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Resumen Objetivo Evaluar la utilidad de la escala de cribado de la fragilidad (Identification of Senior at Risk [ISAR]) para predecir la mortalidad a los 30 dias en los pacientes mayores atendidos por insuficiencia cardiaca aguda (ICA) en los servicios de urgencias hospitalarios (SUH). Diseno Estudio multicentrico observacional de cohorte multiproposito. Ambito Registro OAK-3. Participantes Pacientes ≥ 65 anos atendidos por ICA en 16 SUH espanoles de enero a febrero del 2016. Intervencion Ninguna. Variables La variable de estudio fue la escala ISAR. La variable de resultado fue la mortalidad por cualquier causa a los 30 dias. Resultados Se incluyo a 1.059 pacientes (edad media 85 ± 5,9 anos). Ciento sesenta (15,1%) casos tuvieron 0-1 puntos, 278 (26,3%) 2 puntos, 260 (24,6%) 3 puntos, 209 (19,7%) 4 puntos y 152 (14,3%) 5-6 puntos de la escala ISAR. Noventa y cinco (9,0%) pacientes fallecieron a los 30 dias. La frecuencia de mortalidad se incremento en relacion a la categoria del ISAR (p tendencia lineal Conclusiones La escala ISAR es una herramienta breve y sencilla que deberia ser considerada para el despistaje de la fragilidad en la valoracion inicial de los pacientes mayores con insuficiencia cardiaca aguda de cara a predecir la mortalidad a 30 dias.

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.

To the Editor: Acute kidney injury (AKI) is a lesser-known complication of hip fracture that may come about owing to decreased kidney perfusion and heightened inflammation from trauma, pain, bleeding, and fasting. Approximately 15%-20% of patients undergoing surgery for a hip fracture develop AKI, with 0.5%-1.8% receiving dialysis. [...]

Objective This study aimed to assess the probability of reaching an adequate pharmacokinetic/pharmacodynamic (pK/pD) index for different cefepime dosages in frail patients with bacteremia treated in the emergency room. Methods Simulation study based on Gram-negative bacterial strains that cause bacteremia. The probability of reaching a time above the minimum inhibitory concentration (MIC) at 50% and 100% dosing intervals (fT > 50 and fT > 80% MIC) was assessed for two different renal clearance intervals. Results One hundred twenty nine strains were collected, the predominant species being Escherichia coli (n = 83 [64.3%]). In patients with a ClCr of 30 mL/min, an fT > 50% MIC was reached in more than 90% of the simulations. However, a dose of at least 1 g every 12 h must be administered to reach an fT > 80% MIC. In patients with a ClCr of 30–60 mL/min, the probability of reaching an fT > 50% MIC was higher than 90% with doses of 1 g every 8 h or more, but this value was not reached in > 90% simulations for any of the doses tested in this study. Conclusions Standard cefepime dosing can reach an adequate PK/PD index in frail patients. Nevertheless, a high dose or extended infusion is necessary to reach an fT > 80% MIC in patients with a ClCr > 60 mL/min.

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.

Objective To identify patients at risk of in-hospital mortality and adverse outcomes during the vulnerable post-discharge period after the first acute heart failure episode (de novo AHF) attended at the emergency department. Methods This is a secondary review of de novo AHF patients included in the prospective, multicentre EAHFE (Epidemiology of Acute Heart Failure in Emergency Department) Registry. We included consecutive patients with de novo AHF, for whom 29 independent variables were recorded. The outcomes were in-hospital all-cause mortality and all-cause mortality and readmission due to AHF within 90 days post-discharge. A follow-up check was made by reviewing the hospital medical records and/or by phone. Results We included 3422 patients. The mean age was 80 years, 52.1% were women. The in-hospital mortality was 6.9% and was independently associated with dementia (OR = 2.25, 95% CI = 1.62-3.14), active neoplasia (1.97, 1.41-2.76), functional dependence (1.58, 1.02-2.43), chronic treatment with beta-blockers (0.62, 0.44-0.86) and severity of decompensation (6.38, 2.86-14.26 for high-/very high-risk patients). The 90-day post-discharge combined endpoint was observed in 19.3% of patients and was independently associated with hypertension (HR = 1.40, 1.11-1.76), chronic renal insufficiency (1.23, 1.01-1.49), heart valve disease (1.24, 1.01-1.51), chronic obstructive pulmonary disease (1.22, 1.01-1.48), NYHA 3-4 at baseline (1.40, 1.12-1.74) and severity of decompensation (1.23, 1.01-1.50; and 1.64, 1.20-2.25; for intermediate and high-/very high-risk patients, respectively), with different risk factors for 90-day post-discharge mortality or rehospitalisation. Conclusions The severity of decompensation and some baseline characteristics identified de novo AHF patients at increased risk of developing adverse outcomes during hospitalisation and the vulnerable post-discharge phase, without significant differences in these risk factors according to patient age at de novo AHF presentation. [GRAPHICS] .

