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Objective. To estimate the prevalence of unknown HIV infection in patients who consulted in hospital emergency services (ED) for conditions defined in the SEMES-GESIDA Consensus Document (DC), evaluate the efficiency of its im-plementation and investigate the efficiency of HIV serology determination in other conditions. Methods. Results were reviewed in 10 Catalan EDs for 12 months (July-21-June-22) after implementing CD recommendations: request HIV serology in case of suspected sexually transmitted infection, chemsex, post-exposure prophylaxis (PEP), mononucleosis syndrome, community pneumonia (18-65 y-o) or herpes zoster (18-65 y-o). Other reasons for request were included. Prevalence (%) of global seropositivity and for each circumstance was calculated, with a 95% confidence interval (95%CI). The efficient strategy was considered if the lower limit of the CI95%>0.1%. Results. A total of5,107 HIV serologies were performed: 2,847(56%) in situations specified in CD, and 2,266 (44%) in other 138 circumstances. Forty-eight unknown HIV infections were detected (prevalence=0.94%;95%CI=0.69-1.24). The prevalence was somewhat higher in DC requests (30 cas-es 1.12%) than the rest (18 cases 0.71%; p=0.16). The individualized prevalence of CD reasons ranged between 7.41% (95%CI=0.91-24.3) in chemsex and 0.42% 95%CI=0.14-0.98) in PPE, always efficient except herpes zoster (0.76%; CI95%=0.02-4.18). In other reasons, cases were detected in 12 circumstances, and in four the determination could be efficient: lymphopenia (10%;CI95%=0.25-44.5), fever with polyarthralgia-polyarthritis (7.41%;CI95% =0.91-24.3), behavioral alteration-confusion-encephalopathy (3.45%;95%CI=0.42-11.9) and fever of unknown origin (2.50%;95%CI=0.82-5.74). Conclusion. The determination of HIV serology in HES in the processes defined by DC SEMES-GESIDA is efficient. Some circumstances are identified that could be added to those previously contemplated to increase efficiency.

Current American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) and European Society of Cardiology (ESC) guidelines recommend different strategies to avoid low-yield admissions in patients with syncope.The purpose of this study was to directly compare the safety and efficacy of applying admission criteria of both guidelines to patients presenting with syncope to the emergency department in 2 multicenter studies.The international BASEL IX (BAsel Syncope EvaLuation) study (median age 71 years) and the U.S. SRS (Improving Syncope Risk Stratification in Older Adults) study (median age 72 years) were investigated. Primary endpoints were sensitivity/specificity for the adjudicated diagnosis of cardiac syncope (BASEL IX only) and 30-day major adverse cardiovascular events (30d-MACE).Among 2560 patients in the BASEL IX and 2085 in SRS studies, ACC/AHA/HRS and ESC criteria recommended admission for a comparable number of patients in BASEL IX (27% vs 28%), but ACC/AHA/HRS criteria less often in SRS (19% vs 32%; P.01). Recommendations were discordant in ∼25% of patients. In BASEL IX, sensitivity for cardiac syncope and 30d-MACE among patients without admission criteria was comparable for ACC/AHA/HRS and ESC criteria (64% vs 65%, P = .86; and 67% vs 71%, P = .15, respectively). In SRS, sensitivity for 30d-MACE was lower with ACC/AHA/HRS (54%) vs ESC criteria (88%; P.001). Similarly, specificity for cardiac syncope and 30d-MACE in BASEL IX was comparable for both guidelines, but in SRS the ACC/AHA/HRS guidelines showed a higher specificity for 30d-MACE than the ESC guidelines.ACC/AHA/HRS and ESC guidelines showed disagreement regarding admission for 1 in 4 patients and had only modest sensitivity, all indicating possible opportunities for improvements.

