Search

Resumen Antecedentes El aumento de la presion intraabdominal (PIA) se ha correlacionado con elevacion de la creatinina en pacientes con insuficiencia cardiaca con fraccion de eyeccion ventricular izquierda gravemente deprimida (ICFEr). Sin embargo, dicha variable no se ha explorado en pacientes mas estables o con insuficiencia cardiaca y fraccion de eyeccion preservada (ICFEp). Pacientes y metodo Estudio observacional, prospectivo y descriptivo consistente en la medicion de la PIA en pacientes ingresados por insuficiencia cardiaca (IC) descompensada. Se estratifico la muestra segun la fraccion de eyeccion ventricular izquierda (FEVI) con un punto de corte del 50%, con el objetivo de analizar la PIA, asi como las caracteristicas basales y el grado de congestion empleando la ecografia clinica y la impedanciometria. Resultados Se incluyeron un total de 56 pacientes, 22 con ICFEr y 34 con ICFEp. Los pacientes con ICFEr presentaron una mayor prevalencia de cardiopatia isquemica (11 vs. 6; p = 0,010) y EPOC/asma (6 vs. 2%; p = 0,025). La PIA fue mas alta en pacientes con ICFEr (17,2 mmHg vs. 13,3 mmHg; p = 0,004), sin diferencias en la funcion renal al ingreso segun la FEVI (CKD-EPI creatinina) (ICFEr 55,0 mL/min/1,73 m2 [32,6-83,6] vs. ICFEp 55,0 mL/min/1,73 m2 [44,0-74,9]; p = 0,485). Los pacientes con ICFEr presentaron un perfil mas congestivo estimado por ecografia (colapso de la cava inferior [26% vs. 50%; p = 0,001]), impedanciometria (agua corporal total al ingreso: 46 L vs. 41 L; p = 0,052 y a las 72 horas 50,2 L vs. 39,1 L; p = 0,038) y concentracion de CA125 (68 U/mL vs. 39 U/mL; p = 0,037). Conclusiones Durante los episodios de descompensacion los pacientes con ICFEr tienen mayor elevacion de la PIA y un mayor grado de congestion sistemica.

Resumen Fundamento El examen fisico presenta una rentabilidad limitada en la estimacion de la congestion venosa sistemica y en la prediccion de la mortalidad de los pacientes con insuficiencia cardiaca. Hemos evaluado la utilidad del fragmento amino terminal del peptido natriuretico cerebral (NT-proBNP), del antigeno de cancer 125 (CA125), los hallazgos de la ecografia pulmonar, la estimacion del volumen plasmatico relativo (VPr) y el cociente urea/creatinina, como parametros subrogados de congestion venosa y predictores de mortalidad. Material y metodos Estudio retrospectivo de 203 pacientes ingresados por insuficiencia cardiaca aguda en el servicio de medicina interna de un hospital terciario, con seguimiento monografico en consultas externas entre los anos 2013 y 2018. Los datos clinicos se recogieron de los registros hospitalarios. Las intervenciones terapeuticas se guiaron por el criterio clinico del medico responsable de cada paciente. El desenlace principal fue mortalidad general tras un ano de seguimiento. Resultados La edad media de los pacientes fue 78,8 anos, 47% eran varones. Un total de 130 (65%) pacientes presentaban insuficiencia cardiaca cronica, 51 (26,2%) pacientes se encontraban en clase III-IV de la New York Heart Association y 116 (60%) pacientes presentaban fraccion de eyeccion de ventriculo izquierdo preservada. Durante el seguimiento fallecieron 42 (22%) pacientes. Los valores de NT-proBNP ≥ 3.804 pg/mL (HR 2,78 [1,27-6,08]; p = 0,010) y el VPr ≥ –4,54% (HR 2,74 [1,18-6,38]; p = 0,019) fueron predictores independientes de mortalidad general tras un ano de seguimiento. Conclusiones El NT-proBNP y el VPr son predictores independientes de mortalidad a un ano entre los pacientes ingresados por insuficiencia cardiaca descompensada.

