Use of Diagnostic and Therapeutic Resources in Patients Hospitalized for Heart Failure: Influence of Admission Ward Type (INCARGAL Study)

[Resumen] Antecedentes. La insuficiencia cardíaca es la enfermedad cardiológica de más crecimiento en las naciones desarrolladas, y supone ya la primera causa de ingreso en ancianos. No se ha estudiado bien la diferencia que el servicio de ingreso supone en cuanto al manejo de la insuficiencia cardíaca ni los factores que condicionan el servicio de ingreso. Objetivos. Establecer si existen diferencias de manejo pronóstico en función del servicio de ingreso (cardiología frente a medicina interna y geriatría) en pacientes con insuficiencia cardíaca. Pacientes y método. Estudio transversal en que 951 pacientes (505 varones y 446 mujeres) ingresados consecutivamente por insuficiencia cardíaca en los servicios de cardiología (n = 364), medicina interna y geriatría (n = 587) de 14 hospitales de Galicia fueron reclutados durante un período máximo de 6 meses, registrándose en el momento del ingreso las principales variables epidemiológicas y clínicas, complicaciones, tratamientos y situación en el momento del alta. Resultados. Los pacientes con insuficiencia cardíaca tenían una edad media de 75,5 ± 12,4 años (78,5 ± 10,6 en mujeres y 72,7 ± 13,5 en varones). La estancia media fue de 11 ± 8 días, con un 50,8% de primeros ingresos, siendo la mortalidad global hospitalaria del 6,8%. El 58,9% de los pacientes tenía hipertensión arterial, el 31,8% cardiopatía isquémiea, el 27,7% valvulopatía, el 28,4% diabetes mellitus y el 32,5% EPOC. Por servicios, los pacientes atendidos en servicios de cardiología son más jóvenes (72,5 ± 13,3 frente a 77,4 ± 11,4 años; p < 0,005), con más varones (51,9 frente a 3,7%; p < 0,01), mayor proporción de primeros ingresos (54,8 frente a 48,4; p < 0,05) Y de edema agudo de pulmón (22,8 frente a 9,2%; P < 0,001). Las odds ratio (y sus intervalos de confianza [IC] del 95%) de realización de procedimientos diagnósticos y terapéuticos en función del servicio de ingreso (el grupo de referencia es medicina interna-geriatría), ajustando por edad, sexo, función sistólica, número de ingresos y antecedentes personales de demencia, hipertensión arterial, EPOC, infarto agudo de miocardio, valvulopatía, arteriopatía periférica y cardiopatía isquémica, son: ecocardiograma, 3,31 (2,42-4,52); cateterismo, 6,61 (2,78-15,73); ingreso en UCI, 3,4 (1,48-7,8); revascularización, 2,93 (0,54-15,74), y tratamiento con bloqueado res beta 2,87 (1,37-6,04). No se observaron diferencias en la mortalidad temprana (6,6% en cardiología frente a 7% en medicina interna-geriatría) ni en la estancia media. Conclusiones. El servicio de ingreso determinó una clara diferencia en el manejo de la insuficiencia cardíaca, con una mayor adhesión a los protocolos de tratamiento y uso de recursos por parte de los cardiólogos que no se tradujo en diferencias en la mortalidad temprana. Se precisa un seguimiento de los pacientes para evaluar el impacto de estas diferencias en el pronóstico y la evolución de la insuficiencia cardíaca a medio y largo plazos, así como la relación coste-beneficio en una población de edad media avanzada.[Abstract] Background. Heart failure (HF) is the most rapidly growing cardiac pathology in industrialized countries, and already the primary cause of hospital admissions of elderly people. Outside the field of clinical trials, there have not been many studies in Spain of the influence of the admission department on diagnostic and therapeutic management, whether this affects short-term and long-term prognosis, and the factors that determine the department the patient is admitted to. Objectives. To analyze whether management and prognosis of patients admitted with heart failure differ depending on the admission ward (cardiology versus internal medicine-geriatrics). Patients and method. Cross-sectional study of 951 patients (505 men and 446 women) consecutively hospitalized for HF in the cardiology (n = 363) and internal medicine-geriatrics (n = 588) wards of 12 hospitals of Galicia and recruited over a maximum period of 6 months. The main epidemiological and clinical variables were recorded at admission, and the complications, treatments, and clinical status were recorded at release. Results. HF patients had a mean age of 75.5 ± 12 years (women 78.5 years and men 72.6 years). The average hospitalization time was 11 ± 8 days and 50.8% were first admissions. Total hospital mortality was 6.8%. Fifty-nine percent (58.9%) of patients had arterial hypertension, 31.9% ischemic heart disease, 27.6% cardiac valve disease, 28.5% diabetes mellitus, and 32.5% chronic obstructive pulmonary disease (COPO). The patients admitted to cardiology ward were younger (72.5 ± 13 vs 77.4 ± 11 years; p < 0.005), more frequently men (51.9 vs 43.7%; P < 0.005), more often first hospitalizations (54.8 vs 48.4%; P < 0.005), and acute pulmonary edema was more common (22.8 vs 9.2%; P < 0.005). The odds ratio (and 95% CI) for therapeutic and diagnostic procedures in relation to admission ward (reference group internal medicine-geriatrics), adjusted for age, sex, systolic function, number of hospitalizations, and history of dementia, hypertension, COPO, AMI, valve disease and ischemic heart disease, are: echocardiogram, 3.49 (2.58-4.73); catheterization, 6.42 (3.29-12.55), admission to intensive care, 3.94 (2.15-7.25), revascularization, 2.15 (0.57-8.08), and beta-blocker treatment, 3.39 (1.93-5.97). No differences in hospital mortality (6.6% in cardiology vs 7% in internal medicine-geriatrics) or average hospitalization time were found between departments. Conclusions. The admission ward was related with a clear difference in HF management, with better adherence to guidelines and more use of resources by cardiologists. This was unrelated with differences in hospital mortality so a longer follow-up of these patients is required to evaluate the impact of these therapeutic measures on the prognosis and evolution of HF, as well as the cost-benefit relation in an elderly patient population