We investigated if the phenotypic classification of acute heart failure (AHF) based on the number of signs/symptoms of congestion and hypoperfusion at emergency department (ED) arrival identifies subgroups in which intravenous (IV) nitroglycerine (NTG) use improves short-term survival.We included consecutive AHF patients diagnosed in 45 Spanish EDs, who were grouped according to phenotype severity. The main outcome was 30-day all-cause death. Propensity scores (PS) for NTG use were generated using variables associated with death. Analysis of interaction was performed in subgroups of patients based on congestion, hypoperfusion, age, sex, coronary artery disease (CAD), left ventricular ejection fraction (LVEF) and SBP.We analyzed 16 437 AHF patients (median = 83 years; women = 56%); 1882 received NTG (11.4%). In the whole cohort, the cumulative 30-day mortality in patients receiving NTG was higher (11.5% vs. 9.6%; unadjusted HR, 1.19; 95% CI, 1.04-1.36), but not in the PS-matched cohorts (1698 pairs of patients; 11.5% vs. 10.5%; HR, 1.10; 95% CI, 0.90-1.35). Mortality was increased in NTG-treated patients with mild congestion (HR, 2.09; 95% CI, 1.19-3.67), especially in those without hypoperfusion (HR, 2.51; 95% CI, 1.24-5.10). Interaction analysis of the PS-matched cohorts confirmed detrimental effects of NTG use in less congested patients, whereas beneficial effects were only observed in patients with decreased LVEF (50% subgroup: HR, 0.59; 95% CI, 0.37-0.92; ≥50% subgroup: HR, 1.30; 95% CI, 0.66-2.56; P = 0.002).Phenotypical classification of AHF based on congestion/hypoperfusion at ED arrival does not identify subgroups of patients in whom IV-NTG would decrease mortality, although it could potentially be beneficial in those with LVEF of less than 50%. This hypothesis will have to be confirmed in the future. Conversely, our results suggest that IV-NTG may be harmful in patients with only mild clinical congestion.

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. Instituto de Salud Carlos III supported with funds from the Spanish Ministry of Health and FEDER (PI17/01590) No data IDR 2020 18.174 JCR (2021) Q1, 7/143 Cardiac & Cardiovascular Systems 5.231 SJR (2021) Q1, 7/356 Cardiology and Cardiovascular Medicine No data IDR 2021 UEC

Introduction and objectives Composite endpoints are widely used but have several limitations. The Clinical Outcomes, HEalthcare REsource utilizatioN and relaTed costs (COHERENT) model is a new approach for visually displaying and comparing composite endpoints including all their components (incidence, timing, duration) and related costs. We aimed to assess the validity of the COHERENT model in a patient cohort. Methods A color graphic system displaying the percentage of patients in each clinical situation (vital status and location: at home, emergency department [ED] or hospital) and related costs at each time point during follow-up was created based on a list of mutually exclusive clinical situations coded in a hierarchical fashion. The system was tested in a cohort of 1126 patients with acute heart failure from 25 hospitals. The system calculated and displayed the time spent in each clinical situation and health care resource utilization-related costs over 30 days. Results The model illustrated the times spent over 30 days (2.12% in ED, 23.6% in index hospitalization, 2.7% in readmissions, 65.5% alive at home, and 6.02% dead), showing significant differences between patient groups, hospitals, and health care systems. The tool calculated and displayed the daily and cumulative health care-related costs over time (total, €4 895 070; mean, €144.91 per patient/d). Conclusions The COHERENT model is a new, easy-to-interpret, visual display of composite endpoints, enabling comparisons between patient groups and cohorts, including related costs. The model may constitute a useful new approach for clinical trials or observational studies, and a tool for benchmarking, and value-based health care implementation.

