QT interval and short-term outcome in acute heart failure

Acute heart failure; Electrocardiogram; Emergency departmentInsuficiencia cardiaca aguda; Electrocardiograma; EmergenciasInsuficiència cardíaca aguda; Electrocardiograma; Servei d'urgènciesObjective: To investigate the association of corrected QT (QTc) interval duration and short-term outcomes in patients with acute heart failure (AHF). Methods: We analyzed AHF patients enrolled in 11 Spanish emergency departments (ED) for whom an ECG with QTc measurement was available. Patients with pace-maker rhythm were excluded. Primary outcome was 30-day all-cause mortality and secondary outcomes were need of hospitalization, in-hospital mortality and prolonged hospitalization (> 7 days). Association between QTc and outcomes was explored by restricted cubic spline (RCS) curves. Results were expressed as odds ratios (OR) and 95%CI adjusted by patients baseline and decompensation characteristics, using a QTc = 450 ms as reference. Results: Of 1800 patients meeting entry criteria (median age 84 years (IQR = 77-89), 56% female), their median QTc was 453 ms (IQR = 422-483). The 30-day mortality was 9.7%, while need of hospitalization, in-hospital mortality and prolonged hospitalization were 77.8%, 9.0% and 50.0%, respectively. RCS curves found longer QTc was associated with 30-day mortality if > 561 ms, OR = 1.86 (1.00-3.45), and increased up to OR = 10.5 (2.25-49.1), for QTc = 674 ms. A similar pattern was observed for in-hospital mortality; OR = 2.64 (1.04-6.69), for QTc = 588 ms, and increasing up to OR = 8.02 (1.30-49.3), for QTc = 674 ms. Conversely, the need of hospitalization had a U-shaped relationship: being increased in patients with shorter QTc [OR = 1.45 (1.00-2.09) for QTc = 381 ms, OR = 5.88 (1.25-27.6) for the shortest QTc of 200 ms], and also increasing for prolonged QTc [OR = 1.06 (1.00-1.13), for QTc = 459 ms, and reaching OR = 2.15 (1.00-4.62) for QTc = 588 ms]. QTc was not associated with prolonged hospitalization.Open Access funding provided thanks to the CRUE-CSIC agreement with Springer Nature

Chronic Obstructive Pulmonary Disease in Elderly Patients with Acute and Advanced Heart Failure: Palliative Care Needs—Analysis of the EPICTER Study

Introduction: There are studies that evaluate the association between chronic obstructive pulmonary disease (COPD) and heart failure (HF) but there is little evidence regarding the prognosis of this comorbidity in older patients admitted for acute HF. In addition, little attention has been given to the extracardiac and extrapulmonary symptoms presented by patients with HF and COPD in more advanced stages. The aim of this study was to evaluate the prognostic impact of COPD on mortality in elderly patients with acute and advanced HF and the clinical manifestations and management from a palliative point of view. Methods: The EPICTER study (Epidemiological survey of advanced heart failure) is a cross-sectional, multicenter project that consecutively collected patients admitted for HF in 74 Spanish hospitals. Demographic, clinical, treatment, organ-dependent terminal criteria (NYHA III-IV, LVEF <20%, intractable angina, HF despite optimal treatment), and general terminal criteria (estimated survival <6 months, patient/family acceptance of palliative approach, and one of the following: evidence of HF progression, multiple Emergency Room visits or admissions in the last six months, 10% weight loss in the last six months, and functional impairment) were collected. Terminal HF was considered if the patient met at least one organ-dependent criterion and all the general criteria. Both groups (HF with COPD and without COPD) were compared. A Kaplan-Meier survival analysis was performed to evaluate the presence of COPD on the vital prognosis of patients with HF. Results: A total of 3100 patients were included of which 812 had COPD. In the COPD group, dyspnea and anxiety were more frequently observed (86.2% vs. 75.3%, p = 0.001 and 35.4% vs. 31.2%, p = 0.043, respectively). In patients with a history of COPD, presentation of HF was in the form of acute pulmonary edema (21% vs. 14.4% in patients without COPD, p = 0.0001). Patients with COPD more frequently suffered from advanced HF (28.9% vs. 19.4%; p < 0.001). Consultation with the hospital palliative care service during admission was more frequent when patients with HF presented with associated COPD (94% vs. 6.8%; p = 0.036). In-hospital and six-month follow-up mortality was 36.5% in patients with COPD vs. 30.7% in patients without COPD, p = 0.005. The mean number of hospital admissions during follow-up was higher in patients with HF and COPD than in those with isolated HF (0.63 +/- 0.98 vs. 0.51 +/- 0.84; p < 0.002). Survival analysis showed that patients with a history of COPD had fewer survival days during follow-up than those without COPD (log Rank chi-squared 4.895 and p = 0.027). Conclusions: patients with HF and COPD had more severe symptoms (dyspnea and anxiety) and also a worse prognosis than patients without COPD. However, the prognosis of patients admitted to our setting is poor and many patients with HF and COPD may not receive the assessment and palliative care support they need. Palliative care is necessary in chronic non-oncologic diseases, especially in multipathologic and symptom-intensive patients. This is a clinical care aspect to be improved and evaluated in future research studies

