Estancia media, mortalidad intrahospitalaria y reingresos en pacientes hospitalizados por insuficiencia cardiaca en España

La insuficiencia cardiaca (IC) es uno de los principales problemas sanitarios en España, aunque la falta de estudios con un diseño adecuado impide conocer con exactitud la envergadura real de este problema clínico. La prevalencia de la IC se estima en un 2% en otros países europeos y en Estados Unidos, mientras que los estudios epidemiológicos en nuestro país la sitúan en torno al 5%, probablemente debido a sus limitaciones metodológicas. La IC es una auténtica epidemia cardiovascular de nuestro siglo: es la primera causa de ingreso de mayores de 65 años, supone el 3% del total de las hospitalizaciones, y consume el 2,5% del presupuesto sanitario. La IC presenta dos perfiles clínicos diferenciados: la IC con fracción de eyección preservada (IC-FEP), más relacionado con la hipertensión arterial, y la IC con fracción de eyección reducida (IC-FER), asociada frecuentemente a la cardiopatía isquémica. En los últimos años hemos sido testigos de una reducción progresiva de la mortalidad por IC, en parte consecuencia de una mayor aplicación de las recomendaciones de las Guías Internacionales de práctica clínica..

Documento de consenso y recomendaciones sobre cuidados paliativos en insuficiencia cardiaca de las Secciones de Insuficiencia Cardiaca y Cardiología Geriátrica de la Sociedad Española de Cardiología

Review[Abstract] Heart failure is a complex entity, with high morbidity and mortality. The clinical course and outcome are uncertain and difficult to predict. This document, instigated by the Heart Failure and Geriatric Cardiology Working Groups of the Spanish Society of Cardiology, addresses various aspects related to palliative care, where most cardiovascular disease will eventually converge. The document also establishes a consensus and a series of recommendations with the aim of recognizing and understanding the need to implement and progressively apply palliative care throughout the course of the disease, not only in the advanced stages, thus improving the care provided and quality of life. The purpose is to improve and adapt treatment to the needs and wishes of each patient, who must have adequate information and participate in decision-making.[Resumen] La insuficiencia cardiaca es una entidad compleja, que conlleva elevada morbilidad y mortalidad y cuyo curso y evolución son inciertos y difíciles de predecir. Este trabajo, impulsado por las Secciones de Insuficiencia Cardiaca y Cardiología Geriátrica de la Sociedad Española de Cardiología, aborda los diferentes aspectos relacionados con los cuidados paliativos en el campo de la insuficiencia cardiaca, vía final común de la mayoría de las enfermedades cardiovasculares. También establece un consenso y una serie de recomendaciones con el objetivo de reconocer y comprender la necesidad de implementar y aplicar, de modo progresivo, este tipo de cuidados a lo largo del curso de la enfermedad, y no únicamente en sus estadios avanzados, para mejorar la atención que reciben los pacientes y su calidad de vida. La finalidad es mejorar y adecuar los tratamientos a las necesidades y los deseos de cada paciente, que debe contar con información adecuada y ser partícipe de la toma de decisiones

Hyperkalemia in Heart Failure Patients in Spain and Its Impact on Guidelines and Recommendations: ESC-EORP-HFA Heart Failure Long-Term Registry

