Frequency of five cardiovascular/hemostatic entities as primary manifestations of SARS-CoV-2 infection: Results of the UMC-19-S2

Infection by SARS-Cov-2 is mainly characterized by fever and respiratory symptoms, with dyspnea and lung infiltrates in more severe cases [1,2]. Many patients also present a pro-coagulant state, which is biochemically detected by increased D-dimer levels and is related to complications and a worse prognosis [1,3]. In this context, isolated case reports and short case series have suggested an increased risk of patients with COVID-19 to develop clinically relevant cardiovascular and hemostatic disturbances [3–7]. Nonetheless, many of these reports refer to hospitalized patients, and as hospitalization itself usually increases complications in bedridden patients with multidrug treatmentor in very poor condition, it is unknown if such cardiovascular/hemostatic processes are related to the pathogenesis of SARS-Cov-2. Focus on patients with COVID-19 at emergency department (ED) arrival could help to answer this question

Outcomes of patients with heart failure with preserved ejection fraction discharged on treatment with neurohormonal antagonists after an episode of decompensation

Aims: To analyze the frequency with which patients with heart failure with preserved ejection fraction (HFpEF) discharged after an acute heart failure (AHF) episode are treated with antineurohormonal drugs (ANHD), the variables related to ANHD prescription and their relationship with outcomes. Methods: We included consecutive HFpEF patients (left ventricular ejection fraction >= 50%) discharged after an AHF episode from 45 Spanish hospitals whose chronic medications and treatment at discharge were available. Patients were classified according to whether they were discharged with or without ANHD, including beta-blockers (BB), renin-angiotensin-aldosterone-system inhibitors (RAASi) and mineralcorticosteroid-receptor antagonists (MRA). Co-primary outcomes consisted of 1-year all-cause mortality and 90-day combined adverse event (revisit to emergency department -ED-, hospitalization due to AHF or all-cause death). Secondary outcomes were 90-day adverse events taken individually. Adjusted associations of ANHD treatment with outcomes were calculated. Results: We analyzed 3,305 patients with HFpEF (median age: 83, 60% women), 2,312 (70%) discharged with ANHD. The ANHD most frequently prescribed was BB (45.8%). The 1-year mortality was 26.9% (adjusted HR for ANHD patients:1.17, 95%CI=0.98-1.38) and the 90-day combined adverse event was 54.4% (HR=1.14, 95% CI=0.99-1.31). ED revisit was significantly increased by ANHD (HR=1.15, 95%CI=1.01-1.32). MRA and BB were associated with worse results in some co-primary or secondary endpoints, while RAASi (alone) reduced 90-day hospitalization (HR=0.73, 98%CI=0.56-0.96). Conclusion: 70% of HFpEF patients are discharged with ANHD after an AHF episode. ANHD do not seem to reduce mortality or adverse events in HFpEF patients, only RAASi could provide some benefits, reducing the risk of hospitalization for AHF

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

Thirty-day outcomes in frail older patients discharged home from the emergency department with acute heart failure: effects of high-risk criteria identified by the DEED FRAIL-AHF trial