To identify factors associated with worsening renal function (WRF) and explore associations with higher mortality in patients with acute heart failure (AHF).Seven emergency departments (EDs) in the EAHFE-EFRICA study (Spanish acronym for Epidemiology of AHF in EDs - WRF in AHF) consecutively included patients with AHF and creatinine levels determined in the ED and between 24 and 48 hours later. Patients with WRF were identified by an increase in creatinine level of 0.3 mg/dL or more. Forty-seven clinical characteristics were explored to identify those associated with WRF. To analyze for 30-day all-cause mortality we calculated odds ratios (ORs). To analyze mortality at the end of follow-up and by trimester, adjusted for between-group differences, we calculated hazard ratios (HRs). The data were analyzed by subgroups according to age, sex, baseline creatinine levels, AHF type, and risk group.A total of 1627 patients were included. The subgroup of 220 (13.5%) with WRF were older, had higher systolic blood pressure, were more often treated with morphine, and had chronic renal failure; there was also a higher rate of hypertensive crisis as the trigger for AHF in patients with WRF. However, only chronic renal failure was independently associated with WRF (adjusted OR, 1.695; 95% CI, 1.264-2.273). The rate of 30-day mortality was 13.1% overall but higher in patients with WRF (20.9% vs 11.8% in patients without WRF; adjusted OR, 1.793; 95% CI, 1.207-2.664). Accumulated mortality at 18 months (average follow-up time, 14 mo/patient) was 40.0% overall but higher in patients with WRF (adjusted HR, 1.275; 95% CI, 1.018-1.598). Increased risk was greater in the first trimester. Subgroup analyses revealed no differences.AHF with WRF in the first 48 hours after ED care is associated with higher mortality, especially in the first trimester after the emergency.Identificar los factores asociados con el empeoramiento de la función renal (EFR) y si este se asocia a mayor mortalidad en pacientes que presentan un episodio de insuficiencia cardiaca aguda (ICA).Participaron 7 servicios de urgencias (SU) que incluyeron consecutivamente pacientes con ICA con determinación de creatinina en urgencias y a las 24-48 horas, y se identificaron aquellos con EFR (incremento de creatinina $ 0,3 mg/dL). Entre 47 características clínicas, se identificó las asociadas a EFR. Se investigó la mortalidad por cualquier causa a 30 días (OR) y al final del seguimiento (HR), esta última global y por periodos trimestrales, que se ajustó por las diferencias entre grupos. Se analizaron subgrupos según edad, sexo, creatinina basal, tipo de ICA y grupo de riesgo.Se incluyeron 1.627 pacientes, 220 (13,5%) con EFR, los cuales presentaban mayor edad, presión arterial sistólica, crisis hipertensiva como precipitante, tratamiento con morfina e insuficiencia renal crónica, aunque solo esta última se asoció independientemente a EFR (ORajustada = 1,695, IC 95% = 1,264-2,273). La mortalidad a 30 días fue de 13,1% (mayor en pacientes con EFR: 20,9% vs 11,8%, ORajustada = 1,793, IC 95% = 1,207-2,664) y la mortalidad acumulada a 18 meses (tiempo medio de seguimiento 14 meses/paciente) fue del 40,0% (mayor en pacientes con EFR: HRajustada = 1,275, IC 95% = 1,018-1,598). Este incremento de riesgo fue durante el primer trimestre. El análisis de subgrupos no mostró diferencias.La ICA con EFR en las primeras 48 horas posteriores a la atención en el SU se asocia a mayor mortalidad, que se concentra durante el primer trimestre.

