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Digoxin is commonly used to treat acute heart failure (AHF), especially in patients with concurrent atrial fibrillation (AF). Nonetheless, there is little consensus about in which patients digoxin should be given, the proper time for digoxin initiation, and whether digoxin initiation is associated with improved outcomes. We investigated factors related to digoxin initiation after an episode of AHF and whether patients receiving digoxin presented better short-term outcomes. We analyzed digoxin-naïve AHF patients from a Spanish and Swiss database, who were dichotomized into cohorts based on their receipt of digoxin treatment at discharge. The relationship between digoxin initiation and 23 additional patient covariates, including chronic treatment, was investigated, as well as its association with 90-day combined adverse events (defined as all-cause death or AHF hospitalization). Of 13,105 patients (10,600/2505 from the Spanish/Swiss cohorts, respectively), the median (interquartile range) age was 83 (74.87) years, and 51% were women. Of these, 484 (3.7%) received digoxin at discharge, which was associated with AF, female sex, left ventricular ejection fraction (LVEF) < 50%, and coming from the Spanish cohort. Parameters inversely associated with receiving digoxin at discharge included some chronic treatments, diabetes mellitus (DM), and chronic kidney disease (CKD). Digoxin initiation was not association with 90-day adverse events, adjusted hazard ratio (aHR) = 0.939 (0.769-1.146), but there was an interaction for CKD, aHR = 1.390 (0.831-2.325) vs. 0.854 (0.682-1.183), p = 0.039, and for cohort pertinence, with higher risk in the Swiss cohort; aHR = 1.405 (0.827-2.386) vs. 0.862 (0.689-1.077), p = 0.046. Digoxin initiation after an AHF episode was more frequent in the Spanish cohort and was associated with certain patient characteristics (AF, female sex, reduced LVEF, no DM, no CKD), but had no effect on 90-day outcomes., Competing Interests: Declarations. Ethical approval, human and animal rights and informed consent: All patients signed their participation in inclusion in the database by signing the corresponding informed consent. The study was approved by the CEIC with the CEImPA code number 2022.015 Conflict of interest: None declared., (© 2024. The Author(s), under exclusive licence to Società Italiana di Medicina Interna (SIMI).)

Background: Intravenous digoxin is still used in emergency departments (EDs) to treat patients with acute heart failure (AHF), especially in those with rapid atrial fibrillation. Nonetheless, many emergency physicians are reluctant to use intravenous digoxin in patients with advanced age, impaired renal function, and potassium disturbances due to its potential capacity to increase adverse outcomes., Objective: We investigated whether intravenous digoxin used to treat rapid atrial fibrillation in patients with AHF may influence mortality in patients with specific age, estimated glomerular filtration rate (eGFR), and serum potassium classes., Design: A secondary analysis of patients included in in the Spanish EAHFE cohort, which includes patients diagnosed with AHF in the ED., Setting: 45 Spanish EDs., Participants: Two thousand one hundred ninety-four patients with AHF and rapid atrial fibrillation (heart rate ≥100 bpm) not receiving digoxin at home, divided according to whether they were or were not treated with intravenous digoxin in the ED., Outcome: The relationships between age, eGFR, and potassium with 30-day mortality were investigated using restricted cubic spline (RCS) models adjusted for relevant patient and episode variables. The impact of digoxin use on such relationships was assessed by checking interaction., Main Results: The median age of the patients was 82 years [interquartile range (IQR) = 76-87], 61.4% were women, 65.2% had previous episodes of atrial fibrillation, and the median heart rate at ED arrival was 120 bpm (IQR = 109-135). Digoxin and no digoxin groups were formed by 864 (39.4%) and 1330 (60.6%) patients, respectively. There were 191 deaths within the 30-day follow-up period (8.9%), with no differences between patients receiving or not receiving digoxin (8.5 vs. 9.1%, P  = 0.636). Although analysis of RCS curves showed that death was associated with advanced age, worse renal function, and hypo- and