Multidimensional frailty connection in older patients with diabetes mellitus

BACKGROUND AND OBJECTIVE

Patients with diabetes mellitus (DM) experience accelerated aging and, thus, a high prevalence of frailty. Our aim is to outline the type of frailty and prefrailty from a multidimensional perspective and the interaction of these dimensions in this scenery.

MATERIAL AND METHODS

Observational study of patients with DM over 60 years-old. Variables related to nutrition, cognitive and emotional status, physical and instrumental functional capacity and social resources were collected. They were divided into three groups (robust, prefrail and frail) according to the Fried scale. Each of the variables in the groups were compared and a correspondence analysis was carried out to see the influence of some dimensions with others in each stage of frailty.

RESULTS

188 patients (mean age 72.6 + 7.5) were analysed. Of them, 105 patients had prefrailty and 66 were frail. With the exception of social resources, the rest of the variables had an increasing prevalence depending on the stage of frailty. However, in the correspondence analysis (with 22.9% of variation explained by two dimensions) it was only patients with frailty who were associated with worse functional capacity, cognitive and emotional situation and mild to moderate social incapacity.

CONCLUSIONS

In our sample there was a high prevalence of prefrailty, and frailty associated with an increase in the prevalence of other different dimensions except social resources. However, the interaction between these dimensions was only evident in the case of patients with frailty.

Prognosis of acute heart failure in patients followed up in nursing homes in Spain: Results from the RICA registry

BACKGROUND

Patients with chronic diseases such as heart failure (HF) are at risk of hospital admission. We evaluated the impact of living in nursing homes (NH) on readmissions and all-cause mortality of HF patients during a one-year follow up.

METHODS

An observational and multicenter study from the Spanish National Registry of Heart Failure (RICA) was performed. We compared clinical and prognostic characteristics between both groups. Bivariate analyses were performed using Student's t-test and Tukey's method and a Kaplan-Meier survival at one-year follow up. A multivariate proportional hazards analysis of [Cox] regression by the conditional backward method was conducted for the variables being statistically significant related to the probability of death in the univariate.

RESULTS

There were 5644 patients included, 462 (8.2%) of whom were nursing home residents. There were 52.7% women and mean age was 79.7±8.8 years. NH residents had lower Barthel (74.07), Charlson (3.27), and Pfeiffer index (2.2), p<0.001). Mean pro-BNP was 6686pg/ml without statistical significance differences between groups. After 1-year follow-up, crude analysis showed no differences in readmissions 74.7% vs. 72.3%, p=0.292, or mortality 63.9% vs. 61.1%, p=0.239 between groups. However, after controlling for confounding variables, NH residents had a higher 1-year all-cause mortality (HR 1.153; 95% CI 1.011-1.317; p=0.034). Kaplan-Meier analysis showed worse survival in nursing home residents (log-rank of 7.12, p=0.008).

CONCLUSIONS

Nursing home residents with heart failure showed higher one-year mortality which could be due to worse functional status, higher comorbidity, and cognitive deterioration.

Approach to obesity in the elderly population: a consensus report from the Diabetes, Obesity and Nutrition Working Group of SEMI (Spanish Society of Internal Medicine)

Obesity in the elderly not only impacts morbidity and mortality but their quality of life. This phenomenon has sparked extensive research and debate regarding treatment recommendations, primarly due to the lack evidence in this specific population. When addressing possible treatment recommendations for older adults with obesity, it is crucial to assess certain essential aspects such as functional status, sarcopenia, cognitive status, and others. Intentional weight loss in this population can be both effective and safe. The best weight loss plan for the elderly revolves around adopting a healthy lifestyle, which includes following a Mediterranean diet pattern and engaging in physical exercise, particularly strength training. Additionally, the use of weight loss medications, particularly glucagon-like peptide-1 receptor agonists (GLP-1 RA) and novel glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 receptor agonists, can provide an additional stage of treatment. In selective candidates, bariatric surgery may also be considered. The objective of this document is to propose a comprehensive algorithm of recommendations for the management of obesity in the elderly (above the age of 65), based on scientific evidence and the expertise of members from the Diabetes, Obesity, and Nutrition Workgroup of the Spanish Society of Internal Medicine.

