/m2 than in Q1 28.25 k/m2 (P=0.018). There were no differences in age, clinical antecedents, renal function, comorbidities or severity of HF between groups.

CONCLUSION

Higher mean BP at admission is associated with significantly lower mortality during follow-up, in patients hospitalized for HF. With the exception of BMI, positively correlated with blood pressure, this relationship is independent of other clinical factors and medications.

Heart failure in the family practice: a study of the prevalence and co-morbidity

BACKGROUND

Heart failure (HF) is a health problem that particularly affects the elderly population. Its onset is associated with other chronic diseases, a circumstance that makes it a challenge for health care services. The aim of this study is to quantify the prevalence of HF in family medicine offices and describe the chronic co-morbidity associated with it.

METHODS

A cross-sectional, observational descriptive study set in a health area of the Community of Madrid, Spain. The study was carried out in a population of 198,670 individuals over 14 years of age, attended to by 129 specialists in family medicine. The patient was considered to have HF when this diagnosis (ICPC code K77) appeared in his or her electronic medical record. The prevalence of HF was quantified and its association with another 25 chronic diseases was analysed.

RESULTS

The prevalence of HF was 6.9‰, 7.9‰ among women and 5.9‰ among men. Patients with HF had a high rate of chronic co-morbidity, with an average of 5.2 + 2.1 chronic diseases. Only 3% of the patients present with isolated HF and >60% have four or more additional chronic problems. Hypertension, cardiac arrhythmias, hyperlipidaemia, obesity and diabetes mellitus are the chronic diseases most frequently detected in HF patients.

CONCLUSION

Patients with HF frequently visit the offices of family physicians, presenting with a high rate of cardiac and non-cardiac co-morbidity that proves to be a challenge on the clinical level and in terms of the organization of health care services.

[Heart failure: a view from primary care]

OBJECTIVE

Our aim was to find out the situation of heart failure (HF) in primary care.

DESIGN

Cross-sectional multicentre study.

SETTING

Four primary health care centres and a hospital in an urban area of Barcelona.

PARTICIPANTS

From a registered population of 35,212 inhabitants older than 45 years, we studied all patients (333) diagnosed with HF in 2006 in primary care.

MEASUREMENTS

A standardised questionnaire was used to record demographic, clinical and treatment data.

RESULTS

There were 61.4% females. Mean age was 74.5 (standard deviation [SD]: 10) for men and 79 (SD: 9.8) for women. A total of 46% of patients had HF for <5 years. The comorbidity diagnosis and at the beginning of the study were: hypertension 65.4% and 73%, diabetes 33.6% and 40%, dyslipaemia 40% and 53%, coronary disease 30% and 27%, and valvular disease 23.7% and 27%, respectively. A total of 64% of patients had registered New York Heart Association functional class (48% class II, 30% III and 6.6% IV). Blood pressure was controlled in 36% men and 20.5% women (P=0.002); 75.4% had an electrocardiogram, 57% X-ray; 58% of men and 46% of women (P=0.02) had echocardiography. The most prescribed drugs were diuretics 85.3%, the least, beta blockers 27%.

CONCLUSIONS

Patients with HF in primary care are elderly females with a lot of comorbidities. We must be concerned by the suboptimal use of basic investigations (electrocardiogram and X-ray) and beta blocker treatments.

[Chronic obstructive pulmonary disease on inpatients with heart failure. GESAIC study results]

BACKGROUND AND OBJECTIVE

The clinical relevance of Heart failure (HF) and chronic obstructive pulmonary disease (COPD) in the same patient is not well established. We decided to study the prevalence of COPD in patients admitted due to HF, to define their clinical profile and the relationship with adrenergic beta-blockers (BB) treatment.

PATIENTS AND METHOD

Prospective cohort of inpatients with HF admitted in 15 Internal Medicine Services from October 2005 to March 2006. Diagnosis of COPD was established according to clinical criteria or spirometry. Data about neurohormonal treatment (before, during the admission, and at discharge) were collected. Statistical analyses were performed using Ji square test and T Student test. A logistic regression model was designed with data. P<0.05 being considered statistically significant.

RESULTS

About 391 patients were included . CPOD was present in 25.1% of patients. In two thirds of patients, the COPD diagnosis was established by clinical criteria. Regarding GOLD, 23.5% of patients had moderate or severe COPD severity. Bivariate analysis showed that male (<0.05), poor Charlson's Index and overweight (p=0.04 both) had all relationship with COPD. The regression model indicated that only left ventricular ejection fraction (LVEF) and BB treatment before admission had statistical significance (p=0.03 and p<0.001 respectively). At discharge, 27,6% of patients received BB.