Use of anticoagulation at the time of discharge in patients with heart failure and atrial fibrillation

[Resumen] Introducción y objetivos. Evaluar el grado de cumplimiento de las guías sobre uso de anticoagulación crónica en pacientes con insuficiencia cardíaca y fibrilación auricular. Pacientes y método. Se usó la base de datos del estudio INCARGAL, analizando datos de 195 pacientes consecutivos (88 varones, edad 76 ± 10 años) admitidos con ambos diagnósticos en tres hospitales gallegos entre enero y junio de 1999. Se asumió que todos deberían de haber recibido anticoagulación al alta hospitalaria en ausencia de contraindicaciones. Se comparó el tratamiento al alta (anticoagulación o no) con la presencia o ausencia de contraindicaciones. Resultados. Un total de 152 pacientes (78%) no tenían contraindicaciones para la anticoagulación y 43 presentaban alguna (absoluta, 11; relativa, 32). De los pacientes sin contraindicación, sólo recibieron anticoagulación al alta el 50%. Ningún paciente con contraindicación absoluta y tres con contraindicación relativa recibieron anticoagulación. La prescripción de anticoagulación en los pacientes sin contraindicaciones fue menor en los que tenían una mayor edad, antecedente de cardiopatía isquémica, ausencia de valvulopatía, uso de bloqueadores beta, no realización de ecocardiograma e ingreso en un servicio diferente del de cardiología (p < 0,05). En el análisis multivariante, la edad, el infarto de miocardio previo y la ausencia de valvulopatía significativa permanecieron como predictores independientes de menor uso de anticoagulación. Conclusiones. El empleo de anticoagulación al alta hospitalaria en pacientes sin contraindicación para su uso, con fibrilación auricular e insuficiencia cardíaca, es menor del recomendado. La edad avanzada disminuye su empleo. La presencia de otras indicaciones para la antiagregación o la anticoagulación parecen determinar la elección de una u otra terapia. No hubo mala adecuación por exceso de prescripción.[Abstract] Introduction and objectives. To assess the degree of compliance with current guidelines for chronic anticoagulation in patients with heart failure and atrial fibrillation. Patients and method. From the INCARGAL Study database, we analyzed data from 195 consecutive patients (88 men; mean age 76 ± 10 years) with both conditions, admitted to three Galician hospitals between January and March 1999. It was assumed that these patients should have received anticoagulant therapy at discharge, unless contraindicated. We studied the association of treatment at discharge (anticoagulation or not) with the presence or absence of contraindications. Results. -152 patients (78%) had no contraindication for anticoagulation and 43 had at least one (absolute: 11, relative: 32). Only 50% of patients without contraindications received anticoagulation at the time of discharge. No patient with an absolute contraindication and 3 with a relative one received anticoagulation. Factors related with the less frequent prescription of anticoagulation therapy in patients without a formal contraindication were: age, a previous history of coronary heart disease, absence of valvular heart disease, prior' myocardial infarction, treatment with beta-blocking agents, non performance of an echocardiogram, and admission to a department other than cardiology. On multivariate analysis, age, prior myocardial infarction, and non-valvular disease were found to be independent predictors of less use of anticoagulation. Conclusions. Anticoagulant therapy is used less often than recommended at discharge in patients with heart failure and atrial fibrillation for whom there were no contraindications. Advanced age reduces its use. The presence of other indications for antiplatelet or anticoagulatión therapy appears to determine the choice of one or the other. Noncompliance with the guidelines due to overprescription was not found

