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We assessed differences in long-term all-cause and cardiovascular (CV) mortality in heart failure (HF) outpatients based on the etiology of HF. Consecutive patients admitted to the HF Clinic from August 2001 to September 2019 (N = 2587) were considered for inclusion. HF etiology was divided into ischemic heart disease (IHD), dilated cardiomyopathy (DCM), hypertensive heart disease, alcoholic cardiomyopathy, drug-induced cardiomyopathy (DICM), valvular heart disease, and hypertrophic cardiomyopathy. All-cause death and CV death were the primary end points. Among 2387 patients included in the analysis (mean age 66.5 ± 12.5 years, 71.3% men), 1317 deaths were recorded (731 from CV cause) over a maximum follow-up of 18 years (median 4.1 years, interquartile range (IQR) 2–7.8). Considering IHD as the reference, only DCM had a lower risk of all-cause death (adjusted hazard ratio (aHR) 0.68, 95% confidence interval (CI) 0.56–0.83, p < 0.001), and only DICM had a higher risk of all-cause death (aHR 1.47, 95% CI 1.02–2.11, p = 0.04). However, almost all etiologies had a significantly lower risk of CV death than IHD. Among the studied HF etiologies, DCM and DICM have the lowest and highest risk of all-cause death, respectively, whereas IHD has the highest adjusted risk of CV death.

Background Neprilysin serum levels (sNEP) exhibited significant prognostic value in patients with heart failure (HF). In the PARADIGM-HF study benefit of sacubitril/valsartan was observed in patients with reduced ejection fraction (HFrEF), while in the PARAGON-HF benefit was only observed in the subgroup of patients with LVEF Objective To assess the prognostic value of sNEP in ambulatory patients with HF and preserved ejection fraction (HFpEF) and LVEF >57% (group 1), in comparison with patients with LVEF ≤57% (group 2). Methods Consecutive patients with HF attended at the Unit from May 2006 to February 2016 were considered for the study. The primary end-point was the composite of cardiovascular death or HF hospitalization. All-cause death, cardiovascular death, HF hospitalization and the composite of all-cause death or HF hospitalization were secondary end-points. Competing risk methods (R package by Bob Gray for SPSS) were used when required. Results sNEP was measured in 1428 patients (age 67.7±12.7, 70.3% men, LVEF 35.8% ±14, 48.9% from ischemic etiology), 144 of which had a LVEF >57% (age 70.1±15, 43.8% men, 53.5% from hypertensive or valvular etiologies). sNEP levels did not significantly differ between the two groups of patients (p=0.31). During a mean follow-up of 6±3.9 years, 856 deaths were recorded (459 from cardiovascular causes) and 523 patients suffered at least one HF hospitalization. The primary end-point occurred in 941 patients (in 111 of the 144 patients with LVEF >57%). Table 1 shows sNEP age- and sex-adjusted hazard ratios for the primary and secondary end-points. Conclusions sNEP prognostic value in patients with HFpEF and LVEF >57% outperforms that observed in patients with lower LVEF. These data support the personalized use of sNEP in identifying HFpEF patients that may benefit from treatment with sacubitril/valsartan. Funding Acknowledgement Type of funding source: None