CONCLUSIONS

COPD in HF patients is common and most frequent patients are aged men high comorbidity and overweight. BB treatment is conditioned by LVEF, without relationship with COPD severity.

Consultation between specialists in Internal Medicine and Family Medicine improves management and prognosis of heart failure

BACKGROUND AND OBJECTIVE

To evaluate if consultation between specialists in Internal Medicine and family doctors (CIMFD) improves the clinical management and prognosis of patients with heart failure (HF).

DESIGN

prospective case-control study (5 years of follow-up).

SETTING

community-based sample within the area of a university teaching hospital.

SUBJECTS

1857 patients (> or = 14 years) diagnosed for the first time with HF (1stDxHF), in the CIMFD.

CONTROL GROUP

1981 patients (from health centres not covered by the CIMFD), 1stDxHF, in the external consultations of the hospital.

MAIN OUTCOME MEASURES

mortality rate (MR). Admissions (HA). Emergency services visits (ESV). Delays in receiving specialist attention (DRSA), and the resolution of the process (DRP). Number (NTP) and delays in reporting (DTP) tests performed. Proportion (PRC) and delay (DRC) in resolving cases.

RESULTS

We observed a reduction of: MR (by 10.8%, CI 95%, 8.6-13.0, p < 0.005); HA, per patient per year (ppy) (by 1.8, 1.3-2.3, p < 0.01); ESV, ppy (by 1.9, 1.2-2.6, p < 0.01); DRSA (by 26.5 days, 21.8-31.2, p < 0.001); DRP (by 21.0 days, 18.3-23.7, p < 0.001), and DRC (by 25.8 days, 20.3-31.4, p < 0.01). The PRC (17.2%, CI 95%, 15.5-18.9, p < 0.01) was higher for the CIMFD.

CONCLUSION

The CIMFD approach improves prognosis and efficacy in the clinical management of patients with HF because it reduces mortality and morbidity (HA and ESV), shortens the delays in receiving care and in resolving the diagnostic and therapeutic process (DRSA, DRP, DRC), and increases the proportion of diagnosed and treated patients.

Características clínicas de los pacientes diagnosticados de insuficiencia cardíaca crónica asistidos en Atención Primaria. Estudio CARDIOPRES

INTRODUCTION

Scarce information is available on the clinical characteristics and risk factors of patients with chronic heart failure (CHF) attended in Primary Care (PC) setting. The aim of this study was to analyze the clinical characteristics of this population in PC.

PATIENTS AND METHODS

Multicenter, cross-sectional study in patients with CHF, consecutively recruited by 232 physicians in PC. The collected data included sociodemographic, etiologic, clinical and therapeutic variables.

RESULTS

Eight hundred forty seven (847) patients were included (age 73.0 +/- 9.6 years; 50.5% men). Of these, 84.3% had arterial hypertension (AHT), 59.2% hypercholesterolemia and 34.9% diabetes mellitus. The most frequent associated clinical disorders were ischemic heart disease (40.1%) and peripheral artery disease (28.6%). In 69.6% of the patients the physicians knew the type of dysfunction (32.4% systolic, 37.2% diastolic). The main etiologies of CHF were the hypertensive cardiomyopathy (75.0%) and ischemic heart disease (40.1%); the most frequent trigger factor was atrial fibrillation (43.9%). Loop diuretics (72.3%) and angiotensin-converting enzyme inhibitors (60.9%) were the treatments used most and 6.7% of the patients were receiving treatment with beta blockers.

CONCLUSIONS

AHT appears to be primary cause of CHF in PC. Diastolic dysfunction is more frequent than the systolic one, and the PC physicians do not know the cause of the ventricular dysfunction in one third of the cases. Loop diuretics and angiotensin-converting enzyme inhibitors were the most frequently used in these patients; the use of beta blockers in CHF is very scarce in PC.