Resumen Antecedentes El diagnostico de dano renal agudo (DRA) durante los episodios de insuficiencia cardiaca aguda (ICA) sigue siendo un desafio. Analizamos la incidencia y el pronostico del DRA y la importancia de los aumentos pequenos de creatinina durante los episodios de ICA y tras su estabilizacion. Pacientes y metodos Se incluyeron prospectivamente pacientes ingresados por ICA. La creatinina se midio al ingreso, a las 48 h de este y 24 h antes del alta. El DRA se diagnostico cuando la creatinina aumento ≥ 50% en 7 dias (criterio RIFLE) o ≥ 0,3 mg/dL en 48 h (criterio AKIN) durante el ingreso. Se evaluaron los cambios entre la creatinina basal (medida dentro de los 3 meses previos al ingreso) y un mes despues del alta, para buscar el deterioro residual de la funcion renal y su importancia. Resultados Se incluyeron 204 pacientes. La incidencia de DRA fue del 28,4% (n = 58). La creatinina alcanzo su maxima concentracion al quinto dia en pacientes con DRA vs. no DRA (1,9 vs. 1,1 mg/dL; p Conclusiones La presencia de DRA es un potente predictor de mortalidad en las ICA. Pequenos incrementos en las concentraciones de creatinina, por debajo del umbral aceptado para la definicion de DRA, tienen un pronostico significativo.

Resumen Introduccion A pesar de los avances en el diagnostico y el tratamiento, la insuficiencia cardiaca (IC) sigue teniendo una alta morbimortalidad. El tratamiento de las comorbilidades y la educacion sanitaria se han demostrado eficaces, asi como la atencion multidisciplinar, en unidades especializadas, aunque ello implica un esfuerzo organizativo y estructural no siempre disponible. Presentamos los resultados de una consulta ambulatoria simple, centrada en la atencion monografica a la IC. Pacientes y metodos La consulta incluyo a pacientes dados de alta tras una hospitalizacion (ingreso indice) por descompensacion de IC en el servicio de Medicina Interna. El seguimiento se realizo por internistas con especial dedicacion (no exclusiva) en IC y una enfermera con dedicacion compartida. El seguimiento consistio en visitas fijas 1, 3, 6 y 12 meses tras el alta, mas visitas a demanda en caso de necesidad. Resultados Se incluyo a 250 pacientes con un seguimiento minimo de un ano. La disminucion de los ingresos y las visitas a Urgencias por IC fue del 56 y el 61% (p Conclusion Un modelo sencillo basado en la atencion monografica a la IC es eficaz en la reduccion de reingresos y la optimizacion del tratamiento. La carencia de recursos asistenciales no deberia suponer un obstaculo para una atencion monografica a pacientes con IC.

Introducción: El empeoramiento de la función renal es un índice de mal pronóstico en pacientes con insuficiencia cardiaca aguda (ICA). El cociente urea/creatinina (U/C) podría tener significación pronóstica en la ICA. Material y métodos: Estudio observacional, prospectivo, cuyo objetivo fue analizar el valor pronóstico del cociente U/C, determinado en las primeras 24-48 h del ingreso, en pacientes hospitalizados por ICA, así como su relación con el filtrado glomerular estimado (FGe) y el daño renal agudo (DRA). Resultados: Se incluyeron un total de 204 pacientes, con edad media de 79, 3 años. La mediana de FGe fue 55 ml/min/1, 73m2. En el análisis multivariante, un cociente U/C > 50 se asoció con una mayor probabilidad de DRA durante el ingreso (36, 5% vs. 21, 9%) y mortalidad por cualquier causa (odds ratio [OR] 2, 75) y por IC (OR 3, 50) durante el seguimiento. La elevación del cociente U/C fue pronóstica solo en los pacientes con FGe normales (mortalidad 4, 4% vs. 22%; p=0, 01). La combinación del cociente U/C con el FGe tuvo mayor capacidad predictiva de DRA que cada uno de ellos por separado (área bajo la curva 0, 718, intervalo de confianza al 95% 0, 643-0, 793; p 50 predice mortalidad a largo plazo en pacientes con FGe normal, y combinado con el FGe, mejora la identificación del riesgo de DRA, en pacientes ingresados por ICA. Dado lo simple de este biomarcador, sugerimos su uso sistemático en la clínica diaria. Background: Worsening renal function is associated with an adverse prognosis for patients with acute heart failure (AHF). Urea-creatinine ratio (U:C ratio) might be useful for measuring renal function and could help stratify patients with AHF. Material and methods: An observational and prospective study was conducted to analyse the prognostic value of the U:C ratio, measured during the first 24-28 hours of admission, for patients hospitalised for decompensated Heart failure, and its relationship with estimated glomerular filtration rate (eGFR) and acute kidney injury (AKI). Results: The study included 204 patients, with a mean age of 79.3 years, and a median eGFR of 55 mL/min/1.73m2. In the multivariate analysis, an U:C ratio above the median (50) was related to the development of AKI (36.5% vs. 21.9%) and to increased mortality, both overall (OR 2.75) and by HF (OR 3.50) in long term. In combination with eGFR, the U:C ratio showed prognostic value in patients with normal eGFR (mortality of 4.4% for an U:C ratio = 50 vs. 22% for U:C ratio > 50; p=0.01), as well as a better predictive capacity for AKI than each of them separately (AUC, 0.718; 95% CI 0.643-0.793; p>.000). Conclusions: An U:C ratio > 50 is a predictor of increased long-term mortality for patients hospitalised for decompensated HF and with normal eGFR. Given the simplicity of this biomarker, its use in clinical practice should be more systematic.

