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.
Abstract
Aims
To evaluate the association between chronic treatment with betablockers (BB) and the severity of decompensation and short-term outcomes of patients with acute heart failure (AHF).
...Methods and results
We consecutively included all patients presenting with AHF to 45 Spanish emergency departments (ED) during six different time-periods between 2007 and 2018. Patients were stratified according to whether they were on chronic treatment with BB at the time of ED consultation. Those receiving BB were compared (adjusted odds ratio—OR—with 95% confidence interval—CI—) with those not receiving BB group in terms of in-hospital and 7-day all-cause mortality, need for hospitalization, and prolonged length of stay (≥7 days). Among the 17 923 recruited patients (median age: 80 years; 56% women), 7795 (43%) were on chronic treatment with BB. Based on the MEESSI-AHF risk score, those on BB were at lower risk. In-hospital mortality was observed in 1310 patients (7.4%), 7-day mortality in 765 (4.3%), need for hospitalization in 13 428 (75.0%), and prolonged length of stay (43.3%). After adjustment for confounding, those on chronic BB were at lower risk for in-hospital all-cause mortality (OR = 0.85, 95% CI = 0.79–0.92, P < 0.001); 7-day all-cause mortality (OR = 0.77, 95% CI = 0.70–0.85, P < 0.001); need for hospitalization (OR = 0.89, 95% CI = 0.85–0.94, P < 0.001); prolonged length of stay (OR = 0.90, 95% CI = 0.86–0.94, P < 0.001). A propensity matching approach yielded consistent findings.
Conclusion
In patients presenting to ED with AHF, those on BB had better short-term outcomes than those not receiving BB.
To assess the effects of non-invasive ventilation (NIV) in emergency department (ED) patients with acute heart failure (AHF) on short term outcomes.
Patients from the EAHFE Registry (a multicenter, ...observational, multipurpose, cohort-designed database including consecutive AHF patients in 41 Spanish EDs) were grouped based on NIV treatment (NIV+ and NIV–groups). Using propensity score (PS) methodology, we identified two subgroups of patients matched by 38 covariates and compared regarding 30-day survival (primary outcome). Interaction was investigated for age, sex, ischemic cardiomyopathy, chronic obstructive pulmonary disease, AHF precipitated by an acute coronary syndrome (ACS), AHF classified as hypertensive or acute pulmonary edema (APE), and systolic blood pressure (SBP). Secondary outcomes were intensive care unit (ICU) admission; mechanical ventilation; in-hospital, 3-day and 7-day mortality; and prolonged hospitalization (>7 days).
Of 11,152 patients from the EAHFE (age (SD): 80 (10) years; 55.5% women), 718 (6.4%) were NIV+ and had a higher 30-day mortality (HR = 2.229; 95%CI = 1.861–2.670) (p < 0.001). PS matching provided 2 groups of 490 patients each with no significant differences in 30-day mortality (HR = 1.239; 95%CI = 0.905–1.696) (p = 0.182). Interaction analysis suggested a worse effect of NIV on elderly patients (>85 years, p < 0.001), AHF associated with ACS (p = 0.045), and SBP < 100 mmHg (p < 0.001). No significant differences were found in the secondary endpoints except for more prolonged hospitalizations in NIV+ patients (OR = 1.445; 95%CI = 1.122–1.862) (p = 0.004).
The use of NIV to treat AHF in ED is not associated with improved mortality outcomes and should be cautious in old patients and those with ACS and hypotension.
•NIV is a treatment commonly used for treatment in Acute Pulmonary Oedema.•The use of NIV is associated with an unclear improvement in mortality.•NIV-AHF study concludes that NIV is not associated with improved mortality.•NIV must be used with caution in old patients, patients with hypotension and ACS.
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.
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.
Three thousand nine hundred and fifty-eight patients were included: 580 HFmrEF (14.6%), 929 HFrEF (23.5%) and 2449 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=0.933) and lower than the HFrEF group (HR 0.800; 95% CI 0.635–1.008; p=0.058), 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=0.821) or HFrEF group (HRa 0.924; 95% CI 0.720–1.186; p=0.535). 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.
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.
Comparar la evolución tras una descompensación aguda de los pacientes con insuficiencia cardiaca (ICA) con fracción de eyección del ventrículo izquierdo intermedia (ICFEi) respecto a los que la tienen deprimida (ICFEd) o conservada (ICFEc).
Estudio observacional prospectivo, de inclusión consecutiva de pacientes diagnosticados de ICA en 41 servicios de urgencias. Se formaron 3 grupos: ICFEd<40%, ICFEi 40-49% e ICFEc≥50%. Se recogieron 38 variables independientes y se comparó la mortalidad por cualquier causa al año en el grupo de ICFEi, bruta y ajustada, respecto a los de ICFEd e ICFEc. Se estratificó este análisis según el destino del paciente tras la asistencia urgente.
Se incluyeron 3.958 pacientes: 580 ICFEi (14.6%), 929 ICFEd (23.5%) y 2.449 ICFEc (61.9%). La mortalidad global al año fue del 28.5%. La mortalidad bruta en la ICFEi fue similar a la ICFEc (HR 1,009; IC 95% 0,819-1,243; p=0,933) y menor que la ICFEd (HR 0,800; IC 95% 0,635-1,008; p=0,058), pero tras el ajuste por las características basales discordantes entre grupos, la mortalidad de la ICFEi no difirió de la ICFEc (HRa 1,025; IC 95% 0,825-1,275; p=0,821) ni de la ICFEd (HRa 0,924; IC 95% 0,720-1,186; p=0,535). El análisis estratificado según el destino del ingreso o alta directa desde Urgencias tampoco mostró diferencias significativas entre la ICFEi y los otros 2 grupos.
La mortalidad a un año tras un episodio de ICA en pacientes con ICFEi no difiere de la de los pacientes con ICFEc o ICFEd, ni globalmente ni para ninguno de los principales destinos tras la asistencia en Urgencias.
The study of allelopathic activity has been aim of research that evaluates mainly species used in green fertilization. Raphanus sativus L. stands out among these species, because it shows high ...capacity for nutrient recycling, specially nitrogen and phosphorus, what makes it an advantageous cover plant in crop rotation systems. Considering the exposed, the present study had as objective the evaluation of the allelopathic and phytotoxic potentials of different concentrations of the R. sativus leaves ethanolic extract by mean of seeds germination analyses and development of lettuce seedlings, evaluating the phytotoxicity by determination of the mitotic index of lettuce root cells, realizing the phytochemical profile and investigating the antioxidant activity. It was possible to verify that the R. sativus extract interferes in the germination index, decreasing the germinability (5 mg.mL-1 = 9.84%; 10 mg.mL-1 = 11.91% and 20 mg.mL-1= 57.51%). In the lettuce seedlings growth, the extract of this species affected the roots and hypocotyls growth. It was possible to observe phenols and total flavonoids in the extract for the concentration of 1000μg.mL-1(161mg and 83.57 mg, respectively). It was also observed, higher antioxidant activity for the concentration of 1000 μg.mL-1 (89.76%). In the phytotoxicity assay was observed a dose dependent effect in the mitotic index and in the cellular events during cellular division. In this study it was possible to conclude that this species has allelochemical compounds which are able to interfere directly on the stabilization and development of other species.
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.
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