Objectives: To study the effect of high-risk criteria on 30-day outcomes in frail older patients with acute heart failure (AHF) discharged from an emergency department (ED) or an ED's observation and short-stay areas. Material and methods: Secondary analysis of discharge records in the Older AHF Key Data registry. We selected frail patients (aged > 70 years) discharged with AHF from EDs. Risk factors were categorized as modifiable or nonmodifiable. The outcomes were a composite endpoint for a cardiovascular event (revisits for AHF, hospitalization for AHF, or cardiovascular death) and the number of days alive out-of-hospital (DAOH) within 30 days of discharge. Results: We included 380 patients with a mean (SD) age of 86 (5.5) years (61.2% women). Modifiable risk factors were identified in 65.1%, nonmodifiable ones in 47.8%, and both types in 81.6%. The 30-day cardiovascular composite endpoint occurred in 83 patients (21.8%). The mean 30-day DAOH observed was 27.6 (6.1) days. Highrisk factors were present more often in patients who developed the cardiovascular event composite endpoint: the rates for patients with modifiable, nonmodifiable, or both types of risk were, respectively, as follows in comparison with patients not at high risk: 25.0% vs 17.2%, P = .092; 27.6% vs 16.7%, P = .010; and 24.7% vs 15.2%, P = .098). The 30-day DAOH outcome was also lower for at-risk patients, according to type of risk factor present: modifiable, 26.9 (7.0) vs 28.4 (4.4) days, P = .011; nonmodifiable, 27.1 (7.0) vs 28.0 (5.0) days, P = .127; and both, 27.1 (6.7) vs 28.8 (3.4) days, P = .005). After multivariate analysis, modifiable risk remained independently associated with fewer days alive (adjusted absolute difference in 30-day DAOH, -1.3 days (95% CI, -2.7 to -0.1 days). Nonmodifiable factors were associated with increased risk for the 30-day cardiovascular composite endpoint (adjusted absolute difference, 10.4%; 95% CI, -2.1% to 18.7%). Conclusion: Risk factors are common in frail elderly patients with AHF discharged home from hospital ED areas. Their presence is associated with a worse 30-day prognosis

Spanish COPD Guidelines (GesEPOC) 2021 Update Diagnosis and Treatment of COPD Exacerbation Syndrome

[ES] En este artículo se presentan las recomendaciones sobre el diagnóstico y tratamiento del síndrome de agudización de la enfermedad pulmonar obstructiva crónica (EPOC) (SAE) de GesEPOC 2021. Como principales novedades, la guía propone una definición y aproximación sindrómica, una nueva clasificación de gravedad y el reconocimiento de diferentes rasgos tratables (RT), lo que supone un nuevo paso hacia la medicina personalizada. La evaluación de la evidencia se realiza mediante la metodología Grading of Recommendations Assessment, Development and Evaluation (GRADE), con la incorporación de seis nuevas preguntas con enfoque paciente, intervención, comparación y resultados (PICO). El proceso diagnóstico comprende cuatro etapas: 1) establecer el diagnóstico del SAE, 2) valorar la gravedad del episodio, 3) identificar el factor desencadenante y 4) abordar los RT. En este proceso diagnóstico se diferencia una aproximación ambulatoria, en la que se recomienda incluir una batería básica de pruebas y una hospitalaria, más exhaustiva, en la que se contempla el estudio de diferentes biomarcadores y pruebas de imagen. El tratamiento broncodilatador destinado al alivio inmediato de los síntomas se considera esencial para todos los pacientes, mientras que el uso de antibióticos, corticoides sistémicos, oxigenoterapia, ventilación asistida o el tratamiento de las comorbilidades variará en función de la gravedad y de los posibles RT. El empleo de antibióticos estará especialmente indicado ante un cambio en el color del esputo, cuando se requiera asistencia ventilatoria, en los casos que cursen con neumonía y también para aquellos con proteína-C reactiva elevada (≥ 20 mg/L). Los corticoides sistémicos se recomiendan en el SAE que necesita ingreso y se sugieren en el SAE moderado. La eficacia de estos fármacos es mayor en pacientes con recuento de eosinófilos en sangre ≥ 300 células/mm3. La ventilación mecánica no invasiva en fase aguda se establece fundamentalmente para pacientes con SAE que cursen con acidosis respiratoria, a pesar del tratamiento inicial.[EN] This article details the GesEPOC 2021 recommendations on the diagnosis and treatment of COPD exacerbation syndrome (CES). The guidelines propose a definition-based syndromic approach, a new classification of severity, and the recognition of different treatable traits (TT), representing a new step toward personalized medicine. The evidence is evaluated using GRADE methodology, with the incorporation of 6 new PICO questions. The diagnostic process comprises four stages: 1) establish a diagnosis of CES, 2) assess the severity of the episode, 3) identify the trigger, and 4) address TTs. This diagnostic process differentiates an outpatient approach, that recommends the inclusion of a basic battery of tests, from a more comprehensive hospital approach, that includes the study of different biomarkers and imaging tests. Bronchodilator treatment for immediate relief of symptoms is considered essential for all patients, while the use of antibiotics, systemic corticosteroids, oxygen therapy, and assisted ventilation and the treatment of comorbidities will vary depending on severity and possible TTs. The use of antibiotics will be indicated particularly if sputum color changes, when ventilatory assistance is required, in cases involving pneumonia, and in patients with elevated C-reactive protein (≥ 20 mg/L). Systemic corticosteroids are recommended in CES that requires admission and are suggested in moderate CES. These drugs are more effective in patients with blood eosinophil counts ≥ 300 cells/mm3. Acute-phase non-invasive mechanical ventilation is specified primarily for patients with CES who develop respiratory acidosis despite initial treatment.Peer reviewe