Objective: To assess the value of frailty screening tool (Identification of Senior at Risk [ISAR]) in predicting 30-day mortality risk in older patients attended in emergency department (ED) for acute heart failure (AHF). Design: Observational multicenter cohort study. Setting: OAK-3 register. Subjects: Patients aged >= 65 years attended with ADHF in 16 Spanish EDs from January to February 2016. Intervention: No. Variables: Variable of study was ISAR scale. The outcome was all-cause 30-day mortality. Results: We included 1059 patients (mean age 85 +/- 5,9 years old). One hundred and sixty (15.1%) cases had 0-1 points, 278 (26.3%) 2 points, 260 (24.6%) 3 points, 209 (19.7%) 4 points, and 152 (14.3%) 5-6 points of ISAR scale. Ninety five (9.0%) patients died within 30 days. The percentage of mortality increased in relation to ISAR category (lineal trend P value < .001). The area under curve of ISAR scale was 0.703 (95%Cl 0.655-0.751; P

© 2020 Elsevier Ltd Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods: HIP ATTACK was an international, randomised, controlled trial done at 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were aged 45 years or older were eligible. Research personnel randomly assigned patients (1:1) through a central computerised randomisation system using randomly varying block sizes to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. The coprimary outcomes were mortality and a composite of major complications (ie, mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Patients, health-care providers, and study staff were aware of treatment assignment, but outcome adjudicators were masked to treatment allocation. Patients were analysed according to the intention-to-treat principle. This study is registered at ClinicalTrials.gov (NCT02027896). Findings: Between March 14, 2014, and May 24, 2019, 27 701 patients were screened, of whom 7780 were eligible. 2970 of these were enrolled and randomly assigned to receive accelerated surgery (n=1487) or standard care (n=1483). The median time from hip fracture diagnosis to surgery was 6 h (IQR 4–9) in the accelerated-surgery group and 24 h (10–42) in the standard-care group (p

Objectives The authors sought to evaluate clinical outcomes of patients after an episode of acute heart failure (AHF) according to their adherence to the Mediterranean diet (MedDiet). Background It has been proved that MedDiet is a useful tool in primary prevention of cardiovascular diseases. However, it is unknown whether adherence to MedDiet is associated with better outcomes in patients who have already experienced an episode of AHF. Methods We designed a prospective study that included consecutive patients diagnosed with AHF in 7 Spanish emergency departments (EDs). Patients were included if they or their relatives were able to answer a 14-point score of adherence to the MedDiet, which classified patients as adherents (≥9 points) or nonadherents (≤8 points). The primary endpoint was all-cause mortality at the end of follow-up, and secondary endpoints were 1-year ED revisit without hospitalization, rehospitalization, death, and a combined endpoint of all these variables for patients discharged after the index episode. Unadjusted and adjusted hazard ratios (HRs) were calculated. Results We included 991 patients (mean age of 80 ± 10 years, 57.8% women); 523 (52.9%) of whom were adherent to the MedDiet. After a mean follow-up period of 2.1 ± 1.3 years, no differences were observed in survival between adherent and nonadherent patients (HR of adherents [HR adh ] = 0.86; 95% confidence interval [CI]: 0.73 to 1.02). The 1-year cumulative ED revisit for the whole cohort was 24.5% (HR adh = 1.10; 95% CI: 0.84 to 1.42), hospitalization 43.7% (HR adh = 0.74; 95% CI: 0.61 to 0.90), death 22.7% (HR adh = 1.05; 95% CI: 0.8 to 1.38), and combined endpoint 66.8% (HR adh = 0.89; 95% CI: 0.76 to 1.04). Adjustment by age, hypertension, peripheral arterial disease, previous episodes of AHF, treatment with statins, air-room pulsioxymetry, and need for ventilation support in the ED rendered similar results, with no statistically significant differences in mortality (HR adh = 0.94; 95% CI: 0.80 to 1.13) and persistence of lower 1-year hospitalization for adherents (HR adh = 0.76; 95% CI: 0.62 to 0.93). Conclusions Adherence to the MedDiet did not influence long-term mortality after an episode of AHF, but it was associated with decreased rates of rehospitalization during the next year.

