Objectives
To evaluate whether the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) scale for 30‐day prediction of mortality is applicable to elderly adults with acute heart failure (AHF) ...in emergency departments (EDs) and whether discriminatory power is added with the inclusion of the Barthel Index (BI) to this scale (BI‐EFFECT scale).
Design
BI‐EFFECT is a multipurpose, nonintervention, multicenter cohort study.
Setting
Twenty EDs.
Participants
Individuals aged 65 and older with AHF.
Measurements
Information on baseline and episode characteristics and 30‐day mortality was collected, and participants were categorized according to the EFFECT scale. Baseline degree of functional dependence was measured using the BI. Receiver operating characteristic (ROC) curves were made of the EFFECT and BI‐EFFECT scales to predict mortality.
Results
One thousand sixty‐eight participants were included. Thirty‐day mortality was 5.1% and was directly and independently associated with high and very high risk categories of the EFFECT scale and with severe dependence. These two variables remained significant after adjustment of the model for both (OR = 4.5, 95% CI = 1.8–11.1 and OR = 2.9, 95% CI = 1.6–5.4, respectively). The EFFECT and the BI‐EFFECT scales had significant ROC curves (area under the ROC curve (AUC) = 0.69, 95% CI = from 0.62 to 0.76; and AUC = 0.75, 95% CI = 0.69–0.81, respectively), and the difference in discriminatory power between the second and the first was also statistically significant (P = .02).
Conclusion
The EFFECT scale may be applied in the elderly population, and inclusion of functional status according to the BI in the new BI‐EFFECT scale significantly improves the model for the prediction of 30‐day mortality.
Objective
The objective was to determine the effect of frailty on risk of 30‐day mortality in nonseverely disabled older patients with acute heart failure (AHF) attended in emergency departments ...(EDs).
Methodology
The Frailty‐AHF Study is a retrospective analysis of a multicenter, observational, prospective, cohort study (Older‐AHF Register). This study included consecutive patients ≥ 65 years of age without severe functional dependence or dementia attended for AHF in three Spanish EDs for 4 months. Frailty was defined by frailty phenotype as the presence of three or more domains. Baseline and episode characteristics and 30‐day mortality were collected in all the patients.
Results
A total of 465 patients with a mean (±SD) age of 82 (±7) years were included, 283 (61.0%) being female and 225 (51.3%) with severe comorbidity (Charlson index ≥ 3). Frailty was present in 169 (36.3%). The rate of 30‐day mortality was 7.3%. Frailty adjusted for potential confounding factors was an independent factor associated with 30‐day mortality (adjusted hazard ratio = 2.5; 95% confidence interval = 1.0 to 6.0; p = 0.047).
Conclusion
The presence of frailty is an independent risk factor of 30‐day mortality in nonsevere dependent older patients attended with AHF in EDs.
To investigate whether the existence of heart failure units (HFU) and link nurse units (LNU) in the hospital improve short-term outcomes of acute heart failure (AHF) episodes.
Patients with AHF ...diagnosed in 45 Spanish emergency departments were analysed according to whether the hospital had a complete development of follow-up units (HFU + LNU), partial (HFU or LNU) or none. The outcomes were: 30-day mortality, hospitalization, in-hospital mortality, >7 days admission, and adverse event (death, rehospitalisation, or reconsultation to the emergency department) at 30 days post-discharge. Outcomes were adjusted for baseline and AHF episode characteristics.
19,947 patients were included, median age was 82 years (IQR 76‐–87), women were 55%. It was 20% of patients attended in hospitals with null development, 28% with partial development and 52% with complete development. Mortality at 30 days was 10.1% (null/partial/complete development: 10.5%/9.5%/10.4%; p=0.880), hospitalization 74.6% (72.7%/72.7%/75.7%; p<0.001), in-hospital mortality 7.4% (7.6%/7.0%/7.5%; p=0.995), prolonged hospitalization 47.4% (51.1%/52.4%/43.5%; p<0.001) and adverse events 30 days post-hospitalization 30.3% (36.2%/28.9%/30.3%; p < 0.001). In the adjusted analysis, hospital with complete development of follow-up units was not associated with mortality, but with increased hospitalization (OR= 1.172; 95%CI 1.069–1.285) and lower prolonged hospitalization (OR = 0.725; 95%CI 0.660–0.797) and adverse events at 30 days post-discharge (OR=0.831; 95%CI 0.755–0.916). Partial development was only associated with decreased post-discharge adverse events (OR= 0.782; 95%CI 0.702-0.871).
The development of follow-up units is not associated with 30-day mortality, but is associated with less prolonged hospitalization and fewer post-discharge adverse events in patients with AHF.
•Multidisciplinary approach of HF is essential to reduce readmission and improve survival.•The follow-up units minimize hospital stay and avoid related adverse events.•In patients with AHF attended in the ED, development of HF-units did not impact on mortality.•It was found significant reduction of 30-day outcomes, mainly by a in HF decompensation.