Incidence, clinical characteristics, risk factors and outcomes of meningoencephalitis in patients with COVID-19

We investigated the incidence, clinical characteristics, risk factors, and outcome of meningoencephalitis (ME) in patients with COVID-19 attending emergency departments (ED), before hospitalization. We retrospectively reviewed all COVID patients diagnosed with ME in 61 Spanish EDs (20% of Spanish EDs, COVID-ME) during the COVID pandemic. We formed two control groups: non-COVID patients with ME (non-COVID-ME) and COVID patients without ME (COVID-non-ME). Unadjusted comparisons between cases and controls were performed regarding 57 baseline and clinical characteristics and 4 outcomes. Cerebrospinal fluid (CSF) biochemical and serologic findings of COVID-ME and non-COVID-ME were also investigated. We identified 29 ME in 71,904 patients with COVID-19 attending EDs (0.40‰, 95%CI=0.27-0.58). This incidence was higher than that observed in non-COVID patients (150/1,358,134, 0.11‰, 95%CI=0.09-0.13; OR=3.65, 95%CI=2.45-5.44). With respect to non-COVID-ME, COVID-ME more frequently had dyspnea and chest X-ray abnormalities, and neck stiffness was less frequent (OR=0.3, 95%CI=0.1-0.9). In 69.0% of COVID-ME, CSF cells were predominantly lymphocytes, and SARS-CoV-2 antigen was detected by RT-PCR in 1 patient. The clinical characteristics associated with a higher risk of presenting ME in COVID patients were vomiting (OR=3.7, 95%CI=1.4-10.2), headache (OR=24.7, 95%CI=10.2-60.1), and altered mental status (OR=12.9, 95%CI=6.6-25.0). COVID-ME patients had a higher in-hospital mortality than non-COVID-ME patients (OR=2.26; 95%CI=1.04-4.48), and a higher need for hospitalization (OR=8.02; 95%CI=1.19-66.7) and intensive care admission (OR=5.89; 95%CI=3.12-11.14) than COVID-non-ME patients. ME is an unusual form of COVID presentation (<0.5‰ cases), but is more than 4-fold more frequent than in non-COVID patients attending the ED. As the majority of these MEs had lymphocytic predominance and in one patient SARS-CoV-2 antigen was detected in CSF, SARS-CoV-2 could be the cause of most of the cases observed. COVID-ME patients had a higher unadjusted in-hospital mortality than non-COVID-ME patients

Socio-Demographic Health Determinants Are Associated with Poor Prognosis in Spanish Patients Hospitalized with COVID-19