Background Advances in heart failure (HF) treatment have achieved a reduction of death in HF patients in the last two decades. Indeed, not only mortality has been reduced but also the mode of death might have been modified through these years. Purpose To assess the causes of death in outpatients attended in a HF Unit since the year 2002 up to the year 2018. Methods Causes of death were classified as follows: progression of HF (worsening HF or treatment-resistant HF, in the absence of another cause); sudden death (any unexpected death, witnessed or not, of a previously stable patient with no evidence of worsening HF or any other known cause of death); acute myocardial infarction; stroke; procedural (post-diagnostic or post-therapeutic); other cardiovascular causes (e.g., rupture of an aneurysm, peripheral ischemia, or aortic dissection), and non-cardiovascular. Patients who died of unknown cause were excluded from the analysis. Fatal events were identified from the clinical records of patients with HF, hospital wards, the emergency room, general practitioners, or by contacting the patient's relatives. Furthermore, data were verified from the databases of the Catalan and Spanish Health Systems. Trends on every cause of death were assessed by linear regression. Results Since August 2001 to May 2018, 2295 HF patients were admitted to the HF clinic (age 66.4±12.8 years, 71% men, 49% from ischemic aetiology, mean LVEF 35.2% ± 14). During the 17 years of the study, 1201 deaths were recorded. Seventy-eight patients (6.5% of deaths) were excluded due to unknown cause of death. The evolution in the mode of death by years is shown in the figure. Two trends were observed: a decrease in sudden death (p=0.05) and a very significant linear increase in non-cardiovascular causes of death (p Conclusions During the 17 years of the study, a very significant trend towards higher percentage of non-cardiovascular deaths was progressively observed. On the other hand, percentage of sudden death showed a gradual decrease, mainly driven from the changes observed in the first 10 years.

Background The role of lung ultrasound (LUS) in diagnosis and response to diuretic treatment of patients with acute HF has been widely studied, but less is known about its value in chronic HF. Purpose To assess the prognostic value of LUS in a cohort of chronic HF stable ambulatory patients and to explore the relationship of LUS findings with clinical data, such as NYHA functional class, left ventricular ejection fraction (LVEF) and NTproBNP. Methods Consecutive stable ambulatory patients who attended a scheduled follow-up visit in a HF clinic were included. LUS were performed with a pocket device and examined 4 chest areas per side (two anterior and two lateral). Scans were analysed offline by two investigators blinded to clinical data, who evaluated the number of B-lines of each area. The addition number of B-lines of each area and the quartiles of such addition were used for the analyses. The primary outcome end-point was the composite of all-cause death or hospitalization due to HF at one year. Linear regression and Cox regression analyses were performed. Results Five-hundred seventy-seven patients were included between July 2016 and July 2017 (age 69±12 years, 72% men). The main HF aetiology was ischemic heart disease (43%) followed by dilated cardiomyopathy (20%). Median HF duration was 79 months (Q1-Q3 38–144). Mean LVEF was 45%±13 (mean LVEF when admitted at the Unit 34%±13). Most patients were in NYHA functional class II (70%), 13% were in class I and 17% in class III. Median NTproBNP was 722 ng/L (Q1-Q3 262–1760). Mean number of B-lines was 5±6 (Q1, 0; Q2, 1–3; Q3, 4–7; Q4, ≥8). The number of B-lines was associated with age (beta-coefficient 0.11, p Conclusion In outpatients with stable chronic HF, the number of B-lines detected in LUS was associated with age, NYHA functional class and NTproBNP. Patients having ≥8 B-lines had a significant double risk of HF related hospitalization or all-cause death at one year. However, when strongly powerful prognostic variables such as NYHA class and NTproBNP were included in the model LUS did not retain an independent prognostic role.

Objective: To assess the effects of comorbidities, fragility, and quality of life (QOL) on long-term prognosis in ambulatory patients with heart failure (HF) with midrange left ventricular ejection fraction (HFmrEF), an unexplored area. Patients and Methods: Consecutive patients prospectively evaluated at an HF clinic between August 1, 2001, and December 31, 2015, were retrospectively analyzed on the basis of left ventricular ejection fraction category. We compared patients with HFmrEF (n=185) to those with reduced (HFrEF; n=1058) and preserved (HFpEF; n=162) ejection fraction. Fragility was defined as 1 or more abnormal evaluations on 4 standardized geriatric scales (Barthel Index, Older Americans Resources and Services scale, Pfeiffer Test, and abbreviated-Geriatric Depression Scale). The QOL was assessed with the Minnesota Living with Heart Failure Questionnaire. A comorbidity score (0-7) was constructed. All-cause death, HF-related hospitalization, and the composite end point of both were assessed. Results: Comorbidities and QOL scores were similar in HFmrEF (2.41±1.5 and 30.1±18.3, respectively) and HFrEF (2.30±1.4 and 30.8±18.5, respectively) and were higher in HFpEF (3.02±1.5, P

