New onset heart failure--Clinical characteristics and short-term mortality. A RICA (Spanish registry of acute heart failure) study

BACKGROUND

Heart failure (HF) is a growing global epidemic. The main study aims is to evaluate the differences between new-onset and chronic-decompensated HF patients. Secondary objectives related only to new-onset HF patients include the role of left ventricular ejection fraction (LVEF) and mid-term mortality related risk factors

METHODS

We analyzed 2190 patients hospitalized for acute HF. We compare the 683 patients with a new-onset HF episode with the rest. Restricting the analysis to the new-onset HF patients, we also compare patients with preserved LVEF (EF>50%) with those with reduced LVEF, and analyze the factors associated with three-month mortality.

RESULTS

A total of 683 (31.2%) patients fulfill the criteria for "new-onset HF". These patients are older, their HF is more often related to hypertension, show higher blood pressure and heart rate values upon admission, and present with less global and disease-specific comorbidity and better baseline overall functional status. New-onset HF is more often characterized by preserved LVEF, milder baseline NYHA class and lower plasma natriuretic peptide values. After 3 months; 33 (5.2%) new-onset HF patients had died (p<0.001). Cox multivariate analysis showed a correlation between mortality and older age (hazard ratio - HR - 1.08), higher global comorbidity (HR 1.20) and lesser prescription of beta-blockers at discharge (HR 0.34). LVEF was unrelated to mortality.

CONCLUSIONS

New-onset HF patients show a clinical profile different to that of chronic-decompensated patients. For this subset of acute HF patients older age, higher comorbidity and beta-blocker nonprescription predict a higher risk of mid-term post-discharge mortality.

Prevalence and outcome of diuretic resistance in heart failure

Diuretic resistance (DR) is common in patients with decompensated heart failure (HF), and is associated with adverse outcomes. To determine the prevalence of DR and its impact on survival among patients with decompensated HF, we prospectively evaluated the prevalence and influence on prognosis of DR (defined as persistent congestion despite ≥ 80 mg of furosemide per day) in a cohort of elderly patients from the Spanish HF registry (RICA) admitted for an acute decompensation of HF. Patients with new-onset HF were excluded. From the global cohort of 2067 patients, 435 (21%; 95% CI 19.3%-22.7%) patients met criteria for DR. Patients with DR had more comorbidities (hypercholesterolemia, diabetes mellitus, valvular disease, chronic kidney disease, and cancer) and a worse functional status compared to patients without DR. In addition, patients with DR had a higher proportion of ischemic etiology, more advanced functional class and lower left ventricular ejection fraction values. After 1 year of follow-up, all-cause mortality was higher in patients with DR with an adjusted hazard ratio of 1.37 (95% CI 1.06-1.79; p = 0.018). The prevalence of DR in a cohort of elderly patients admitted for acute HF decompensation is 21%. DR is an independent predictor of 1-year mortality.

The Prognostic Value of Eosinophil Recovery in COVID-19: A Multicentre, Retrospective Cohort Study on Patients Hospitalised in Spanish Hospitals

OBJECTIVES

A decrease in blood cell counts, especially lymphocytes and eosinophils, has been described in patients with serious Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), but there is no knowledge of their potential role of the recovery in these patients' prognosis. This article aims to analyse the effect of blood cell depletion and blood cell recovery on mortality due to COVID-19.

DESIGN

This work was a retrospective, multicentre cohort study of 9644 hospitalised patients with confirmed COVID-19 from the Spanish Society of Internal Medicine's SEMI-COVID-19 Registry.

SETTING

This study examined patients hospitalised in 147 hospitals throughout Spain.

PARTICIPANTS

This work analysed 9644 patients (57.12% male) out of a cohort of 12,826 patients ≥18 years of age hospitalised with COVID-19 in Spain included in the SEMI-COVID-19 Registry as of 29 May 2020.

MAIN OUTCOME MEASURES

The main outcome measure of this work is the effect of blood cell depletion and blood cell recovery on mortality due to COVID-19. Univariate analysis was performed to determine possible predictors of death, and then multivariate analysis was carried out to control for potential confounders.