Introduction Social vulnerability is a known determinant of health in respiratory diseases. Our aim was to identify whether there are socio-demographic factors among COVID-19 patients hospitalized in Spain and their potential impact on health outcomes during the hospitalization. Methods A multicentric retrospective case series study based on administrative databases that included all COVID-19 cases admitted in 19 Spanish hospitals from 1 March to 15 April 2020. Socio-demographic data were collected. Outcomes were critical care admission and in-hospital mortality. Results We included 10,110 COVID-19 patients admitted to 18 Spanish hospitals (median age 68 (IQR 54–80) years old; 44.5% female; 14.8% were not born in Spain). Among these, 779 (7.7%) cases were admitted to critical care units and 1678 (16.6%) patients died during the hospitalization. Age, male gender, being immigrant, and low hospital saturation were independently associated with being admitted to an intensive care unit. Age, male gender, being immigrant, percentile of average per capita income, and hospital experience were independently associated with in-hospital mortality. Conclusions Social determinants such as residence in low-income areas and being born in Latin American countries were associated with increased odds of being admitted to an intensive care unit and of in-hospital mortality. There was considerable variation in outcomes between different Spanish centers.JPA is under contract within the Ramón y Cajal Program (RYC-2016-20155, Ministerio de Economía, Industria y Competitividad, Spain). Investigators of Spanish Social-Environmental COVID-19 Register: Steering Committee: F. Javier Martín-Sánchez, Adrián Valls Carbó, Carmen Martínez Valero, Juan de D. Miranda, Juan Pedro Arrebola, Marta Esteban López, Annika Parviainen, Òscar Miró, Pere Llorens, Sònia Jiménez, Pascual Piñera, Guillermo Burillo, Alfonso Martín, Jorge García Lamberechts, Javier Jacob, Aitor Alquézar, Juan González del Castillo, Amanda López Picado and Iván Núñez. Participating centers: Oscar Miró y Sonia Jimenez. Hospital Clinic de Barcelona. José María Ferreras Amez. Hospital Clínico Universitario Lozano Blesa. Rafael Rubio Díaz. Complejo Hospitalario de Toledo. Julio Javier Gamazo del Rio. Hospital Universitario de Galdakao. Héctor Alonso. Hospital Universitario Miguel de Valdecilla. Pablo Herrero. Hospital Universitario Central de Asturias. Noemí Ruiz de Lobera. Hospital San Pedro de Logroño. Carlos Ibero. Complejo Hospitalario de Navarra. Plácido Mayan. Hospital Clínico Universitario de Santiago. Rosario Peinado. Complejo Hospitalario Universitario de Badajoz. Carmen Navarro Bustos. Hospital Universitario Virgen de la Macarena. Jesús Álvarez Manzanares. Hospital Universitario Rio Hortega. Francisco Román. Hospital Universitario General de Alicante. Pascual Piñera. Hospital Universitario Reina Sofia de Murcia. Guillermo Burillo. Hospital Universitario de Canarias de Tenerife. Javier Jacob. Hospital Universitario de Bellvitge. Carlos Bibiano. Hospital Universitario Infanta Leonor.Peer reviewe

Safety and Revisit Related to Discharge the Sixty-one Spanish Emergency Department Medical Centers Without Hospitalization in Patients with COVID-19 Pneumonia. A Prospective Cohort Study UMC-Pneumonia COVID-19

Background: Information is needed on the safety and efficacy of direct discharge from the emergency department (ED) of patients with COVID-19 pneumonia. Objectives: The objectives of the study were to study the variables associated with discharge from the ED in patients presenting with COVID-19 pneumonia, and study ED revisits related to COVID-19 at 30 days (EDR30d). Methods: Multicenter study of the SIESTA cohort including 1198 randomly selected COVID patients in 61 EDs of Spanish medical centers from March 1, 2020, to April 30, 2020. We collected baseline and related characteristics of the acute episode and calculated the adjusted odds ratios (aOR) for ED discharge. In addition, we analyzed the variables related to EDR30d in discharged patients. Results: We analyzed 859 patients presenting with COVID-19 pneumonia, 84 (9.8%) of whom were discharged from the ED. The variables independently associated with discharge were being a woman (aOR 1.890; 95%CI 1.176-3.037), age 1200/mm(3) (aOR 4.667; 95%CI 1.045-20.839). The EDR30d of the ED discharged group was 40.0%, being lower in women (aOR 0.368; 95%CI 0.142-0.953). A total of 130 hospitalized patients died (16.8%) as did two in the group discharged from the ED (2.4%) (OR 0.121; 95%CI 0.029-0.498). Conclusion: Discharge from the ED in patients with COVID-19 pneumonia was infrequent and was associated with few variables of the episode. The EDR30d was high, albeit with a low mortality

Características evolutivas de los pacientes con insuficiencia cardiaca aguda atendidos en Servicios de Urgencias españoles

