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We investigated if the phenotypic classification of acute heart failure (AHF) based on the number of signs/symptoms of congestion and hypoperfusion at emergency department (ED) arrival identifies subgroups in which intravenous (IV) nitroglycerine (NTG) use improves short-term survival.We included consecutive AHF patients diagnosed in 45 Spanish EDs, who were grouped according to phenotype severity. The main outcome was 30-day all-cause death. Propensity scores (PS) for NTG use were generated using variables associated with death. Analysis of interaction was performed in subgroups of patients based on congestion, hypoperfusion, age, sex, coronary artery disease (CAD), left ventricular ejection fraction (LVEF) and SBP.We analyzed 16 437 AHF patients (median = 83 years; women = 56%); 1882 received NTG (11.4%). In the whole cohort, the cumulative 30-day mortality in patients receiving NTG was higher (11.5% vs. 9.6%; unadjusted HR, 1.19; 95% CI, 1.04-1.36), but not in the PS-matched cohorts (1698 pairs of patients; 11.5% vs. 10.5%; HR, 1.10; 95% CI, 0.90-1.35). Mortality was increased in NTG-treated patients with mild congestion (HR, 2.09; 95% CI, 1.19-3.67), especially in those without hypoperfusion (HR, 2.51; 95% CI, 1.24-5.10). Interaction analysis of the PS-matched cohorts confirmed detrimental effects of NTG use in less congested patients, whereas beneficial effects were only observed in patients with decreased LVEF (50% subgroup: HR, 0.59; 95% CI, 0.37-0.92; ≥50% subgroup: HR, 1.30; 95% CI, 0.66-2.56; P = 0.002).Phenotypical classification of AHF based on congestion/hypoperfusion at ED arrival does not identify subgroups of patients in whom IV-NTG would decrease mortality, although it could potentially be beneficial in those with LVEF of less than 50%. This hypothesis will have to be confirmed in the future. Conversely, our results suggest that IV-NTG may be harmful in patients with only mild clinical congestion.

Introduction and objectives Composite endpoints are widely used but have several limitations. The Clinical Outcomes, HEalthcare REsource utilizatioN and relaTed costs (COHERENT) model is a new approach for visually displaying and comparing composite endpoints including all their components (incidence, timing, duration) and related costs. We aimed to assess the validity of the COHERENT model in a patient cohort. Methods A color graphic system displaying the percentage of patients in each clinical situation (vital status and location: at home, emergency department [ED] or hospital) and related costs at each time point during follow-up was created based on a list of mutually exclusive clinical situations coded in a hierarchical fashion. The system was tested in a cohort of 1126 patients with acute heart failure from 25 hospitals. The system calculated and displayed the time spent in each clinical situation and health care resource utilization-related costs over 30 days. Results The model illustrated the times spent over 30 days (2.12% in ED, 23.6% in index hospitalization, 2.7% in readmissions, 65.5% alive at home, and 6.02% dead), showing significant differences between patient groups, hospitals, and health care systems. The tool calculated and displayed the daily and cumulative health care-related costs over time (total, €4 895 070; mean, €144.91 per patient/d). Conclusions The COHERENT model is a new, easy-to-interpret, visual display of composite endpoints, enabling comparisons between patient groups and cohorts, including related costs. The model may constitute a useful new approach for clinical trials or observational studies, and a tool for benchmarking, and value-based health care implementation.

Resumen Introduccion y objetivos Investigar si diferentes caracteristicas estructurales/organizativas del hospital y del servicio de urgencias (SU) impactan en los resultados de la insuficiencia cardiaca aguda (ICA). Metodos Analisis secundario del Registro EAHFE. Se recogieron 6 caracteristicas hospitalarias y del SU, y se relacionaron con 7 resultados tras el evento indice y tras el alta, ajustados por ano de inclusion, caracteristicas basales y del episodio de ICA y por dichas caracteristicas estructurales/organizativas. Tambien se relaciono el porcentaje de altas directas desde urgencias (ADU) y resultados, y si habia interaccion segun las caracteristicas hospitalarias o del SU. Resultados Cuarenta SU espanoles incluyeron 17.974 episodios de ICA. Hubo menos estancias prolongadas en hospitales de alta tecnologia, con hospitalizacion a domicilio y con SU con alta frecuentacion, y mas estancias prolongadas en hospitales con unidad de insuficiencia cardiaca y area de observacion en urgencias. Los hospitales de alta tecnologia presentaron menor mortalidad hospitalaria (OR = 0,78; IC95%, 0,65-0,94). Respecto a eventos 30 dias tras el alta, los hospitales con unidad de corta estancia (UCE) tuvieron mas hospitalizaciones (OR = 1,19; IC95%, 1,02-1,38); los SU con alta afluencia, menor mortalidad (OR = 0,73; IC95%, 0,56-0,96) y eventos combinados (OR = 0,87; IC95%, 0,76-0,99), y los hospitales con unidad de insuficiencia cardiaca, menos reconsultas a urgencias (OR = 0,83; IC95%, 0,76-0,91), hospitalizaciones (OR = 0,85; IC95%, 0,75-0,97) y eventos combinados (OR = 0,84; IC95%, 0,77-0,92). A mas ADU, menos estancias prolongadas. Entre otras interacciones, el incremento de ADU se asocio con mas reconsultas, hospitalizaciones y eventos combinados a los 30 dias del alta en hospitales sin UCE, pero no en hospitales con UCE. Conclusiones Las caracteristicas estructurales/organizativas de hospitales y SU y la agresividad en el tratamiento en urgencias influyen significativamente en los resultados en la ICA.

ResumenIntroducción. El síndrome de Foville (síndrome pontino dorsal inferior) es una entidad clínica que hace parte de una subclasificación de la categoría más amplia de eventos cerebrovasculares de la circulación posterior, se presenta como resultado de la oclusión de la arteria basilar debido a lesiones en el tegmento pontino. Este síndrome tiene una muy baja incidencia a nivel mundial, pero es de gran relevancia clínica. Presentación del caso. Hombre de 41 años sin antecedentes patológicos, que ingresó al servicio de urgencias por signos de focalización neurológica. Sus hallazgos imagenológicos fueron compatibles con una lesión isquémica en el tronco encefálico y la angiografía cerebral evidenció un compromiso en el territorio de la arteria basilar. El paciente fue diagnosticado y se le dio seguimiento en la unidad de cuidados intensivos (UCI) hasta su rehabilitación. Conclusión. El síndrome de Foville es una enfermedad infrecuente y de alta mortalidad. El reconocimiento temprano de esta afección y un abordaje multidisciplinario son determinantes para mejorar el pronóstico del paciente.