Resumen Introduccion y objetivos Investigar si diferentes caracteristicas estructurales/organizativas del hospital y del servicio de urgencias (SU) impactan en los resultados de la insuficiencia cardiaca aguda (ICA). Metodos Analisis secundario del Registro EAHFE. Se recogieron 6 caracteristicas hospitalarias y del SU, y se relacionaron con 7 resultados tras el evento indice y tras el alta, ajustados por ano de inclusion, caracteristicas basales y del episodio de ICA y por dichas caracteristicas estructurales/organizativas. Tambien se relaciono el porcentaje de altas directas desde urgencias (ADU) y resultados, y si habia interaccion segun las caracteristicas hospitalarias o del SU. Resultados Cuarenta SU espanoles incluyeron 17.974 episodios de ICA. Hubo menos estancias prolongadas en hospitales de alta tecnologia, con hospitalizacion a domicilio y con SU con alta frecuentacion, y mas estancias prolongadas en hospitales con unidad de insuficiencia cardiaca y area de observacion en urgencias. Los hospitales de alta tecnologia presentaron menor mortalidad hospitalaria (OR = 0,78; IC95%, 0,65-0,94). Respecto a eventos 30 dias tras el alta, los hospitales con unidad de corta estancia (UCE) tuvieron mas hospitalizaciones (OR = 1,19; IC95%, 1,02-1,38); los SU con alta afluencia, menor mortalidad (OR = 0,73; IC95%, 0,56-0,96) y eventos combinados (OR = 0,87; IC95%, 0,76-0,99), y los hospitales con unidad de insuficiencia cardiaca, menos reconsultas a urgencias (OR = 0,83; IC95%, 0,76-0,91), hospitalizaciones (OR = 0,85; IC95%, 0,75-0,97) y eventos combinados (OR = 0,84; IC95%, 0,77-0,92). A mas ADU, menos estancias prolongadas. Entre otras interacciones, el incremento de ADU se asocio con mas reconsultas, hospitalizaciones y eventos combinados a los 30 dias del alta en hospitales sin UCE, pero no en hospitales con UCE. Conclusiones Las caracteristicas estructurales/organizativas de hospitales y SU y la agresividad en el tratamiento en urgencias influyen significativamente en los resultados en la ICA.

The 2020 guidelines of the European Society of Cardiology (ESC) recommend a novel ESC 0/2h-algorithm as the preferred alternative to the ESC 0/1h-algorithm in the early triage for rule-out and/or rule-in of Non-ST-segment-elevation myocardial infarction (NSTEMI). The aim was to prospectively validate the performance of the ESC 0/2h-algorithm using the high-sensitivity cardiac troponin I (hs-cTnI) assay (ARCHITECT) in an international, multicenter diagnostic study enrolling patients presenting with acute chest discomfort to the emergency department.

AIMS: Although acute heart failure (AHF) with volume overload is treated with loop diuretics, their dosing and type of administration are mainly based upon expert opinion. A recent position paper from the Heart Failure Association (HFA) proposed a step-wise pharmacologic diuretic strategy to increase the diuretic response and to achieve rapid decongestion. However, no study has evaluated this protocol prospectively. METHODS AND RESULTS: The Efficacy of a Standardized Diuretic Protocol in Acute Heart Failure (ENACT-HF) study is an international, multicentre, non-randomized, open-label, pragmatic study in AHF patients on chronic loop diuretic therapy, admitted to the hospital for intravenous loop diuretic therapy, aiming to enrol 500 patients. Inclusion criteria are as follows: at least one sign of volume overload (oedema, ascites, or pleural effusion), use=40mg of furosemide or equivalent for >1month, and a BNP>250ng/L or an N-terminal pro-B-type natriuretic peptide>1000pg/L. The study is designed in two sequential phases. During Phase 1, all centres will treat consecutive patients according to the local standard of care. In the Phase 2 of the study, all centres will implement a standardized diuretic protocol in the next cohort of consecutive patients. The protocol is based upon the recently published HFA algorithm on diuretic use and starts with intravenous administration of two times the oral home dose. It includes early assessment of diuretic response with a spot urinary sodium measurement after 2h and urine output after 6h. Diuretics will be tailored further based upon these measurements. The study is powered for its primary endpoint of natriuresis after 1day and will be able to detect a 15% difference with 80% power. Secondary endpoints are natriuresis and diuresis after 2days, change in congestion score, change in weight, in-hospital mortality, and length of hospitalization. CONCLUSIONS: The ENACT-HF study will investigate whether a step-wise diuretic approach, based upon early assessment of urinary sodium and urine output as proposed by the HFA, is feasible and able to improve decongestion in AHF with volume overload.

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large phenotypic variability in CS, as a result of the diverse aetiologies, pathogenetic mechanisms, haemodynamics, and stages of severity. Although early revascularization remains the most important intervention for CS in settings of acute myocardial infarction, the administration of timely and effective antithrombotic therapy is critical to improving outcomes in these patients. In addition, other clinical settings or non‐acute myocardial infarction aetiologies, associated with high thrombotic risk, may require specific regimens of short‐term or long‐term antithrombotic therapy. In CS, altered tissue perfusion, inflammation, and multi‐organ dysfunction induce unpredictable alterations to antithrombotic drugs' pharmacokinetics and pharmacodynamics. Other interventions used in the management of CS, such as mechanical circulatory support, renal replacement therapies, or targeted temperature management, influence both thrombotic and bleeding risks and may require specific antithrombotic strategies. In order to optimize safety and efficacy of these therapies in CS, antithrombotic management should be more adapted to CS clinical scenario or specific device, with individualized antithrombotic regimens in terms of type of treatment, dose, and duration. In addition, patients with CS require a close and appropriate monitoring of antithrombotic therapies to safely balance the increased risk of bleeding and thrombosis.