Aims Heart failure (HF) is a chronic condition that typically affects a patient's quality of life (QoL). Little is known about long-term QoL monitoring in HF. This study aimed to evaluate the temporal changes and prognostic value of QoL assessment in a real-life cohort of HF patients. Methods and results The Minnesota Living with Heart Failure Questionnaire was used to monitor QoL at baseline and at 1, 3, and 5 years for 1151 consecutive patients {71.7% men, median age 69 years [25th–75th percentiles (P25–P75) 59–76]} in an HF unit. Follow-up for prognosis assessment was extended to 6 years. The number of answered questionnaires was 1151 at baseline, 746 at 1 year, 268 at 3 years, and 240 at 5 years. QoL scores showed a steep decrease (indicating QoL improvement) during the first year [29 (P25–P75 16–43) at baseline vs. 15 (P25–P75 8–27) at 1 year, P < 0.001], which was tempered, yet significant up to 5 years [12 (P25–P75 7–23) at 3 years vs. 10 (P25–P75 5–21) at 5 years, P = 0.012]. We recorded 457 deaths during follow-up. In a comprehensive multivariable Cox regression analysis, baseline QoL remained a significant prognosticator during follow-up [hazard ratio (HR)Cox for death 1.012, 95% confidence interval 1.006–1.018, P < 0.001]. QoL monitoring showed that a score increase ≥10% between consecutive assessments stratified high-risk patients within the next 12 months (P = 0.008). Conclusion Both baseline and follow-up QoL monitoring were useful for patient risk stratification in a real-life HF cohort. Worse QoL may warn of a worse prognosis. Widespread QoL monitoring in routine clinical practice is recommended.

Balance alteration is a risk factor for falls in elderly individuals that has physical, psychological and economic consequences. The objectives of this study are to evaluate the usefulness of an intervention utilizing the Nintendo™ Wii console in order to improve balance, thereby decreasing both the fear of falling as well as the number of falls, and to evaluate the correlation between balance as determined by the console and the value obtained in the Tinetti tests and the one foot stationary test. This is a controlled, randomized clinical trial of individual assignment, carried out on patients over 70 years in age, from five primary care centers in the city of Mataro (Barcelona). 380 patients were necessary for the intervention group that carried out the balance board exercises in 2 sessions per week for a 3 month period, and 380 patients in the control group who carried out their usual habits. Balance was evaluated using the Tinetti test, the one foot stationary test and with the console, at the start of the study, at the end of the intervention (3 months) and one year later. Quarterly telephone follow-up was also conducted to keep track of falls and their consequences. The study aimed to connect the community with a technology that may be an easy and fun way to assist the elderly in improving their balance without the need to leave home or join rehabilitation groups, offering greater comfort for this population and decreasing healthcare costs since there is no need for specialized personnel. Current Control Trial NCT02570178 .

Introduccion y objetivos La mortalidad de la insuficiencia cardiaca es similar o incluso superior a la de muchos canceres. Suele ocurrir por progresion de la enfermedad, aunque la muerte subita se ha descrito como una causa frecuente. El objetivo es evaluar la mortalidad y sus causas en una poblacion ambulatoria de pacientes con insuficiencia cardiaca de etiologia diversa tratados en una unidad especializada multidisciplinaria y analizar los factores asociados con ellas. Metodos Estudio de seguimiento de cohorte (mediana, 36 meses) de 960 pacientes (el 70,9% varones; mediana de edad, 69 anos; mayoritariamente de etiologia isquemica, con fraccion de eyeccion del 31% y en clase funcional fundamentalmente II y III). Resultados Se registraron 351 fallecimientos (36,5%): 230 de causa cardiovascular (65,5%), fundamentalmente por insuficiencia cardiaca (33,2%) y muerte subita (16%), 94 de causa no cardiovascular (26,8%), fundamentalmente neoplasias (10,5%) y procesos septicos (6,8%), y 27 (7,7%) de causa desconocida. Mostraron relacion independiente con la mortalidad: edad, sexo, clase funcional, fraccion de eyeccion, tiempo de evolucion, etiologia isquemica, diabetes mellitus, aclaramiento de creatinina, vasculopatia periferica, fragilidad y ausencia de tratamiento con inhibidores de la enzima de conversion de angiotensina o antagonistas de los receptores de la angiotensina II, bloqueadores beta, estatinas y antiagregantes. El factor principal asociado a muerte cardiovascular fue la etiologia isquemica. No hallamos ningun factor predictor claramente determinante de muerte subita. Conclusiones Aunque la mortalidad de los pacientes atendidos en una unidad especializada de insuficiencia cardiaca no fue baja, una cuarta parte fallecio de causa no cardiovascular. El principal factor asociado a muerte cardiovascular fue la etiologia isquemica. La muerte subita afecto solo al 5,8% de la poblacion.