Resumo: Introdução e objetivos: A Internet é fundamental na divulgação de informação médica. Contudo, a ausência de controlo de qualidade potencia a “desinformação” da população. Pretendemos caraterizar a relevância e qualidade da informação sobre enfarte agudo do miocárdio em língua portuguesa no site YouTube (www.youtube.com). Métodos: Analisaram‐se 1.000 vídeos correspondentes aos primeiros 100 resultados da pesquisa no YouTube dos termos: “ataque + cardíaco”, “ataque + coração”, “enfarte ‐ cerebral”, “infarto ‐ cerebral”, “enfarte + miocárdio”, “enfarte + agudo + miocárdio”, “infarto + miocárdio”, “infarto + agudo + miocárdio”, “trombose + coração” e “trombose + coronária”. Excluíram‐se vídeos irrelevantes (n = 316), duplicados (n = 345), sem áudio (n = 24) e de língua não portuguesa (n = 106). Os vídeos elegíveis foram analisados quanto a origem, tema, público‐alvo e imprecisões científicas. A qualidade foi avaliada com os scores Health on the Net Code (HONCode, de 0‐8) e DISCERN (0‐5) – quanto maior, melhor a qualidade. Resultados: Incluíram‐se 242 vídeos, a maioria de formadores independentes (n = 95, 39%) e destinados à população‐geral (n = 202, 83,5%). Um terço (n = 79) apresentou imprecisões; vídeos de sociedades científicas e instituições de saúde/governamentais não apresentaram quaisquer imprecisões. A qualidade média foi baixa/moderada; apenas um vídeo apresentou boa qualidade, sem imprecisões. Instituições de saúde/governamentais foram a fonte com melhor qualidade (HONCode 4±1, DISCERN 2±1). Conclusões: A informação sobre enfarte agudo do miocárdio em língua portuguesa é irrelevante em um terço dos casos e um terço dos vídeos relevantes é impreciso. A qualidade média da informação é reduzida, sendo importante definir estratégias de controlo de qualidade da informação médica online. Abstract: Introduction and objectives: The Internet is a fundamental aspect of health information. However, the absence of quality control encourages misinformation. We aim to assess the relevance and quality of acute myocardial infarction videos shared on YouTube (www.youtube.com) in Portuguese. Methods: We analyzed 1,000 videos corresponding to the first 100 search results on YouTube using the following terms (in Portuguese): “cardiac + arrest”; “heart + attack”; “heart + thrombosis”; “coronary + thrombosis”; “infarction – brain”, “myocardial + infarction” and “acute + myocardial + infarction”. Irrelevant (n=316), duplicated (n=345), without audio (n=24) or non‐Portuguese (n=106) videos were excluded. Included videos were assessed according to source, topic, target audience and scientific inaccuracies. Quality of information was assessed using The Health on the Net Code (HONCode from 0 to 8) and DISCERN (from 0 to 5) scores – the higher the score, the better the quality. Results: 242 videos were included. The majority were from independent instructors (n=95, 39.0%) and were addressed to the general population (n=202, 83.5%). One third of the videos (n=79) contained inaccuracies while scientific society and governmental/health institution videos had no inaccuracies. The mean video quality was poor or moderate; only one video was good quality without any inaccuracies. Governmental/health institutions were the source with the best quality videos (HONCode 4±1, DISCERN 2±1). Conclusions: One third of the videos had irrelevant information and one third of the relevant ones contained inaccuracies. The average video quality was poor; therefore it is important to define strategies to improve the quality of online health information.

To analyze whether short-term outcomes are affected when patients diagnosed with acute heart failure (AHF) spend time in an emergency department observation unit (EDOU) before hospital admission.Baseline and emergency episode data were collected for patients diagnosed with AHF in the EDs of 15 Spanish hospitals. We analyzed crude and adjusted associations between EDOU stay and 30-day mortality (primary outcome) and in-hospital mortality and a prolonged hospital stay of more than 7 days (secondary outcomes).A total of 6597 patients with a median (interquartile range) age of 83 (76-88 years) were studied. Fifty-five percent were women. All were hospitalized for AHF (50% in internal medicine wards, 23% in cardiology, 11% in geriatrics, and 16 in other specialties. Of these patients, 3241 (49%) had had EDOU stays and 3350 (51%) had been admitted immediately, with no EDOU stay. Having an EDOU stay was associated with female sex, dementia or chronic obstructive pulmonary disease, long-term treatment with certain drugs for heart failure, greater baseline deterioration in function, and a higher degree of decompensation. Patients in the EDOU group were more often admitted to an internal medicine ward and had shorter stays; cardiology, geriatric, and intensive care admissions were less likely to have had an EDOU stay. Overall, 30-day mortality was 12.6% (13.7% in the EDOU group and 11.4% in the no-EDOU group; P = .004). In-hospital mortality was 10.4% overall (EDOU, 11.1% and no-EDOU, 9.6%; P = .044). Prolonged hospitalization occurred in 50.0% (EDOU, 48.7% and no-EDOU, 51.2%; P = .046). After adjusting for between-group differences, the EDOU stay was not associated with 30-day mortality (hazard ratio, 1.14; 95% CI, 0.99-1.31). Odds ratios for associations between EDOU stay and in-hospital mortality and prolonged hospital stay, respectively, were 1.09 (95% CI, 0.92-1.29) and 0.91 (95% CI, 0.82-1.01).Although mortality higher in patients hospitalized for AHF who spend time in an EDO, the association seems to be accounted for by their worse baseline situation and the greater seriousness of the decompensation episode, not by time spent in the EDOU.Analizar si la estancia en el área de observación de urgencias (AOU) de pacientes que han sido diagnosticados de insuficiencia cardiaca aguda (ICA) y que deben ingresar está asociada con algún cambio en la evolución a corto plazo.Se recogieron datos basales y clínicos de pacientes diagnosticados de ICA en el servicio de urgencias de 15 hospitales españoles. Se analizó la asociación cruda y ajustada de la estancia en el AOU previa a la hospitalización con mortalidad a 30 días (objetivo primario) y con mortalidad intrahospitalaria e ingreso prolongado (7 días) (objetivos secundarios).Se incluyeron 6.597 pacientes (mediana = 83 años, RIC = 76-88; mujeres = 55%) hospitalizados por ICA (50% en medicina interna, 23% en cardiología, 11% en geriatría y 16% en otros servicios); de ellos, 3.241 (49%) permanecieron en observación en urgencias (grupo AOU) y 3.350 (51%) hospitalizaron sin observación previa (grupo no-AOU). La observación en urgencias se asoció con ser mujer, tener demencia o enfermedad pulmonar obstructiva crónica, recibir crónicamente fármacos específicos para insuficiencia cardiaca, mayor deterioro funcional basal y mayor gravedad de la descompensación. El grupo AOU más frecuentemente hospitalizó en medicina interna y corta estancia, y menos frecuentemente en cardiología, geriatría y cuidados intensivos. La mortalidad a 30 días fue del 12,6% (AOU = 13,7%, no-AOU = 11,4%, p = 0,004); la mortalidad intrahospitalaria fue del 10,4% (AOU = 11,1%, no-AOU = 9,6%, p = 0,044) y el ingreso prolongado del 50,0% (AOU = 48,7%, no-AOU = 51,2%, p = 0,046). Tras ajustar por las diferencias entre grupos, la estancia en observación en urgencias no se asoció con mortalidad a 30 días (HR = 1,14, IC 95% = 0,99-1,31), mortalidad intrahospitalaria (OR = 1,09, IC 95% = 0,92-1,29) o estancia prolongada (OR = 0,91, IC 95% = 0,82-1,01).Aunque los pacientes hospitalizados por ICA que permanecen en observación en urgencias presentan mayor mortalidad, esta asociación parece explicarse por su peor situación de base y la mayor gravedad del episodio de descompensación y no por su paso por el AOU.

