Incidence, risk factors, clinical characteristics and outcomes of deep venous thrombosis in patients with COVID-19 attending the Emergency Department: results of the UMC-19-S8

Background and importance: A higher incidence of venous thromboembolism [both pulmonary embolism and deep vein thrombosis (DVT)] in patients with coronavirus disease 2019 (COVID-19) has been described. But little is known about the true frequency of DVT in patients who attend emergency department (ED) and are diagnosed with COVID-19. Objective: We investigated the incidence, risk factors, clinical characteristics and outcomes of DVT in patients with COVID-19 attending the ED before hospitalization. Methods: We retrospectively reviewed all COVID patients diagnosed with DVT in 62 Spanish EDs (20% of Spanish EDs, case group) during the first 2 months of the COVID-19 outbreak. We compared DVT-COVID-19 patients with COVID-19 without DVT patients (control group). Relative frequencies of DVT were estimated in COVID and non-COVID patients visiting the ED and annual standardized incidences were estimated for both populations. Sixty-three patient characteristics and four outcomes were compared between cases and controls. Results: We identified 112 DVT in 74 814 patients with COVID-19 attending the ED [1.50‰; 95% confidence interval (CI), 1.23-1.80‰]. This relative frequency was similar than that observed in non-COVID patients [2109/1 388 879; 1.52‰; 95% CI, 1.45-1.69‰; odds ratio (OR) = 0.98 [0.82-1.19]. Standardized incidence of DVT was higher in COVID patients (98,38 versus 42,93/100,000/year; OR, 2.20; 95% CI, 2.03-2.38). In COVID patients, the clinical characteristics associated with a higher risk of presenting DVT were older age and having a history of venous thromboembolism, recent surgery/immobilization and hypertension; chest pain and desaturation at ED arrival and some analytical disturbances were also more frequently seen, d-dimer >5000 ng/mL being the strongest. After adjustment for age and sex, hospitalization, ICU admission and prolonged hospitalization were more frequent in cases than controls, whereas mortality was similar (OR, 1.37; 95% CI, 0.77-2.45). Conclusions: DVT was an unusual form of COVID presentation in COVID patients but was associated with a worse prognosis

Model d'atenció integrada al pacient crònic: insuficiència cardíaca (IC), malaltia pulmonar obstructiva crònica (MPOC)

Atenció al pacient crònic; Insuficiència cardíaca; Malaltia pulmonar obstructiva crònicaAtención al paciente crónico; Insuficiencia cardíaca; Enfermedad pulmonar obstructiva crónicaChronic patient care; Heart failure; Chronic obstructive pulmonary diseaseAquest document pretén establir un marc d’actuació per a la transformació a mitjà termini de l’atenció que es presta als i les pacients crònics des de l’Institut Català de la Salut (ICS), però tenint en compte que molts dels canvis necessaris només són possibles si s’estableixen els mecanismes de col·laboració adequats entre tots els actors del sistema, específicament, si s’estableixen els incentius per tal de garantir-ne la continuïtat, i si evolucionem cap a un model d’atenció que curi i tingui cura dels i les pacients, i alhora serveixi també per reduir les hospitalitzacions innecessàries. L’abordatge s’ha fet escollint la insuficiència cardíaca (IC) i la malaltia pulmonar obstructiva crònica (MPOC), perquè són dues de les malalties que tenen un major impacte en dependència, discapacitat, qualitat de vida i anys de vida perduts al nostre país, i també, perquè concentren una part molt important del cost de la cronicitat

Short-term outcomes of heart failure patients with reduced and preserved ejection fraction after acute decompensation according to the final destination after emergency department care