Introducción La insuficiencia cardiaca aguda (ICA) es una de las principales causas de hospitalización y representa una de las mayores cargas económicas y médicas dentro de cualquier sistema público de salud. Está asociada a una elevada mortalidad intrahospitalaria y, tras el alta, con altos índices de reingreso. El diagnostico, manejo y tratamiento de la ICA en la práctica clínica habitual se basa en datos de diferentes estudios epidemiológicos de tipo observacional, en ensayos clínicos y en documentos de consenso entre expertos. Toda esta información se plasma en las guías de diferentes sociedades y países. Sin embargo, los registros realizados en diferentes países muestran que las terapias utilizadas se alejan, en ocasiones sustancialmente, de las indicaciones propuestas en las guías. Objetivo Principal Describir las características evolutivas (de laboratorio, terapéuticas y de morbi-mortalidad) de los pacientes con insuficiencia cardiaca aguda atendidos en los Servicios de Urgencias Hospitalarios españoles y detectar si han existido cambios en el manejo de estos pacientes en dichos Servicios de Urgencias Hospitalarios con el paso del tiempo. Material y método. Es un estudio observacional, de cohortes prospectivo, sin intervención y multicéntrico realizado sobre pacientes que acudieron a consulta a los servicios de urgencias hospitalarios por un episodio de insuficiencia cardiaca aguda. Se recogieron datos en cinco periodos 2007, 2009, 2012, 2014, 1026. Se analizaron los cambios observados en 57 variables correspondientes a datos basales, de atención urgente y evolutivos. Resultados. La edad de los pacientes ha ido aumentando, pasando de 78 a 80,3 años (p<0,001) siendo el aumento de edad a consta de los mayores de 75 años (66,8% al 74,4% p=0,002). En los antecedentes personales vemos que las alteraciones significativas son el aumento de dislipemias e insuficiencia renal crónica con un descenso del antecedente de insuficiencia cardiaca que pasa del 70 al 55% (p<0,001). Funcionalmente los pacientes no han sufrido variación en estos años en cuando a NYHA y Barthel pero si han disminuido los pacientes con fracción de eyección del ventrículo izquierdo reducida 14,9 al 9,5% (p<0,001) y aumentado los que la tienen preservada (42% al 62% p<0,001). En cuanto al tratamiento previo tenemos que los betabloqueantes (24,8 a 48,6 p<0,001) y los anticoagulantes (36,0 a 45.4% p<0,001) aumentan su uso significativamente mientras que digoxina (22,3 a 13,4% p<0,001) y nitratos (21,3 a 13.5 p<0,001) disminuyen su uso de forma significativa. En cuanto a las constantes vitales, los pacientes con hipertensión han disminuido (22,3% a 17,7% p<0,001). Valorando las exploraciones complementarias observamos un descenso significativo de hiponatrémicos (16,8% a 15,5% p<0,001) con un aumento de las solicitudes de troponina (48,8% a 57,7% p<0,001) y péptidos natriuréticos (7,2% a 46,3% p<0,001). Valorando el tratamiento aplicado en urgencias, hay un descenso en el uso de oxigenoterapia convencional (81,8% a 64,5% p<0,001). El uso de diurético en perfusión ha disminuido (20,5% a 3,1% p<0,001) así como la nitroglicerina intravenosa (21,3% a 11,3% p<0,001), inotropos (2,4% a 1,3% p<0,001) y digoxina (21,9% a 11,0% p<0,001). En cuando al destino aumentan los pacientes dados de alta directamente desde el Servicio de Urgencias (24,8% a 27,8% p=0,003) sin mostrar variaciones en reconsulta ni en mortalidad intrahospitalaria, al mes ni al año. Entre las variables relacionadas con la reconsulta a 30 días tenemos que la presencia de diabetes mellitus, dislipemia, insuficiencia renal crónica, fibrilación auricular, arteriopatía periférica e insuficiencia cardiaca previa es un factor que favorece la reconsulta. Analizando el tratamiento crónico los que tomaban diuréticos, amiodarona, nitratos o estaban anticoagulados se muestra como un factor de riesgo de reconsulta. En cuanto a las características del episodio agudo podemos destacar que la presencia de hiponatremia, así como el tratamiento con diurético en perfusión influye en la reconsulta a los 30 días. Ajustando las características basales en cuanto antecedentes médicos y tratamiento con domicilio vemos que la presencia de insuficiencia renal crónica, fibrilación auricular arteriopatía periférica e insuficiencia cardíaca previa, así como, el tratamiento domiciliario con nitratos y los pacientes anticoagulados son factores independientes para la reconsulta a los 30 días. Conclusiones Los pacientes con