Introduccion y objetivos Los pacientes con insuficiencia cardiaca presentan un elevado grado de fragilidad y dependencia. Durante 1 ano de seguimiento, examinamos la relacion de la fragilidad y los sintomas depresivos con la mortalidad a 1 ano y con la hospitalizacion por insuficiencia cardiaca. Metodos Todos los pacientes fueron sometidos a una valoracion geriatrica que permitiria la deteccion de fragilidad y de sintomas depresivos. Se evaluo a 622 pacientes (el 72,5% varones; mediana de edad, 68 anos; el 92% se hallaba en clase II o III de la NYHA; la mediana de fraccion de eyeccion era del 30%). Resultados Fallecieron durante el seguimiento 60 (9,5%) pacientes, y 101 (16,2%) tuvieron que ser hospitalizados por insuficiencia cardiaca. Se detecto fragilidad en el 39,9% de los pacientes y sintomas depresivos en el 25,2%. La fragilidad (el 16,9 frente al 4,8%; p Conclusiones En el analisis univariable, la fragilidad y los sintomas depresivos mostraron una relacion significativa con la mortalidad a 1 ano; ademas, la fragilidad mostro una relacion significativa con la necesidad de hospitalizacion por insuficiencia cardiaca. Sin embargo, solo la fragilidad mostro un valor predictivo de mortalidad independiente de otras variables con fuerte influencia en el pronostico

La insuficiencia renal es un importante factor pronostico en pacientes con insuficiencia cardiaca. Para valorar la funcion renal se suelen utilizar las cifras de creatinina serica. Sin embargo, cifras normales pueden ocultar una insuficiencia renal establecida. Hemos evaluado el significado pronostico del aclaramiento de creatinina estimado (Cockcroft) en 235 pacientes con insuficiencia cardiaca y cifras de creatinina normales. Los pacientes con insuficiencia renal establecida (aclaramiento

Background: Heart failure (HF) patients have a high degree of fragility and dependence from physical, cognitive and psychological points ofview, and are a mainly geriatric population.Aim: To detect the existence of fragility in all patients treated in a Heart Failure Unit and to evaluate age and sex differences.Methods: All patients underwent a basic geriatric evaluation to detect possible loss of autonomy for doing basic and instrumental activities,cognitive deterioration, emotional disturbance or social risk.Results: Three hundred sixty patients (mean age 65.2 years, 41.7% z70 years, 27.5% women) were evaluated. Fragility was detected in41.7% of patients, being more prevalent in patients z70 years (pb0.001) and in women (pb0.001). A Barthel Index b90 was found in 22.5%of patients and an anomalous OARS Scale was found in 18.3%. Pfeiffer test’s score was abnormal in 7.8% of patients. A positive depressionresponse in abbreviate GDS was observed in 29.7%. All items analysed were more prevalent in patients z70 years and in women, with theunexpected exception of depression symptoms that were as prevalent in younger as in older patients.Conclusion: Fragility is common in patients with heart failure, even in younger patients, and can be detected easily using standardisedgeriatric scales. Prevalence of fragility was significantly higher in older patients and in women, although the presence of depressionsymptoms was as prevalent in younger as in older patients.D 2004 European Society of Cardiology. Published by Elsevier B.V. All rights reserved.