Improving prediction of COVID-19 mortality using machine learning in the Spanish SEMI-COVID-19 registry

COVID-19 is responsible for high mortality, but robust machine learning-based predictors of mortality are lacking. To generate a model for predicting mortality in patients hospitalized with COVID-19 using Gradient Boosting Decision Trees (GBDT). The Spanish SEMI-COVID-19 registry includes 24,514 pseudo-anonymized cases of patients hospitalized with COVID-19 from 1 February 2020 to 5 December 2021. This registry was used as a GBDT machine learning model, employing the CatBoost and BorutaShap classifier to select the most relevant indicators and generate a mortality prediction model by risk level, ranging from 0 to 1. The model was validated by separating patients according to admission date, using the period 1 February to 31 December 2020 (first and second waves, pre-vaccination period) for training, and 1 January to 30 November 2021 (vaccination period) for the test group. An ensemble of ten models with different random seeds was constructed, separating 80% of the patients for training and 20% from the end of the training period for cross-validation. The area under the receiver operating characteristics curve (AUC) was used as a performance metric. Clinical and laboratory data from 23,983 patients were analyzed. CatBoost mortality prediction models achieved an AUC performance of 84.76 (standard deviation 0.45) for patients in the test group (potentially vaccinated patients not included in model training) using 16 features. The performance of the 16-parameter GBDT model for predicting COVID-19 hospital mortality, although requiring a relatively large number of predictors, shows a high predictive capacity.

Projected effectiveness of dapagliflozin in heart failure with reduced ejection fraction in clinical practice

Aim: To estimate the projected effectiveness of dapagliflozin in subjects with heart failure (HF) with reduced ejection fraction in clinical practice in Spain. Materials & methods: This multicenter cohort study included subjects aged 50 years or older consecutively hospitalized for HF in internal medicine departments in Spain. The projected clinical benefits of dapagliflozin were estimated based on results from the DAPA-HF trial. Results: A total of 1595 patients were enrolled, of whom 1199 (75.2%) were eligible for dapagliflozin. Within 1 year after discharge, 21.6% of patients eligible for dapagliflozin were rehospitalized for HF and 20.5% died. Full implementation of dapagliflozin led to an absolute risk reduction of 3.5% for mortality (number needed to treat = 28) and 6.5% (number needed to treat = 15) for HF readmission. Conclusion: Treatment with dapagliflozin in clinical practice may markedly reduce mortality and readmissions for HF.

Effect of semaglutide on fatty liver disease biomarkers in patients with diabetes and obesity

AIM

This work aims to assess the effect of weekly subcutaneous semaglutide on biomarkers of metabolic-associated fatty liver disease (MAFLD), namely the hepatic steatosis index (HSI) and the fibrosis-4 (FIB-4) index, at 24 weeks in outpatients attended to in internal medicine departments.

METHODS

This study analyzed patients in an ongoing, multicenter, prospective, pre-post, uncontrolled cohort registry that enrolls unique, consecutive patients with type 2 diabetes treated with weekly subcutaneous semaglutide. Steatosis/fibrosis were determined by HSI (<30 ruled out, >36 steatosis) and FIB-4 (<1.3 ruled out, >2.67 fibrosis), respectively.

RESULTS

The sample included 213 patients (46.9% women) with a median age of 64 (19) years. The median baseline body mass index and weight were 36.1 (8.4) kg/m² and 98 (26.9) kg, respectively. A total of 99.9% had HSI values indicating steatosis, with a mean HSI of 47.9 (8.2). Additionally, 10.8% had fibrosis (FIB-4 > 2.67) and 42.72% had values in intermediate ranges (FIB-4 1.3-2.67). At 24 weeks, there was a significant reduction in HSI (-2.36 (95%CI 1.83-2.9) p < 0.00001) and FIB-4 (-0.075 (95%CI 0.015-0.14) p < 0.016), mainly related to declines in body weight, triglyceride levels, insulin resistance (estimated by the triglyceride-glucose index), and liver enzymes.

CONCLUSION

These results show that weekly subcutaneous semaglutide had a beneficial effect on liver steatosis that went beyond glucose control. Its effects were mainly related to weight loss, a decline in biomarkers, and improvements in insulin sensitivity. For many patients, early detection is essential for improving MAFLD outcomes and may allow for selecting the most efficient treatment options.