insuficiencia cardiaca aguda que acuden a los Servicios de Urgencias presentan una edad media progresivamente mayor al haber aumentado la esperanza de vida en España. Los factores de riesgo más influyentes en el desarrollo de la insuficiencia cardiaca han aumentado de forma significativa con el paso de los años. En cuanto al tratamiento domiciliario vemos que tanto lo diuréticos como los betabloqueantes han sufrido un aumento en su uso mientras que los IECA no han variado. Nitratos y digoxina su uso han ido en descenso progresivo. Las peticiones de biomarcadores como troponina y péptidos natriuréticos se solicitan cada vez más. Atendiendo a la terapia farmacológica y a los fármacos más usados en la fase aguda el uso de diuréticos es mayoritario y el uso de nitratos ha ido en descenso significativo. La digoxina, siguiendo las recomendaciones de las guías, su uso de ha visto disminuido de forma significativa. En relación con el destino del paciente hemos visto que el número de pacientes dados de alta directamente de los Servicios de Urgencias ha sufrido un ascenso significativo sin que la mortalidad a 30 días ni las reconsultas se hay visto alterado. Analizando las variables relacionadas con la reconsulta a los 30 días hemos comprobado como la presencia de insuficiencia renal crónica, fibrilación auricular, arteriopatía periférica y la insuficiencia cardiaca previa fueron factores que influyeron de forma independiente en la reconsulta a los 30 días del alta del Servicio de Urgencias. Por otro lado. analizando las variables del tratamiento domiciliario se determinó que el uso de nitratos y la toma de anticoagulantes están relacionados con la reconsulta los 30 días. Hemos comentado la importancia que puede tener la formación en el mejor manejo de la insuficiencia cardiaca aguda, al hilo de esto, debemos de destacar la labor que esta desarrollando SEMES, a través del Grupo ICA-SEMES, para el fomento de la investigación, la formación y la colaboración activa en consensos interdisciplinares para mejorar el manejo de los pacientes con insuficiencia cardiaca aguda y con ello, probablemente, el pronostico de estos enfermos. Pensamos que los Médicos de Urgencias tienen, progresivamente, una preparación cada vez mayor para la asistencia a pacientes con insuficiencia cardiaca aguda, que la implantación y seguimiento de las guías de práctica clínica son cada ve mayor lo que influye en el correcto manejo de los pacientes.Introduction Acute heart failure (AHF) is one of the main causes of hospitalization and represents one of the greatest economic and medical burdens within any public health system. It is associated with high in-hospital mortality and, after discharge, with high readmission rates. The diagnosis, management and treatment of AHF in routine clinical practice is based on data from different epidemiological observational studies, on clinical trials and on consensus documents among experts. All this information is reflected in the guides of different societies and countries. However, the registries made in different countries show that the therapies used deviate, sometimes substantially, from the indications proposed in the guidelines. Main goal Describe the evolutionary characteristics (laboratory, therapeutic and morbidity and mortality) of patients with acute heart failure treated in the Spanish Hospital Emergency Services and detect if there have been changes in the management of these patients in said Hospital Emergency Services with the pass of the time. Material and method. It is an observational, prospective cohort study, without intervention and multicenter carried out on patients who attended the hospital emergency services for an episode of acute heart failure. Data were collected in five periods 2007, 2009, 2012, 2014, 1026. The changes observed in 57 variables corresponding to baseline, urgent care and evolutionary data were analyzed. Results. The age of the patients has been increasing, going from 78 to 80.3 years (p <0.001), with the increase in age consisting of those over 75 years (66.8% to 74.4% p = 0.002). In the personal history we see that the significant alterations are the increase in dyslipidemia and chronic renal failure with a decrease in the history of heart failure that goes from 70 to 55 (p <0.001). Functionally, patients have not undergone variation in these years in terms of NYHA and Barthel, but the number of patients with reduced left ventricular ejection fraction has decreased from 