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

Normothermic regional perfusion vs. super-rapid recovery in controlled donation after circulatory death liver transplantation

[Background & Aims] Although there is increasing interest in its use, definitive evidence demonstrating a benefit for postmortem normothermic regional perfusion (NRP) in controlled donation after circulatory death (cDCD) liver transplantation is lacking. The aim of this study was to compare results of cDCD liver transplants performed with postmortem NRP vs. super-rapid recovery (SRR), the current standard for cDCD.[Methods] This was an observational cohort study including all cDCD liver transplants performed in Spain between June 2012 and December 2016, with follow-up ending in December 2017. Each donor hospital determined whether organ recovery was performed using NRP or SRR. The propensity scores technique based on the inverse probability of treatment weighting (IPTW) was used to balance covariates across study groups; logistic and Cox regression models were used for binary and time-to-event outcomes.[Results] During the study period, there were 95 cDCD liver transplants performed with postmortem NRP and 117 with SRR. The median donor age was 56 years (interquartile range 45–65 years). After IPTW analysis, baseline covariates were balanced, with all absolute standardised differences <0.15. IPTW-adjusted risks were significantly improved among NRP livers for overall biliary complications (odds ratio 0.14; 95% CI 0.06–0.35, p <0.001), ischaemic type biliary lesions (odds ratio 0.11; 95% CI 0.02–0.57; p = 0.008), and graft loss (hazard ratio 0.39; 95% CI 0.20–0.78; p = 0.008).[Conclusions] The use of postmortem NRP in cDCD liver transplantation appears to reduce postoperative biliary complications, ischaemic type biliary lesions and graft loss, and allows for the transplantation of livers even from cDCD donors of advanced age.[Lay summary] This is a propensity-matched nationwide observational cohort study performed using livers recovered from donors undergoing cardiac arrest provoked by the intentional withdrawal of life support (controlled donation after circulatory death, cDCD). Approximately half of the livers were recovered after a period of postmortem in situ normothermic regional perfusion, which restored warm oxygenated blood to the abdominal organs, whereas the remainder were recovered after rapid preservation with a cold solution. The study results suggest that the use of postmortem normothermic regional perfusion helps reduce rates of post-transplant biliary complications and graft loss and allows for the successful transplantation of livers from older cDCD donors.Peer reviewe