[Abstract] Introduction and objectives: Hyperkalemia is a growing concern in the treatment of patients with heart failure and reduced ejection fraction because it limits the use of effective drugs. We report estimates of the magnitude of this problem in routine clinical practice in Spain, as well as changes in potassium levels during follow-up and associated factors. Methods: This study included patients with acute (n=881) or chronic (n=3587) heart failure recruited in 28 Spanish hospitals of the European heart failure registry of the European Society of Cardiology and followed up for 1 year. Various outcomes were analyzed, including changes in serum potassium levels and their impact on treatment. Results: Hyperkalemia (K+> 5.4 mEq/L) was identified in 4.3% (95%CI, 3.7%-5.0%) and 8.2% (6.5%-10.2%) of patients with chronic and acute heart failure, respectively, and was responsible for 28.9% of all cases of contraindication to mineralocorticoid receptor antagonist use and for 10.8% of all cases of failure to reach the target dose. Serum potassium levels were not recorded in 291 (10.8%) of the 2693 chronic heart failure patients with reduced ejection fraction. During follow-up, potassium levels increased in 179 of 1431 patients (12.5%, 95%CI, 10.8%-14.3%). This increase was directly related to age, diabetes, and history of stroke and was inversely related to history of hyperkalemia. Conclusions: This study highlights the magnitude of the problem of hyperkalemia in patients with heart failure in everyday clinical practice and the need to improve monitoring of this factor in these patients due to its interference with the possibility of receiving optimal treatment.[Resumen] Introducción y objetivos. La hiperpotasemia es una preocupación creciente en el tratamiento de los pacientes con insuficiencia cardiaca y fracción de eyección reducida, pues limita el uso de fármacos eficaces. Este trabajo ofrece estimaciones de la magnitud de este problema en la práctica clínica habitual en España, los cambios en las concentraciones de potasio en el seguimiento y los factores asociados. Métodos. Pacientes con insuficiencia cardiaca aguda (n = 881) y crónica (n = 3.587) seleccionados en 28 hospitales españoles del registro europeo de insuficiencia cardiaca de la European Society of Cardiology y seguidos 1 año para diferentes desenlaces, incluidos cambios en las cifras de potasio y su impacto en el tratamiento. Resultados. La hiperpotasemia (K+ > 5,4 mEq/l) está presente en el 4,3% (IC95%, 3,7-5,0%) y el 8,2% (6,5-10,2%) de los pacientes con insuficiencia cardiaca crónica y aguda; causa el 28,9% de todos los casos en que se contraindica el uso de antagonistas del receptor de mineralocorticoides y el 10,8% de los que no alcanzan la dosis objetivo. Del total de 2.693 pacientes ambulatorios con fracción de eyección reducida, 291 (10,8%) no tenían registrada medición de potasio. Durante el seguimiento, 179 de 1.431 (12,5%, IC95%, 10,8-14,3%) aumentaron su concentración de potasio, aumento relacionado directamente con la edad, la diabetes mellitus y los antecedentes de ictus e inversamente con los antecedentes de hiperpotasemia. Conclusiones. Este trabajo destaca el problema de la hiperpotasemia en pacientes con insuficiencia cardiaca de la práctica clínica habitual y la necesidad de continuar y mejorar la vigilancia de este factor en estos pacientes por su interferencia en el tratamiento óptimo

Estratificación del riesgo y prevención de la muerte súbita en pacientes con insuficiencia cardíaca

Los pacientes con insuficiencia cardíaca (IC) pueden fallecer como consecuencia de un fallo progresivo de bomba o de muerte súbita (MS). En este artículo analizaremos los predictores de MS en pacientes con IC secundaria a disfunción sistólica ventricular izquierda. Aunque en los estudios realizados en estos pacientes se han detectado distintos predictores univariados independientes relacionados con la supervivencia, la mayor parte de ellos ha demostrado tener un valor predictivo positivo muy limitado. El desfibrilador implantable ha confirmado ser el tratamiento más eficaz en pacientes resucitados de una parada cardíaca debida a fibrilación ventricular o a una taquicardia ventricular hemodinámicamente mal tolerada. La presencia de una fracción de eyección ventricular izquierda baja, un mal grado funcional, una taquicardia ventricular no sostenida y la inducibilidad de arritmias ventriculares en el estudio electrofisiológico ayudan a identificar a los pacientes candidatos al implante de un desfibrilador. El papel de la amiodarona a la hora de prevenir la MS en pacientes de riesgo elevado con fracaso cardíaco parece pequeño. Se necesitan más estudios que nos ayuden a conseguir una mejor estratificación del riesgo en pacientes con IC, con el fin de reconocer mejor a los candidatos a un desfibrilador implantabl

A Delphi consensus on the management of oral anticoagulation in patients with non-valvular atrial fibrillation in Spain: ACOPREFERENCE study.

OBJECTIVE:To evaluate the level of agreement between cardiologists regarding the management of oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (NVAF) in Spain. MATERIALS AND METHODS:A two-round Delphi study was performed using an online survey. In round 1, panel members rated their level of agreement with the questionnaire items on a 9-point Likert scale. Item selection was based on acceptance by ≥66.6% of panellists and the agreement of the scientific committee. In round 2, the same panellists evaluated those items that did not meet consensus in round 1. RESULTS:A total of 238 experts participated in round 1; of these, 217 completed the round 2 survey. In round 1, 111 items from 4 dimensions (Thromboembolic and bleeding risk evaluation for treatment decision-making: 18 items; Choice of OAC: 39 items; OAC in specific cardiology situations: 12 items; Patient participation and education: 42 items) were evaluated. Consensus was reached for 92 items (83%). Over 80% of the experts agreed with the use of DOACs as the initial anticoagulant treatment when OAC is indicated. Panellists recommended the use of DOACs in patients at high risk of thromboembolic complications (CHA2DS2-VASc ≥3) (83%), haemorrhages (HAS-BLED ≥3) (89%) and poor quality of anticoagulation control (SAMe-TT2R2 >2) (76%), patients who fail to achieve an optimal therapeutic range after 3 months on VKA treatment (93%), and those who are to undergo cardioversion (80%). Panellists agreed that the efficacy and safety profile of each DOAC (98%), the availability of a specific reversal agent (72%) and patient's preference (85%) should be considered when prescribing a DOAC. A total of 97 items were ultimately accepted after round 2. CONCLUSIONS:This Delphi panel study provides expert-based recommendations that may offer guidance on clinical decision-making for the management of OAC in NVAF. The importance of patient education and involvement has been highlighted