RESULTS

An increase in the eosinophil count on the seventh day of hospitalisation was associated with a better prognosis, including lower mortality rates (5.2% vs. 22.6% in non-recoverers, OR 0.234; 95% CI, 0.154 to 0.354) and lower complication rates, especially regarding the development of acute respiratory distress syndrome (8% vs. 20.1%, p = 0.000) and ICU admission (5.4% vs. 10.8%, p = 0.000). Lymphocyte recovery was found to have no effect on prognosis. Treatment with inhaled or systemic glucocorticoids was not found to be a confounding factor.

CONCLUSION

Eosinophil recovery in patients with COVID-19 who required hospitalisation had an independent prognostic value for all-cause mortality and a milder course.

Cocaine administration enhances platelet reactivity to subendothelial components: studies in a pig model

Myocardial infarction in cocaine abusers may be related to a direct platelet-activating effect. We analysed this possibility in an experimental model. Studies were carried out in eight normal, anaesthetized pigs with a weight of 30.7 +/- 3.7 kg. Blood samples were withdrawn before and 20 min after i.v. administration of cocaine (10 mg kg-1; at 1 mg kg-1 every 2 min). Modifications in platelet responses to arachidonic acid (AA; 1.4 mmol L-1), ADP (1-4 microM), synthetic thromboxane endoperoxide analogue (U46619; 1 microM), collagen (2.5-5 micrograms mL-1), adrenaline (10 microM) and ristocetin (0.8-1 mg mL-1) were tested by conventional aggregometry. Changes in the capacity of platelets to form aggregates on damaged subendothelium were assessed by means of an ex vivo perfusion system in which blood was circulated for 10 min at 800 s-1, a shear rate similar to that found in normal coronary arteries. The interaction of platelets with perfused denuded arterial segments was morphometrically quantified and expressed as a percentage of damaged vessel surface covered by platelets (%CS). Cocaine administration did not influence platelet aggregation patterns in pigs. However, there was a significant increase in the interaction of pig platelets with subendothelial structures after cocaine infusion (%CS = 40 +/- 17% vs. 27 +/- 16% baseline; mean +/- SD; P < 0.01). Cocaine administration in this animal model increases the reactivity of platelets exposed to subendothelium. These results support the concept that the administration of cocaine to pigs has a prothrombotic effect by facilitating the interaction of platelets with damaged arteries.

[The use of acetylsalicylic acid in patients with ischemic cardiomyopathy cared for in Spanish emergency services (results of the EVICURE Study). Evaluacion del Manejo de la cardiopatia isquemica en los Servicios de Urgencias Hospitalarios of the Sociedad Espanola de Medicina de Urgencias y Emergencias (SEMES)]

BACKGROUND

Acetyl salicylic acid is a drug with demonstrated effectiveness in ischemic cardiomyopathy. The objective of our study was to know the use of this drug in the emergency services of Spain.

PATIENTS AND METHOD

The EVICURE study analyzes the use of acetyl salicylic acid in 35 emergency services of Spanish hospitals.

RESULTS

2,168 patients were studied. Of the 473 patients with stable angina, 9.2% received acetyl salicylic acid before going to the hospital and 90,7% at the arrival to the hospital, of 1,067 with unstable angina 13% received acetyl salicylic acid before the arrival to the hospital and 56% at the arrival to the hospital. Of 600 patients affected of myocardial infarction only 17% received acetyl salicylic acid before the arrival to the hospital and 59.8% received this drug in the emergency room.

CONCLUSIONS

The use of acetyl salicylic acid in patients affected of ischemic cardiopathy assisted in the emergency services of Spain is improperly low.

The role of endogenous nitric oxide in the response of coronary blood flow to tachycardia

BACKGROUND

The role of endogenous nitric oxide as mediator of flow-dependent dilation is well established. However, its role in the adaptation of coronary blood flow to tachycardia is less well defined. This study was designed to determine whether nitric oxide is a mediator in pacing-induced hyperaemia.