hyperkalemia, use of intravenous digoxin did not interact with any of these relationships ( P  = 0.156 for age, P  = 0.156 for eGFR; P  = 0.429 for potassium)., Conclusion: The use of intravenous digoxin in the ED was not associated with significant changes in 30-day mortality, which was confirmed irrespective of patient age or the existence of renal dysfunction or serum potassium disturbances., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To analyze factors related to the use of digoxin to treat patients with acute heart failure (AHF) in emergency departments (EDs) and the impact of digoxin treatment on short-term outcomes., Material and Methods: We included patients diagnosed with AHF in 45 Spanish EDs. The patients, who were not undergoing long-term treatment for heart failure, were classified according to whether or not they were given intravenous digoxin in the ED. Fifty-one patient or cardiac decompensation episode variables were recorded to profile ED patients treated with digoxin. Outcome variables studied were the need for hospital admission, prolonged stay in the ED (> 24 hours) for discharged patients, prolonged hospitalization (> 7 days) for admitted patients, and all-cause in-hospital or 30-day mortality. The associations between digoxin treatment and the outcomes were studied with odds ratios (ORs) adjusted for patient and AHF episode characteristics., Results: Data for 15 549 patients (median age, 83 years; 55% women) were analyzed; 1430 (9.2%) were treated with digoxin. Digoxin was used more often in women, young patients, and those with better New York Heart Association (NYHA) classifications but more severe cardiac decompensation, especially if the trigger was atrial fibrillation with rapid ventricular response. Admissions were ordered for 75.4% of the patients overall (81.6% of digoxin-treated patients vs 74.8% of nontreated patients; P .001). The ED stay was prolonged in 38.3% of patients discharged from the ED (52.9% of digoxin-treated patients vs 37.2% of nontreated patients; P .001). The duration of hospital stay was prolonged in 48.1% (digoxin-treated, 49.3% vs 47.9%; P = .385). In-hospital mortality was 7.2% overall (6.9% vs 7.2%, P= .712), and 30-day mortality was 9.7% (9.3% vs 9.7%, P = .625). ED use of digoxin was associated with a prolonged stay in the department (adjusted OR, 1.883; 95% CI, 1.359-2.608) but not with hospitalization or mortality., Conclusion: Digoxin continues to be used in one out of ten ED patients who are not already on long-term treatment with the drug. Digoxin use is associated with cardiac decompensation triggered by atrial fibrillation with rapid ventricular response, younger age, women, and patients with better initial NYHA function status but possibly more severe decompensation. Digoxin use leads to a longer ED stay but is safe, as it is not associated with need for admission, prolonged hospitalization, or short-term mortality.

Objective: Both hyperkalemia (HK) and Acute Heart Failure (AHF) are associated with increased short-term mortality, and the management of either may exacerbate the other. As the relationship between HK and AHF is poorly described, our purpose was to determine the relationship between HK and short-term outcomes in Emergency Department (ED) AHF., Methods: The EAHFE Registry enrolls all ED AHF patients from 45 Spanish ED and records in-hospital and post-discharge outcomes. Our primary outcome was all-cause in-hospital death, with secondary outcomes of prolonged hospitalization (>7 days) and 7-day post-discharge adverse events (ED revisit, hospitalization, or death). Associations between serum potassium (sK) and outcomes were explored using logistic regression by restricted cubic spline (RCS) curves, with sK =4.0 mEq/L as the reference, adjusting by age, sex, comorbidities, patient baseline status and chronic treatments. Interaction analyses were performed for the primary outcome., Results: Of 13,606 ED AHF patients, the median (IQR) age was 83 (76-88) years, 54% were women, and the median (IQR) sK was 4.5 mEq/L (4.3-4.9) with a range of 4.0-9.9 mEq/L. In-hospital mortality was 7.7%, with prolonged hospitalization in 35.9%, and a 7-day post-discharge adverse event rate of 8.7%. Adjusted in-hospital mortality increased steadily from sK ≥4.8 (OR = 1.35, 95% CI = 1.01-1.80) to sK = 9.9 (8.41, 3.60-19.6). Non-diabetics with elevated sK