To compare short-term outcomes after an episode of acute heart failure (AHF) in patients with reduced and preserved ejection fractions (HFrEF,  49%; respectively) according to their destinations after emergency department (ED) care. Methods and results: This secondary analysis of the EAHFE Registry (consecutive AHF patients diagnosed in 41 Spanish EDs) investigated 30-day all-cause mortality, in-hospital all-cause mortality, prolonged hospitalisation (> 7 days), and 30-day post-discharge ED revisit due to AHF, all-cause death, and combined endpoint (ED revisit/death) in 5829 patients with echocardiographically documented HFrEF and HfpEF (HFrEF/HFpEF: 1,442/4,387). Adjusted ratios were calculated for patients admitted to internal medicine (IM), short stay unit (SSU), and discharged from the ED without hospitalisation (DEDWH) and compared with those admitted to cardiology. For HFrEF, the only significant differences were lower in-hospital mortality (OR = 0.26; 95% CI 0.08-0.81; p = 0.021) and prolonged hospitalisation (OR = 0.07; 95% CI 0.04-0.13; p < 0.001) related to SSU admission. For HFpEF, IM admission had a higher post-discharge 30-day mortality (HR = 1.85; 95% CI 1.05-3.25; p = 0.033) and combined endpoint (HR = 1.24; 95% CI 1.01-1.64; p = 0.044); SSU admission had a lower in-hospital mortality (OR = 0.43; 95% CI 0.23-0.80; p = 0.008) and prolonged hospitalisation (OR = 0.17; 95% CI 0.13-0.23; p < 0.001) but a higher post-discharge 30-day combined endpoint (HR = 1.29; 95% CI 1.01-1.64; p = 0.041); and DEDDWH had a lower 30-day mortality (HR = 0.46; 95% CI 0.28-0.75; p = 0.002) but higher post-discharge ED revisit (HR = 1.62; 95% CI 1.31-2.00; p < 0.001). Conclusion: While HFrEF patients have similar short-term outcomes irrespective of the destination after ED care for an AHF episode, HFpEF patients present worse short-term outcomes when managed by non-cardiology departments, despite adjustment for different clinical patient profiles. Reasons for this heterogeneous specialty-related performance should be investigated.Sin financiación4.907 JCR (2018) Q1, 32/136 Cardiac & Cardiovascular Systems2.206 SJR (2018) Q1, 34/365 Cardiology and Cardiovascular Medicine, 131/2844 Medicine (miscellaneous)No data IDR 2018UE

Hyperkalemia in acute heart failure: Short term outcomes from the EAHFE registry

Objective Both hyperkalemia (HK) and Acute Heart Failure (AHF) are associated with increased short-term mortality, and the management of either may exacerbate the other. As the relationship between HK and AHF is poorly described, our purpose was to determine the relationship between HK and short-term outcomes in Emergency Department (ED) AHF. Methods The EAHFE Registry enrolls all ED AHF patients from 45 Spanish ED and records in-hospital and post-discharge outcomes. Our primary outcome was all-cause in-hospital death, with secondary outcomes of prolonged hospitalization (>7 days) and 7-day post-discharge adverse events (ED revisit, hospitalization, or death). Associations between serum potassium (sK) and outcomes were explored using logistic regression by restricted cubic spline (RCS) curves, with sK =4.0 mEq/L as the reference, adjusting by age, sex, comorbidities, patient baseline status and chronic treatments. Interaction analyses were performed for the primary outcome. Results Of 13,606 ED AHF patients, the median (IQR) age was 83 (76-88) years, 54% were women, and the median (IQR) sK was 4.5 mEq/L (4.3-4.9) with a range of 4.0-9.9 mEq/L. In-hospital mortality was 7.7%, with prolonged hospitalization in 35.9%, and a 7-day post-discharge adverse event rate of 8.7%. Adjusted in-hospital mortality increased steadily from sK ≥4.8 (OR = 1.35, 95% CI = 1.01-1.80) to sK = 9.9 (8.41, 3.60-19.6). Non-diabetics with elevated sK had higher odds of death, while chronic treatment with mineralocorticoid-receptor antagonists exhibited a mixed effect. Neither prolonged hospitalization nor post-discharge adverse events was associated with sK. Conclusion In ED AHF, initial sK >4.8 mEq/L was independently associated with in-hospital mortality, suggesting that this cohort may benefit from aggressive HK treatmen