Resumen Objetivo Determinar la asociacion entre la puntuacion de la escala de Norton (que valora el riesgo de padecer ulceras por presion) y la mortalidad a corto, medio y largo plazo en los pacientes hospitalizados en Medicina Interna. Pacientes y metodos Estudio de cohortes prospectivo, unicentrico, de pacientes ingresados en los meses de octubre de 2010, y enero, mayo y octubre de 2011. Se recogieron la edad, sexo, indice de Barthel, escala de Norton, presencia de ulceras por presion, categoria diagnostica mayor, estancia hospitalaria y peso del grupo relacionado de diagnostico. Se dividio a los pacientes segun las categorias de riesgo de la escala de Norton. El seguimiento fue de 3 anos. Resultados Se incluyeron 624 pacientes con una edad mediana (rango intercuartilico) de 79 (17) anos y una puntuacion mediana en la escala de Norton de 16 (7). Durante el ingreso fallecieron 74 (11,9%) pacientes, a los 6 meses 176 (28,2%), al ano 212 (34,0%), y a los 3 anos 296 (47,4%). La mortalidad fue mayor en las categorias de mas riesgo en la escala de Norton. La puntuacion en la escala de Norton se asocio de forma independiente con la mortalidad a los 6 meses (p Conclusiones La escala de Norton es util para predecir el pronostico a corto, medio y largo plazo en pacientes ingresados en Medicina Interna.

Systemic venous congestion is present in most cases of acute decompensated heart failure (ADHF). An accurate assessment of congestion is key to improve outcomes and avoid residual congestion. Physical examination has limitations for grading congestion; hence, new methods for assessing congestion have been developed. A multimodal approach, combining surrogate markers of congestion, may be a suitable strategy. The aim of this study was to compare the prognostic value of Amino terminal fragment of pro-Brain Natriuretic Peptide (NT-proBNP), Carbohydrate cancer antigen 125 (CA125), lung ultrasound, relative plasma volume status (rPVS) and urea/Creatinine ratio (U/C ratio), to predict one-year all-cause mortality.Retrospective, observational analysis of 203 patients admitted at the Internal Medicine ward of a tertiary teaching Hospital due to ADHF, followed in monographic outclinic. Clinical data were obtained from hospital records. Therapeutic interventions followed exclusively the clinical judgement of the physician responsible for each patient.203 patients were included for the final analysis between 2013 and 2018. Chronic heart failure (CHF) was present in 130 patients (65%); 51 patients (26.2%) had class III-IV of New York Heart Association (NYHA); 116 patients (60%) had HF with preserved ejection fraction (HFpEF). Forty-two patients (21.6%) died during follow-up. NT-proBNP≥3804 pg/mL (HR 2.78 [1.27 - 6.08]; P=.010) and rPVS≥-4.54% (HR 2.74 [1.18 - 6.38]; P=.019), were independent predictors for 1-year all-cause mortality on top of CA125, lung ultrasound and U/C ratio.NT-proBNP and rPVS are independent predictors of one-year mortality among patients admitted for ADHF.