Association between arterial stiffness and fat mass in patients with obesity

OBJECTIVE

The aim is to observe whether body composition in patients with high-risk obesity (body mass index >35 or between 30 and 34.9kg/m² with a waist circumference greater than 102cm in men or greater than 88cm in women) is related with vascular disease.

METHODS

This is a cross-sectional study of patients with high-risk obesity. Their fat mass was measured through bioimpedance and arterial stiffness through pulse wave velocity (PWV). Tertiles of patients were analyzed according to PWV distribution.

RESULTS

A total of 59 patients were analyzed. As PWV increased, BMI (p=0.02) and fat mass content (p<0.00) increased. There was also a significant increase in inflammation indicators.

CONCLUSIONS

In patients with high-risk obesity, there were differences in their body composition which were associated with changes in arterial stiffness and inflammatory burden.

High-Risk Obesity Phenotypes: Target for Multimorbidity Prevention at the ROFEMI Study

Background: Describe the profile of patients with obesity in internal medicine to determine the role of adiposity and related inflammation on the metabolic risk profile and, identify various “high-risk obesity” phenotypes by means of a cluster analysis. This study aimed to identify different profiles of patients with high-risk obesity based on a cluster analysis. Methods: Cross-sectional, multicenter project that included outpatients attended to in internal medicine. A total of 536 patients were studied. The mean age was 62 years, 51% were women. Patients were recruited from internal medicine departments over two weeks in November and December 2021 and classified into four risk groups according to body mass index (BMI) and waist circumference (WC). High-risk obesity was defined as BMI > 35 Kg/m2 or BMI 30−34.9 Kg/m2 and a high WC (>102 cm for men and >88 cm for women). Hierarchical and partitioning clustering approaches were performed to identify profiles. Results: A total of 462 (86%) subjects were classified into the high-risk obesity group. After excluding 19 patients missing critical data, two profiles emerged: cluster 1 (n = 396) and cluster 2 (n = 47). Compared to cluster 1, cluster 2 had a worse profile, characterized by older age (77 ± 16 vs. 61 ± 21 years, p < 0.01), a Charlson Comorbidity Index > 3 (53% vs. 5%, p < 0.001), depression (36% vs. 19%, p = 0.008), severe disability (64% vs. 3%, p < 0.001), and a sarcopenia score ≥ 4 (79% vs. 16%, p < 0.01). In addition, cluster 2 had greater inflammation than cluster 1 (hsCRP: 5.8 ± 4.1 vs. 2.1 ± 4.5 mg/dL, p = 0.008). Conclusions: Two profiles of subjects with high-risk obesity were identified. Based on that, older subjects with obesity require measures that target sarcopenia, disability, psychological health, and significant comorbidities to prevent further health deterioration. Longitudinal studies should be performed to identify potential risk factors of subjects who progress from cluster 1 to cluster 2.

The importance of association of comorbidities on COVID-19 outcomes: a machine learning approach

BACKGROUND

The individual influence of a variety of comorbidities on COVID-19 patient outcomes has already been analyzed in previous works in an isolated way. We aim to determine if different associations of diseases influence the outcomes of inpatients with COVID-19.

METHODS

Retrospective cohort multicenter study based on clinical practice. Data were taken from the SEMI-COVID-19 Registry, which includes most consecutive patients with confirmed COVID-19 hospitalized and discharged in Spain. Two machine learning algorithms were applied in order to classify comorbidities and patients (Random Forest -RF algorithm, and Gaussian mixed model by clustering -GMM-). The primary endpoint was a composite of either, all-cause death or intensive care unit admission during the period of hospitalization. The sample was randomly divided into training and test sets to determine the most important comorbidities related to the primary endpoint, grow several clusters with these comorbidities based on discriminant analysis and GMM, and compare these clusters.

RESULTS

A total of 16,455 inpatients (57.4% women and 42.6% men) were analyzed. According to the RF algorithm, the most important comorbidities were heart failure/atrial fibrillation (HF/AF), vascular diseases, and neurodegenerative diseases. There were six clusters: three included patients who met the primary endpoint (clusters 4, 5, and 6) and three included patients who did not (clusters 1, 2, and 3). Patients with HF/AF, vascular diseases, and neurodegenerative diseases were distributed among clusters 3, 4 and 5. Patients in cluster 5 also had kidney, liver, and acid peptic diseases as well as a chronic obstructive pulmonary disease; it was the cluster with the worst prognosis.