had higher odds of death, while chronic treatment with mineralocorticoid-receptor antagonists exhibited a mixed effect. Neither prolonged hospitalization nor post-discharge adverse events was associated with sK., Conclusion: In ED AHF, initial sK >4.8 mEq/L was independently associated with in-hospital mortality, suggesting that this cohort may benefit from aggressive HK treatment., Competing Interests: Declaration of Competing Interest The authors state that they have no conflict of interests with the present work. The ICA-SEMES Research Group has received unrestricted support from Orion Pharma, Novartis and Boehringer. The present study has been designed, performed, analyzed and written exclusively by the authors independently of these pharmaceutical companies., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: To analyze the consistency between decisions to discharge or admit patients with acute heart failure (AHF) treated in emergency departments (EDs) and the level of risk of adverse events, and to analyze the impact of decisions to discharge patients., Material and Methods: Prospective study of baseline clinical data collected from patients diagnosed with AHF in 16 Spanish emergency departments. Patients were stratified by severity of decompensated AHF based on MEESSI assessment (Multiple Estimation of Risk Based on the Spanish Emergency Department Score). The distribution of severity was described for patients who were hospitalized (overall and for departments receiving the largest number of admissions) and for discharged patients. We analyzed the data for discharged patients for associations with the following quality-of-care indicators: all-cause mortality of less than 2% at 30 days, revisits to the ED for AHF in less than 10% of patients within 7 days of discharge, and revisits to the ED or admission for AHF in less than 20% within 30 days of discharge., Results: We included 2855 patients with a median (interquartile range) age of 84 (76-88) years. Fifty-four percent were women, 1042 (36.5%) were classified as low risk, 1239 (43.4%) as intermediate risk, 301 (10.5%) as high risk, and 273 (9.6%) as very high risk. Thirty-day mortality rates by level of low to very high risk were 1.9%, 9.3%, 15.3%, and 38.4%, respectively. One-year mortality rates by risk level were 15.4%, 35.6%, 52.0%, and 74.2%. Admission rates by risk level were 62.2%, 77.4%, 87.0%, and 88.3%. Overall, 47.1% o patients discharged from the ED were in the 3 higher-risk categories (intermediate to very high), and 30.7% were in the lowest risk category. The 5 hospital areas receiving the most admissions, in order of lowest-to-highest risk classification, were internal medicine, the short-stay unit, cardiology, intensive care, and geriatrics. Rates and 95% CIs for quality-of-care indicators in patients discharged from EDs were as follows: 30-day mortality, 4.3% (3.0%-6.1%); ED revisits within 7 days, 11.4% (9.2%-14.0%), and ED revisits or admissions within 30 days, 31.5% (28.0%-35.1%). In patients classified as low risk on ED discharge, these percentages were lower, as follows, respectively: 0.5% (0.1%-1.8%), 10.5% (7.6%-14.0%), and 29.5% (26.6%-32.6%)., Conclusion: We detected disparity between severity of AHF decompensation and the decision to discharge or admit patients. Outcomes in patients discharged from EDs do not reach the recommended quality-of-care standards. Reducing inconsistencies between severity of decompensation and ED decisions could help to improve quality targets.

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 <2% (outcome A); 7-day ED revisit due to AHF < 10% (outcome B); and 30-day ED revisit/hospitalization due to AHF < 20% (outcome C). We investigated these outcomes in a nationwide cohort and their relationship with the ED DDWH percentage., Methods: We analyzed the EAHFE registry (includes about 15% of Spanish EDs), calculated DDWH percentage of each ED, and A/B/C outcomes of DDWH patients, overall and in each individual ED. Relationship between ED DDWH and outcomes was assessed by linear and quadratic regression models, non-weighted and weighted by DDWH patients provided by each ED., Results: Among 17,420 patients, 4488 had DDWH (25.8%, median ED stay = 0 days, IQR = 0-1). Only 12.9% EDs achieved DDWH > 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., (Copyright © 2020. Published by Elsevier Ltd.)