© 2020 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. This is an open access article under the CC-BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/), Atrial fibrillation (AF), the most common arrhythmia in the adult population worldwide, represents a significant burden in terms of cardiovascular mortality and morbidity and has repercussions on health economics. Oral anticoagulation (OAC) is key to stroke prevention in AF and, in recent years, results from landmark clinical trials of non-vitamin K oral anticoagulants (NOAC) have triggered a paradigm shift in thrombocardiology. Despite these advances, there is still a significant residual vascular risk associated with silent AF, bleeding, premature sudden death and heart failure. The authors review AF epidemiologic data, the importance of new tools for early AF detection, the current role of catheter ablation for rhythm control in AF, the state-of-the-art in periprocedural OAC, the optimal management of major bleeding, the causes of residual premature death and future strategies for improvements in AF prognosis., A arritmia mais comum na população adulta em todo o mundo, a fibrilhação auricular (FA), contribui decisivamente para a elevada mortalidade e morbilidade cardiovascular, com repercussões na economia da saúde. A anticoagulação oral (ACO) é a chave para a prevenção do acidente vascular cerebral na FA. Nos últimos anos, os resultados dos grandes ensaios clínicos com os ACO não antagonista da vitamina K mudaram o paradigma na trombocardiologia. Apesar deste avanço, o risco vascular residual associado à FA silenciosa, hemorragia, morte súbita prematura e insuficiência cardíaca continua a ser significativo. Os autores fazem uma revisão dos dados epidemiológicos da FA, a importância das novas ferramentas para a deteção precoce da FA, o papel atual da ablação por cateter no controlo do ritmo na FA, o estado da arte na ACO periprocedimento, a gestão ideal de hemorragias graves, as causas de morte prematura residual e estratégias futuras para a melhoria do prognóstico da FA.

Aims To assess whether symptoms/signs of congestion and perfusion in acute heart failure (AHF) evaluated at patient arrival to the emergency department (ED) can predict the severity of decompensation and short-term outcomes. Methods and results We included patients from the Epidemiology of AHF Emergency Registry (EAHFE Registry). We registered seven clinical surrogates of congestion and five of hypoperfusion. Patients were grouped according to severity of congestion/hypoperfusion. We assessed the need for hospitalization, in-hospital all-cause mortality for patients needing hospitalization, and prolonged hospitalization for patients surviving the decompensation episode. Outcomes were adjusted for patient characteristics and the coexistence of congestion and hypoperfusion. We analysed 18 120 patients (median = 83 years, interquartile range = 76–88; women = 55.7%). Seventy-two per cent presented >2 signs/symptoms of congestion and 18% had at least 1 sign/symptom of hypoperfusion. Seventy-five per cent were hospitalized with in-hospital death in 9% and prolonged hospitalization in 47% discharged alive. The presence of congestion/hypoperfusion was independently associated with poorer outcomes. An increase in the number of signs/symptoms of congestion was associated with increased risk of hospitalization (P < 0.001) and prolonged stay (P = 0.011), but not mortality (P = 0.06). Increased signs/symptoms of hypoperfusion were associated with hospitalization (P < 0.001) and mortality (P < 0.001), but not prolonged stay (P = 0.227). In the combined model, including congestion and hypoperfusion, both had additive effects on hospitalization, in-hospital mortality was driven by hypoperfusion and no differences were observed for prolonged hospitalization. Conclusion The presence of congestion/hypoperfusion at ED arrival is a simple clinical marker associated with a higher risk of severity/adverse short-term outcomes.

The sistodiastolic dysfunction of the heart measured through global ejection of the left ventricle as systolic parameter and the ventricular rapid filling plus the time of ventricular total filling as parameters of function diastólica are informational facts of complementary examinations of high sensibility and specificity for this type of study. It was established a relationship between the fraction of left ventricular ejection global and segment, measured for ventriculografía radioisotópica of balance, with the disorders electrocardiográficos in chronic chagásic patients. It is possible to conclude that while major alteration exists in the fraction of ventricular ejection, major abnormal variations exist in the electrocardiography of the chronical chagasic patients. Those who presented complete block of right branch show the possible existence of association in the deterioration of the fraction of ejection apicoseptal, aspect that would allow to conclude that the complete blockade of right branch can be a variable predisposed. The statistical analysis of the fraction of ejection apical that was found shows that the decrease of this region has a statistical force with the electrocardiografic deterioration complete blockade of right branch more front left hemibloqueo, This scientific evidence is confirmed across the statistical and epidemiological evidence which indicators allow to observe a major prevalency in 66 % and a major association of 1.51 times of complete Blockade of Right Branch more front left hemibloqueo in relation to other segments.

Aims We investigated the incidence, risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with COVID-19 attending emergency departments (EDs), before hospitalization. Methods and Results We retrospectively reviewed all COVID-19 patients diagnosed with PE in 62 Spanish EDs (20% of Spanish EDs, case group) during the first COVID-19 outbreak. COVID-19 patients without PE and non-COVID-19 patients with PE were included as control groups. Adjusted comparisons for baseline characteristics, acute episode characteristics, and outcomes were made between cases and randomly selected controls (1:1 ratio). We identified 368 PE in 74 814 patients with COVID-19 attending EDs (4.92‰). The standardized incidence of PE in the COVID-19 population resulted in 310 per 100 000 person-years, significantly higher than that observed in the non-COVID-19 population [35 per 100 000 person-years; odds ratio (OR) 8.95 for PE in the COVID-19 population, 95% confidence interval (CI) 8.51–9.41]. Several characteristics in COVID-19 patients were independently associated with PE, the strongest being D-dimer >1000 ng/mL, and chest pain (direct association) and chronic heart failure (inverse association). COVID-19 patients with PE differed from non-COVID-19 patients with PE in 16 characteristics, most directly related to COVID-19 infection; remarkably, D-dimer >1000 ng/mL, leg swelling/pain, and PE risk factors were significantly less present. PE in COVID-19 patients affected smaller pulmonary arteries than in non-COVID-19 patients, although right ventricular dysfunction was similar in both groups. In-hospital mortality in cases (16.0%) was similar to COVID-19 patients without PE (16.6%; OR 0.96, 95% CI 0.65–1.42; and 11.4% in a subgroup of COVID-19 patients with PE ruled out by scanner, OR 1.48, 95% CI 0.97–2.27), but higher than in non-COVID-19 patients with PE (6.5%; OR 2.74, 95% CI 1.66–4.51). Adjustment for differences in baseline and acute episode characteristics and sensitivity analysis reported very similar associations. Conclusions PE in COVID-19 patients at ED presentation is unusual (about 0.5%), but incidence is approximately ninefold higher than in the general (non-COVID-19) population. Moreover, risk factors and leg symptoms are less frequent, D-dimer increase is lower and emboli involve smaller pulmonary arteries. While PE probably does not increase the mortality of COVID-19 patients, mortality is higher in COVID-19 than in non-COVID-19 patients with PE.

Copyright © 2020 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. All rights reserved., © 2020 Sociedade Portuguesa de Cardiologia. Published by Elsevier Espa ̃na, S.L.U. This is an open access article under the CC-BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)., Introduction and objectives: Cardiovascular disease is the leading cause of death in Portugal and atherosclerosis is the most common underlying pathophysiological process. The aim of this study was to quantify the economic impact of atherosclerosis in Portugal by estimating disease-related costs. Methods: Costs were estimated based on a prevalence approach and following a societal perspective. Three national epidemiological sources were used to estimate the prevalence of the main clinical manifestations of atherosclerosis. The annual costs of atherosclerosis included both direct costs (resource consumption) and indirect costs (impact on population productivity). These costs were estimated for 2016, based on data from the Hospital Morbidity Database, the health care database (SIARS) of the Regional Health Administration of Lisbon and Tagus Valley including real-world data from primary care, the 2014 National Health Interview Survey, and expert opinion. Results: The total cost of atherosclerosis in 2016 reached 1.9 billion euros (58% and 42% of which was direct and indirect costs, respectively). Most of the direct costs were associated with primary care (55%), followed by hospital outpatient care (27%) and hospitalizations (18%). Indirect costs were mainly driven by early exit from the labor force (91%). Conclusions: Atherosclerosis has a major economic impact, being responsible for health expenditure equivalent to 1% of Portuguese gross domestic product and 11% of current health expenditure in 2016.