CONCLUSION

The interplay of several comorbidities may affect the outcome and complications of inpatients with COVID-19.

Changes over time in the association between type 2 diabetes and post-discharge outcomes in decompensated chronic heart failure patients: Findings from the RICA Registry

AIMS

Heart failure (HF) and diabetes are 2 strongly associated diseases. The main objective of this work was to analyze changes in the prognosis of patients with diabetes who were admitted for heart failure in 2 time periods.

METHODS

This work is a prospective study comparing prognosis at one year of follow-up among patients with diabetes who were hospitalized for HF in either 2008-2011 or 2018. The patients are from the Spanish Society of Internal Medicine's National Heart Failure Registry (RICA, for its initials in Spanish). The primary endpoint was to analyze the composite outcome of total mortality and/or readmission due to HF in 12 months. A multivariate Cox regression model was used to evaluate the strength of association (hazard ratio [HR]) between diabetes and the outcomes between both periods.

RESULTS

A total of 936 patients were included in the 2018 cohort, of which 446 (48%) had diabetes. The baseline characteristics of the populations from the 2 periods were similar. In patients with diabetes, the composite outcome was observed in 233 (47.5%) in the 2008-2011 cohort and 162 (36%) in the 2018 cohort [HR 1.48; 95% confidence interval (95%CI) 1.18-1.85; p < .001]. The proportion of readmissions (HR 1.39; 95%CI 1.07-1.80; p = .015) and total mortality (HR 1.60; 95%CI 1.20-2.14; p < .001) were also significantly higher in patients with diabetes from the 2008-2011 cohort compared to the 2018 cohort.

CONCLUSIONS

In 2018, an improvement was observed in the prognosis for all-cause mortality and readmissions over one year of follow-up in patients with diabetes hospitalized for HF compared to the 2008-2011 period.

Morbidity and mortality in elderly patients with heart failure managed with a comprehensive care model vs. usual care: The UMIPIC program

BACKGROUND

Elderly patients with heart failure (HF) have a high degree of comorbidity which leads to fragmented care, with frequent hospitalizations and high mortality. This study evaluated the benefit of a comprehensive continuous care model (UMIPIC program) in elderly HF patients.

METHODS AND RESULTS

We prospectively analyzed data from the RICA registry on 2862 patients with HF treated in internal medicine departments. They were divided into two groups: one monitored in the UMIPIC program (UMIPIC group, n: 809) and another which received conventional care (RICA group, n: 2.053). We evaluated HF readmissions during 12 months of follow-up and total mortality after episodes of HF hospitalization. UMIPIC patients were older with higher rates of comorbidity and preserved ejection fraction than the RICA group. However, the UMIPIC group had a lower rate of HF readmissions (17% vs. 26%, p < .001) and mortality (16% vs. 27%, respectively; p < .001). In addition, we selected 370 propensity score-matched patients from each group and the differences in HF readmissions (15% UMIPIC vs. 30% RICA; hazard ratio [HR] = 0.44; 95% confidence interval [CI] 0.32-0.60; p < .001) and mortality (17% UMIPIC vs. 28% RICA; hazard ratio = 0.58; 95% CI 0.42-0.79; p = .001) were maintained.

CONCLUSIONS

The implementation of the UMIPIC program, based on comprehensive continuous care of elderly patients with HF and high comorbidity, markedly reduce HF readmissions and total mortality.

Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study

INTRODUCTION

Ambulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis.

METHODS AND RESULTS

Prospective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (± 8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p=.024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95% CI 1.70-7.26; p=.001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926-0.997; p=.032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year.

CONCLUSION

In older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF.

Comorbidities and their implications in patients with and without type 2 diabetes mellitus and heart failure with preserved ejection fraction. Findings from the rica registry

AIM

To determine if patients with heart failure and preserved ejection fraction (HFpEF) and type 2 diabetes mellitus (T2DM) have a higher comorbidity burden than those without T2DM, if other comorbidities are preferentially associated with T2DM and if these conditions confer a worse patient prognosis.