Enfermedad Renal Crónica y Terapia Renal Sustitutiva en Pacientes con Infección por el Virus de la Inmunodeficiencia Humana: Prevalencia y Supervivencia en Terapia Renal Sustitutiva (Diálisis y Trasplante Renal)

INTRODUCCIÓN: Desde la introducción del TARGA la historia natural de la infección por el virus de la inmunodeficiencia humana (VIH) ha cambiado. El descenso en eventos definitorios de SIDA y el aumentado en la supervivencia han hecho que estos pacientes presenten enfermedades órgano-terminales como enfermedad renal crónica (ERC). Existe poca información clínica y epidemiológica respecto los pacientes con infección por el VIH que están en terapia renal sustitutiva (diálisis o trasplante renal –TR-) en España y en Europa. OBJETIVO GENERAL: tener un mejor conocimiento global de la patología renal en pacientes con infección por el VIH; estudiar las características clínicas, epidemiológicas, la prevalencia, las tasas de supervivencia y los factores pronóstico de los pacientes con infección por el VIH y ERC que están en terapia renal sustitutiva en España y en Europa. MÉTODOS: se han realizado 3 estudios epidemiológicos de prevalencia (2 en España y uno en Europa), un estudio de cohortes retrospectivo para el análisis de la supervivencia y dos descripciones de la experiencia aislada con casos clínicos. RESULTADOS Y CONCLUSIONES: los resultados se recogen en 6 trabajos originales y 3 trabajos relacionados con esta tesis doctoral con las siguientes conclusiones: 1. Epidemiología del VIH en diálisis 1.1.- La prevalencia del VIH en centros de diálisis en España es del 0.54%, siendo superior en diálisis peritoneal respecto a hemodiálisis. 1.2.- Los pacientes con VIH en diálisis en España son jóvenes, de raza blanca, afectos de distintas glomerulonefritis no-NAVIH y con un buen control del VIH bajo TARGA. 1.3.- Los pacientes con VIH en diálisis en Europa son también jóvenes y con un buen control del VIH, pero con una mayor presencia de raza negra y de NAVIH como causa de ERC. 1.4.- Un 39.5% de pacientes con VIH en diálisis cumple criterios para su inclusión en lista de espera para TR, pero solo un 12% estaba en lista de espera. Las causas de exclusión más frecuentes están relacionadas con un mal control del VIH. 1.5.- Dos tercios de los pacientes con VIH en diálisis en España presentan coinfección por el VHC, al ser la transmisión parenteral la vía más frecuente. En Europa la transmisión sexual es más frecuente, siendo el porcentaje de coinfectados por el VHC muy inferior. 1.6.- Los pacientes coinfectados VIH/VHC en diálisis no presentan mayor mortalidad respecto a los monoinfectados por el VIH, pero sí tienen alguna característica diferencial, siendo la más importante el menor acceso al TR. 2. Supervivencia del VIH en diálisis 2.1.- La supervivencia a medio plazo de los pacientes con VIH en diálisis es inferior respecto a la población control sin VIH. 2.2.- Los factores asociados a mal pronóstico son la ausencia de una pauta efectiva de TARGA y estar en diálisis peritoneal respecto a hemodiálisis. 3. TR en pacientes con VIH 3.1.- El TR en pacientes con VIH en Europa tiene una prevalencia del 0.04%, siendo las tasas de supervivencia a medio plazo (de injerto y paciente) muy elevadas y similares a les series publicadas en pacientes sin VIH. 3.2.- La tasa de rechazo agudo en receptores europeos de TR con VIH fue del 30%, siendo superior a la de las series publicadas en pacientes sin VIH. 3.3.- El uso de timoglobulina como agente inductor en receptores de TR con VIH produce una rápida y profunda linfocitopenia que no se asoció a un mayor número de infecciones respecto a un grupo control sin VIH. 3.4.- El cambio de TARGA por una combinación que incluya raltegravir en el periodo post-trasplante es una estrategia segura y eficaz para el manejo del VIH por la ausencia de interacciones farmacológicas con inmunosupresores. 3.5.- El doble trasplante reno-pancreático es también posible en pacientes con VIH pero la experiencia es muy escasa.BACKGROUND: Antiretroviral therapy (ART) has been immensely successful in reducing AIDS-events and death after HIV infection, raising the interest in non-infectious comorbidities including kidney disease. There is a lack of clinical and epidemiological data regarding kidney issues in HIV-infected patients. OBJECTIVE: to improve global knowledge on kidney diseases in HIV-infected patients, focusing on clinical and epidemiological issues (prevalence, survival and prognostic factors) among HIV infection on dialysis or renal transplantation (RT) in Spain and Europe. METHODS: the following studies were conducted: three cross-sectional prevalence studies, one retrospective survival cohort study and two descriptive case series experiences. RESULTS AND CONCLUSIONS: the results are included in 6 original and 3 related studies with the following conclusions: 1.- Prevalence of HIV on dialysis units in Spain was 0.54% being higher on peritoneal dialysis. 2.- Spanish HIV-infected patients on dialysis were young males, with no-HIVAN glomerulonephritis and with a good control of HIV. In European patients a higher proportion of black race and HIVAN was found. 3.- 39.5% of HIV-infected patients on dialysis met criteria to be included on RT waiting list. Only 12% were already included. The most frequent exclusion criteria were related with poor control of HIV. 4.- HCV coinfection was present in 2/3 of HIV-infected patients on dialysis, was not associated with mortality but with lower access to RT. 5.- Survival of HIV-infected patients on dialysis was lower than that of matched HIV-negative patients. Factors related with poor prognosis were the absence of ART and peritoneal dialysis. 6.- Patients and graft survival rates of European HIV-infected RT recipients were similar to HIV-negative patients. Acute rejection was more frequent (30%). 7.- Thymoglobulin produced a profound lymphocytopenia that was not associated with increased risk of infections. 8.- Raltegravir had no interactions with immunosuppressants and can be used safely after transplant

