Valor pronóstico de un nuevo modelo de evaluación clínica de pacientes ambulatorios con insuficiencia cardiaca

[Resumen] Introducción y objetivos. Estudiar el valor pronóstico de un modelo de 5 ítems clínicos basado en las recomendaciones IC-BERG para la evaluación en consulta de pacientes ambulatorios con insuficiencia cardiaca (IC). Métodos. Estudio observacional basado en la cohorte histórica de pacientes con IC remitidos a una consulta monográfica entre 2010 y 2019. Se evaluó la presencia de 5 ítems clínicos de riesgo: NYHA III-IV, signos de congestión, ingreso por descompensación en el último año, dosis diaria de furosemida ≥ 40 mg o equivalente y NT-proBNP ≥ 1.000 pg/ml. Se estudió la incidencia de desenlaces clínicos adversos mediante el método de Kaplan-Meier y la regresión de Cox. Resultados. Se estudiaron 1.909 pacientes, que presentaban una media de 2,29 ítems de riesgo. El análisis de Kaplan-Meier mostró una tendencia incremental entre un mayor número de ítems de riesgo y el desenlace combinado muerte o ingreso por IC, la mortalidad global y la mortalidad cardiovascular (p < 0,001). Las hazard ratio ajustadas para el desenlace muerte o ingreso por IC, estimadas por regresión multivariante de Cox, fueron de 1,47 (IC95%, 1-2,15), 2,03 (IC95%, 1,41-2,92), 2,98 (IC95%, 2,08-4,28), 5,07 (IC95%, 3,51-7,32) y 7,73 (IC95%, 5,21-11,45) para pacientes con 1, 2, 3, 4 o 5 ítems de riesgo, respectivamente. El peso proporcional de las causas cardiovasculares de muerte, y en especial la IC, fue mayor en los pacientes con mayor número de ítems de riesgo. Conclusiones. Este estudio apoya el valor pronóstico de un modelo de evaluación clínica para pacientes ambulatorios con IC basado en las recomendaciones IC-BERG.[Abstract] Introduction and objectives. To assess the prognostic value of a 5-item clinical model based in the IC-BERG recommendations to evaluate ambulatory patients with heart failure (HF) in the clinic. Methods. Observational study based on the historical cohort of patients with HF referred to a specific facility since 2010 to 2019. The presence of 5 clinical ítems was evaluated: NYHA III-IV class, signs of congestion, admission due to decompensation in the previous year, daily dose ≥ 40 mg furosemide or equivalent, and NT-proBNP ≥ 1,000 pg/ml. The incidence of adverse clinical events was assessed by means of the Kaplan-Meier method and multivariable Cox's regression. Results. We studied 1909 patients, whose mean number of clinical ítems indicating risk was 2.29. Kaplan-Meier survival analysis showed an incremental trend between an increasing number of clinical ítems of risk and the combined event death or admission due to HF, overall mortality, and cardiovascular mortality (P < .001). Adjusted hazard-ratio for the combined end-point death or admission due to HF, as estimated by means of multivariable Cox's regression, were 1.47 (95%CI, 1–2.15), 2.03 (95%CI, 1.41–2.92), 2.98 (95%CI, 2.08–4.28), 5.07 (95%C,: 3.51–7.32), and 7.73 (95%CI, 5.21–11.45) for patients who showed 1, 2, 3, 4, or 5 clinical ítems indicating risk, respectively. The proportional weight of cardiovascular causes of risk, especially refractory HF, was higher in patients with a higher number of clinical ítems of risk. Conclusions. This study supports the prognostic value of a 5-item clinical model based on IC-BERG recommendations in ambulatory patients with HF

Incidence and Prognosis of Colorectal Cancer After Heart Transplantation: Data From the Spanish Post-Heart Transplant Tumor Registry

In this observational and multicenter study, that included all patients who underwent a heart transplantation (HT) in Spain from 1984 to 2018, we analyzed the incidence, management, and prognosis of colorectal cancer (CRC) after HT. Of 6,244 patients with a HT and a median follow-up of 8.8 years since the procedure, 116 CRC cases (11.5% of noncutaneous solid cancers other than lymphoma registered) were diagnosed, mainly adenocarcinomas, after a mean of 9.3 years post-HT. The incidence of CRC increased with age at HT from 56.6 per 100,000 person-years among under 45 year olds to 436.4 per 100,000 person-years among over 64 year olds. The incidence rates for age-at-diagnosis groups were significantly greater than those estimated for the general Spanish population. Curative surgery, performed for 62 of 74 operable tumors, increased the probability of patient survival since a diagnosis of CRC, from 31.6% to 75.7% at 2 years, and from 15.8% to 48.6% at 5 years, compared to patients with inoperable tumors. Our results suggest that the incidence of CRC among HT patients is greater than in the general population, increasing with age at HT