METHODS AND RESULTS

Cohort study based on the RICA Spanish Heart Failure Registry, a multicentre, prospective registry that enrols patients admitted for decompensated HF and follows them for 1 year. We selected only patients with HFpEF, classified as having or not having T2DM and performed an agglomerative hierarchical clustering based on variables such as the presence of arrhythmia, chronic obstructive pulmonary disease, dyslipidemia, liver disease, stroke, dementia, body mass index, haemoglobin levels, estimated glomerular filtration rate and systolic blood pressure. A total of 1934 patients were analysed: 907 had T2DM (mean age 78.4 ± 7.6 years) and 1027 did not (mean age 81.4 ± 7.6 years). The analysis resulted in four clusters in patients with T2DM and three in the reminder. All clusters of patients with T2DM showed higher BMI and more kidney disease and anaemia than those without T2DM. Clusters of patients without T2DM had neither significantly better nor worse outcomes. However, among the T2DM patients, clusters 2, 3 and 4 all had significantly poorer outcomes, the worst being cluster 3 (HR 2.0, 95% CI 1.36-2.93, P = .001).

CONCLUSIONS

Grouping our patients with HFpEF and T2DM into clusters based on comorbidities revealed a greater disease burden and prognostic implications associated with the T2DM phenotype, compared with those without T2DM.

Blood Pressure, Congestion and Heart Failure with Preserved Ejection Fraction Among Patients with and Without Type 2 Diabetes Mellitus. A Cluster Analysis Approach from the Observational Registry DICUMAP

INTRODUCTION

The association of patients with heart failure (HF) and preserved ejection fraction (HFpEF) and with type 2 diabetes mellitus (T2DM) is strong and related additionally to blood pressure (BP).

AIMS

To analyze distinctive clinical profiles among patients with HFpEF both with and without T2DM.

METHODS

The study was based on a Spanish National Registry (multicenter and prospective) of patients with HF (DICUMAP), that enrolled outpatients with HF who underwent an ambulatory BP monitoring (ABPM) and then were followed-up for 1 year. We categorized patients according to the presence/absence of T2DM then building different clusters based on K-medoids algorithm.

RESULTS

103 patients were included. T2DM was present in 44.7%. The patients with T2DM were grouped into two clusters and those without T2DM into three. All patients with T2DM had kidney disease and anemia. Among them, cluster 2 had higher systolic blood pressure and pulse pressure (PP) with a bad outcome (p = 0.03) regarding HF mortality and readmissions, influenced by eGFR (HR 0.93, 95% CI 0.97-0.87, p = 0.04), and hemoglobin (HR 0.65, 95% CI 0.71-0.63, p = 0.03). Among those without T2DM, cluster 3 had a pathological ABPM pattern with the highest PP, cluster 4 was slightly similar to cluster 2, and cluster 5 expressed a more benign pattern without differences on both, HF mortality and readmissions.

CONCLUSIONS

Patients with HFpEF and T2DM expressed two different profiles depending on neurohormonal activation and arterial stiffness with prognostic implications. Patients without T2DM showed three profiles depending on ABPM pattern, kidney disease and PP without prognostic repercussion.

Influence of potassium levels on one-year outcomes in elderly patients with acute heart failure

BACKGROUND

Abnormal serum potassium levels (K⁺) in patients with heart failure (HF) relate to worse prognosis. We evaluated whether admission K⁺ levels predict 1-year outcomes in elderly patients admitted for acute HF.

METHODS

We evaluated 2865 patients aged >74 years from the RICA Spanish Heart Failure Registry, classified according to admission serum K⁺ levels: hyperkalemia (>5.5 mmol/L), normokalemia (3.5-5.5 mmol/L) and hypokalemia (<3.5 mmol/L). We explored whether K⁺ levels were significantly associated with one-year all-cause mortality or hospital readmission and their combination.

RESULTS

Mean admission K⁺ value was 4.3 ± 0.6 mmol/L; 97 patients (3.38%) presented with hyperkalemia and 174 (6.06%) with hypokalemia. Overall, 43% of the patients died or were readmitted for HF during the follow-up period; the risk was higher for those with hyperkalemia (59% vs 41% in hypokalemic patients). The HR for one-year mortality was 1.43 (p = .073) and 1.67 for readmissions (p = .007) when K⁺ was >5.5 mmol/L and 1.08 (p = .618) and 0.90 (p = .533) respectively for K⁺ < 3.5 mmol/L. The HR for the combined outcome was 1.59 (1.19-2.13); p = .002 in hyperkalemic patients and 0.96 (0.75-1.23); p = .751in hypokalemic patients. Multivariate analysis showed a significant association of admission K⁺ values >5.5 mmol/L with the combined outcome of mortality and readmission (HR 1.15 [95% CI 1.04-1.27], p = .008).