To determine the rate of adverse events in patients with acute heart failure (AHF) who were discharged from the emergency department (ED) after classification as low risk according to MEESSI score (multiple risk estimate based on the Spanish ED scale), to analyze the ability of the score to predict events, and to explore variables associated with adverse events.Patients in the EAHFE registry (Epidemiology of Acute Heart Failure in EDs) were stratified according to risk indicated by MEESSI score in order to identify those considered at low risk on discharge. All-cause 30-day mortality and revisits related to AHF within 7 days and 30 days were recorded. The area under the receiver operating characteristic curve (AUC) was calculated for the MEESSI score's ability to predict these events. Associations between 42 variables and 7-day and 30-day revisits to the ED were analyzed by multivariable logistic regression.A total of 1028 patients were included. The 30-day mortality rate was 1.6% (95% CI, 0.9%-2.5%). The 7-day and 30-day revisit rates were 8.0% (95% CI, 6.4%-9.8%) and 24.7% (95% CI, 22.1%-25.7%), respectively. The AUCs for MEESSI score discrimination between patients with and without these outcomes were as follows: 30-day mortality, 0.69 (95% CI, 0.58-0.80); 7-day revisiting, 0.56 (95% CI, 0.49-0.63); and 30-day revisiting, 0.54 (95% CI, 0.50-0.59). Variables associated with 7-day revisits were long-term diuretic treatment (odds ratio [OR], 2.45; 95% CI, 1.01-5.98), hemoglobin concentration less than 110 g/L (OR, 1.68; 95% CI, 1.02-2.75), and intravenous diuretic treatment in the ED (OR, 0.53; 95% CI, 0.31-0.90). Variables associated with 30-day revisits were peripheral artery disease (OR, 1.74; 95% CI, 1.01-3.00), prior history of an AHF episode (OR, 1.42; 95% CI, 1.02-1.98), long-term mineralocorticoid receptor antagonist treatment (OR, 1.71; 95% CI, 1.09-2.67), Barthel index less than 90 points in the ED (OR, 1.48; 95% CI, 1.07-2.06), and intravenous diuretic treatment in the ED (OR, 0.58; 95% CI, 0.40-0.84).Patients with AHF who are at low risk for adverse events on discharge from our EDs have event rates that are near internationally recommended targets. The MEESSI score, which was designed to predict 30-day mortality, is a poor predictor of 7-day or 30-day revisiting in these low-risk patients. We identified other factors related to these events.Investigar la tasa de eventos adversos en pacientes con insuficiencia cardiaca aguda (ICA) clasificados de bajo riesgo por la escala MEESSI y dados de alta desde urgencias, la capacidad discriminativa de dicha escala para estos eventos en dichos pacientes y las variables asociadas.Se estratificó el riesgo de los pacientes del Registro EAHFE (cohortes 2-5) mediante la escala MEESSI y se analizaron los clasificados de bajo riesgo dados de alta desde urgencias. Se investigó la mortalidad por cualquier causa a 30 días (M-30d), la revisita a urgencias por ICA a 7 días (REV-7d) y la revisita a urgencias u hospitalización por ICA a 30 días (REV-H-30d). Se calculó el área bajo la curva (ABC) de la característica operativa del receptor (COR) de la escala MEESSI para estos eventos. Se analizó la relación entre 42 variables y RV-7d y RV-H-30d mediante regresión logística multivariable.Se incluyeron 1028 pacientes. La M-30d fue 1,6% (IC 95%: 0,9-2,5), la REV-7d fue 8,0% (6,4-9,8) y la REV-H-30d fue 24,7% (22,1-25,7). El ABC ROC de la puntuación MEESSI para discriminar estos eventos adversos fue 0,69 (0,58-0,80), 0,56 (0,49-0,63) y 0,54 (0,50-0,59), respectivamente. Se asociaron con RV-7d: tratamiento diurético crónico (OR 2,45; 1,01-5,98), hemoglobina110 g/L (1,68; 1,02-2,75) y tratamiento diurético intravenoso en urgencias (0,53; 0,31-0,90). Se asociaron con REV-H-30d: arteriopatía periférica (1,74; 1,01-3,00), episodios previos de ICA (1,42; 1,02-1,98), tratamiento crónico con inhibidores de receptores mineralocorticoides (1,71; 1,09-2,67), índice de Barthel en urgencias90 puntos (1,48; 1,07-2,06) y tratamiento diurético intravenoso en urgencias (0,58; 0,40-0,84).Los pacientes con ICA de bajo riesgo dados de alta desde urgencias presentan tasas de eventos adversos cercanas a los estándares recomendados internacionalmente. La escala MEESSI, diseñada para predecir M-30d, tiene escasa capacidad predictiva para REV-7d y REV-H-30d en los pacientes de bajo riesgo. Este estudio describe otros factores asociados a tales eventos.