Background: The coexistence of other comorbidities confers poor outcomes in patients with acute heart failure. Our aim was to determine the characteristics of patients with acute heart failure and cardiorenal anaemia syndrome and the relationship between renal dysfunction and anaemia, alone or combined as cardiorenal anaemia syndrome, on short-term outcomes., Methods: We analysed the Epidemiology of Acute Heart Failure in Emergency Departments registry (cohort of patients with acute heart failure in Spanish emergency departments). Renal dysfunction was defined by an estimated glomerular filtration rate <60 ml/min/m 2 , anaemia by haemoglobin values <12/<13 g/dl in women/men, and cardiorenal anaemia syndrome as the presence of both. Comparisons were made according to cardiorenal-anaemia syndrome positive (CRAS+) with respect to the rest of patients (CRAS-) and according the presence of renal dysfunction (RD+) and anaemia (A+), (alone, RD+/A-, RD-/A+) or in combination (RD+/A+; i.e. CRAS+) with respect to patients without renal dysfunction and anaemia (RD-/A-). The primary outcome was 30-day mortality, and the secondary outcomes were need for admission, prolonged hospitalisation (>10 days), in-hospital mortality during the index event, and reconsultation and the combination of 30-day post-discharge reconsultation/death. These short-term outcomes were compared and adjusted for differences among groups., Results: Of the 13,307 patients analysed, CRAS+ (36.4%) was associated with older age, multiple comorbidities, chronic use of loop diuretics, oedemas and hypotension. The 30-day mortality in CRAS+ was greater than in CRAS- (hazard ratio = 1.46, 95% confidence interval = 1.26-1.68) and RD-/A- (hazard ratio = 1.83, 95% confidence interval = 1.46-2.28) control groups. The mortality level was also higher in RD+/A- (hazard ratio = 1.40, 95% confidence interval = 1.10-1.78) and higher, but not statistically significant, in RD-/A+ (hazard ratio = 1.28, 95% confidence interval = 0.99-1.63) with respect to RD-/A-. All of the secondary outcomes, when related to CRAS- and RD-/A- control groups, were worse for CRAS+ and to a lesser extent, RD+/A-, being more rarely observed in RD-/A+., Conclusions: Cardiorenal anaemia syndrome in acute heart failure is related to greater mortality and worse short-term outcomes, and the impact of renal dysfunction and anaemia seems to be additive.

Objective: To investigate the relationship between length of hospitalisation (LOH) and post-discharge outcomes in acute heart failure (AHF) patients and to ascertain whether there are different patterns according to department of initial hospitalisation., Methods: Consecutive AHF patients hospitalised in 41 Spanish centres were grouped based on the LOH (<6/6-10/11-15/>15 days). Outcomes were defined as 90-day post-discharge all-cause mortality, AHF readmissions, and the combination of both. Hazard ratios (HRs), adjusted by chronic conditions and severity of decompensation, were calculated for groups with LOH >6 days vs. LOH <6 days (reference), and stratified by hospitalisation in cardiology, internal medicine, geriatrics, or short-stay units., Results: We included 8563 patients (mean age: 80 (SD = 10) years, 55.5% women), with a median LOH of 7 days (IQR 4-11): 2934 (34.3%) had a LOH <6 days, 3184 (37.2%) 6-10 days, 1287 (15.0%) 11-15 days, and 1158 (13.5%) >15 days. The 90-day post-discharge mortality was 11.4%, readmission 32.2%, and combined endpoint 37.4%. Mortality was increased by 36.5% (95%CI = 13.0-64.9) when LOH was 11-15 days, and by 72.0% (95%CI = 42.6-107.5) when >15 days. Conversely, no differences were found in readmission risk, and the combined endpoint only increased 21.6% (95%CI = 8.4-36.4) for LOH >15 days. Stratified analysis by hospitalisation departments rendered similar post-discharge outcomes, with all exhibiting increased mortality for LOH >15 days and no significant increments in readmission risk., Conclusions: Short hospitalisations are not associated with worse outcomes. While post-discharge readmissions are not affected by LOH, mortality risk increases as the LOH lengthens. These findings were similar across hospitalisation departments., (Copyright © 2019 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