CONCLUSION

In patients hospitalized for decompensated HF, admission hyperkalemia predicts a higher mid-term risk for HF readmission and mortality, probably related to the significant higher risk of readmission.

Association between serum uric acid and carotid disease in patients with atherosclerotic acute ischemic stroke

Aim

The role of serum uric acid in ischemic stroke is controversial. On the one hand, it has a role as neuroprotectant in acute phase, but on the other hand, it may promote atherosclerosis in carotid arteries. Our aim is to investigate the association of serum uric acid levels at admission of acute ischemic stroke patients with carotid disease.

Methods

Cross-sectional study of patients admitted due to acute ischemic stroke. Clinical and laboratory variables were recorded. The carotid disease was defined based on the findings of carotid echography intima to media thickness and stenosis. Patients were grouped according to these findings. Robust statistical methods were applied into analysis.

Results

A total of 245 patients were recruited through a stroke registry. Their values of serum uric acid were related to both carotid intima to media thickness and stenosis showing a positive relationship between serum uric acid levels and intima to media thickness by Pearson correlation ( p < 0.05). Similarly, after adjusting for all potential confounders, eGFR, glucose, age and serum uric acid levels, (OR 1.26 (95% CI 1.04 −1.52, p¼0.01), were identified as independent predictors for having a intima to media thickness ≥1 mm. Similarly, by grouping patients in tertiles of the serum uric acid distribution, we found a predominantly greater carotid disease in the tertile with the highest levels of serum uric acid ( p < 0.005).

Conclusion

Our study supports the hypotheses that serum uric acid levels have different roles in the case of ischemic stroke. Its effects on the vascular wall contribute to the development of atherosclerosis and carotid disease.

Ambulatory blood pressure monitoring in heart failure and serum sodium levels

AIMS

To determine whether there are differences in blood pressure profile on dynamic assessment by ambulatory blood pressure monitoring (ABPM) according to serum sodium levels in stable heart failure patients.

METHODS

Data were collected from the Spanish National Registry on Ambulatory Blood Pressure Monitoring in Heart Failure (DICUMAP). Patients underwent ABPM by the oscillometric principle using a Spacelabs 90121 monitor. The sample was divided into three groups according to sodium levels and their clinical and laboratory data and echocardiographic findings were analyzed. Robust statistical methods were used to compare the groups in univariate and multivariate models.

RESULTS

A total of 175 patients (44.57% male) were analyzed. We found a predominance of anomalous circadian blood pressure profiles in all three groups, with a significantly higher percentage of risers in the lowest serum sodium group (p=0.05). In addition, in this group there were significant differences in mean 24-hour systolic blood pressure (SBP) (24-h SBP, p=0.05) and in mean daytime SBP (dSBP, p=0.008), with significant differences in nocturnal fall in SBP (p=0.05) and in diastolic blood pressure (p=0.005). In multivariate analysis a significant relationship was found between sodium levels and 24-h SBP (OR 0.97, 95% CI 0.95-0.99, p=0.01) and dSBP (OR 0.96, 95% CI 0.94-0.99, p=0.004).

CONCLUSION

A relationship was found between lower sodium levels and lower systolic blood pressure, especially during waking hours, with a lower decline between daytime and night-time blood pressure.