Model d'atenció integrada al pacient crònic: insuficiència cardíaca (IC), malaltia pulmonar obstructiva crònica (MPOC)

Atenció al pacient crònic; Insuficiència cardíaca; Malaltia pulmonar obstructiva crònicaAtención al paciente crónico; Insuficiencia cardíaca; Enfermedad pulmonar obstructiva crónicaChronic patient care; Heart failure; Chronic obstructive pulmonary diseaseAquest document pretén establir un marc d’actuació per a la transformació a mitjà termini de l’atenció que es presta als i les pacients crònics des de l’Institut Català de la Salut (ICS), però tenint en compte que molts dels canvis necessaris només són possibles si s’estableixen els mecanismes de col·laboració adequats entre tots els actors del sistema, específicament, si s’estableixen els incentius per tal de garantir-ne la continuïtat, i si evolucionem cap a un model d’atenció que curi i tingui cura dels i les pacients, i alhora serveixi també per reduir les hospitalitzacions innecessàries. L’abordatge s’ha fet escollint la insuficiència cardíaca (IC) i la malaltia pulmonar obstructiva crònica (MPOC), perquè són dues de les malalties que tenen un major impacte en dependència, discapacitat, qualitat de vida i anys de vida perduts al nostre país, i també, perquè concentren una part molt important del cost de la cronicitat

The FAST-FURO study: effect of very early administration of intravenous furosemide in the prehospital setting to patients with acute heart failure attending the emergency department

AIMS The effect of early administration of intravenous (IV) furosemide in the emergency department (ED) on short-term outcomes of acute heart failure (AHF) patients remains controversial, with one recent Japanese study reporting a decrease of in-hospital mortality and one Korean study reporting a lack of clinical benefit. Both studies excluded patients receiving prehospital IV furosemide and only included patients requiring hospitalization. To assess the impact on short-term outcomes of early IV furosemide administration by emergency medical services (EMS) before patient arrival to the ED. METHODS AND RESULTS In a secondary analysis of the Epidemiology of Acute Heart Failure in Emergency Departments (EAHFE) registry of consecutive AHF patients admitted to Spanish EDs, patients treated with IV furosemide at the ED were classified according to whether they received IV furosemide from the EMS (FAST-FURO group) or not (CONTROL group). In-hospital all-cause mortality, 30-day all-cause mortality, and prolonged hospitalization (>10 days) were assessed. We included 12 595 patients (FAST-FURO = 683; CONTROL = 11 912): 968 died during index hospitalization [7.7%; FAST-FURO = 10.3% vs. CONTROL = 7.5%; odds ratio (OR) = 1.403, 95% confidence interval (95% CI) = 1.085-1.813; P = 0.009], 1269 died during the first 30 days (10.2%; FAST-FURO = 13.4% vs. CONTROL = 9.9%; OR = 1.403, 95% CI = 1.146-1.764; P = 0.004), and 2844 had prolonged hospitalization (22.8%; FAST-FURO = 25.8% vs. CONTROL = 22.6%; OR = 1.189, 95% CI = 0.995-1.419; P = 0.056). FAST-FURO group patients had more diabetes mellitus, ischaemic cardiomyopathy, peripheral artery disease, left ventricular systolic dysfunction, and severe decompensations, and had a better New York Heart Association class and had less atrial fibrillation. After adjusting for these significant differences, early IV furosemide resulted in no impact on short-term outcomes: OR = 1.080 (95% CI = 0.817-1.427) for in-hospital mortality, OR = 1.086 (95% CI = 0.845-1.396) for 30-day mortality, and OR = 1.095 (95% CI = 0.915-1.312) for prolonged hospitalization. Several sensitivity analyses, including analysis of 599 pairs of patients matched by propensity score, showed consistent findings. CONCLUSION Early IV furosemide during the prehospital phase was administered to the sickest patients, was not associated with changes in short-term mortality or length of hospitalization after adjustment for several confounders

Clinical phenotypes of acute heart failure based on signs and symptoms of perfusion and congestion at emergency department presentation and their relationship with patient management and outcomes.