Background We aimed to derive and validate a 0/2 h-algorithm using the new high-sensitivity cardiac troponin I (hs-cTnI)-VITROS assay (VITROS® Immunodiagnostic Products hs-Troponin I Reagent Pack, Ortho Clinical Diagnostics) for rapid rule-out/in of non-ST-segment elevation myocardial infarction (NSTEMI). Methods The final diagnosis was centrally adjudicated by 2 independent cardiologists according to the fourth universal definition of myocardial infarction (MI) among 1888 patients presenting to the emergency department with acute chest pain. hs-cTnI-VITROS concentrations were measured at presentation and at 2 h in a blinded fashion. The optimal assay-specific thresholds for the hs-cTnI-VITROS 0/2 h-algorithm were derived in a randomly selected 70% of the cohort and validated in the remaining 30%. Results NSTEMI was the final diagnosis in 216/1322 (16.3%) patients of the derivation cohort. Rule-out was defined as baseline hs-cTnI concentrations of 3 h or a baseline hs-cTnI concentration of Conclusion hs-cTnI-VITROS concentrations at presentation combined with absolute changes within the first 2 h allowed safe rule-out and accurate rule-in of NSTEMI in two-thirds of unselected patients presenting with acute chest pain to the emergency department. Trial registration www.clinicaltrials.gov: NCT0047058

To investigate whether the severity of acute recreation drug toxicity presentations to emergency departments (EDs) in Europe has changed in recent years and to uncover potential sex differences.We analysed presentations to 36 EDs in 24 European countries relating to acute recreational drug toxicity, with separate analysis for presentations involving lone use of cannabis, cocaine, and heroin. As severity markers, we calculated rates of hospitalization, admission to ICU, intubation, and death by annual quarters between 2014 and 2019. Trends on severity over time were estimated by logistic regression. Differences between men and women were assessed by interaction. Sensitivity analysis was performed including only EDs that provided data for all 24 quarters. Analyses of intoxications taken altogether were adjusted by age and sex, while of lone intoxications being also adjusted by ethanol co-ingestion.There were 43 633 presentations (median age = 31 years, interquartile range = 25-40 years, men = 76.5%) resulting in 10 344 hospitalizations (23.9%), 2568 ICU admissions (5.9%), 1391 intubations (3.2%), and 171 deaths (0.39%). Hospitalization, ICU admission and death did not differ by sex, but intubation was more frequent in men (3.4% vs. 2.3%, P0.001). No significant changes in the severity of drug intoxications over time were found when considered altogether, neither for lone cannabis (n = 4264) nor cocaine (n = 3562). Conversely, significant increases in hospitalization [odds ratios (OR) = 1.023, 95% confidence interval (CI) = 1.004-1.041], ICU admission (OR = 1.080, 95% CI = 1.042-1.118) and in intubation (OR = 1.049, 95% CI = 1.001-1.099) were detected for lone heroin presentations (n = 1997). Sensitivity analysis (32 245 presentations, 14 EDs, 9 countries) confirmed the overall absence of changes in severity markers (except for death rate, which significantly decreased by quarter: OR = 0.968, 95% CI = 0.943-0.994). Additionally, it suggested an increased risk over time of intubation for cocaine (OR = 1.068, 95% CI = 1.009-1.130) and confirmed the increased risk of ICU admission for heroin (OR = 1.058, 95% CI = 1.013-1.105). Changes in severity over time did not differ according to sex in the main analysis of the whole cohort, while a significantly higher decrease in risk of death in men was found in the sensitivity analysis (OR = 0.894, 95% CI = 0.825-969 vs. OR = 0.949, 95% CI = 0.860-1.048; P interaction = 0.042).The severity of presentations to European EDs remained mainly unchanged during 2014-2019, but the risk of death may have decreased. Conversely, intubation in lone cocaine and ICU admission in lone heroin intoxications have increased. Although men and women exhibited a similar pattern over the period for the majority of comparisons, our data suggest that women exhibited a smaller decrease of the overall risk of death.