Hypotension, acidosis and vasodilation syndrome after heart transplant: incidence, risk factors, and prognosis

[Abstract] Background. HAV syndrome, the combination of hypotension, acidosis and vasodilation (HAV), is a serious postoperative complication after heart transplantation (HT). Its etiology and prognosis are poorly understood. Aim. To determine the incidence and prognosis of post-HT HAV syndrome and examine possible risk factors. Methods. Retrospective examination of the records of 85 consecutive patients who underwent HT between December 1999 and June 2002 sought the HAV criteria: systolic BP <85 mm Hg plus HCO3 <19 mEq/l whole excluding cardiogenic, hypovolemic and septic shock. Donor variables included sex, age, weight, height, cause of death, time in ICU, and ischemic time; while recipient variables, sex, age, weight, height, etiology of cardiopathy, previous cardiopulmonary bypass surgery, preoperative amiodarone, β-blockers, catecholamines, mechanical ventilation or intra aortic balloon pump (IABP), RVP, time on waiting list, pump time, reoperations, polytransfusion, preoperative creatinine, GOT, GPT and GGT, induction with OKT3 or anti-CD25, bypass-to-HAV time, duration of catecholamine treatment, and 1 month survival after HT. Results. The 11 HAV cases (13%) appeared between 1 and 72 h after HT (75% in the first hour). Catecholamines were used for 1 to 6 days; control was achieved within 48 h in 58% of cases. Two HAV patients (18%) died within the first month versus six non-HAV patients (8.1%) (P = .275). Only polytransfusion showed more than a borderline value to predict HAV syndrome. Conclusions. HAV syndrome has an incidence of 13% and a mortality of 18% within 1 month post-HT. The only likely risk factor is polytransfusion

Prognostic Value of Treadmill Exercise Echocardiography

[Abstract] Introduction and objectives. Exercise echocardiography (EE) is useful for diagnosing coronary disease, but little is known about its value for risk stratification. We aimed to determine: a) whether data from EE supplemented clinical data and data from exercise testing and resting echocardiography in predicting cardiac events; and b) whether the number and location of abnormal regions and their responses to exercise influenced risk stratification. Patients and method. The 2,436 patients referred for EE were followed up for 2.1 ±1.5 years. Some 120 serious cardiovascular events (i.e., non-fatal myocardial infarction or cardiovascular death) occurred before revascularization. Results. In 1203 patients (49%), EE gave abnormal results. There were 89 events in patients with an abnormal result (7.3%) and 31 in those with a normal result (2.5%; P <.0001). Multivariate analysis of clinical data, and data from exercise testing, resting echocardiography, and EE showed that male sex (RR=1.7; 95% CI, 1.1–2.8; P = .02), metabolic equivalents or METs (RR=0.9; 95% CI, 0.86–0.98; P=.01), peak heart rate × blood pressure (RR= 0.9; 95% CI, 0.9; P=.002), resting wall motion score index (RR=2.5; 95% CI, 1.5–4.1; P <.0001), and number of abnormal regions at peak exercise (RR=1.4; 95% CI, 1.2–1.7; P<.0001) were independently associated with the risk of a serious event (final model χ2, 170; incremental P <.0001). The same variables, excluding sex, were independently associated with cardiovascular death (final model χ2, 169; incremental P = .01). Conclusions. Exercise echocardiography supplements clinical data and data from exercise testing and resting echocardiography in patients with known or suspected coronary artery disease.[Resumen] Introducción y objetivos. Aunque la ecocardiografía de ejercicio es útil para el diagnóstico de la enfermedad coronaria, hay menos datos referentes a su valor pronós-tico. El objetivo de este estudio fue esclarecer: a) si hay un valor incremental de la ecocardiografía en el pico del ejercicio respecto a las variables clínicas, la prueba de esfuerzo y la ecocardiografía en reposo, y b) si el número y la localización de los territorios afectados, así como el tipo de respuesta al ejercicio, influyen en la estratificación. Pacientes y método. En 2.436 pacientes referidos para ecocardiografía de ejercicio se realizó un seguimien-to de 2,1 ± 1,5 años. Hubo 120 eventos (infarto no fatal o muerte cardiovascular) antes de la revascularización. Resultados. La ecocardiografía fue anormal en 1.203 pacientes (49%). Hubo 89 eventos en pacientes con resul-tado anormal (7,3%) frente a 31 con resultado normal (2,5%; p < 0,001). Mediante un análisis multivariable de variables clínicas, de la prueba de esfuerzo y de la ecocardiografía en reposo y ejercicio encontramos que las variables asociadas de manera independiente con el riesgo de eventos eran: ser varón (riesgo relativo [RR] = 1,7; interva-lo de confianza [IC] del 95%, 1,1–2,8; p = 0,02), los equiva-lentes metabólicos o MET (RR = 0,9; IC del 95%, 0,9–1,0; p = 0,01), el producto frecuencia cardíaca × presión arterial (RR = 0,9; IC del 95%, 0,9–1,0; p = 0,02), el índice de moti-lidad segmentaria basal (RR = 2,5; IC del 95%, 1,5–4,1; p < 0,0001) y el número de territorios afectados (RR = 1,4; IC del 95%, 1,2-1,7; p < 0,0001) (χ2 final = 170, valor incremental de la ecocardiografía en el máximo esfuerzo; p < 0,0001). Las mismas variables, excepto el sexo, estaban asociadas con la muerte (χ2 final = 169, valor incremental de la ecocardiografía de ejercicio; p = 0,01). Conclusiones. La ecocardiografía en el máximo ejercicio incrementa el valor pronóstico de las variables clínicas, la prueba de esfuerzo y la ecocardiografía de reposo