Introduccion y objetivos Evaluar el valor pronostico de las concentraciones de hemoglobina (Hb) en relacion con la mortalidad y con los ingresos hospitalarios por insuficiencia cardiaca (IC) al ano de la primera visita a la Unidad de IC. Pacientes y metodo Conocemos la situacion vital y los ingresos por IC al ano en 337 pacientes admitidos entre agosto de 2001 y marzo de 2003. Las concentraciones de Hb se recogieron en la primera visita. Resultados Fallecieron 28 (8%) pacientes y hubo 158 ingresos por IC en 66 pacientes. Los valores de Hb se asociaron con la mortalidad a 1 ano (pacientes vivos, 13,0 ± 1,7 g/dl; pacientes fallecidos, 11,6 ± 1,7 g/dl; p Conclusiones Los valores de Hb se asocian inversamente con la mortalidad y los ingresos por IC en el primer ano de seguimiento. La prevalencia de anemia en nuestra poblacion con IC es elevada y tiene valor pronostico independiente.

Introduccion y objetivos La calidad de vida es, junto con la mortalidad y las hospitalizaciones, un objetivo importante en los estudios sobre insuficiencia cardiaca. El cuestionario «Minnesota Living With Heart Failure» es el instrumento mas extensamente utilizado para valorarla en los trabajos de investigacion. Nuestro objetivo ha sido conocer la calidad de vida mediante este cuestionario en una poblacion general atendida en una unidad de insuficiencia cardiaca. Pacientes y metodo Se evaluo a 326 pacientes en la primera visita. Hemos analizado la correlacion entre la puntuacion obtenida y diversos factores clinicos y demograficos. Resultados La puntuacion global fue relativamente baja (28). Encontramos una fuerte correlacion (p Conclusiones La aplicacion del «Minnesota Living With Heart Failure» a una poblacion general con insuficiencia cardiaca ha mostrado puntuaciones relativamente bajas. A pesar de ello, hemos encontrado una correlacion importante de la puntuacion obtenida con la clase funcional y con el numero de ingresos en el ano previo, lo que sugiere que el cuestionario refleja correctamente el grado de severidad de la enfermedad.

To assess the relationship between statins and prognosis in ischemic and nonischemic patients with heart failure (HF) in a real-life cohort followed up for a long period.This prospective study included 960 patients with HF with preserved or depressed left ventricular ejection fraction (LVEF), irrespective of HF etiology, who were referred to the HF clinic of a university hospital between August 1, 2001, and December 31, 2008. The patients were followed up for a maximum of 9.1 years (median, 3.7 years), and survival in ischemic and nonischemic patients was determined.Median age was 69 years, and median LVEF was 31%. Of the 960 patients, 532 (55.4%) had ischemic HF etiology, and most received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (846; 88.1%) and β-blockers (776; 80.8%). Patients with HF of ischemic origin were more often treated with statins (P.001). During follow-up, 440 patients (45.8%) died. Statin therapy was associated with significantly improved survival (hazard ratio, 0.45 [95% confidence interval, 0.37-0.54]; P.001). After adjustment for HF prognostic factors (age, sex, cholesterol level, New York Heart Association class, HF etiology, LVEF, body mass index, HF duration, atrial fibrillation, implantable cardioverter-defibrillator therapy, and medicines), statins remained significantly associated with lower mortality risk in both ischemic (P=.007) and nonischemic (P=.002) patients.In contrast to results of large randomized trials, statins were independently and significantly associated with lower mortality risk in our real-life HF cohort, including patients with nonischemic HF etiology.