14.9 to 9.5% (p <0.001) and those with preserved it have increased. (42% to 62% p <0.001). Regarding previous treatment, we have that beta-blockers (24.8 to 48.6 p <0.001) and anticoagulants (36.0 to 45.4% p <0.001) increase their use significantly while digoxin (22.3 to 13.4 % p <0.001) and nitrates (21.3 to 13.5 p <0.001) decrease their use significantly. Regarding vital signs, patients with hypertension have decreased (22.3% to 17.7% p <0.001). Assessing the complementary examinations, we observed a significant decrease in hyponatremia (16.8% to 15.5% p <0.001) with an increase in requests for troponin (48.8% to 57.7% p <0.001) and natriuretic peptides (7.2% to 46.3% p <0.001). Assessing the treatment applied in the emergency room, there is a decrease in the use of conventional oxygen therapy (81.8% to 64.5% p <0.001). The use of diuretic infusion has decreased (20.5% to 3.1% p <0.001) as well as intravenous nitroglycerin (21.3% to 11.3% p <0.001), inotropes (2.4% to 1, 3% p <0.001) and digoxin (21.9% to 11.0% p <0.001). Regarding the destination, the number of patients discharged directly from the Emergency Service increased (24.8% to 27.8% p=0.003) without showing variations in reconsultation or in-hospital mortality, at one month or one year. Among the variables related to the 30-day reconsultation, we have that the presence of diabetes mellitus, dyslipidemia, chronic renal failure, atrial fibrillation, peripheral arterial disease and previous heart failure is a factor that favors the reconsultation. Analyzing the chronic treatment those who took diuretics, amiodarone. nitrates or were anticoagulated is a risk factor for reconsultation. Regarding the characteristics of the acute episode, we can highlight that the presence of hyponatremia, as well as the treatment with a diuretic infusion influences the re-consultation at 30 days. Adjusting the baseline characteristics in terms of medical history and home treatment, we see that the presence of chronic renal failure, atrial fibrillation, peripheral arterial disease, and previous heart failure, as well as home treatment with nitrates and anticoagulated patients are independent factors for reconsultation at 30 days. Conclusions Patients with acute heart failure who come to the Emergency Services have a progressively older mean age as life expectancy has increased in Spain. The most influential risk factors in the development of heart failure have increased significantly over the years. Regarding home treatment, we see that both diuretics and beta-blockers have experienced an increase in their use while ACE inhibitors have not changed. Nitrates and digoxin, their use has been progressively decreasing. Requests for biomarkers such as troponin and natriuretic peptides are in increasing demand. Based on pharmacological therapy and the drugs most used in the acute phase, the use of diuretics is the majority and the use of nitrates has been in significant decline. Digoxin, following the recommendations of the guidelines, its use has been significantly reduced. In relation to the destination of the patient, we have seen that the number of patients discharged directly from the Emergency Services has undergone a significant rise, without the 30-day mortality or reconsultations having been altered. Analyzing the variables related to the 30-day re-consultation, we have verified that the presence of chronic renal failure, atrial fibrillation, peripheral arterial disease, and previous heart failure were factors that independently influenced the re-consultation 30 days after discharge from the Hospital Service. Emergencies On the other hand. Analyzing the variables of home treatment, it was determined that the use of nitrates and the taking of anticoagulants are related to the 30-day re-consultation. We have commented on the importance that training in the best management of acute heart failure can have, in line with this, we must highlight the work that SEMES is developing, through the ICA-SEMES Group, to promote research, training and active collaboration in interdisciplinary consensus to improve the management of patients with acute heart failure and with it, probably, the prognosis of these patients. We believe that Emergency Physicians have, progressively, an increasing preparation for the care of patients with acute heart failure, that the implantation and follow-up of the clinical practice guidelines are increasing, which influences the correct management of patients