To study the impact of geriatric assessment variables on 30-day mortality among older patients with acute heart failure (AHF).Retrospective analysis of cases in the OAK Registry (Older Acute Heart Failure Key Data), a prospectively compiled database of consecutive patients aged 65 years or older treated for AHF in 3 Spanish emergency departments over a 4-month period (November-December 2011 and January-February 2014). The patients underwent a geriatric assessment adapted for emergency department use on weekdays between 8 AM and 10 PM. Demographic, clinical, laboratory, and geriatric assessment variables were recorded. The geriatric variables were concurrent diseases; polypharmacy; frailty; functional, social, and cognitive status at baseline; results of screening for confusional state, cognitive impairment, and depression; and nutritional status. The primary outcome was all-cause mortality at 30 days.We included 565 patients with a mean (SD) age of 83 (7.1) years; 346 (61.6%) were women. Sixty-five (11.5%) died within 30 days. Independent factors associated with 30-day mortality were acute confusional state (adjusted odds ratio [aOR], 2.2; 95% CI, 1.0–4.8; P=.04), acute illness (aOR, 1.8; 95% CI, 0.9–3.4; P=.05), loss of appetite in the past 3 months (aOR, 1.8; 95% CI, 1.0–3.4; P=.04), frailty (aOR, 2.0, 95% CI, 1.0–4.1; P=.05), and severe disability (aOR, 4.4; 95% CI, 1.9–11.4; P=.01).Certain geriatric variables should be considered when assessing short-term risk in older patients with AHF.Estudiar el impacto de las variables geriátricas en la mortalidad a 30 días entre los ancianos con insuficiencia cardiaca aguda (ICA).Análisis retrospectivo del registro Older Acute heart failure Key data (OAK) que incluye prospectivamente a pacientes consecutivos 65 años con ICA en 3 servicios de urgencias españoles durante 4 meses (noviembre-diciembre 2011 y enero-febrero 2014). Se realizó una valoración geriátrica adaptada a urgencias durante los días laborales de 8 am a 10 pm. Se recogieron variables demográficas, clínicas, analíticas y geriátricas (comorbilidad, polifarmacia, fragilidad, situación basal funcional, cognitiva y social, despistaje de síndrome confusional, deterioro cognitivo y depresión, y situación nutricional). La variable de resultado fue la mortalidad por cualquier causa a los 30 días.Se incluyeron 565 pacientes con edad media 83 años (DE 7,1), 346 mujeres (61,6%). Sesenta y cinco sujetos (11,5%) fallecieron a los 30 días. La presencia de síndrome confusional agudo (OR ajustada = 2,2; IC95% 1,0-4,8; p = 0,04), de enfermedad aguda (OR ajustada = 1,8; IC95% 0,9-3,4; p = 0,05) o pérdida de apetito (OR ajustada = 1,8; IC95% 1-3,4; p = 0,04) en los últimos 3 meses, y de fragilidad (OR ajustada = 2,0; IC95% 1,0-4,1; p = 0,05) o dependencia funcional grave (OR ajustada = 4,4; IC95% 1,9-11,4; p = 0,01) fueron factores independientes asociados con mortalidad a los 30 días.Existen ciertas variables geriátricas que debieran contemplarse en la estratificación de riesgo a corto plazo de los pacientes ancianos con ICA.