Objective. To assess the effectiveness of an intervention after comprehensive geriatric assessment (CGA) in reducing morbidity and mortality in patients over 74 years in primary care. Methods. Randomized controlled trial with 18 months of follow-up. Patients in the control group (CG) followed usual care. Patients in the intervention group (IG) were classified as at risk or non-risk of frailty based on the CGA. Patients at non-risk of frailty in the IG were provided with recommendations about healthy habits and adherence to treatment in group sessions, while patients at risk of frailty were visited individually by a geriatrician. Results. Six hundred and twenty patients were randomized to the IG (49.7%) or to the CG (50.3%), 83.2% completed follow-up. Cox’s proportional hazards model showed as covariates the study group (hazard ratio [HR] 0.58; 95% confidence interval [CI] 0.28–1.22), risk of frailty (HR 1.33; 95% CI 0.71–2.51) and the interaction between both (HR 3.08; 95% CI 1.22–7.78). Forty-nine percent of the patients in the IG and 43% in the CG were at risk of frailty at baseline. At the end of the study, 27.9% of the IG and 13.5% of the CG had reversed their initial at risk of frailty status (P = 0.027). Multivariate predictors of reversible risk of frailty were younger age, not being at risk of depression, low consumption of medications and the intervention itself. Conclusions. A specific intervention in patients over 74 years attended in primary care reduces morbidity and mortality in patients at risk of frailty and increases the proportion of patients that reversed their initial status at risk of frailty.

Kidney failure is an important prognostic factor in patients with heart failure. Renal function is usually evaluated by measuring the serum creatinine level. However, a normal creatinine level can mask established kidney failure. We investigated the prognostic significance of the estimated creatinine clearance rate (Cockcroft formula) in 235 patients with heart failure and a normal serum creatinine level. The two-year mortality rate was significantly higher in patients who had established kidney disease (i.e., a creatinine clearance rate60 mL/min) than in those who did not (35.1% vs. 10.1%, P.001). Even when only patients without established kidney failure were analyzed, the creatinine clearance rate had prognostic significance (rateor = 90 mL/min, mortality 3.2%; rate 89-60 mL/min, mortality 13.9%; P=.02). On Cox regression analysis, which included age, sex, heart failure etiology, left ventricular ejection fraction, diabetes and hypertension, the creatinine clearance rate remained an independent predictor of mortality.

Introduction and objectives. Heart failure leads to frequent hospital readmissions. The aim of this study was to assess how receiving attention at our multidisciplinary unit influenced hospitalization for heart failure. We compared the number of admissions in the year preceding attendance with that in the first year of follow-up. Patients and method. In total, 366 patients were admitted between August 2001 and June 2003. Of these, 332 were still alive and could be assessed clinically 1 year later. The most common etiologies were ischemic heart disease in 60%, and dilated cardiomyopathy in 10%. Results. The number of admissions in the year preceding attendance was 246, while that during the first year of follow-up was 125, which corresponds to a statistically significant reduction of 49% (P

Introduction: Heart failure (HF) is one of the most important chronic diseases that cause quality of life (QOL) impairment. The Minnesota Living with Heart Failure Questionnaire (MLWHFQ) is probably the most comprehensively used tool for studying QoL in HF patients. It is a disease-specific questionnaire, but it can be related to frailty, as we previously observed in elderly patients. Geriatric evaluations have been applied successfully to general population regardless the age. Objective and methods: To assess the relationship between the MLWHFQ score and the results obtained in a basic geriatric evaluation with standardised geriatric scales such as Barthel Index, OARS Scale, Pfeiffer Test, and abbreviate Geriatric Depression Scale (GDS), in a general population admitted to a HF Unit. The MLWHFQ and the basic geriatric evaluation were performed at the first visit to the Unit. Predefined criteria (Barthel 3 (±1 depending on educational grade) and 1 positive depression response in abbreviate GDS), were considered abnormal. Every patient having at least one abnormal evaluation was considered frail. Results: 1405 patients were evaluated (1015 men and 390 women). Median age was 69 years (P25-75 59-76). 44.2% of patients (621) fulfilled frailty criteria. Two hundred and eighty six patients (20.4%) had a Barthel Index