The objective was to determine the relationship between short-term mortality and intravenous morphine use in ED patients who received a diagnosis of acute heart failure (AHF).
Consecutive patients ...with AHF presenting to 34 Spanish EDs from 2011 to 2014 were eligible for inclusion. The subjects were divided into those with (M) or without IV morphine treatment (WOM) groups during ED stay. The primary outcome was 30-day all-cause mortality, and secondary outcomes were mortality at different intermediate time points, in-hospital mortality, and length of hospital stay. We generated a propensity score to match the M and WOM groups that were 1:1 according to 46 different epidemiological, baseline, clinical, and therapeutic factors. We investigated independent risk factors for 30-day mortality in patients receiving morphine.
We included 6,516 patients (mean age, 81 SD, 10 years; 56% women): 416 (6.4%) in the M and 6,100 (93.6%) in the WOM group. Overall, 635 (9.7%; M, 26.7%; WOM, 8.6%) died by day 30. After propensity score matching, 275 paired patients constituted each group. Patients receiving morphine had a higher 30-day mortality (55 20.0% vs 35 12.7% deaths; hazard ratio, 1.66; 95% CI, 1.09-2.54; P = .017). In patients receiving morphine, death was directly related to glycemia (P = .013) and inversely related to the baseline Barthel index and systolic BP (P = .021) at ED arrival (P = .021). Mortality was increased at every intermediate time point, although the greatest risk was at the shortest time (at 3 days: 22 8.0% vs 7 2.5% deaths; OR, 3.33; 95% CI, 1.40-7.93; P = .014). In-hospital mortality did not increase (39 14.2% vs 26 9.1% deaths; OR, 1.65; 95% CI, 0.97-2.82; P = .083) and LOS did not differ between groups (median interquartile range in M, 8 7; WOM, 8 6; P = .79).
This propensity score-matched analysis suggests that the use of IV morphine in AHF could be associated with increased 30-day mortality.
Although recommended for the treatment of acute heart failure (AHF), the use of intravenous (IV) nitroglycerin (NTG) is supported by scarce and contradicting evidence. In the current analysis, we ...have assessed the impact of IV NTG administration by EMS or in emergency department (ED) on outcomes of AHF patients.
We analyze AHF patients included by 45 hospitals that were delivered to ED by EMS. Patients were grouped according to whether treatment with IV NTG was started by EMS before ED admission (preED-NTG), during the ED stay (ED-NTG) or were untreated with IV NTG (no-NTG, control group). In-hospital, 30-day and 365-day all-cause mortality, prolonged hospitalization (>7 days) and 90-day post-discharge combined adverse events (ED revisit, hospitalization or death) were compared in EMS-NTG and ED-NTG respect to control group.
We included 8424 patients: preED-NTG = 292 (3.5%), ED-NTG = 1159 (13.8%) and no-NTG = 6973 (82.7%). preED-NTG group had the most severely decompensated cases of AHF (p < 0.001) but it had lower in-hospital (OR = 0.724, 95%CI = 0.459–1.114), 30-day (HR = 0.818, 0.576–1.163) and 365-day mortality (HR = 0.692, 0.551-0.869) and 90-day post-discharge events (HR = 0.795, 0.643–0.984) than control group. ED-NTG group had mortalities similar to control group (in-hospital: OR = 1.164, 0.936–1.448; 30-day: HR = 0.980, 0.819–1.174; 365-day: HR = 0.929, 0.830–1.039) but significantly decreased 90-day post-discharge events (HR = 0.870, 0.780–0.970). Prolonged hospitalization rate did not differ among groups. Five different analyses confirmed these findings.
Early prehospital IV NTG administration was associated with lower mortality and post-discharge events, while IV NTG initiated in ED only improved post-discharge event rate. Further studies are needed to assess the role of early prehospital administration of IV NTG to patients with AHF.
•Use of intravenous nitrates for Acute Heart Failure is supported by contradicting evidence.•In prehospital setting, intravenous nitrates could be associated with lower mortality and post discharge events.•The administration of intravenous nitrates in Emergency Department seems to have a more reduced beneficial effects.