[Terminal heart failure]

Heart failure (HF) is a cardiovascular disease with a permanent increase in prevalence, incidence and mortality. Current optimal therapies for HF are effective only for slowing, but not stopping, its progression. HF-related mortality is high, even at the time of the disease onset. Approximately 40% of HF-attributable deaths will be related to disease progression - however, its course is difficult to predict and therefore identifying patients experiencing the terminal stage of the disease is not correctly done. Most patients and their relatives do not identify HF as a progressive, terminal disease, and this perception also stands among health professionals - in consequence, end-stage HF patients often undergo active treatment procedures, event near the occurrence of death, although its implementation will be occasionally futile. Efforts should be undertaken by all health professionals to improve the identification and management of HF patients in the terminal stage of their disease.

Factores de riesgo asociados a la mortalidad y al deterioro funcional en la insuficiencia cardíaca del paciente pluripatológico

OBJECTIVES

Incidence, clinical features, and outcome of heart failure in patients with other chronic pathologies have been scarcely evaluated. The aim of the present study was to prospectively assess these issues, and the prognostic and factors associated to functional deterioration in a cohort of pluripathologic patients (PP) with heart failure (HF), attended in areas of Internal Medicine of a tertiary teaching hospital in the south of Spain.

METHODS

Prospective observational study of all patients, attended in Internal Medicine areas of a tertiary teaching hospital, during June 2003. Patients were stratified in two cohorts: PP with HF as main category (PP-HF), and PP with no HF. Patients with two or more chronic diseases, distributed into seven categories (defined by a panel of experts) were considered PP. Incidence of PP-HF, functional evaluation (at baseline, at admission, and at discharge), and burden of hospital care (by means of urgent and programmed assistances, as well as episodes of hospitalization) in the last 12 months were analyzed. Chi-square, Fisher, "t" Student or U-Mann-Whitney and Rho de Spearman test were used for group comparisons. A multivariate analysis of predictors of survival and functional deterioration (fall in Barthel's scale > or = 10 points between baseline-discharge values) was performed in the PP-HF cohort. A p < 0.05 was considered significant.

RESULTS

132 pluripathologic patients (55 in PP-HF, and 77 in PP cohort) were included, from a global cohort of 339. Global incidence of PP-HF was 38,9/100 admissions. Mean age of PP-HF patients was 78, 50.9% were females; mortality rate and mean hospital stay were 23.6% and 12.2 days, respectively. Patients of PP-HF cohort compared to those of PP, were older (78 +/- 9.5 vs 73 +/- 10.8; p < 0.005), and suffered more chronic diseases (p = 0.0001). Functional abilities (at baseline, at admission, and at discharge), mean hospital stay, mortality, and burden of care in the previous 12 months were similar. Better functional abilities (OR: 1.136 [0.94-1.842]; p = 0.055), and less associated chronic diseases (OR: 0.072 [0.006-0.943], p = 0.045) were independently associated to survival; while older age (OR: 1,217 [1.016-1.457]; p = 0.03), and a poorer functional status at baseline (OR:1.80 [1.019-1.144]; p = 0.01) were associated to functional deterioration.

CONCLUSIONS

Heart failure prevalent disease in pluripathologic patients. Specific factors associated to survival were gender and less chronic conditions; while those associated to functional deterioration during hospital stay were age and a poor functional status at baseline.

Predictors of in-hospital mortality present at admission among patients hospitalised because of decompensated heart failure

Chronic heart failure (HF) is associated with a poor prognosis and causes considerable mortality. The aim of this study was to identify the admission characteristics useful to predict in-hospital mortality in patients admitted because of decompensation of HF. We evaluated 414 patients (age 76.2 years, 57% women). The hospital mortality rate was 11.1%. We identified 4 independent predictors of mortality: low Barthel index (odds ratio 1.03; 95% confidence interval 1.01-1.04), creatinine level >200 mumol/l (odds ratio 3.40; 95% confidence interval 1.51-7.66), peripheral oedema (odds ratio 3.12; 95% confidence interval 1.28-7.58) and the protective effect of the new onset of the disease (odds ratio 0.2; 95% confidence interval 0.08-0.77). In conclusion, the mortality of patients admitted to the hospital with an exacerbation of HF can be predicted if either poor functional capacity, renal insufficiency, peripheral oedema or previous diagnoses of HF are present. This clinical finding may help clinicians in their decision making in HF in the emergency room.

Características clínicas y terapéuticas de los pacientes con insuficiencia cardíaca en un hospital de tercer nivel

INTRODUCTION

Heart failure shows high incidence and prevalence in our population. Objectives of our study are to describe the profile of patients cared in the Internal Medicine Department of our hospital, in order to analyze the therapeutic characteristics and to know the degree of utilization of different pharmacological groups.