Ultraporous nitrogen-doped zeolite-templated carbon for high power density aqueous-based supercapacitors

Two zeolite templated carbons (ZTC) with comparable structure and different surface chemistry have been synthesized by chemical vapor deposition of different precursors, producing a non-doped and a N-doped carbon material (4 at. % XPS) in which most of the functionalities are quaternary N. A larger specific capacitance (farads per surface area) has been measured in acid electrolyte for the N-doped ZTC, that can be related to an improved wettability due to the presence of nitrogen and oxygen. The capacitance of N-doped ZTC is lower in alkaline electrolyte, probably due to the loss of electrochemical activity of certain oxygen functionalities. Interestingly, the electro-oxidation process of N-ZTC implies lower irreversible currents (providing higher electrochemical stability) than for ZTC. The presence of quaternary nitrogen greatly improves the electric conductivity of N-ZTC, which shows a superior rate performance. ZTC and N-ZTC capacitors were constructed using 1 M H2SO4. Under the same conditions, N-doped ZTC based capacitor has higher energy density, 6.7 vs 5.9 W h/kg. The power density of N-ZTC is four times higher, producing an outstanding maximum power of 98 kW/kg. These results provide clear evidences of the advantages of doping advanced porous carbon materials with nitrogen functionalities.The authors would like to thank GV and FEDER (PROMETEOII/2014/010), projects CTQ2015-66080-R (MINECO/FEDER) and MAT2016-76595-R (MINECO/FEDER) for financial support. MJML acknowledges Generalitat Valenciana for the financial support through a VALi+d contract (ACIF/2015/374)

EcoCyc: fusing model organism databases with systems biology.

EcoCyc (http://EcoCyc.org) is a model organism database built on the genome sequence of Escherichia coli K-12 MG1655. Expert manual curation of the functions of individual E. coli gene products in EcoCyc has been based on information found in the experimental literature for E. coli K-12-derived strains. Updates to EcoCyc content continue to improve the comprehensive picture of E. coli biology. The utility of EcoCyc is enhanced by new tools available on the EcoCyc web site, and the development of EcoCyc as a teaching tool is increasing the impact of the knowledge collected in EcoCyc

Long-term results of heart transplant in recipients older and younger than 65 years: a comparative study of mortality, rejections, and neoplasia in a cohort of 445 patients