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., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To analyse time trends in patient characteristics, clinical course, hospitalisation rate, and outcomes in acute heart failure along a 10-year period (2007-2016)., Methods: The EAHFE registry has prospectively collected 13,971 consecutive AHF patients diagnosed in 41 Spanish emergency departments (EDs) at five different time points (2007/2009/2011/2014/2016). Eighty patient-related variables and outcomes were described and statistically significant changes along time were evaluated. We also compared our data with large ED- and hospital-based registries., Results: Compared to other large registries, our patients were older [80 (10) years], more frequently women (55.5%), and had a higher prevalence of hypertension (83.5%) and a lower prevalence of ischaemic cardiomyopathy (29.4%). De novo AHF was observed in 39.6%. 63.6% showed some degree of functional dependence and 56.1% had preserved left ventricular ejection fraction (LVEF). 56.8% of the patients arrived at the ED by ambulance, 4.5% arrived hypotensive, and 21.3% hypertensive. Direct discharge from the ED home was seen in 24.9%, and internal medicine (32.5%) and cardiology (15.8%) were the main hospital destinations. Triggers for decompensation were identified in 75.4%, the most being frequent infection (35.2%) and rapid atrial fibrillation (14.7%). The AHF phenotypes were: warm/wet 82.0%, warm/dry 6.2%, cold/wet 11.1%, and cold/dry 0.7%. The length of hospitalisation was 9.3 (8.6) days, and in-hospital, 30-day, and 1-year all-cause mortality were 7.8, 10.2 and 30.3%, respectively; and 30-day re-hospitalisation and ED revisit due to AHF were 16.9 and 24.8%, respectively. Thirty-nine of the eighty characteristics studied showed significant changes over time, while all outcomes remained unchanged along the 10-year period., Conclusions: The EAHFE Registry is the first European ED-based registry describing the characteristics, clinical course, and outcomes of a cohort resembling the universe of patients with AHF. Significant changes were observed over time in some aspects of AHF characteristics and management, but not in outcomes.

Background and Objective: To compare the outcome of patients with acute heart failure (AHF) with a mid-range left ventricular ejection fraction (HFmrEF) with patients with a reduced (HFrEF) or preserved (HFpEF) left ventricular ejection fraction., Patients and Method: A prospective observational study included patients diagnosed with AHF in 41 emergency departments. Patients were divided into 3 groups: HFrEF<40%, HFmrEF 40-49% and HFpEF≥50%. We collected 38 independent variables and the adjusted and crude all-cause mortality at one-year in the HFmrEF group was compared with that of the HFrEF and HFpEF groups. The analysis was stratified according to patient destination following ED care., Results: Three thousand nine hundred and fifty-eight patients were included: 580 HFmrEF (14.6%), 929 HFrEF (23.5%) and 2,449 HFpEF (61.9%). Global mortality at one year was 28.5%. The crude mortality of the HFmrEF group was similar to that of the HFpEF group (HR 1.009; 95% CI 0.819-1.243; P=.933) and lower than the HFrEF group (HR 0.800; 95% CI 0.635-1.008; P=.058), but after adjustment for discordant basal characteristics among groups, the mortality of the HFmrEF group did not differ from that of the HFpEF (HRa 1.025; 95% CI 0.825-1.275; P=.821) or HFrEF group (HRa 0.924; 95% CI 0.720-1.186; P=.535). Neither were significant differences found between the HFmrEF group and the other 2 groups in the analysis stratified according to admission or discharge direct from the emergency department., Conclusion: Mortality at one-year after an AHF episode in patients with HFmrEF does not differ from that of patients with HFpEF or HfrEF, either globally or based on the main destinations after emergency department care., (Copyright © 2017 Elsevier España, S.L.U. All rights reserved.)