Objective: Experts recommended that direct discharge without hospitalization (DDWH) for emergency departments (EDs) able to observe acute heart failure (AHF) patients should be 40%, and these discharged patients should fulfil the following outcome standards: 30-day all-cause mortality 40%. Considering DDWH patients altogether, outcomes A/C were above the recommended standards (4.3%/29.4%), while outcome B was nearly met (B = 10.1%). When analyzing individual EDs, 58.1% of them achieved the outcome B standard, while outcomes A/C standards were barely achieved (19.3%/9.7%). We observed clinically relevant linear/quadratic relationships between higher DDWH and worse outcomes B (weighted R-2 = 0.184/0.322) and C (weighted R-2 = 0.430/0.624), but not with outcome A (weighted R-2 = 0.002/0.022). Conclusions: The EDs of this nationwide cohort do not fulfil the standards for AHF patients with DDWH. High DDWH rates negatively impact ED revisit or hospitalization but not mortality. This may represent an opportunity for improvement in better selecting patients for early ED discharge and in ensuring early follow-up after ED discharge. (c) 2020 Published by Elsevier Ltd on behalf of Japanese College of Cardiology.

We present here a first principles study of the structural, electronic, magnetic, and hyperfine properties of magnesium ferrite, MgFe2O4 (spinel structure). The study was carried out within the framework of Functional Density Theory (DFT) using the full potential linearized augmented plane waves method (FPLAPW) using both the Generalized Gradient (GGA) and the GGA+U approximations for the exchange and correlation potential. To discuss the magnetic ordering and the lowest energy structure of the system we consider different distributions of Mg and Fe ions in both cationic sites of the spinel structure, as well as different spin configurations. Our calculations predict that the equilibrium structure corresponds to an inverted antiferromagnetic configuration, in which the magnetic moments of the Fe atoms located at sites A are ferromagnetically ordered among themselves and antiferromagnetically with respect to the Fe located at the sublattice of sites B. Our GGA calculations underestimate the energy band-gap of the system, while GGA+U predict a band-gap of 2.3 eV, in excellent agreement with the reported values. The results for the hyperfine properties at the Fe sites (isomer shift, quadrupole splitting and hyperfine field) are in excellent agreement with the Mössbauer spectroscopy results reported in the literature, giving support to the equilibrium structure predicted by FP-LAPW.

OBJECTIVE To describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU). METHOD We included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge. RESULTS The study included 1473 patients (HH/IM/SSU: 68/979/384). The HH rate was 4.7% (95% CI, 3.8-6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5-12), similar to that of IM (median stay, 8 days; IQR, 5-13; p=.106) and longer than that of SSU (median stay, 4 days; IQR, 3-7; p

Resumen Objetivo Describir frecuencia, caracteristicas clinicas y evolucion de los pacientes con insuficiencia cardiaca aguda (ICA) ingresados directamente desde urgencias en hospitalizacion a domicilio (HaD) asi como compararlos con los ingresados en medicina interna (MI) o unidad de corta estancia (UCE). Metodo Se incluyeron los pacientes con ICA ingresados en HaD por parte de los hospitales que contemplaban esta opcion durante los Registros EAHFE 4-5-6 y se compararon con los casos que ingresaron en MI o UCE en estos centros. Se compararon la mortalidad por cualquier causa al ano y los eventos adversos a los 30 dias tras el alta de forma ajustada. Resultados Se incluyeron 1.473 pacientes (HaD/MI/UCE: 68/979/384). La frecuencia de HaD fue del 4,7% (IC95% = 3,8-6,0%). Los pacientes en HaD tuvieron escasas diferencias respecto a los ingresados en MI y UCE. Su mortalidad durante el ingreso fue del 1,5% y la duracion de la estancia mediana fue de 7,5 dias (RIC = 4,5-12), parecida a MI (mediana = 8; RIC = 5-13; p = 0,106) y superior a UCE (mediana = 4; RIC = 3-7; p Conclusiones El ingreso directo desde urgencias en HaD es poco frecuente a pesar de ser una opcion segura en un determinado perfil de pacientes con ICA.

OBJECTIVES To investigate whether the diagnosis of acute coronary syndrome (ACS) in coronary artery bypass grafting (CABG) patients with chest pain (CP) is more difficult based on the initial clinical and electrocardiogram (ECG) findings. METHODS We included consecutive CP patients attended at a single emergency department (ED) during a 10-year period. CABG status and the final diagnosis of ACS were considered as stated in the ED discharge report. We evaluated the frequency of 21 CP characteristics (CPC) and four ECG signatures, their individual and collective association with ACS, and ED length of stay (LOS) in CABG and non-CABG patients. RESULTS We included 34 429 patients [median age: 61 years; female: 41.8%; CABG: 2204 patients (6.4%)], and ACS was diagnosed in 6727 (19.5%; CABG/non-CABG 37.2%/18.3%; P < 0.001). CABG patients more frequently had CPC and ECG findings typically associated with ACS, but their final association with ACS was weaker than in non-CABG patients (only significant after adjustment for attendant diaphoresis, throat irradiation, ST-segment elevation and T-wave inversion). The collective discriminative capacity was significantly lower in CABG patients (area under the curve 0.710 vs. 0.793; P < 0.001), even after adjustment (0.708 vs. 0.790; P < 0.001). ED LOS was longer for CABG patients, overall (P < 0.001) and for patients diagnosed with ACS (P = 0.008) and non-ACS (P < 0.001), but these differences disappeared after adjustment. CONCLUSION CABG substantially reduces the diagnostic performance of CPC and ECG findings to suggest ACS. A longer LOS in the ED in CABG patients is more related to their baseline characteristics than to CABG itself.

Sugarcane (Saccharum spp. hybrids) is the primary source of sugar and renewable biofuel energy worldwide. Nevertheless, sugarcane production is affected by different biotic and abiotic stresses. In this work, we analysed the impact of Puccinia melanocephala infection and salt stress on the expression profile of genes related with inositol phosphate synthesis and TOR (Target of Rapamycin) signalling pathway regulation in sugarcane. In this sense, two-month-old plants of rust resistant and susceptible cultivars were infected with P. melanocephala and leaf samples were collected daily during the first seven days post-inoculation. A second group of plants was treated with NaCl, previous to leaf sampled at 2 h and 72 h post-stress, leaf chlorophyll content was measured. Quantitative PCR was used to obtain gene expression profiles. Tctp gene was up-regulated in the rust resistant cultivar suggesting that a component of TOR signalling pathway is involving in early pathogen recognition. Biotic and abiotic stresses modified the transcript profile of Mips2 and Tap46 genes, depending on the sugarcane stress resistance. Our results contribute to a better understanding of stress signalling networks in sugarcane.