To compare the clinical characteristics and outcomes of patients with acute heart failure (AHF) according to clinical profiles based on congestion and perfusion determined in the emergency department (ED). Overall, 11 261 unselected AHF patients from 41 Spanish EDs were classified according to perfusion (normoperfusion = warm; hypoperfusion = cold) and congestion (not = dry; yes = wet). Baseline and decompensation characteristics were recorded as were the main wards to which patients were admitted. The primary outcome was 1-year all-cause mortality; secondary outcomes were need for hospitalisation during the index AHF event, in-hospital all-cause mortality, prolonged hospitalisation, 7-day post-discharge ED revisit for AHF and 30-day post-discharge rehospitalisation for AHF. A total of 8558 patients (76.0%) were warm + wet, 1929 (17.1%) cold + wet, 675 (6.0%) warm + dry, and 99 (0.9%) cold + dry; hypoperfused (cold) patients were more frequently admitted to intensive care units and geriatrics departments, and warm + wet patients were discharged home without admission. The four phenotypes differed in most of the baseline and decompensation characteristics. The 1-year mortality was 30.8%, and compared to warm + dry, the adjusted hazard ratios were significantly increased for cold + wet (1.660; 95% confidence interval 1.400-1.968) and cold + dry (1.672; 95% confidence interval 1.189-2.351). Hypoperfused (cold) phenotypes also showed higher rates of index episode hospitalisation and in-hospital mortality, while congestive (wet) phenotypes had a higher risk of prolonged hospitalisation but decreased risk of rehospitalisation. No differences were observed among phenotypes in ED revisit risk. Bedside clinical evaluation of congestion and perfusion of AHF patients upon ED arrival and classification according to phenotypic profiles proposed by the latest European Society of Cardiology guidelines provide useful complementary information and help to rapidly predict patient outcomes shortly after ED patient arrival

Clinical phenotypes of acute heart failure based on signs and symptoms of perfusion and congestion at emergency department presentation and their relationship with patient management and outcomes

To compare the clinical characteristics and outcomes of patients with acute heart failure (AHF) according to clinical profiles based on congestion and perfusion determined in the emergency department (ED). Overall, 11 261 unselected AHF patients from 41 Spanish EDs were classified according to perfusion (normoperfusion = warm; hypoperfusion = cold) and congestion (not = dry; yes = wet). Baseline and decompensation characteristics were recorded as were the main wards to which patients were admitted. The primary outcome was 1-year all-cause mortality; secondary outcomes were need for hospitalisation during the index AHF event, in-hospital all-cause mortality, prolonged hospitalisation, 7-day post-discharge ED revisit for AHF and 30-day post-discharge rehospitalisation for AHF. A total of 8558 patients (76.0%) were warm + wet, 1929 (17.1%) cold + wet, 675 (6.0%) warm + dry, and 99 (0.9%) cold + dry; hypoperfused (cold) patients were more frequently admitted to intensive care units and geriatrics departments, and warm + wet patients were discharged home without admission. The four phenotypes differed in most of the baseline and decompensation characteristics. The 1-year mortality was 30.8%, and compared to warm + dry, the adjusted hazard ratios were significantly increased for cold + wet (1.660; 95% confidence interval 1.400-1.968) and cold + dry (1.672; 95% confidence interval 1.189-2.351). Hypoperfused (cold) phenotypes also showed higher rates of index episode hospitalisation and in-hospital mortality, while congestive (wet) phenotypes had a higher risk of prolonged hospitalisation but decreased risk of rehospitalisation. No differences were observed among phenotypes in ED revisit risk. Bedside clinical evaluation of congestion and perfusion of AHF patients upon ED arrival and classification according to phenotypic profiles proposed by the latest European Society of Cardiology guidelines provide useful complementary information and help to rapidly predict patient outcomes shortly after ED patient arrival