espanolFundamento. Describir el numero de consultas, total y por COVID-19, atendidas en servicios de urgencias hospitalarios (SUH) espanoles durante marzo y abril de 2020, compararlo con el mismo periodo del ano anterior, cuantificar el cambio de actividad asistencial e investigar la posible influencia del tamano del hospital y de la seroprevalencia provincial de COVID-19. Metodos. Estudio transversal. Se envio una encuesta a todos los responsables de SUH espanoles del sistema publico de salud sobre el numero de consultas atendidas durante marzo y abril de 2019 y de 2020. Se calculo el cambio de actividad asistencial por comunidad autonoma, y se comparo en funcion del tamano del hospital y del impacto provincial de la pandemia. Resultados. Participaron el 66 % de los 283 SUH. Se observo un descenso del 49,2 % de las consultas totales (solo los SUH de Castilla-La Mancha mostraron un descenso inferior al 30 %) y del 60 % de las consultas no-COVID-19 (solo los SUH de Asturias y Extremadura mostraron un descenso inferior al 50 %). el cambio de actividad asistencial no difirio en funcion del tamano del hospital, pero si en relacion al impacto provincial de la pandemia, con una correlacion directa respecto al descenso de actividad no-COVID-19 (a mayor impacto, mayor descenso; R2 = 0,05; p = 0,002) e inversa en relacion a la actividad global (a mayor impacto, menor descenso; R2 = 0,05; p = 0,002). Conclusiones. Durante la primera ola pandemica descendio el numero de consultas en los SUH, si bien dicho descenso no se explica unicamente por la incidencia local de la pandemia. EnglishBackground. To describe the number of visits (total and per COVID-19) attended by the Spanish hospital emergency departments (EDs) during March and April 2020 compared to the same period in 2019, and to calculate the quantitative changes in healthcare activity and investigate the possible influence of hospital size and regional COVID-19 seroprevalence. Method. Cross-sectional study that analyzes the number of visits to Spanish public EDs, reported through a survey of ED chiefs during the study periods. Changes in healthcare activity were described in each autonomous community and compared according to hospital size and the regional impact of the pandemic. Results. The 66% of the 283 Spanish EDs participated in the study. The total number of patients attended decreased to 49.2 % ( Conclusion. There was a very significant decrease in the number of ED visits during the first pandemic wave, although this decrease cannot be explained solely by the local incidence of the pandemic.

To define quality of care indicators and care process standards for treating patients with COVID-19 in hospital emergency departments (EDs), to determine the level of adherence to standards during the first wave in 2020, and to detect factors associated with different levels of adherence.We selected care indicators and standards by applying the Delphi method. We then analyzed the level of adherence in the SIESTA cohort (registered by the Spanish Investigators in Emergency Situations Team). This cohort was comprised of patients with COVID-19 treated in 62 Spanish hospitals in March and April 2020. Adherence was compared according to pandemic-related ED caseload pressure, time periods during the wave (earlier and later), and age groups.Fourteen quality indicators were identified. Three were adhered to in less than 50% of the patients. Polymerase chain reaction testing for SARS-CoV-2 infection was the indicator most often disregarded, in 29% of patients when the caseload was high vs 40% at other times (P .001) and in 30% of patients in the later period vs 37% in the earlier period (P = .04). Adherence to the following indicators was better in the later part of the wave: monitoring of oxygen saturation (100% vs 99%, P = .035), electrocardiogram monitoring in patients treated with hydroxychloroquine (87% vs 65%, P .001), and avoiding of lopinavir/ritonavir treatment in patients with diarrhea (79% vs 53%, P .001). No differences related to age groups were found.Adherence to certain quality indicators deteriorated during ED treatment of patients with COVID-19 during the first wave of the pandemic. Pressure from high caseloads may have exacerbated this deterioration. A learning effect led to improvement. No differences related to patient age were detected.Definir indicadores de calidad y sus estándares para el proceso asistencial del paciente con COVID-19 en servicios de urgencias hospitalarios (SUH), así como determinar su grado de cumplimiento durante el primer pico pandémico e investigar si existieron diferencias en relación con diferentes factores.Siguiendo la metodología del Delphi, los autores seleccionaron los indicadores y sus estándares. Posteriormente, se analizó el grado de cumplimiento en la cohorte SIESTA, formada por pacientes COVID-19 de 62 SUH españoles atendidos en marzo y abril de 2020. Se comparó el cumplimiento de los indicadores según la presión asistencial generada por la pandemia en el SUH, el periodo asistencial y el grupo etario.Se definieron 14 indicadores. Tres de ellos se cumplieron en 50% de los pacientes. La realización de la reacción en cadena de la polimerasa (PCR) para el SARS-CoV-2 tuvo peor cumplimiento en SUH con alta presión (29% frente a 40%, p 0,001) y durante el periodo tardío (30% frente a 37%, p = 0,04). Durante el periodo tardío, mejoró la medida de saturación de oxígeno (100% frente a 99%, p = 0,035), la realización de electrocardiograma en pacientes tratados con hidroxicloroquina (87% frente a 65%, p 0,001) y la no administración de lopinavir-ritonavir en pacientes con diarrea (79% frente a 53%, p 0,001). No hubo diferencias en relación con el grupo etario.Durante el primer pico pandémico, diversos aspectos de la calidad de la atención a pacientes COVID-19 en los SUH españoles se vieron deteriorados. La presión asistencial pudo incrementar este deterioro. Hubo un efecto de aprendizaje que condicionó una mejora, pero no se observaron diferencias según la edad de los pacientes.