Background The multiple estimation of risk based on the emergency department Spanish score in patients with acute heart failure (MEESSI-AHF) is a risk score designed to predict 30-day mortality in acute heart failure patients admitted to the emergency department. Using a derivation cohort, we evaluated the performance of the MEESSI-AHF risk score to predict 11 different short-term outcomes. Methods Patients with acute heart failure from 41 Spanish emergency departments (n=7755) were recruited consecutively in two time periods (2014 and 2016). Logistic regression models based on the MEESSI-AHF risk score were used to obtain c-statistics for 11 outcomes: three with follow-up from emergency department admission (inhospital, 7-day and 30-day mortality) and eight with follow-up from discharge (7-day mortality, emergency department revisit and their combination; and 30-day mortality, hospital admission, emergency department revisit and their two combinations with mortality). Results The MEESSI-AHF risk score strongly predicted mortality outcomes with follow-up starting at emergency department admission (c-statistic 0.83 for 30-day mortality; 0.82 for inhospital death, P=0.121; and 0.85 for 7-day mortality, P=0.001). Overall, mortality outcomes with follow-up starting at hospital discharge predicted slightly less well (c-statistic 0.80 for 7-day mortality, P=0.011; and 0.75 for 30-day mortality, P Conclusions The MEESSI-AHF risk score strongly predicts mortality outcomes in acute heart failure patients admitted to the emergency department, but the model performs poorly for outcomes involving hospital admission or emergency department revisit. There is a need to optimise this risk score to predict non-fatal events more effectively.

Resumo: Nos últimos anos, temos assistido a um aumento do número de doentes com necessidade de cuidados cardíacos agudos, com patologia cardiovascular progressivamente mais complexa, muitas vezes complicada por comorbilidades não cardiovasculares agudas ou crónicas, com impacto na abordagem e prognóstico destes doentes. As unidades coronárias têm evoluído para unidades de cuidados intensivos cardíacos, caracterizadas por cuidados de saúde altamente especializados ao doente cardíaco crítico. Tendo em conta que os recursos humanos e técnicos nesta área são limitados, considerámos ser urgente uma reflexão profunda sobre o modelo de organização dos cuidados ao doente cardíaco agudo, incluindo a definição do nível de cuidados, a constituição e formação da equipa e a criação de redes de referenciação.Paralelamente, é fundamental um investimento claro dos serviços nesta área central da cardiologia, de forma a alavancar o desenvolvimento contínuo e sustentado de outras áreas cardiológicas essenciais, nomeadamente a eletrofisiologia e a cardiologia de intervenção, assegurando cuidados de excelência e de elevada diferenciação a todos os doentes cardíacos críticos. Abstract: In recent years, the number of patients requiring acute cardiac care has increased, with progressively more complex cardiovascular conditions, often complicated by acute or chronic non‐cardiovascular comorbidities, which affects the management and prognosis of these patients. Coronary care units have evolved into cardiac intensive care units, which provide highly specialized health care for the critical heart patient. In view of the limited human and technical resources in this area, we consider that there is an urgent need for an in‐depth analysis of the organizational model for acute cardiac care, including the definition of the level of care, the composition and training of the team, and the creation of referral networks. It is also crucial to establish protocols and to adopt safe clinical practices to improve levels of quality and safety in the treatment of patients. Considering that acute cardiac care involves conditions with very different severity and prognosis, it is essential to define the level of care to be provided for each type of acute cardiovascular condition in terms of the team, available techniques and infrastructure. This will lead to improvements in the quality of care and patient prognosis, and will also enable more efficient allocation of resources.

To describe routine diagnostic and therapeutic care processes and assignment of resources available for treating patients with acute heart failure (AHF) in Spanish hospital emergency departments (EDs).We surveyed the heads of all hospital EDs in the Spanish national health service concerning their routine diagnostic, therapeutic, and decision-making processes for treating patients with AHF. Questions also covered processes related to continuity of care for patients after discharge. Responses were grouped by hospital size and location (Spanish autonomous community) for comparison.Heads of 250 of the 282 EDs (89%) responded. Thirty-two percent had a cardiologist on call, and a specialized AHF unit was present in 35%. Such untis were present in more than half the EDs in the Community of Madrid and in Catalonia. Eighty-four percent of EDs measured natriuretic peptide (NP) levels, 80% carried out echocardiographic assessments (although only 24% reported that more than half their staff were trained to undertake echocardiography), and 64% had high-flow nasal cannula (HFNC) systems. Only the Community of Valencia, Navarre, and La Rioja had the capacity for NP analysis, echocardiography, and HFNC therapy in 80% or more of their hospital EDs. Forty-six percent had admission protocols for patients with AHF, and 60% scheduled outpatient clinic appointments on discharge. Fifty-seven percent of the hospitals with AHF units had consensus-based protocols with their EDs, and 40% of them could schedule clinic appointments from the ED. Large hospitals had significantly better conditions with respect to some of these aspects of organization and care.There is room for improvement in the diagnosis and treatment of patients with AHF. We detected opportunities to ensure more effective continuity of care for these patients.Conocer la práctica clínica diagnóstico-terapéutica y de disposición en los servicios de urgencias hospitalarios (SUH) españoles en los pacientes con insuficiencia cardiaca aguda (ICA).Encuesta a los responsables de todos los SUH públicos españoles sobre rutinas asistenciales diagnóstico-terapéuticas y de toma de decisión en urgencias en la atención a pacientes con ICA. Se indagaron procesos relacionados con la continuidad asistencial de pacientes dados de alta. Los resultados se comparan según tamaño del hospital y se detallan por comunidad autónoma.Respondieron 250 de los 282 SUH españoles (89%): 32% tenían cardiólogo de guardia y 35% unidad de insuficiencia cardiaca (UIC), presente en más del 50% de hospitales de la Comunidad de Madrid y Cataluña. El 84% de SUH determina péptidos natriuréticos (PN), 80% realiza evaluación ecográfica (aunque solo el 24% tiene más del 50% de sus facultativos formados) y el 64% dispone de cánulas nasales de alto flujo (CNAF). Solo la Comunidad Valenciana, Navarra y La Rioja disponen de PN, exploración ecográfica y CNAF en $ 80% de sus SUH. El 46% tiene protocolizado dónde ingresar el paciente con ICA y el 60% dan cita ambulatoria. Un 57% de los hospitales con UIC tienen un protocolo consensuado con el SUH: el 40% puede asignar la citación desde urgencias. Los hospitales grandes muestran datos significativamente mejores en algunas de las características anteriormente mencionadas.Existe margen de mejora en los SUH en cuanto a sus capacidades diagnóstico-terapéuticas de pacientes con ICA, y se detectan oportunidades para asegurar una continuidad asistencial más efectiva.

The HEFESTOS scale was developed in 14 Spanish primary care centres and validated in 9 primary care centres of other European countries. It showed good performance to predict death/hospitalisation during the first 30 days after an episode of acute heart failure (AHF), with c-statistics of 0.807/0.730 in the derivation/validation cohorts. We evaluated this scale in the emergency department (ED) setting, comparing it to the EHMRG and MEESSI scales in the ED and the EFFECT and GWTG scales in hospitalised patients, to predict 30-day outcomes, including death and hospitalisation. Consecutive AHF patients were enrolled in 34 Spanish EDs in January-February 2016, 2018, and 2019 with variables needed to calculate outcome scores. Thirty-day hospitalisation/death (together and separately) and post-discharge combined adverse event (ED revisit or hospitalisation for AHF or all-cause death) were determined for patients discharged home after ED care. Predictive capacity was assessed by c-statistic with 95% confidence intervals. Of 10,869 patients, 4,044 were included (median age: 83 years, 54% women). The performance of HEFESTOS was modest for 30-day hospitalisation/death, c-statistic=0.656 (0.637-0.675), hospitalisation, 0.650 (0.631-0.669), and death, 0.610 (0.576-0.644). Of 1,034 patients with scores for the 5 scales, HEFESTOS had the numerically highest c-statistic for hospitalisation/death at 30 days, 0.666 (0.627-0.704), vs. MEESSI= 0.650 (0.612-0.687, p=0.51), EFFECT=0.633 (0.595-0.672, p=0.21), GWTG=0.618 (0.578-0.657, p=0.06) and EHMRG=0.617 (0.577-0.704, p=0.07). Similar modest performances were observed for predicting hospitalisation [ranging from HEFESTOS=0.656 (0.618-0.695) to GWTG=0.603 (0.564-0.643)]. Conversely, prediction of 30-day death was good with the MEESSI=0.787 (0.728-845), EFFECT=0.754 (0.691-0.818) and GWTG=0.749 (0.689-0.809) scales, and modest with EHMRG=0.649 (0.581-0.717) and HEFESTOS=0.610 (0.538-0.683). Although the HEFESTOS scale was numerically better for predicting 30-day hospitalisation/death in ED AHF patients, its modest performance precludes routine use. Only 30-day mortality was adequately predicted by some scales, with the MEESSI achieving the best results.