Clinical relevance for lowering C-reactive protein with statins

The role of statins in the protection of atherosclerosis and reducting cardiovascular (CV) events is well established. On the other hand, the role of inflammation in the propagation and propensity to CV events has also been demonstrated. High-sensitivity C-reactive protein (CRP) which is involved in the immunologic process of inflammation has received the interest for its use in screening and risk reclassification. However, evidence for its causal relationship with atherothrombosis is lacking, and even more, knowing that statins influence on the reduction of CRP levels, a relevant evidence of their clinical benefits in this regard is also lacking. This article reviews four different key points regarding the issue, to better understand the current state and application of the treatment with statins in order to achieve benefits from lowering CRP's levels regarding CV diseases: (1) the mechanisms of reduction of CRP levels by statins; (2) the role of statin-mediated CRP reduction in the atherosclerotic plaque regression; (3) the role in the prevention of CV diseases; and (4) the role in case of secondary prevention. With this basis, the reduction of CRP levels should be interpreted as a reduction of inflammatory burden thus its clinical benefits could be more interesting in secondary prevention. KEY MESSAGES It could be admitted a role of statin-mediated CRP diminution to reduce the rate of progression in atherosclerotic plaque. In general, and in the absence of specific clinical trials, the role of statins by lowering CRP and consequently, preventing cardiovascular events may be superior in case of secondary prevention because a more pronounced state of inflammation and regardless of its levels at baseline.

Secondary hyperparathyroidism prevalence and profile, between diabetic and non-diabetic patients with stage 3 to 4 chronic kidney disease attended in internal medicine wards. MiPTH study

AIMS

Secondary hyperparathyroidism (SHPTH) is a leading cause of renal osteodystrophy, and an independent risk factor for all-cause and cardiovascular mortality. Our aim is to establish differences in prevalence and profile of SHPTH, regarding diabetics or non-diabetics with chronic kidney disease (CKD).

METHODS

Cross-sectional multicenter study which included patients with stages 3 to 4 CKD. SHPTH was considered when the intact PTH levels (iPTH) were equal or higher than 70pg/ml. We divided the sample into two groups (diabetics and non-diabetics). We used robust statistical methods.

RESULTS

409 patients (214 diabetics) were studied. HPTH was found in 60.4% of diabetics vs 65% of non-diabetics (P=0.42). Diabetics with HPTH were younger (79.5 vs 82.3 years-old, P=0.005), and had more hypertension (P=0.0014), dyslipidemia (P=0.0001) and comorbidities. In multivariate analysis, we found a significant relationship in case of diabetics, with age (OR: 1.04, 95%CI 1.005-1.09 P=0.02 ), and with statins treatment (OR 2.3, 95%CI 1.17-4.54, P=0.01).

DISCUSSION

The prevalence of SHPTH between the groups was similar, however, diabetics had more presence of hypertension and dyslipidemia, and SHPTH in this case was also related with moderate microalbuminuria and lower levels of vitamin D. An association with statins was also found in this group.

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.

Lowering C-reactive protein with statins after an ischemic stroke avoids mortality and readmissions. A prospective cohort study

AIMS

A hypothetical benefit of statins after an ischemic stroke could be provided by their pleiotropic effects. Our aim is to test if statins are able to avoid mortality and readmissions of patients with ischemic stroke, by lowering their levels of not only LDL-cholesterol but also CRP.

METHODS

A prospective cohort study was performed. Pre-stroke and post-stroke medications were recorded. Cholesterol and hsCRP levels were measured at admission and 90 days post-stroke. Rankin score and fatality or readmissions were assessed at 90 days and 1 year. We have used robust statistical methods.

RESULTS

Of 359 stroke patients, statins were prescribed before stroke onset in 30.6% (110/359) and were begun during hospitalization in an additional 32.3% (116/359). In logistic regression analysis adjusted, statins therapy was independently associated with improved total mortality (OR 0.30; 95% CI 0.11-0.86; P < 0.02), improved cardiovascular mortality (OR 0.29; 95% CI 0.08-0.98; P < 0.04), and improved total mortality and readmission rates (OR 0.35; 95% CI 0.18-0.7; P < 0.003). In the final model, lowering the levels of hsCRP by 0.4mg/dL, a 30% of mortality or readmissions would be avoided.

CONCLUSIONS

Therapy with statins, either previous or early initiation, after an ischemic stroke, could improve the survival and readmission rates by lowering both cholesterol and hsCRP levels.

Cerebral venous thrombosis with subarachnoid hemorrhage: a case report

Cerebral venous thrombosis (CVT) presenting as subarachnoid hemorrhage (SAH) is infrequent. We present the case of a man with CVT of the right transverse sinus who presented with a SAH in the right parietal sinus. In this case, we describe a hyper-homocysteinemia in a heterozygous patient for the methylenetetrahydrofolate reductase C667T mutation. Our report highlights the value of an early diagnosis of CVT, the importance of identifying possible causes that could be reversed with an appropriate treatment, and the controversy about the timing for starting anticoagulation therapy in such cases.