Discharge treatment with angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker after a heart failure hospitalisation is associated with a better prognosis irrespective of left ventricular ejection fraction

Background Medical therapy could improve the prognosis of real‐life patients discharged after a heart failure (HF) hospitalisation. Aim To determine the impact of discharge HF treatment on mortality and readmissions in different left ventricular ejection fraction (LVEF) groups. Methods Multicentre prospective registry in 20 Spanish hospitals. Patients were enrolled after a HF hospitalisation. Results A total of 1831 patients was included (583 (31.8%) HF with reduced ejection fraction (HFrEF); 227 (12.4%) HF with midrange ejection fraction (HFmrEF); 610 (33.3%) HF with preserved ejection fraction (HFpEF), and 411 (22.4%) with unknown LVEF). Angiotensin‐converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARB) at discharge were independently associated with a reduction in: (i) all‐cause mortality: hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.41–0.74, P < 0.001, with a similar effect in the four groups; (ii) mortality due to refractory HF HR 0.45, 95% CI 0.29–0.64, P < 0.001, with a similar effect in the three groups with known LVEF; (iii) mortality/HF admissions (HR 0.61; 95% CI: 0.50–0.74), more evident in HFrEF (HR 0.54; 95% CI: 0.38–0.78) compared with HRmEF (HR 0.64; 95% CI 0.40–1.02), or HFpEF (HR 0.70; 95% CI 0.53–0.92). In patients with HFrEF triple therapy (ACE inhibitor/ARB + beta blocker + mineralocorticoid receptor antagonist) was associated with the lowest mortality risk (HR 0.21; 95% CI: 0.08–0.57, P = 0.002) compared with patients that received none of these drugs. Conclusions Discharge treatment with ACE inhibitor/ARB after a HF hospitalisation is associated with a reduction in all‐cause and refractory HF mortality, irrespective of LVEF.CIBERCV - Instituto de Salud Carlos III1.677 JCR (2019) Q3, 86/165 Medicine, General & Internal0.573 SJR (2019) Q2, 66/139 Internal MedicineNo data IDR 2019UE

Prognostic Impact of Hyponatremia and Hypernatremia at Admission and Discharge in Heart Failure Patients With Preserved, Mid-Range, and Reduced Ejection Fraction

Background Hyponatremia is common in patients with acute heart failure (HF). Our aim was to determine the impact of sodium disturbances on mortality and readmissions in HF with reduced left ventricular ejection fraction (HFrEF), preserved ejection fraction (HFpEF), and mid‐range ejection fraction (HFmrEF). Methods Prospective multicentre consecutive registry in 20 hospitals including patients admitted due to acute HF in cardiology departments. Sodium 145 mmol/L hypernatremia, and 135–145 mmol/L normal. Results A total of 1309 patients were included. Mean age was 72.0 ± 11.9 years, 810 (61.9%) were male. Mean serum sodium level was 138.6 ± 4.7 mmol/L at hospital admission, and 138.1 ± 4.1 mmol/L at discharge. The evolution of sodium levels was: normal‐at‐admission/normal‐at‐discharge 941 (71.9%), abnormal‐at‐admission/normal‐at‐discharge 127 (9.7%), normal‐at‐admission/abnormal‐at‐discharge 155 (11.8%), and abnormal‐at‐admission/abnormal‐at‐discharge 86 (6.6%). Hyponatremia at discharge was more common in HFrEF (109 (20.7%)) than in HFpEF (79 (13.9%)) and HFmrEF (27 (12%)), P = 0.003. The prevalence of hypernatremia at discharge was similar in the three groups: HFrEF (10 (1.9%)), HFpEF (12 (2.1%)), and HFmrEF (4 (1.9%)), P = 0.96. In multivariate analysis, abnormal sodium concentrations at hospital admission (Hazard Ratio (HR) 1.42, 95% confidence interval (CI) 1.15–1.76, P = 0.001), and discharge (HR 1.33, 95% CI 1.08–1.64, P = 0.007) were both independently associated with increased mortality and readmissions at 12 months. Conclusions Hyponatremia and hypernatremia at admission and discharge predict a poor outcome in patients with acute HF, regardless of LVEF. Hyponatremia at discharge is more frequent in HFrEF than in the other LVEF groups.Sin financiación2.048 JCR (2020) Q3, 95/167 Medicine, General & Internal0.596 SJR (2020) Q3, 67/131 Internal MedicineNo data IDR 2020UE