Background: Physical activity (PA), fatness and fitness in children and teenagers have been associated with short and long-term health benefits. However, little research analyzing these variables focuses on the preschool education stage. Thus, the objective of this research is to study the relationship between PA, fatness and fitness in 3–6 years old boys and girls. Methods: This cross-sectional study includes 150 boys and girls at age between 3 and 6 years. Fatness and fitness were assessed using a PREFIT (FITness testing in PREschool children) battery as well as the sit and reach test. PA levels were measured using accelerometers for 7 days. Results: Higher PA levels were related to better fitness values. In addition, differences were found in the PA levels between boys and girls. However, PA subcomponents were not related to fatness. Furthermore, there were no significant differences in fitness tests between underweight, normal-weight and over-weight children, except in handgrip strength. Conclusions: The few studies that have analyzed the relationship between fatness, fitness and PA in preschool have revealed controversial results. However, our study is in accordance with the majority of studies which prove that PA is associated with better fitness performances in preschool children. Since fitness is an important indicator of health, schools and parents should encourage children to practice more daily PA, especially girls, who are less active than boys. However, the discrepancy about the relationship between PA and fatness between the results of the different research highlights the necessity of carrying out further studies that analyze the relationship between these 3 variables separately in each age group (3, 4, 5 and 6 years). This is due to the fact that associations were stronger in older children rather than in younger children

To investigate the relationship of ambient temperature and atmospheric pressure (AP) at patient discharge after an episode of acute heart failure (AHF) with very early post-discharge adverse outcomes. We analyzed 14,656 patients discharged after an AHF episode from 26 hospitals in 16 Spanish cities. The primary outcome was the 7-day post-discharge combined adverse event (emergency department -ED- revisit or hospitalization due to AHF, or all-cause death), and secondary outcomes were these three adverse events considered individually. Associations (adjusted for patient and demographic conditions, and length of stay -LOS- during the AHF index episode) of temperature and AP with the primary and secondary outcomes were investigated. We used restricted cubic splines to model the continuous non-linear association of temperature and AP with each endpoint. Some sensitivity analyses were performed. Patients were discharged after a median LOS of 5 days (IQR = 1-10). The highest temperature at discharge ranged from - 2 to 41.6 °C, and AP was from 892 to 1037 hPa. The 7-day post-discharge combined event occurred in 1242 patients (8.4%), with percentages of 7-day ED-revisit, hospitalization and death of 7.8%, 5.1% and 0.9%, respectively. We found no association between the maximal temperature and AP on the day of discharge and the primary or secondary outcomes. Similarly, there were no significant associations when the analyses were restricted to hospitalized patients (median LOS = 7 days, IQR = 4-11) during the index event, or when lag-1, lag-2 or the mean of the 3 post-discharge days (instead of point estimation) of ambient temperature and AP were considered. Temperature and AP on the day of patient discharge are not independently associated with the risk of very early adverse events during the vulnerable post-discharge period in patients discharged after an AHF episode.

Aims To evaluate the association between chronic treatment with betablockers (BB) and the severity of decompensation and short-term outcomes of patients with acute heart failure (AHF). Methods and results We consecutively included all patients presenting with AHF to 45 Spanish emergency departments (ED) during six different time-periods between 2007 and 2018. Patients were stratified according to whether they were on chronic treatment with BB at the time of ED consultation. Those receiving BB were compared (adjusted odds ratio—OR—with 95% confidence interval—CI—) with those not receiving BB group in terms of in-hospital and 7-day all-cause mortality, need for hospitalization, and prolonged length of stay (≥7 days). Among the 17 923 recruited patients (median age: 80 years; 56% women), 7795 (43%) were on chronic treatment with BB. Based on the MEESSI-AHF risk score, those on BB were at lower risk. In-hospital mortality was observed in 1310 patients (7.4%), 7-day mortality in 765 (4.3%), need for hospitalization in 13 428 (75.0%), and prolonged length of stay (43.3%). After adjustment for confounding, those on chronic BB were at lower risk for in-hospital all-cause mortality (OR = 0.85, 95% CI = 0.79–0.92, P < 0.001); 7-day all-cause mortality (OR = 0.77, 95% CI = 0.70–0.85, P < 0.001); need for hospitalization (OR = 0.89, 95% CI = 0.85–0.94, P < 0.001); prolonged length of stay (OR = 0.90, 95% CI = 0.86–0.94, P < 0.001). A propensity matching approach yielded consistent findings. Conclusion In patients presenting to ED with AHF, those on BB had better short-term outcomes than those not receiving BB.

To determine whether there are differences in the clinical characteristics, management, and outcome of episodes of acute heart failure (AHF) in residents of the Canary Islands, where the climate is subtropical, and episodes in continental Spain.Cases were identified in the registry for Epidemiology of Acute Heart Failure in Emergency Departments and categorized as in the Canary Islands or continental Spain. Data for 38 demographic, baseline, clinical, and therapeutic variables were extracted. We analyzed statistics for in-hospital and 30-day mortality, long hospital stay (more than 7 days), and a composite outcome after discharge (revisits or death within 30 days). The results for island and continental patients were compared and adjusted for between-group differences.A total of 18 390 patients were studied, 697 islanders (3.8%) and 17 673 continental patients (96.2%). Comparisons showed that the islanders were younger; more often women; and more likely to have hypertension, diabetes, and a prior AHF episode. Their New York Heart Association functional class was also likely to be higher. However, their rates of dyslipidemia, valve disease, and functional dependence were lower, and they were also less likely to be on reninangiotensin system blockers. Although the severity of cardiac decompensation was similar in island and continental patients, the islanders received more intravenous treatments in the emergency department and were admitted less often. The adjusted risk of a long hospital stay was higher for the islanders (odds ratio [OR], 2.36; 95% CI, 1.52-3.02) but their risk for mortality and the composite outcome did not differ: in-hospital mortality, OR 0.97 (95% CI, 0.68-1.37); 30-day mortality, OR, 0.9 (95% CI, 0.67-1.27); and the post-discharge composite, OR, 1.19 (95% CI, 0.93-1.53).Baseline patient characteristics and clinical management of AHF episodes differ between the subtropical region and those in southern continental Europe. Hospitalization was required less often, but hospital stays were longer.Investigar si existen diferencias clínicas, asistenciales y evolutivas entre los episodios de insuficiencia cardiaca aguda (ICA) desarrollados en residentes en las Islas Canarias (CAN), de clima subtropical, y en los del territorio español continental (CON).. Los pacientes con ICA incluidos en el registro EAHFE se dividieron en CAN o CON. Se recogieron 38 variables demográficas, de estado clínico basal, clínicas y terapéuticas. Se analizó la mortalidad intrahospitalaria y a los 30 días, la hospitalización prolongada (7 días) y el evento combinado post-alta (reconsulta o muerte a 30 días). Se compararon los pacientes CAN y CON, ajustando los resultados por las diferencias entre grupos.Se incluyeron 18.390 pacientes: CAN = 697 (3,8%), CON = 17.673 (96,2%). Tras el ajuste, los CAN eran más jóvenes, más frecuentemente mujeres, tenían más antecedentes de hipertensión, diabetes e ICA previa, y estaban en clase funcional más avanzada, pero tenían menos dislipemia, valvulopatías y dependencia funcional, y recibían menos frecuentemente inhibidores del eje renina-angiotensina. Aunque la gravedad del episodio de descompensación fue similar, los CAN recibían más tratamientos endovenosos en urgencias y se hospitalizaban menos. El riesgo ajustado de hospitalización prolongada en los CAN resultó incrementado (OR 2,36; IC 95%:1,52-3,02), pero no hubo diferencias en la mortalidad intrahospitalaria (OR 0,97; IC 95%: 0,68-1,37), a 30 días (OR 0,9; IC 95%: 0,67-1,27) o en los eventos combinados post-alta a los 30 días (OR 1,19; IC 95%: 0,93-1,53).Existen diferencias tanto en las características basales como en el manejo clínico de los episodios de insuficiencia cardiaca en los residentes de una región subtropical respecto a los de una zona meridional europea. Además, tienen menor necesidad de hospitalización, aunque estas son más prolongadas.