Prevalence and risk factors of mild chronic renal failure in HIV-infected patients: influence of female gender and antiretroviral therapy

ABSTRACT Background In people living with HIV, much is known about chronic kidney disease, defined as a glomerular filtration rate under 60 mL/min. However, there is scarce data about prevalence and risk factors for milder impairment (60-89 mL/min). Objective The present study aims to assess the influence of sex, antiretroviral therapy, and classical risk factors on the occurrence of mild decreased renal function in a large Spanish cohort of HIV-infected patients. Methods Cross-sectional, single center study, including all adult HIV-1-infected patients under antiretroviral treatment with at least two serum creatinine measures during 2014, describing the occurrence of and the risk factors for mildly decreased renal function (eGFR by CKD-EPI creatinine equation of 60-89 mL/min). Results Among the 4337 patients included, the prevalence rate of mildly reduced renal function was 25%. Independent risk factors for this outcome were age older than 50 years (OR 3.03, 95% CI 2.58-3.55), female sex (OR 1.23, 95% CI 1.02-1.48), baseline hypertension (OR 1.57, 95% CI 1.25-1.97) or dyslipidemia (OR 1.48, 95% CI 1.17-1.87), virologic suppression (OR 1.88, 95% CI 1.39-2.53), and exposure to tenofovir disoproxil-fumarate (OR 1.67, 95% CI 1.33-2.08) or ritonavir-boosted protease-inhibitors (OR 1.19, 95% CI 1.03-1.39). Conclusions Females and patients over 50 seem to be more vulnerable to renal impairment. Potentially modifiable risk factors and exposure to tenofovir disoproxil-fumarate or ritonavir-boosted protease-inhibitors are present even in earlier stages of chronic kidney dysfunction. It remains to be determined whether early interventions including antiretroviral therapy changes (tenofovir alafenamide, cobicistat) or improving comorbidities management will improve the course of chronic kidney disease