Diagnosis of acute kidney injury (AKI) during acute decompensations of heart failure (ADHF) remain challenging. We analysed the incidence and prognosis of AKI, and the significance of small increases of creatinine, during ADHF and after stabilization.Patients admitted for ADHF were prospectively included. Creatinine was measured at admission, 48h thereafter and 24h before discharge. AKI was diagnosed when creatinine increased≥50% in 7 days (RIFLE criteria) or≥0.3mg/dL in 48h (AKIN criteria) during admission. Changes between baseline creatinine (measured within 3-month before admission) and one month after discharge were assessed, to seek for residual impairment of renal function and its significance.Two hundred and four patients were included. Incidence of AKI was 28.4% (n=58). Creatinine peaked by day 5 in patients with AKI vs. non-AKI (1.9 vs. 1.1mg/dL; P.000) and remained significantly higher among patients with AKI 3 months after discharge (increase of 20 vs. 4%; P=.013). Twelve-months mortality was associated with increases in cystatin C, NT-proBNP and AKI (15.5 vs. 44.8%, P.000), being the latter the most powerful independent predictor of death ?Exp(B)=5.34; P=.009?. Minor increases in creatinine (20% or 0.2mg/dL) during admission associated lesser 12-months survival (P=.033 and P=.019, respectively). Increases in creatinine≥10% between baseline and one month after discharge are associated with higher mortality (12.6 vs. 22.5%, P=.044).AKI is a strong predictor of mortality after ADHF. Minor increments in creatinine concentrations, below the accepted threshold for AKI definition, are prognostically meaningful.

Despite advances in the diagnosis and treatment of heart failure (HF), the condition still has high morbidity and mortality. Health education and the treatment of comorbidities have been shown to be effective, as has multidisciplinary care in specialised units, although this involves organisational and structural efforts that are not always feasible. We present the results of a simple outpatient consultation, focused on the specialised care of HF.The consultation included patients discharged after hospitalisation (index hospitalisation) for decompensated HF from an internal medicine department. The follow-up was conducted by internists especially dedicated (not exclusively) to HF and a nurse partially dedicated to HF. The follow-up consisted of fixed visits 1, 3, 6 and 12 months after the discharge, with more visits on demand if needed.A total of 250 patients were included with a minimum follow-up of 1 year. The reduction in hospitalisations and emergency department visits was 56% and 61% (P.05), respectively, for HF and 46% and 40% (P.05), respectively, for any cause. Treatment optimisation was also achieved, with a significant increase in the evidence-based drug prescription rate and the reduction of other drugs, such as calcium antagonists.A simple model based on a specialised care consultation for HF is effective in reducing readmissions and optimising the treatment. The lack of healthcare resources should not be an obstacle for specialised care for patients with HF.

Resumen La prevalencia de insuficiencia cardiaca aumenta con la edad y se acompana de otras enfermedades, englobadas en un «fenotipo cardiometabolico». Su interrelacion modifica la evolucion y tratamiento que cada una tendria aisladamente. El paciente con insuficiencia cardiaca y comorbilidad es un enfermo fragil y complejo. Precisa una valoracion integral, no solo biomedica, que incluya aspectos funcionales, cognitivos, afectivos y psicosociales. El tratamiento global, no recogido en las guias de practica clinica, ha de adaptarse a todas y cada unas de las comorbilidades. Debe evitarse, en lo posible, la polifarmacia, por sus interacciones y la disminucion de adherencia. Es necesario optimizar y adaptar el tratamiento a la fase evolutiva de la enfermedad y las necesidades especificas de cada paciente. La complejidad del proceso asistencial del paciente con insuficiencia cardiaca y comorbilidades exige la coordinacion de los proveedores de salud, el apoyo familiar y del entorno.

An increase in intraabdominal pressure (IAP) during acute heart failure, seems to be directly related to worsening renal function, which leads to worse clinical outcomes. We aimed to analyze the relationship between IAP and determinants of renal function during admission for acute decompensation of heart failure (ADHF) in a conventional Internal Medicine Ward.Descriptive and prospective study. Patients admitted for ADHF with an estimated glomerular filtration rate 30mL/min/1.73 mWe hereby report the results of an interim analysis of the first 28 patients included. Patients were divided in 2groups according to the median of IAP measured during the first 24h after admission for ADHF, namely high IAP (IAP15mmHg) and low (IAP15mmHg). Fourteen patients were included in each group. No differences were found in baseline clinical characteristics, comorbidities or treatment between both groups. Patients with IAP above 15mmHg, showed a significant lower baseline estimated glomerular filtration rate (70.7 vs. 44.4mL/min/1.73 mThe increase in IAP seems to be a frequent finding in patients admitted for ADHF. Patients share similar clinical profile irrespective of IAP, although the increase in IAP is associated with a significant baseline impairment of renal function.