Background and Objective: To study the factors associated with prolonged hospitalization in patients admitted for acute heart failure (AHF) in Spanish short-stay units (SSUs)., Patients and Methods: This was a multicentre, multipurpose cohort study with prospective follow-up including all patients admitted for AHF in the 11 SSUs of the EAHFE registry. Demographic data, previous illness, baseline cardiorespiratory and functional status, acute episode and admission and follow up variables at 60 days were recorded. The primary outcome was prolonged hospitalization in the SSU (>72h). A logistic regression model was used to control the effects of confounding factors., Results: Eight-hundred and nineteen patients were included with a mean age of 80.9 (SD 8.4) years, 483 (59.0%) being women. The median length stay was 3.0 (IQR 2.0-5.0) days with an in-hospital mortality of 2.7%. The independent factors associated with prolonged hospitalization were the coexistence of chronic obstructive pulmonary disease (odds ratio [OR] 1.56; 95% IC 1.02-2.38; P=.040) and anaemia (OR 1.72; 95% CI 1.21-2.44; P=.002), basal oxygen saturation<90% on arrival to the Emergency Department (OR 2.21, 95% CI 1.51-3.23; P<.001), hypertensive episode as the precipitating factor of the AHF (protective factor OR 0.49; 95% CI 0.26-0.93; P=.028) and admission on Thursday (OR 1.90; 95% CI 1.19-3.05; P=.008). There were no significant differences between both groups regarding to in-hospital mortality (2.4 vs. 3.0%), mortality (4.1 vs. 4.2%) or revisit at 60 days (18.4 vs. 21.6%)., Conclusions: Several factors including hypertensive episode, insufficiency respiratory, anaemia, chronic obstructive pulmonary disease, and admission on Thursday should be taken into account in patients with AHF admitted in SSU stay to avoid prolonged hospitalization., (Copyright © 2013 Elsevier España, S.L.U. All rights reserved.)

Background: The mainstay of treatment for acutely decompensated heart failure (ADHF) is intravenous diuretic therapy either as a bolus or via continuous infusion., Objectives: We evaluated the clinical effects and safety of three strategies of intravenous furosemide administration used in emergency departments (EDs) for ADHF., Methods: We performed a multicentre, randomised, parallel-group study. Patients with ADHF were randomised within 2 h of ED arrival to receive furosemide by continuous infusion (10 mg/h, group 1) or boluses (20 mg/6 h, group 2; or 20 mg/8 h, group 3). The primary end point was total diuresis, and secondary end points were dyspnoea, orthopnoea, extension of rales and peripheral oedema, blood pressure, respiratory and heart rates, and pulse oximetry, which were measured at arrival and 3, 6, 12 and 24 h after treatment onset. We also measured serum creatinine, sodium and potassium levels at arrival and after 24 h., Results: Group 1 patients (n=36) showed greater 24 h diuresis (3705 mL) than those in groups 2 (n=37) and 3 (n=36) (3093 and 2670 mL, respectively; p<0.01), and this greater diuretic effect was observed earlier. However, no differences were observed among groups in the nine secondary clinical end points evaluated. Creatinine deterioration developed in 15.6% of patients, hyponatraemia in 9.2%, and hypokalaemia in 19.3%, with the only difference among groups observed in hypokalaemia (group 1, 36.3%; group 2, 13.5%; group 3, 8.3%; p<0.01)., Conclusions: In patients with ADHF attending the ED, boluses of furosemide have a smaller diuretic effect but provide similar clinical relief, similar preservation of renal function, and a lower incidence of hypokalaemia than continuous infusion., Trial Registration Number: This randomised trial was registered in the European Clinical Trial Database (EudraCT) with the reference number 2008-004488-20., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Patients with acute heart failure (AHF) are frequently evaluated in the Emergency Departments (ED) and discharged from their observation units (OU) without hospital admission. We examined direct discharge rates from the ED OU, risk factors for returning to the ED, and returning and mortality rates., Patients and Methods: This prospective, longitudinal, noninterventional, population-based cohort study included all the patients with AHF consecutively attended in seven Spanish EDs who were directly discharged without hospital admission. Reattendance (dependent variable) was accepted if occurred during the next 30 days after discharge. Twenty-nine independent variables were recorded, covering epidemiological, clinical, and functional data., Results: Two hundred and fifty-nine of 740 patients (35%) diagnosed with AHF were entirely managed in the ED OU and discharged home (mean stay: 18.8 h); 26.7% of them were reattended. Only three variables were independently associated with the chance of reattendance: functional impairment predicted adverse outcomes [odds ratio (OR): 4.0, 95% confidence interval (95% CI): 1.7-9.1], while past history of hypertension and a systolic blood pressure greater than 160 mmHg at ED arrival decreased the risk of ED return (OR: 0.4, 95% CI: 0.2-0.9; and OR: 0.3; 95% CI: 0.1-0.9; respectively). An overall mortality of 4.7% was recorded during the next 30 days., Conclusion: One-third of the patients consulting at the ED for an episode of AHF can be directly discharged from the OU of ED, with relatively low rates of reattendance (26.7%) and mortality (4.7%). Emergency physicians should be especially cautious discharging patients with functional dependence because they are at increased risk of returning.