METHODS

Twenty pigs were instrumented for coronary blood flow, aortic pressure and atrial pacing measurements. Their heart rate was increased by 20 beats every 5 min. Coronary blood flow was measured basally and at each pacing interval before and after each of the following interventions: intracoronary saline infusion (n = 6), N omega-nitro-L-arginine methyl ester infusion (L-NAME, 20 micrograms/kg per min intracoronarily, n = 9) and infusion of L-NAME plus L-arginine (0.3 mg/kg per min intracoronarily, n = 5).

RESULTS

The coronary peak flow increased with atrial pacing. The maximum increase in coronary blood flow with pacing was significantly reduced after infusion of L-NAME (159 +/- 33 versus 143 +/- 30%), whereas no change was observed in the saline group (163 +/- 28 versus 172 +/- 29%). However, it increased significantly in the group receiving L-NAME plus L-arginine (147 +/- 29 versus 182 +/- 40%).

CONCLUSIONS

In the pig, the increase in coronary blood flow and therefore the vasodilation of the microvasculature that accompanies tachycardia depend, partly, on the release of endogenous nitric oxide.

Effect of a rehabilitation-based chronic disease management program targeting severe COPD exacerbations on readmission patterns

Background

Pulmonary rehabilitation (PR) is recommended after a severe COPD exacerbation, but its short- and long-term effects on health care utilization have not been fully established.

Aims

The aims of this study were to evaluate patient compliance with a chronic disease management (CDM) program incorporating home-based exercise training as the main component after a severe COPD exacerbation and to determine its effects on health care utilization in the following year.

Materials and methods

COPD patients with a severe exacerbation were included in a case-cohort study at admission. An intervention group participated in a nurse-supervised CDM program during the 2 months after discharge, comprising of home-based PR with exercise components directly supervised by a physiotherapist, while the remaining patients followed usual care.

Results

Nineteen of the twenty-one participants (90.5%) were compliant with the CDM program and were compared with 29 usual-care patients. Compliance with the program was associated with statistically significant reductions in admissions due to respiratory disease in the following year (median [interquartile range]: 0 [0–1] vs 1 [0–2.5]; P=0.022) and in days of admission (0 [0–7] vs 7 [0–12]; P=0.034), and multiple linear regression analysis confirmed the protective effect of the CDM program (β coefficient −0.785, P=0.014, and R²=0.219).

Conclusion

A CDM program incorporating exercise training for COPD patients without limiting comorbidities after a severe exacerbation achieves high compliance and reduces admissions in the year following after the intervention.

Nitric oxide inhibition intensifies the depressant effect of cocaine on the left ventricular function in anaesthetized pigs

Myocardial ischaemia and left ventricular dysfunction have been described in cocaine users. Whether nitric oxide (NO) inhibition may potentiate the effects of cocaine on coronary circulation and ventricular function is still unknown. In order to test this hypothesis, 38 pentobarbital-anaesthetized pigs were instrumented for systolic blood pressure, coronary blood flow, left ventricular dp/dt, cardiac output, left ventricular end-diastolic and end-systolic lengths and shortening fraction. The pigs were randomized into three groups: control group: i.v. saline (n = 5); group 1: i.v. cocaine, 10 mg kg-1 over 20 min (n = 17); group 2: the same doses of cocaine 30 min after i.c. L-NAME 20 microg/kg min-1 infusion (n = 16). In order to know whether the observed effects were specific of NO inhibition, in five pigs i.c. L-arginine was simultaneously infused with L-NAME, in five pigs i.c. NTG, an endothelial-independent vasodilator, was simultaneously infused with L-NAME before cocaine was administered, and in nine additional pigs the proximal left anterior descending (LAD) flow was reduced to around 20% of the basal value by means of a mechanical occluder before cocaine was administered. Cocaine i.v did not change the coronary blood flow, while it induced a significant reduction in cardiac output, left ventricular dp/dt and shortening fraction (15 +/- 4-8 +/- 4%, P < 0.05). When cocaine was administered after L-NAME infused i.c. during 30 min, a significantly more severe reduction of the shortening fraction (12 +/- 3-4 +/- 2%, P < 0.0001) was induced; this effect was abolished by simultaneous perfusion of L-arginine i.c. NTG. The results when cocaine was administered after the 20% LAD flow reduction by mechanical occluder did not differ from those of cocaine alone. NO inhibition intensifies the cocaine-induced left ventricular dysfunction.

