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Aims: Benzodiazepines have been used as safe anxiolytic drugs for decades and some authors have suggested they could be an alternative for morphine for treating acute cardiogenic pulmonary oedema (ACPE). We compared the efficacy and safety of midazolam and morphine in patients with ACPE.Methods and Results: A randomized, multicentre, open-label, blinded endpoint clinical trial was performed in seven Spanish emergency departments (EDs). Patients >18 years old clinically diagnosed with ACPE and with dyspnoea and anxiety were randomized (1:1) at ED arrival to receive either intravenous midazolam or morphine. Efficacy was assessed by in-hospital all-cause mortality (primary endpoint). Safety was assessed through serious adverse event (SAE) reporting, and the composite endpoint included 30-day mortality and SAE. Analyses were made on an intention-to-treat basis. The trial was stopped early after a planned interim analysis by the safety monitoring committee. At that time, 111 patients had been randomized: 55 to midazolam and 56 to morphine. There were no significant differences in the primary endpoint (in-hospital mortality for midazolam vs. morphine 12.7% vs. 17.9%; risk ratio[RR] 0.71, 95% confidence interval [CI] 0.29-1.74; p = 0.60). SAE were less common with midazolam versus morphine (18.2% vs. 42.9%; RR 0.42, 95% CI 0.22-0.80; p = 0.007), as were the composite endpoint (23.6% vs. 44.6%; RR 0.53, 95% CI 0.30-0.92; p = 0.03).Conclusion: Although the number of patients was too small to draw final conclusions and there were no significant differences in mortality between midazolam and morphine, a significantly higher rate of SAEs was found in the morphine group. [ABSTRACT FROM AUTHOR]

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]

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To study the outcomes of patients with acute heart failure (AHF) presenting renal dysfunction (RD) or hyperkalaemia (Hk) alone or in combination. We analysed the data of the EAHFE registry, a multicentre, non interventionist cohort with prospective follow-up of patients with AHF. Four groups were defined based on the presence or not of RD or Hk alone or in combination. The primary endpoint was 30-day all-cause mortality. A total of 11,935 of the 13,791 patients included in the EAHFE registry were analysed. Of these, 5088 (42.6%) did not have RD or Hk (NoRD-NoHk), 150 (1.3%) had no RD but had Hk (NoRD-Hk), 6012 (50.4%) had RD but not Hk (RD-NoHk) and 685 (5.7%) had both RD and Hk (RD-Hk). Thirty-day all-cause mortality was greatest in the RD-Hk group with an adjusted Hazard Ratio (HR) of 2.44 (confidence interval 95% [CI95%] 1.67–3.55; p < 0.001) and in the RD-NoHk group with an adjusted HR of 1.34 (CI95% 1.04–1.71; p = 0.022). There were no significant differences in in-hospital mortality and reconsultation at 30 days for HF. For the combined endpoint of 30-day all-cause mortality the adjusted HR was 1.33 (CI95% 1.04–1.70); (p = 0.021) for the RD-Hk group. The association of 30-day all-cause mortality with the presence of RD and Hk in patients presenting AHF at admission is greater than in those without this combination. • The presence of renal dysfunction and hyperkalemia is common in patients with acute heart failure. • The combination of both is associated with more 30-day all-cause mortality. • This combination was not related to more in-hospital all-cause mortality. • This combination was not related to more 30-day ED reconsultation for HF. [ABSTRACT FROM AUTHOR]

Objective A multimarker strategy may help determine the prognosis of patients with acute heart failure (AHF). The aim of this study was to evaluate the capacity of mid-regional pro-adrenomedullin (MRproADM), copeptin and interleukin-6 (IL-6) combined with conventional clinical and biochemical markers to predict the 30-day mortality of patients with AHF. Methods We performed an observational, multicenter, prospective study of patients attended in the emergency department (ED) for AHF. We collected clinical and biochemical data as well as comorbidities and biomarker values. The endpoint variable was mortality at 7, 14, 30, 90 and 180 days. The clinical model included: gender, age, blood pressure values, hemoglobin, sodium < 135 mmol/L and estimated glomerular filtration < 60 mL/min/1.73 m2. We made receiver operating curves (ROC) curves, and areas under the curve (AUC) and survival analysis for each model and calculated the hazard ratio (HR) and its 95% confidence interval. Results A total of 547 individuals were included: 55.6% were women with a mean age of 79.9 (9.5) years. Copeptin alone showed greater discriminatory power for 30-mortality [AUC 0.70 (0.62–0.78)]. The AUC for 30-day mortality of the clinical model plus copeptin and NTproBNP was 0.75 (0.67–0.83), being better than the clinical model alone with 0.67 (0.58–0.76; p = 0.19). The discriminatory power of the different biomarkers alone, in combination or together with the clinical model decreased over time. Conclusions The combination of a clinical model with copeptin and NTproBNP, which are available in the ED, is able to prognose early mortality in patients with an episode of AHF. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: To determine the characteristics and prognostic factors of early death in the very elderly with acute heart failure (AHF). Patients and methods: We performed a prospective, observational study of AHF patients attended in Emergency Departments (ED), analyzing 45 variables collected in ED and studying troponin, natriuretic peptides and echocardiographies, not always available in the ED. The patients were divided into 2 groups: nonagenarian (age ≥90years) and controls (age <90years). The study variables were mortality and death or reconsultation to the ED for AHF within 30days after inclusion. Results: We included 4700 patients (nonagenarians: 520, 11.1%). The 30-day mortality was 21.5% and 8.7% (p<0.01), respectively with a combined event of 33.3% and 26.7% (p=0.001). Age ≥90years was maintained in all the models associated with death (OR: 1.94, CI 95%: 1.40–2.70). In nonagenarians, chronic kidney insufficiency (OR: 2.07, CI95%: 1.16–3.69), severe functional dependence (OR: 2.18, CI95%; 1.30–3.64) and basal oxygen saturation <90% (OR: 1.97, CI95%: 1.17–3.32) and hyponatremia <135mEq/L (OR: 1.89, CI95%: 1.05–3.42) were predictive variables of mortality. We observed an association between elevated troponin levels and natriuretic peptide values >5180pg/mL and mortality (OR: 4.26, CI95%: 1.83–9.89; and OR: 3.51, CI95%: 1.45–8.48; respectively). Conclusions: The profile of nonagenarians with AHF differs from that of younger patients. Although very advanced age is an independent prognostic factor of mortality, these patients have fewer predictive factors of mortality, being only functional deterioration, basal kidney disease, hyponatremia and respiratory insufficiency on arrival at the ED and probably troponin values and elevated natriuretic peptides. [Copyright &y& Elsevier]