Background Left ventricular myocardial work (LVMW) is a novel method to evaluated left ventricular (LV) function using pressure-strain loops. It might correct global longitudinal strain (GLS) for afterload, being eventually useful to assess whether GLS reduction is due to reduced contractility (reflected as reduced myocardial work) or increased afterload (reflected as increased myocardial work). Aim To describe indices of LVMW in a group of patients with severe symptomatic aortic stenosis (AS). Methods We prospectively studied 104 consecutive patients (age: 71 years [IQR 66.5–75.5] years, 51% men) with severe symptomatic high gradient AS: mean transaortic pressure gradient: 56.5mmHg [IQR 46.8–67.8]; aortic valve area: 0.73cm2 [IQR 0.61–0.88]; indexed stroke volume: 47.7±1.3 mL/m2 (11 patients with low-flow AS), preserved LV ejection fraction (EV) (LVEF: 56.0% [51.0–61.3]; GLS: −14.5% [IQR −16.1 to −10.6]), with no previous coronary artery disease and no history of cardiomyopathy. Beyond complete transthoracic echocardiography, all patients underwent cardiac magnetic resonance for LV myocardium tissue characterization. As proposed for AS, LV systolic pressure was corrected adding the mean transaortic pressure gradient to non-invasive systolic blood pressure cuff measurement in the echocardiographic algorithm. Four LVMW indices were collected in 83 patients (patients excluded for atrial fibrillation, left bundle branch block or absence of non-invasive blood pressure registration) and correlated to LV function indexes, LV hypertrophy and remodeling, myocardial tissue characterization, BNP and troponin levels (Pearson or Spearman correlation). These same indexes were compared in patients with LV ejection fraction (EF) below and above 50%, normal and reduced flow and presence of replacement fibrosis. Results Global constructive work (GCW) (2658.6±76.4mmHg%), global myocardial work (GMW) (2218.7±74.9mmHg%) and global wasted work (GWE) (262.0mmHg% [198.8–339.5]) were high above normal with concomitant lower work efficiency (WE) (88.0% [83.2–91.8]. Weak correlations were found between LVMW indexes and parameters describing aortic valve severity, flow and LV function (table). Except for significant differences of LVMI in patients with reduced LV ejection fraction (GCW 2770.3±687.4 vs 2056.0±380.7mmHg%, p=0,014 and GMW 2362.5±657.9 vs 1621.3±319.9, p=0,021 in patients with LV EF>50% vs. LV EF Conclusions Global constructive and myocardial work are increased in these patients with severe aortic stenosis. This might reflect an increased afterload predominance rather than a LV functional impairment, particularly relevant in this group of patients with exclusive high gradient disease and preserved LVEF. Funding Acknowledgement Type of funding sources: None. Correlations between LVMI – LV function

To determine the prevalence, characteristics and association with prognosis of left bundle branch block (LBBB) in 3 different cohorts of patients with acute heart failure (AHF).We retrospectively analyzed 12,950 patients with AHF who were included in the EAHFE (Epidemiology Acute Heart Failure Emergency), RICA (National Heart Failure Registry of the Spanish Internal Medicine Society), and BASEL-V (Basics in Acute Shortness of Breath Evaluation of Switzerland) registries. We independently analyzed the relationship between baseline and clinical characteristics and the presence of LBBB and the potential association of LBBB with 1-year all-cause mortality and a 90-day postdischarge combined endpoint (Emergency Department reconsultation, hospitalization or death). The prevalence of LBBB was 13.5% (95% confidence interval: 12.9%-14.0%). In all registries, patients with LBBB more commonly had coronary artery disease and previous episodes of AHF, were taking chronic spironolactone treatment, had lower left ventricular ejection fraction and systolic blood pressure values and higher NT-proBNP levels. There were no differences in risk for patients with LBBB in any cohort, with adjusted hazard ratios (95% confidence interval) for 1-year mortality in EAHFE/RICA/BASEL-V cohorts of 1.02 (0.89-1.17), 1.15 (0.95-1.38) and 1.32 (0.94-1.86), respectively, and for 90-day postdischarge combined endpoint of 1.00 (0.88-1.14), 1.14 (0.92-1.40) and 1.26 (0.84-1.89). These results were consistent in sensitivity analyses.Less than 20% of patients with AHF present LBBB, which is consistently associated with cardiovascular comorbidities, reduced left ventricular ejection fraction and more severe decompensations. Nonetheless, after taking these factors into account, LBBB in patients with AHF is not associated with worse outcomes.

The impact of diabetes mellitus (DM) and hyperglycemia on short-term prognosis in patients with acute heart failure (AHF) remains controversial as most data comes from series of hospitalized patients. Our purpose was to analyze outcomes in a nation-wide registry of AHF patients attended in emergency department (ED). ED AHF patients were prospectively enrolled, with the index event and the vulnerable post-discharge phase outcomes recorded. The influence of presenting hyperglycemia ( 180 mg/dL) and DM treatment on prognosis were also investigated. All results were adjusted (a) for baseline characteristics. Of 9192 enrolled AHF patients, 4544 (49,4%) were diabetic, with 24% of diabetics and 25.1% of non-diabetic (p = 0.247) directly discharged from the ED also included. Diabetics had higher rates of comorbidities, but were slightly younger and had lower in-hospital and 30 day all-cause mortality than non-diabetics (a-OR = 0.827, 95% CI = 0.690-0980; and a-HR = 0.850, 95% CI = 0.814-1.071, respectively). Conversely, hyperglycemia on-arrival was associated with increased in-hospital, and 30 day all-cause mortality, in both DM (a-OR = 1.933, 95% CI = 1.378-2.712, and a-HR = 1.590, 95% CI = 1.304-1.938, respectively) and non-DM patients (a-OR = 1.498, 95% CI = 1.175-1.909, and a-HR = 1.719, 95% CI = 1.306-2.264, respectively). However, during the vulnerable phase, diabetics had worse short-term outcomes, with higher rates of ED-revisit and rehospitalization. These worse outcomes seemed to be unrelated to the severity of DM. In patients with AHF attended in ED, diabetes was associated with lower index event case fatality, but higher rates of rehospitalization and re-consultation in the vulnerable post-discharge period. Conversely, hyperglycemia at hospital arrival was strongly associated with early mortality, regardless of diabetes status.