Association between type-2 diabetes mellitus and post-discharge outcomes in heart failure patients: findings from the RICA registry

AIMS

Heart failure (HF) and diabetes are common clinical conditions that may coexist. The main objective was to analyze the association of type-2 diabetes mellitus (T2DM) on prognosis in hospitalized patients with HF.

METHODS

We evaluated the association between T2DM with all-cause mortality and readmissions in the Spanish National Registry on Heart Failure-"Registro Nacional de Insuficiencia Cardiaca" (RICA). This is a multi-center and prospective cohort study that includes patients admitted for decompensated HF from 2008 to 2011. Study endpoints were all-cause mortality and hospital readmission. We determined the adjusted hazard ratio (HR) by a multivariable Cox regression model.

RESULTS

A total of 1082 patients (mean age 77.6±8.5) were included of whom 490 (45.3%) had diabetes and 592 patients (54.7%) had preserved left ventricular ejection fraction (LVEF). During one-year follow-up, 287 patients died (151 patients with diabetes) and 383 patients were readmitted (197 patients with diabetes). After adjusting for baseline characteristics T2DM was significantly associated with all-cause mortality (HR 1.54; 95%CI 1.20-1.97, p=0.001) and readmissions (HR 1.46; 95%CI 1.18-1.80, p<0.001). Age, dementia, peripheral vascular disease, NYHA class, renal insufficiency, hyponatremia and anemia were also independently associated with outcomes. There were no differences in mortality (p=0.415) and readmissions (p=0.514) according to preserved or reduced LVEF.

CONCLUSION

T2DM is very common in patients hospitalized for HF. This condition is a strong and independent co-morbidity of all-cause mortality and readmission for both HF with preserved and reduced LVEF.

Mean platelet volume predicting carotid atherosclerosis in atherothrombotic ischemic stroke

BACKGROUND

Platelets are involved in atherosclerosis. Mean platelet volume (MPV) could be a marker of platelet activation. We aim to determine whether MPV levels were correlated with the presence of atherosclerotic disease in carotid arteries of patients with stroke.

METHODS

We recruited 215 patients with atherothrombotic stroke. All the participants underwent ultrasonographic evaluation of their extracranial carotid arteries. MPV was measured in automated hematology analysis system. The subjects were divided according to plaques and severity of carotid stenosis. Univariate and multivariate statistical analyses and a ROC curve to predict carotid stenosis were performed.

RESULTS

Univariate analysis showed a positive relationship between MPV and the degree of carotid atherosclerosis (p < 0.00007), and with carotid intima to media thickness (p < 0.00002). In ROC curve, a MPV cut-off of 11.25 fl was obtained for a sensibility of 70% and a specificity of 71% (p < 0.02). Multivariate analysis showed significant correlation with severity of carotid stenosis, when MPV was higher than 11.25 fl (OR: 2.9, p < 0.00007).

CONCLUSIONS

Our results indicate that an elevated MPV could be an easily measurable marker of severity of carotid stenosis in patients with atherothrombotic stroke.

[C-reactive protein in the acute phase of ischemic stroke]

BACKGROUND AND OBJECTIVE

We aimed to assess the prognostic importance of C-reactive protein (CRP) in the acute phase of ischemic stroke in-patients.

PATIENTS AND METHOD

One hundred and seventeen patients within 48 h after index ischemic stroke were included. CRP levels and blood samples were obtained at this time, and a brain computerized tomography or magnetic resonance imaging were performed. Neurological and functional disability were evaluated and patients were divided according to the outcome into the following categories: transient ischemic attack, favorable stroke, and non-favorable stroke.

RESULTS

32 in-patients were classified as transient ischemic attack, 31 as favourable stroke, and 54 as non-favorable stroke. There was a worsening in neurological (p < 0.0001) and functional (p < 0.005) disabilities from the TIA group to non-favorable stroke. The CRP mean, by category, was 1.7, 1.07 and 3.6 mg/dl, respectively (p < 0.0001).

CONCLUSIONS

We found increased levels of CRP in the non-favorable stroke category, that was related with neurological and functional disabilities, and with radiological findings, mainly when levels were greater than 3.6 (0.49) mg/dl.