To determine the association between the Norton scale score (which assesses the risk of pressure ulcers) and mortality in the short, medium and long term in patients hospitalised in Internal Medicine departments.A prospective, single-centre cohort study was conducted on patients hospitalised in the months of October 2010 and January, May and October 2011. Data was collected on age, sex, Barthel index, Norton scale, presence of pressure ulcers, major diagnostic category, hospital stay and weight of the diagnosis-related group. The patients were divided according to the risk categories of the Norton scale. The follow-up was 3 years.The study included 624 patients with a median age (interquartile range) of 79 (17) years and a median Norton scale score of 16 (7). During hospitalisation, 74 (11.9%) patients died, 176 (28.2%) died at 6 months, 212 (34.0%) died at 1 year, and 296 (47.4%) died at 3 years. Mortality was greater in the higher risk categories of the Norton scale. The Norton score was independently associated with mortality at 6 months (p.001), at 1 year (p=.005), and at 3 years (p=.002). The areas under the curve of the Norton scale were 0.746 (95% CI 0.686-0.806), 0.735 (95% CI 0.691-0.780) and 0.751 (95% CI 0.713-0.789), respectively (p.001).The Norton scale is useful for predicting the prognosis in the short, medium and long term in patients hospitalized in internal medicine departments.

Worsening renal function is associated with an adverse prognosis for patients with acute heart failure (AHF). Urea-creatinine ratio (U:C ratio) might be useful for measuring renal function and could help stratify patients with AHF.An observational and prospective study was conducted to analyse the prognostic value of the U:C ratio, measured during the first 24-28 hours of admission, for patients hospitalised for decompensated Heart failure, and its relationship with estimated glomerular filtration rate (eGFR) and acute kidney injury (AKI).The study included 204 patients, with a mean age of 79.3 years, and a median eGFR of 55 mL/min/1.73mAn U:C ratio50 is a predictor of increased long-term mortality for patients hospitalised for decompensated HF and with normal eGFR. Given the simplicity of this biomarker, its use in clinical practice should be more systematic.

Resumen Objetivos Valorar la utilidad de la medicion del diametro y colapso de la vena cava inferior (VCI) en la insuficiencia cardiaca aguda (ICA), su relacion con el pronostico y con biomarcadores sericos de congestion. Pacientes y metodos Estudio prospectivo observacional que incluyo 85 pacientes con ICA, clasificandolos en 4 grupos segun el diametro de la VCI (≤ o > 20 mm) y su colapso inspiratorio ( Resultados El 24,7% de los pacientes presento una VCI no dilatada y colapso ≥50% (grupo 1); el 20% VCI no dilatada y colapso Conclusiones La dilatacion y la ausencia de colapso inspiratorio de la VCI es frecuente en el contexto de la ICA. La ausencia de colapso inspiratorio de la VCI durante la fase de descompensacion identifica un subgrupo de pacientes con peor pronostico a los 6 meses.

The prevalence of heart failure increases with age and is accompanied by other diseases, which are encompassed within a «cardiometabolic phenotype». Their interrelation changes the evolution and treatment that each disease would have in isolation. Patients with heart failure and comorbidity are frail and complex. They require a comprehensive assessment (not just biomedical), which includes functional, cognitive, affective and psychosocial aspects. The overall treatment, which is not covered in the clinical practice guidelines, should adapt to each and every one of the comorbidities. Polypharmacy should be avoided as much as possible, due to its interactions and reduced adherence. Treatment needs to be optimised and adapted to the evolutionary phase of the disease and the specific needs of each patient. The complexity of the care process for patients with heart failure and comorbidities requires the coordination of healthcare providers and support from family and others involved in the patient's care.

To assess the utility of measuring the diameter and collapse of the inferior vena cava (IVC) in acute heart failure (AHF), its relationship with the prognosis and serum biomarkers of congestion.An observational prospective study was conducted that included 85 patients with AHF, classifying them into 4 groups according to IVC diameter (≤ or20mm) and inspiratory collapse (or ≥50%) at admission. The endpoints were mortality due to HF and the combined event of mortality and readmission for HF at 180 days.Some 24.7% of the patients had an undilated IVC and ≥50% collapse (group 1); 20% had an undilated IVC and50% collapse (group 2), 5.9% had a dilated IVC and ≥50% collapse (group 3); and 49.4% had a dilated IVC and50% collapse (group 4). The lack of inspiratory collapse but not IVC dilation was related to higher concentrations of urea (P=.007), creatinine (P=.004), uric acid (P=.008), NT-proBNP (P=.009) and CA125 (P=.005). Survival free of the combined event at 180 days was lower in those patients with no IVC collapse.Dilation and the absence of the inspiratory collapse of the IVC are common in the context of AHF. The lack of inspiratory collapse of the IVC during the decompensation phase identifies a subgroup of patients with poorer prognosis at 6 months.