The authors sought to evaluate clinical outcomes of patients after an episode of acute heart failure (AHF) according to their adherence to the Mediterranean diet (MedDiet).It has been proved that MedDiet is a useful tool in primary prevention of cardiovascular diseases. However, it is unknown whether adherence to MedDiet is associated with better outcomes in patients who have already experienced an episode of AHF.We designed a prospective study that included consecutive patients diagnosed with AHF in 7 Spanish emergency departments (EDs). Patients were included if they or their relatives were able to answer a 14-point score of adherence to the MedDiet, which classified patients as adherents (≥9 points) or nonadherents (≤8 points). The primary endpoint was all-cause mortality at the end of follow-up, and secondary endpoints were 1-year ED revisit without hospitalization, rehospitalization, death, and a combined endpoint of all these variables for patients discharged after the index episode. Unadjusted and adjusted hazard ratios (HRs) were calculated.We included 991 patients (mean age of 80 ± 10 years, 57.8% women); 523 (52.9%) of whom were adherent to the MedDiet. After a mean follow-up period of 2.1 ± 1.3 years, no differences were observed in survival between adherent and nonadherent patients (HR of adherents [HRAdherence to the MedDiet did not influence long-term mortality after an episode of AHF, but it was associated with decreased rates of rehospitalization during the next year.

Objective: Patients with heart failure (HF) seen at the emergency department (ED) are increasingly older and more likely to present delirium. Little is known, however, about the impact of this syndrome on outcome in these patients. We aimed to investigate the prognostic value and risk factors of delirium at admission (prevalent delirium) in ED patients with decompensated HF. Methods and Results: We performed a prospective, observational study, analyzing the presence of prevalent delirium in decompensated HF patients attended at the ED in 2 hospitals in Spain in the context of the Epidemiology Acute Heart Failure Emergency project. We used the brief Confusion Assessment Method to assess the presence of delirium. Patients were followed for 1 month after discharge. Of 239 enrolled patients (81.7 +/- 9.4 years, women 61.1%, long-term care [LTC] 11%), 35 (14.6%) had prevalent delirium (20% LTC vs 9.4% in-home, P = .078). The factors associated with delirium in the multivariate analysis were functional dependence (P = .001) and dementia (P = .005). Prevalent delirium was an independent risk factor of death within 30 days (OR 3.532; 95% CI 1.422-8.769, P = .007) whereas autonomy in basic activities of daily living was a protective factor (OR 0.971; 95% CI 0.956-0.986, P = .001). The area under the ROC curve for our 30-day mortality model was 0.802 (95% CI 0.721-0.883, P = .001). Conclusion: Prevalent delirium in patients with decompensated HF was a predictor of short-term mortality. Routine identification of delirium in patients at risk, particularly those with greater functional dependence, can help emergency physicians in decision-making and enhance care in patients with decompensated HF. (C) 2015 AMDA - The Society for Post-Acute and Long-Term Care Medicine.

Hemos leido con interes la carta publicada por FabregatAndres et al. sobre la «Determinacion de troponina I (TnI) en el servicio de urgencias de un hospital terciario (SUH)». En relacion con ella, nos gustaria realizar un comentario con respecto a la determinacion de troponina I en un SUH. Como explican los autores, es necesaria su realizacion para efectuar el diagnostico de infarto agudo de miocardio (IAM), pero requiere una sospecha clinica solida. No obstante, se han descrito otras entidades diferentes del IAM en las que pueden haber cambios en la determinacion seriada de troponina, y en muchos de estos cuadros clinicos este cambio se ha asociado con un peor pronostico del paciente (tabla 1). Estas situaciones son mucho mas habituales con la introduccion de los inmunoanalisis denominados de elevada