Resumen Antecedentes y objetivos Describir las caracteristicas clinicas y el pronostico–mortalidad intrahospitalaria, a 30 dias y a 12 meses y reconsulta en urgencias a 30 dias por insuficiencia cardiaca aguda– de pacientes atendidos en servicios de urgencias hospitalarios por insuficiencia cardiaca aguda de nueva aparicion o de novo (ICAN) y compararlas con los que consultan por insuficiencia cardiaca cronica descompensada (ICAD). Pacientes NOVICA es un analisis secundario del registro Epidemiology of Acute Heart Failure in Emergency Departments. Se compararon variables demograficas, caracteristicas basales, datos del episodio agudo y seguimiento a 30 dias y al ano de pacientes con ICAN e ICAD. Resultados Se analizaron 8647 pacientes, 3288 ICAN (38%) y 5359 ICAD (62%). Las ICAN asociaron menor comorbilidad, mejor estado basal, datos de menor gravedad del episodio agudo: menor uso de diureticos en perfusion intravenosa y de oxigenoterapia, menor tasa de hospitalizacion. Las ICAN ingresaron mas frecuentemente en cardiologia o unidades de cuidados intensivos y las ICAD en unidades de corta estancia. La mortalidad cruda a 30 dias y a 12 meses y la reconsulta a 30 dias fueron inferiores en pacientes con ICAN. No obstante, en el analisis ajustado solo la reconsulta a 30 dias fue inferior en las ICAN (p Conclusiones Los pacientes que consultan en servicios de urgencias hospitalarios por ICAN muestran un perfil clinico diferente a los pacientes con ICAD. En los analisis ajustados, no hay diferencias entre los dos grupos en relacion a mortalidad intrahospitalaria, a 30 dias ni a 12 meses.

Objectives This study investigated whether systemic corticosteroids (new onset) administered to patients with acute heart failure (AHF) have any association with outcomes, with differentiated analyses for patients with and without chronic obstructive pulmonary disease (COPD) as a comorbidity. Background Patients with undiagnosed dyspnea frequently receive corticosteroids in emergency departments while determining a final diagnosis, but their effect on the outcomes of patients with AHF without overt COPD exacerbation is unknown. Methods We selected patients with AHF from the EAHFE (Epidemiology of Acute Heart Failure in the Emergency Departments) registry, recording key data (new-onset corticosteroid therapy, COPD condition). Patients with and without COPD were analyzed separately. We calculated unadjusted and adjusted ratios for corticosteroid-treated compared with corticosteroid-untreated patients for 2 coprimary endpoints: 90-day all-cause mortality (from index episode) and 90-day post-discharge combined endpoint (all-cause mortality or readmission for AHF), with intermediate time-point estimations. Other secondary endpoints were calculated, and some sensitive and stratified analyses were performed. Results We analyzed 11,356 patients: 8,635 without COPD (841 corticosteroid-treated, 9.7%) and 2,721 with COPD (753 corticosteroid-treated, 27.7%). There were several differences between treated and untreated patients, essentially because corticosteroid-treated patients were sicker. Although unadjusted outcomes were worse in corticosteroid-treated patients, especially in patients without COPD, these differences disappeared after adjustment: hazard ratios for 90-day mortality (without/with COPD) were 0.91 (95% confidence interval (CI): 0.76 to 1.10)/0.99 (95% CI: 0.78 to 1.26), and 1.09 (95% CI: 0.93 to 1.28)/1.02 (95% CI: 0.86 to 1.21) for the post-discharge combined endpoint. Analyses of intermediate time-point coprimary endpoints and secondary outcomes rendered similar estimations. Sensitivity and stratified analysis did not significantly modify these results. Conclusions There is no evidence of harm related to the new onset of systemic corticosteroid therapy during an episode of AHF, either in patients with or without concomitant COPD.

Background: Little is known about the prevalence and impact of risk of malnutrition on short-term mortality among seniors presenting with acute heart failure (AHF) in emergency setting. The objective was to determine the impact of risk of malnutrition on 30-day mortality risk among older patients who attended in Emergency Departments (EDs) for AHF. Material and methods: We performed a secondary analysis of the OAK-3 Registry including all consecutive patients >= 65 years attending in 16 Spanish EDs for AHF. Risk of malnutrition was defined by the Mini Nutritional Assessment Short Form (MNA-SF) < 12 points. Unadjusted and adjusted logistic regression models were used to assess the association between risk of malnutrition and 30-day mortality. Results: We included 749 patients (mean age: 85 (SD 6); 55.8% females). Risk of malnutrition was observed in 594 (79.3%) patients. The rate of 30-day mortality was 8.8%. After adjusting for MEESSI-AHF risk score clinical categories (model 1) and after adding all variables showing a significantly different distribution among groups (model 2), the risk of malnutrition was an independent factor associated with 30-day mortality (adjusted OR by model 1 = 3.4; 95% CI 1.2-9.7; p = .020 and adjusted OR by model 2 = 3.1; 95% CI 1.1-9.0; p = .033) compared to normal nutritional status. Conclusions: The risk of malnutrition assessed by the MNA-SF is associated with 30-day mortality in older patients with AHF who were attended in EDs. Routine screening of risk of malnutrition may help emergency physicians in decision-making and establishing a care plan.

Resumen Introduccion y objetivos En los servicios de urgencias hospitalarios (SUH), la escala MEESSI estratifica a los pacientes diagnosticados de insuficiencia cardiaca aguda (ICA) segun su riesgo de mortalidad a 30 dias. Se valida la escala de riesgo MEESSI en una nueva cohorte de pacientes para evaluar su precision al estratificar el riesgo y compararla en diferentes entornos. Metodos Se incluyo a los pacientes consecutivos diagnosticados de ICA en 30 SUH durante enero y febrero de 2016. Se calculo la puntuacion MEESSI de cada paciente. El estadistico C midio la capacidad discriminatoria para predecir la mortalidad a 30 dias del modelo MEESSI completo y los modelos secundarios. Se realizaron comparaciones entre los subgrupos de pacientes de hospitales universitarios y comunitarios, de SUH con actividad alta, media o baja y de SUH que reclutaron o que no reclutaron a pacientes de la cohorte original de derivacion de la escala MEESSI. Resultados Se analizo a 4.711 pacientes (hospitales universitarios/comunitarios: 3.811/900; SUH alta/media/baja actividad: 2.695/1.479/537; SUH participantes/no participantes en el estudio de derivacion original: 3.892/819). La distribucion de pacientes segun las categorias de riesgo de la escala MEESSI fue: 1.673 (35,5%) de bajo riesgo, 2.023 (42,9%) de riesgo intermedio, 530 (11,3%) de alto riesgo y 485 (10,3%) de muy alto riesgo, con mortalidades a 30 dias del 2,0, el 7,8, el 17,9 y el 41,4% respectivamente. El estadistico C para el modelo completo fue 0,810 (IC95%, 0,790-0,830) y vario de 0,731 a 0,785 para los modelos secundarios. La capacidad discriminatoria de la escala de riesgo MEESSI fue similar entre los subgrupos de hospitales, entre SUH de distinta actividad y entre hospitales reclutadores originales y nuevos. Conclusiones La escala MEESSI estratifica con exito a los pacientes con ICA en los SUH segun el riesgo de muerte a 30 dias, lo cual puede ayudar en urgencias a la toma de decisiones sobre el destino de estos pacientes.