[Role of emergency departments in acute myocardial infarction care. EVICURE study]

No published information is available about myocardial infarction management in Spanish emergency departments. The EVICURE is a prospective, multicenter, observational study involving 35 hospitals that for a 3-week period collected all the cases of patients requiring care in which the final diagnosis of the cause of symptoms was ischemic heart disease. The study included 2,216 patients, of which 600 (27.1%) with acute myocardial infarction formed the study population. Fifteen patients died in the emergency department (2.5%) and 80 (13.3%) diagnosed as myocardial infarction were admitted to the ward instead of the coronary care unit. The median time before patients were admitted to the coronary care unit was 32 minutes versus a median time of 111 minutes for all patients. Before leaving the emergency room, 461 patients (76.5%) received aspirin and 93 (15.5%) underwent fibrinolysis. We concluded that there is room for improvement in light of current standards of care.

Differential characteristics of acute heart failure in very elderly patients: the prospective RICA study

INTRODUCTION

Acute heart failure (AHF) is a frequent epidemic in geriatrics. The main aim of this study was to evaluate the clinical and prognostic differences of very elderly patients with AHF compared to the rest, and evaluate the factors associated with 90-day mortality.

METHODS

We analyzed 3828 patients hospitalized for AHF with an age of ≥ 70 years. The population was divided into three groups: 70-79, 80-89 and ≥ 90 years old (nonagenarians). The baseline characteristics of patients nonagenarians were compared with the rest. In the group of nonagenarians, their clinical characteristics were analyzed according to the left ventricular ejection fraction (LVEF) and the factors associated with mortality at 90 days of follow-up.

RESULTS

Nonagenarians showed higher comorbidity and cognitive deterioration, worse basal functional status, and preserved LVEF. Alternatively, they presented a lower rate of diabetes mellitus, lower incidence of de novo AHF, and lower prescription of angiotensin-converting-enzyme inhibitors, aldosterone blockers, anticoagulants, and statins at hospital discharge. Of the total, 334 patients (9.3%) had died by 90 days. The 90-day mortality rate was highest in nonagenarians (7.1% vs 9.8% vs 17%; p = 0.001). Multivariate analysis showed that renal failure, New York Heart Association (NYHA) functional classifications of III-IV, and a more advanced functional deterioration at baseline are predictors of mortality within 90 days.

CONCLUSIONS

The AHF in patients nonagenarians has a different clinical profile compared to younger patients and a higher mortality. In this subgroup of patients having a worse baseline functional status, higher NYHA classification (III-IV), and renal failure are predictors of 90-day mortality.

A Method for Projections of the Emergency Department Behaviour by Non-Communicable Diseases From 2019 to 2039

In this paper, a new method for prediction of future performance and demand on emergency department (ED) in Spain is presented. Increased life expediency and population aging in Spain, along with their corresponding health conditions such as non-communicable diseases (NCDs), have been suggested to contribute to higher demands on ED. These lead to inferior performance of the department and cause longer ED length of stay (LoS). Prediction and quantification of behavior of ED is, however, challenging as ED is one of the most complex parts of hospitals. Using detailed computational approaches integrated with clinical data behavior of Spain's ED in future years was predicted. First, statistical models were developed to predict how the population and age distribution of patients with non-communicable diseases change in Spain in future years. Then, an agent-based modeling approach was used for simulation of the emergency department to predict impacts of the changes in population and age distribution of patients with NCDs on the performance of ED, reflected in ED LoS, between years 2019 and 2039. Results from different projection scenarios indicated that Spain would experience a continuous increase in total ED LoS from 5.7 million hours in 2019 to 6.2 million hours in 2039 if same human and physical resources, as well as same ED configuration, are used. The results from this study can provide health care provider with quantitative information on required staff and physical resources in the future and allow health care policymakers to improve modifiable factors contributing to the demand and performance of ED.