PATIENTS AND METHODS

A cross-sectional study with collection of data from clinical records of patients admitted to 2002 with the diagnosis of heart failure in Internal Medicine Department of San Carlos Hospital in Madrid. Total patients with heart failure was 1,338. Calculating the sample size with a precision of 5% and a confidence interval of 95%, the number of randomly selected clinical records was 130. Data were obtained with a questionnaire for analysis of different clinical and therapeutic parameters.

RESULTS

The average age was 80.3 (SD: 9.64) years, and most patients were women. Most frequent associated pathology was hypertension, and in 70.2% patients a diagnosis of some disease was established. Diuretics were the drugs most utilized and its prescription increased at discharge (p < 0.0001). Furthermore, the higher the functional class the more diuretics were prescribed. Beta-blockers were prescribed in 7.1% patients, more frequently in patients with an ejection fraction higher than 35% (p = 0.042).

DISCUSSION AND CONCLUSIONS

Patients with heart failure in our environment have advanced age, shows important comorbidities, and suffer an advanced functional class heart failure, being the diuretics their essential treatment. We observed that there is no uniformity concerning the treatment with regard to the last recommendations, and that there is a limited utilization of drugs as beta-blockers that have demonstrated increase the survival of patients with heart failure.

[Congestive heart failure in Spain: cost-effectiveness and cost-benefit analyses of treatment with beta-blockers]

OBJECTIVE

Beta-blockers (BB) have proven to be effective in the treatment of congestive heart failure (CHF). This study is an economic analysis for the addition of BB to standard treatment of CHF.

PATIENTS AND METHOD

Randomized, double-blinded controlled studies are included, with 1,647 patients treated with bisoprolol, 3,034 treated with carvedilol, 2,432 treated with metoprolol, and 6,807 treated with placebo. Direct costs of BB treatment and of every hospitalization episode are assessed. Cost-effectiveness is assessed as cost in euros by prevented death, and cost-benefit as the difference between hospitalization costs and BB costs. The study is conducted from the perspective of a third-party payer.

RESULTS

Two studies with bisoprolol, six with carvedilol, and five with metoprolol are included, with an average follow-up of 13.5 months. Carvedilol prevents 5.07% of deaths per year of treatment and is more effective than bisoprolol (3.82% of avoided deaths) and metoprolol (3.03%). Cost-effectiveness ratio (cost for every prevented death and year) was 10,832 euros for bisoprolol, 17,516 euros for carvedilol and 16,664 euros for metoprolol. Incremental cost-effectiveness ratio for carvedilol ranges between 12,631 euros and 86,610 euros for life saved. All BB generate costs saving for hospitalization but only bisoprolol provides a net profit. Benefit-cost index is 1.13 for bisoprolol, 0.26 for carvedilol and 0.59 for metoprolol.

CONCLUSIONS

Use of BB in the treatment of CHF is an effective and cost-effective alternative. Carvedilol is the most effective alternative, and bisoprolol the most cost-effective alternative and the drug with greater benefit-cost index.

[Admissions and mortality changes in a third-level care Hospital Internal Medicine Department (1996-2000). Influence of the modifications in the HIV infection treatment]

OBJECTIVE

To analyze the impact of highly active anti-retroviral therapy (HAART) on the admissions and mortality of patients with human immunodeficiency virus (HIV) infection and of all patients cared in an Internal Medicine Department.

METHODS

A retrospective study with analysis of admissions and deaths in the Internal Medicine Department of a third-level care hospital between January 1996 and December 2000. HAART was introduced starting in 1997. Age, gender, main diagnosis at discharge, diagnosis related group (DRG) weight, death cause, and hospital stay were assessed globally and annually.

RESULTS

During the study period 7,580 admissions took place, of which 939 were secondary to HIV infection related diseases. The incidence of HIV-related admissions declined in 32.9% and the case-fatality rate in 67.8% between 1996 and 2000, with increase at the same time of the number of patients with noninfectious respiratory pathology and of overall number of patients with infections. Average hospital stay of patients cared in the Internal Medicine Department remained stable, with reduction of 31.5% of that of the group with HIV infection starting in 1997. DRG complexity in this group decreased 0.56 points.

CONCLUSIONS

The introduction of HAART has been associated to a reduction in the incidence of admissions, in the complexity of the diagnoses, and in the mortality in the group of patients with HIV infection. At the same time there was an increased in the number of patients with respiratory and infectious pathology different from that related to HIV.