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Aims Residual pulmonary congestion at hospital discharge can worsen the outcomes in patients with heart failure (HF) and can be detected by lung ultrasound (LUS). The aim of this study was to analyse the prevalence of subclinical pulmonary congestion at discharge and its impact on prognosis in patients admitted for acute HF. Methods and results This is a post‐hoc analysis of the LUS‐HF trial. LUS was performed by the investigators in eight chest zones with a pocket device. Physical exam was subsequently performed by the treating physicians. Primary outcome was a combined endpoint of rehospitalization, unexpected visit for HF worsening or death at 6‐ month follow‐up. Subclinical pulmonary congestion at discharge was defined as the presence of ≥5 B‐lines in LUS in absence of rales in the auscultation employing the area under the ROC curve. At discharge, 100 patients (81%) did not show clinical signs of pulmonary congestion. Of these, 41 had ≥5 B‐lines. Independent factors related with the presence of subclinical pulmonary congestion were anaemia, higher New York Heart Association (NYHA) class, and N terminal pro brain natriuretic peptide (NT‐proBNP). After adjusting by propensity score analysis including age, renal insufficiency, atrial fibrillation, NYHA class, NT‐proBNP levels, clinical congestion, and the trial intervention, the presence of subclinical pulmonary congestion at discharge was a risk factor for the occurrence of the primary outcome (hazard ratio 2.63; 95% confidence interval: 1.08–6.41; P = 0.033). Conclusions Up to 40% of patients considered ‘dry’ according to pulmonary auscultation presents subclinical congestion at hospital discharge that can be detected by LUS and implies a worse prognosis at 6‐ month follow‐up. Comorbidities, high values of natriuretic peptides, and higher NYHA class are the factors related with its presence.

Aims: Intraventricular conduction defects (IVCDs) can impair prognosis of heart failure (HF), but their specific impact is not well established. This study aimed to analyse the clinical profile and outcomes of HF patients with LBBB, right bundle branch block (RBBB), left anterior fascicular block (LAFB), and no IVCDs. Methods and results: Clinical variables and outcomes after a median follow-up of 21 months were analysed in 1762 patients with chronic HF and LBBB (n = 532), RBBB (n = 134), LAFB (n = 154), and no IVCDs (n = 942). LBBB was associated with more marked LV dilation, depressed LVEF, and mitral valve regurgitation. Patients with RBBB presented overt signs of congestive HF and depressed right ventricular motion. The LAFB group presented intermediate clinical characteristics, and patients with no IVCDs were more often women with less enlarged left ventricles and less depressed LVEF. Death occurred in 332 patients (interannual mortality = 10.8%): cardiovascular in 257, extravascular in 61, and of unknown origin in 14 patients. Cardiac death occurred in 230 (pump failure in 171 and sudden death in 59). An adjusted Cox model showed higher risk of cardiac death and pump failure death in the LBBB and RBBB than in the LAFB and the no IVCD groups. Conclusion: LBBB and RBBB are associated with different clinical profiles and both are independent predictors of increased risk of cardiac death in patients with HF. A more favourable prognosis was observed in patients with LAFB and in those free of IVCDs. Further research in HF patients with RBBB is warranted. © The Author 2013.

[Abstract] Chronic kidney disease (CKD) is staged on the basis of glomerular filtration rate; generally, the MDRD study estimate, eGFR, is used. Renal dysfunction (RD) in heart transplant (HT) patients is often evaluated solely in terms of serum creatinine (SCr). In a cross-sectional, 14-center study of 1062 stable adult HT patients aged 59.1 ± 12.5 yr (82.3% men), RD was graded as absent-or-mild (AoM), moderate, or severe (this last including dialysis and kidney graft) by two classifications: SCr-RD (SCr cutoffs 1.6 and 2.5 mg/dL) and eGFR-RD (eGFR cutoffs 60 and 30 mL/min/1.73 m2). SCr-RD was AoM in 68.5% of patients, moderate in 24.9%, and severe in 6.7%; eGFR-RD, AoM in 38.6%, moderate in 52.2%, severe in 9.2%. Among patients evaluated 9.5 yr post-HT (the periods defined by time-since-transplant quartiles), AoM/moderate/severe RD prevalences were 9.5, SCr-RD 58/32/10%, eGFR-RD 32/52/16%. The prevalence of severe RD increases with time since transplant. If the usual CKD stages are appropriate for HT patients, the need for less nephrotoxic immunosuppressants and other renoprotective measures is greater than is suggested by direct SCr-based grading, which should be abandoned as excessively insensitive.

La multimorbiditat i complexitat terapèutica poden comprometre els resultats en salut en poblacions cròniques d'elevada complexitat. Baixes xifres d'adherència terapèutica podrien estar relacionades amb aquesta complexitat, i resulten ser una causa directa de pèrdua de l'empelt i mort després d'un trasplantament cardíac. Les creences negatives del pacient versus la seva pauta terapèutica poden estar al seu torn afectant l'experiència del pacient i a l'adherència a les recomanacions. Molt poc es sap sobre la magnitud real en el nostre entorn d'aquest problema, quins són els instruments per a mesurar-lo, així com quines són les estratègies més eficients per a reduir el seu impacte. Tenint en compte aquesta problemàtica, es van implementar 4 fases abreujades com l'estudi mHeart (The mHeart Study). Els objectius de cadascuna de les fases van donar lloc a aquesta tesi doctoral dividida en 4 sub-estudis consecutius. La primera de les fases va ser dirigida a mesurar quantitativament la complexitat terapèutica mitjançant un índex àmpliament validat en patologia crònica i descrit en la literatura, així com la mesura de la càrrega de morbiditat que suporten les persones trasplantades cardíaques en estadi crònic (>1.5 anys des del trasplantament). El nivell de complexitat mitjançant el total pMRCI-S va obtenir una mitjana de 42 (SD 11), molt superior al nivell publicat per a altres patologies cròniques. Els tractaments per a les comorbiditats van ser els principals causants de l’elevada complexitat terapèutica [OR=3.1 (2.8;3.4), P-valor0.7, P-valor1.5 años desde el trasplante). El nivel de complejidad mediante el total pMRCI-S obtuvo una media de 42 (SD 11), muy superior al nivel publicado para otras patologías crónicas. Los tratamientos para las comorbilidades se asociaron con una elevada complejidad terapéutica [OR=3.1 (2.8;3.4), P-valor0.7, P-valor