[Resumen] Background. Whether being older than 65 years should be considered an absolute counterindication to heart transplant (HT), as it is in some centers, is controversial. In our centre, patients older than 65 years are accepted for HT if they satisfy stringent conditions. The aim of this study was to examine whether heart recipients older than 65 years have a greater risk of rejection, neoplasia, or mortality than younger ones. Methods. We studied 445 patients who underwent HT between April 1991 and December 2003, 42 of whom were older than 65 years and 403 who were 65 years or younger. The parameters evaluated were the cumulative incidences of neoplasias and rejections (ISHLT grade ≥ 3A), and the survival rates 1 month, 1 year, and 5 years post-HT. Results. The two groups had similar percentages of patients with at least one rejection episode (≤65 years 56.9%, >65 years 51.3%; P > .05), and although there were proportionally almost twice as many tumors in the older group (14.2%) as in the younger (7.9%), this difference was not statistically significant either. Nor were there any significant differences in survival, the 1-month, 1-year, and 5-year rates being 87.8%, 82.1%, and 68.8%, respectively, in the younger group and 85.7%, 78.6%, and 73.4%, respectively, in the older. Conclusions. Among carefully selected patients aged more than 65 years, HT can be performed without incurring greater risk of rejection, malignancy, or death than is found among recipients younger than 65 years

Usefulness of the INTERMACS scale for predicting outcomes after urgent heart transplantation

[Abstract] Introduction and objectives. Our aim was to assess the prognostic value of the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) scale in patients undergoing urgent heart transplantation (HT). Methods. Retrospective analysis of 111 patients treated with urgent HT at our institution from April, 1991 to October, 2009. Patients were retrospectively assigned to three levels of the INTERMACS scale according to their clinical status before HT. Results. Patients at the INTERMACS 1 level (n = 31) more frequently had ischemic heart disease (p = 0.03) and post-cardiothomy shock (p = 0.02) than patients at the INTERMACS 2 (n = 55) and INTERMACS 3-4 (n = 25) levels. Patients at the INTERMACS 1 level showed higher preoperative catecolamin doses (p = 0.001), a higher frequency of use of mechanical ventilation (p < 0.001), intraaortic balloon (p = 0.002) and ventricular assist devices (p = 0.002), and a higher frequency of preoperative infection (p = 0.015). The INTERMACS 1 group also presented higher central venous pressure (p = 0.02), AST (p = 0.002), ALT (p = 0.006) and serum creatinine (p < 0.001), and lower hemoglobin (p = 0.008) and creatinine clearance (p = 0.001). After HT, patients at the INTERMACS 1 level had a higher incidence of primary graft failure (p = 0.03) and postoperative need for renal replacement therapy (p = 0.004), and their long-term survival was lower than patients at the INTERMACS 2 (log rank 5.1, p = 0.023; HR 3.1, IC 95% 1.1-8.8) and INTERMACS 3-4 level (log rank 6.1, p = 0.013; HR 6.8, IC 95% 1.2-39.1). Conclusions. Our results suggest that the INTERMACS scale may be a useful tool to stratify postoperative prognosis after urgent HT.[Resumen] Introducción y objetivos. Analizar el valor pronóstico de la escala INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) en pacientes tratados con trasplante cardiaco urgente. Métodos. Análisis retrospectivo de 111 pacientes tratados con trasplante cardiaco urgente en nuestro centro entre abril de 1991 y octubre de 2009. Se asignó retrospectivamente a los pacientes a tres niveles de la escala INTERMACS en función de su situación clínica previa al trasplante cardiaco. Resultados. Los pacientes del grupo INTERMACS 1 (n = 31) presentaban mayor frecuencia de cardiopatía isquémica (p = 0,03) y shock tras cardiotomía (p = 0,02) que los pacientes del grupo INTERMACS 2 (n = 55) y los pacientes del grupo INTERMACS 3-4 (n = 25), así como mayores dosis de catecolaminas (p = 0,001), mayor empleo de ventilación mecánica (p < 0,001), balón de contrapulsación (p = 0,002) y dispositivos de asistencia ventricular (p = 0,002) y mayores tasas de infección preoperatoria (p = 0,015). El grupo INTERMACS 1 también mostraba mayores cifras de presión venosa central (p = 0,02), GOT (p = 0,002), GPT (p = 0,006) y creatinina (p < 0,001) y menores cifras de hemoglobina (p = 0,008) y aclaramiento de creatinina (p = 0,001). Tras el trasplante cardiaco, los pacientes del grupo INTERMACS 1 presentaron mayores incidencias de fracaso primario del injerto (p = 0,03) y necesidad de terapia de sustitución renal (p = 0,004), y su supervivencia a largo plazo fue menor que la de los pacientes de los grupos INTERMACS 2 (log rank = 5,1; p = 0,023; razón de riesgos [HR] = 3,1; intervalo de confianza [IC] del 95%, 1,4-6,8) e INTERMACS 3-4 (log rank = 6,1; p = 0,013; HR = 4; IC del 95%, 1,3-12,3). Conclusiones. Nuestros resultados indican que la escala INTERMACS resulta útil para estratificar el pronóstico postoperatorio tras el trasplante cardiaco urgente