Introduction and Objectives: To investigate factors associated with short-term mortality in elderly patients seen in emergency departments for an episode of acute heart failure., Methods: A prospective, non-interventional, multicenter, cohort study was carried out in patients aged 65 years and older who were treated in the emergency department of one of eight tertiary hospitals in Spain. Twenty-eight independent variables that could influence mortality at 30 days were assessed. They covered epidemiological and clinical factors and daily functioning. Data were obtained by reviewing medical records or by interviewing the patient or a relative. Multivariate logistic regression analysis was performed., Results: The study included 623 patients, 42 of whom (6.7%) died within 30 days of visiting the emergency department. Four variables were significantly associated with higher mortality: functional dependence at baseline (i.e., Barthel index=60; odds ratio [OR]=2.9; 95% confidence interval [CI], 1.2-6.5), New York Heart Association class III-IV (OR=3; 95% CI, 1.3-7), systolic blood pressure <100 mmHg (OR=4.8; 95% CI, 1.6-14.5) and blood sodium <135 mEq/l (OR=4.2; 95% CI, 1.8-9.6)., Conclusions: Several factors evaluated on initial assessment in the emergency department, including the level of functional dependence, were found to determine a poor short-term prognosis in elderly patients who present with an episode of acute heart failure.

Background: Acute heart failure (AHF) patients with high troponin levels have a worse prognosis. High‐sensitive troponin T (hs‐TnT) has been used as a tool to stratify prognosis in many scales but always as a qualitative and not as a quantitative variable. Objectives: The main objective of this study was to determine the best hs‐TnT cut‐off for prediction of 30‐day all‐cause mortality. Methods: The EAHFE registry, a prospective follow‐up cohort of patients with AHF, was analysed. We performed a propensity score analysis of the optimal hs‐TnT cut‐off point previously determined by receiver operating characteristic (ROC) curve analysis. Results: Of the 13 791 patients in the EAHFE cohort, we analysed 3190 patients in whom hs‐TnT determination was available. The area under the ROC curve for 30‐day all‐cause mortality was 0.70 (CI95% 0.68 to 0.71; P <.001), establishing an optimal cut‐off of hs‐TnT of 35 ng/L. The sensitivity and specificity of this cut‐off were 76.2 and 55.5%, respectively, with a negative predictive value (NPV) of 95.3%. A propensity score was made with 34 variables showing differences based on the cut‐off of 35 ng/L for hs‐TnT. In the analysis of the population obtained with the propensity score, patients with hs‐TnT > 35 ng/L showed a greater 30‐day all‐cause mortality, with a HR of 2.95 (CI95% 1.83‐4.75; P <.001). External validation reported similar results. Conclusions: An hs‐TnT value of 35 ng/L is an adequate cut‐off to evaluate the prediction of 30‐day all‐cause mortality with a NPV of 95.3%. [ABSTRACT FROM AUTHOR]