Background and objective: Although recommended for the treatment of acute heart failure (AHF), the use of intravenous (IV) nitroglycerin (NTG) is supported by scarce and contradicting evidence. In ...the current analysis, we have assessed the impact of IV NTG administration by EMS or in emergency department (ED) on outcomes of AHF patients.Methods: We analyze AHF patients included by 45 hospitals that were delivered to ED by EMS. Patients were grouped according to whether treatment with IV NTG was started by EMS before ED admission (preED-NTG), during the ED stay (ED-NTG) or were untreated with IV NTG (no-NTG, control group). In-hospital, 30-day and 365-day all-cause mortality, prolonged hospitalization (>7 days) and 90-day post-discharge combined adverse events (ED revisit, hospitalization or death) were compared in EMS-NTG and ED-NTG respect to control group.Results: We included 8424 patients: preED-NTG = 292 (3.5%), ED-NTG = 1159 (13.8%) and no-NTG = 6973 (82.7%). preED-NTG group had the most severely decompensated cases of AHF (p < 0.001) but it had lower in-hospital (OR = 0.724, 95%CI = 0.459-1.114), 30-day (HR = 0.818, 0.576-1.163) and 365-day mortality (HR = 0.692, 0.551-0.869) and 90-day post-discharge events (HR = 0.795, 0.643-0.984) than control group. ED-NTG group had mortalities similar to control group (in-hospital: OR = 1.164, 0.936-1.448; 30-day: HR = 0.980, 0.819-1.174; 365-day: HR = 0.929, 0.830-1.039) but significantly decreased 90-day post-discharge events (HR = 0.870, 0.780-0.970). Prolonged hospitalization rate did not differ among groups. Five different analyses confirmed these findings.Conclusions: Early prehospital IV NTG administration was associated with lower mortality and post-discharge events, while IV NTG initiated in ED only improved post-discharge event rate. Further studies are needed to assess the role of early prehospital administration of IV NTG to patients with AHF.
Background and objective: Although recommended for the treatment of acute heart failure (AHF), the use of intravenous (IV) nitroglycerin (NTG) is supported by scarce and contradicting evidence. In ...the current analysis, we have assessed the impact of IV NTG administration by EMS or in emergency department (ED) on outcomes of AHF patients.Methods: We analyze AHF patients included by 45 hospitals that were delivered to ED by EMS. Patients were grouped according to whether treatment with IV NTG was started by EMS before ED admission (preED-NTG), during the ED stay (ED-NTG) or were untreated with IV NTG (no-NTG, control group). In-hospital, 30-day and 365-day all-cause mortality, prolonged hospitalization (>7 days) and 90-day post-discharge combined adverse events (ED revisit, hospitalization or death) were compared in EMS-NTG and ED-NTG respect to control group.Results: We included 8424 patients: preED-NTG = 292 (3.5%), ED-NTG = 1159 (13.8%) and no-NTG = 6973 (82.7%). preED-NTG group had the most severely decompensated cases of AHF (p < 0.001) but it had lower in-hospital (OR = 0.724, 95%CI = 0.459-1.114), 30-day (HR = 0.818, 0.576-1.163) and 365-day mortality (HR = 0.692, 0.551-0.869) and 90-day post-discharge events (HR = 0.795, 0.643-0.984) than control group. ED-NTG group had mortalities similar to control group (in-hospital: OR = 1.164, 0.936-1.448; 30-day: HR = 0.980, 0.819-1.174; 365-day: HR = 0.929, 0.830-1.039) but significantly decreased 90-day post-discharge events (HR = 0.870, 0.780-0.970). Prolonged hospitalization rate did not differ among groups. Five different analyses confirmed these findings.Conclusions: Early prehospital IV NTG administration was associated with lower mortality and post-discharge events, while IV NTG initiated in ED only improved post-discharge event rate. Further studies are needed to assess the role of early prehospital administration of IV NTG to patients with AHF.
To analyze whether the high levels of air pollutants are related to a greater severity of decompensated heart failure (HF).
Patients diagnosed with decompensated HF in the emergency department of 4 ...hospitals in Barcelona and 3 in Madrid were included. Clinical data (age, sex, comorbidities, baseline functional status), atmospheric (temperature, atmospheric pressure) and pollutant data (SO
, NO
, CO, O
, PM
, PM
) were collected in the city on the day of emergency care. The severity of decompensation was estimated using 7-day mortality (primary indicator) and the need for hospitalization, in-hospital mortality, and prolonged hospitalization (secondary indicators). The association adjusted for clinical, atmospheric and city data between pollutant concentration and severity was investigated using linear regression (linearity assumption) and restricted cubic spline curves (no linearity assumption).
A total of 5292 decompensations were included, with a median age of 83 years (IQR=76-88) and 56% women. The medians (IQR) of the daily pollutant averages were: SO
=2.5μg/m
(1.4-7.0), NO
=43μg/m
(34-57), CO=0.48mg/m
(0.35-0.63), O
=35μg/m
(25-48), PM
=22μg/m
(15-31) and PM
=12μg/m
(8-17). Mortality at 7 days was 3.9%, and hospitalization, in-hospital mortality, and prolonged hospitalization were 78.9, 6.9, and 47.5%, respectively. SO
was the only pollutant that showed a linear association with the severity of decompensation, since each unit of increase implied an OR for the need for hospitalization of 1.04 (95% CI 1.01-1.08). The restricted cubic spline curves study also did not show clear associations between pollutants and severity, except for SO
and hospitalization, with OR of 1.55 (95% CI 1.01-2.36) and 2.71 (95% CI 1.13-6.49) for concentrations of 15 and 24μg/m
, respectively, in relation to a reference concentration of 5μg/m
.
Exposure to ambient air pollutants, in a medium to low concentration range, is generally not related to the severity of HF decompensations, and only SO
may be associated with an increased need for hospitalization.
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