Real world comparison of spironolactone and eplerenone in patients with heart failure

[Abstract] Aims. In the absence of previous direct comparative studies, we aimed to evaluate the effectiveness of spironolactone and eplerenone in patients with heart failure and reduced ejection fraction (HFrEF) in a real-world clinical setting. Methods. Using Fine-Gray´s competing risk regression, we compared the clinical outcomes of 293 patients with chronic HF and left ventricular ejection fraction <40% treated with eplerenone and 293 propensity-score matched individuals treated with spironolactone. Study subjects were selected from a prospective cohort of 1404 ambulatory patients with HFrEF seen since 2010 to 2019 in a single specialized HF clinic, among which 992 received a mineralocorticoid receptor antagonist at baseline. Median follow-up was 3.95 years. Results. No statistically significant differences between patients treated with eplerenone versus spironolactone were observed with regard to the risk of the primary composite end-point cardiovascular death or HF hospitalization (HR 0.95; 95% CI 0.73–1.23; p= 0.677). However, eplerenone use was associated to lower cardiovascular mortality (HR 0.55; 95% CI 0.35–0.85; p= 0.008) and lower all-cause mortality (HR 0.67; 95% CI 0.47–0.95; p= 0.027). The incidence of drug suspension due to side effects (HR 0.58, 95% CI 0.40–0.85; p= 0.005) and drug suspension due to any reason (HR 0.70, 95% CI 0.51–0.97; p= 0.033) were lower among patients treated with eplerenone. Conclusions. In this observational, real-world, propensity-score matched study of patients with HFrEF, eplerenone was associated to lower cardiovascular mortality and lower all-cause mortality than spironolactone

Cancer in patients with heart failure: incidence, risk factors and prognostic impact

Observational study[Abstract] Aims: To assess the incidence of cancer diagnosis and cancer-related mortality in patients with heart failure (HF). Methods: Observational study based in a prospective cohort of patients with HF referred to a specialized Spanish clinic between 2010 and 2019. The observed incidence of malignancies (excluding non-melanoma skin cancer) was compared to that expected for the general Spanish population according to the Global Cancer Observatory. Results: We studied 1909 consecutive patients with HF. Over a median follow-up of 4.07 years, 165 new cases of malignancy were diagnosed. Observed age-standardized incidence rates of cancer were 861 (95% CI 618.4-2159.4) cases per 100,000 patients-years in men and 728.5 (95% CI 451.1-4308.7) cases per 100,000 patients-years in women; while age-standardized incidence rates of cancer expected for the general Spanish population were 479.4 cases per 100,000 patients-years in men (risk ratio = 1.80) and 295.5 cases per 100,000 patients-years in women (risk ratio = 2.46). Both a history of pre-existing malignancy at baseline and the development of new malignancies during follow-up were associated with reduced survival. Observed age-standardized cancer-related mortality was 344.1 (95% CI 202.1-1675) deaths per 100,000 patient-years in men and 217.0 (95% CI 32.8-3949.3) deaths per 100,000 patient-years in women; while age-standardized cancer-related mortality expected for the general Spanish population was 201.4 deaths per 100,000 patients-years in men (risk ratio = 1.71) and 96.2 deaths per 100,000 patients-years in women (risk ratio = 2.26). Conclusion: Patients with HF showed higher incidence rates of cancer diagnosis and cancer-related mortality than those expected for the general population

Incidence and prognosis of colorectal cancer after heart transplantation: data from the Spanish Post-Heart Transplant Tumor Registry

In this observational and multicenter study, that included all patients who underwent a heart transplantation (HT) in Spain from 1984 to 2018, we analyzed the incidence, management, and prognosis of colorectal cancer (CRC) after HT. Of 6,244 patients with a HT and a median follow-up of 8.8 years since the procedure, 116 CRC cases (11.5% of noncutaneous solid cancers other than lymphoma registered) were diagnosed, mainly adenocarcinomas, after a mean of 9.3 years post-HT. The incidence of CRC increased with age at HT from 56.6 per 100,000 person-years among under 45 year olds to 436.4 per 100,000 person-years among over 64 year olds. The incidence rates for age-at-diagnosis groups were significantly greater than those estimated for the general Spanish population. Curative surgery, performed for 62 of 74 operable tumors, increased the probability of patient survival since a diagnosis of CRC, from 31.6% to 75.7% at 2 years, and from 15.8% to 48.6% at 5 years, compared to patients with inoperable tumors. Our results suggest that the incidence of CRC among HT patients is greater than in the general population, increasing with age at HT