To analyze whether short-term outcomes are affected when patients diagnosed with acute heart failure (AHF) spend time in an emergency department observation unit (EDOU) before hospital admission.Baseline and emergency episode data were collected for patients diagnosed with AHF in the EDs of 15 Spanish hospitals. We analyzed crude and adjusted associations between EDOU stay and 30-day mortality (primary outcome) and in-hospital mortality and a prolonged hospital stay of more than 7 days (secondary outcomes).A total of 6597 patients with a median (interquartile range) age of 83 (76-88 years) were studied. Fifty-five percent were women. All were hospitalized for AHF (50% in internal medicine wards, 23% in cardiology, 11% in geriatrics, and 16 in other specialties. Of these patients, 3241 (49%) had had EDOU stays and 3350 (51%) had been admitted immediately, with no EDOU stay. Having an EDOU stay was associated with female sex, dementia or chronic obstructive pulmonary disease, long-term treatment with certain drugs for heart failure, greater baseline deterioration in function, and a higher degree of decompensation. Patients in the EDOU group were more often admitted to an internal medicine ward and had shorter stays; cardiology, geriatric, and intensive care admissions were less likely to have had an EDOU stay. Overall, 30-day mortality was 12.6% (13.7% in the EDOU group and 11.4% in the no-EDOU group; P = .004). In-hospital mortality was 10.4% overall (EDOU, 11.1% and no-EDOU, 9.6%; P = .044). Prolonged hospitalization occurred in 50.0% (EDOU, 48.7% and no-EDOU, 51.2%; P = .046). After adjusting for between-group differences, the EDOU stay was not associated with 30-day mortality (hazard ratio, 1.14; 95% CI, 0.99-1.31). Odds ratios for associations between EDOU stay and in-hospital mortality and prolonged hospital stay, respectively, were 1.09 (95% CI, 0.92-1.29) and 0.91 (95% CI, 0.82-1.01).Although mortality higher in patients hospitalized for AHF who spend time in an EDO, the association seems to be accounted for by their worse baseline situation and the greater seriousness of the decompensation episode, not by time spent in the EDOU.Analizar si la estancia en el área de observación de urgencias (AOU) de pacientes que han sido diagnosticados de insuficiencia cardiaca aguda (ICA) y que deben ingresar está asociada con algún cambio en la evolución a corto plazo.Se recogieron datos basales y clínicos de pacientes diagnosticados de ICA en el servicio de urgencias de 15 hospitales españoles. Se analizó la asociación cruda y ajustada de la estancia en el AOU previa a la hospitalización con mortalidad a 30 días (objetivo primario) y con mortalidad intrahospitalaria e ingreso prolongado (7 días) (objetivos secundarios).Se incluyeron 6.597 pacientes (mediana = 83 años, RIC = 76-88; mujeres = 55%) hospitalizados por ICA (50% en medicina interna, 23% en cardiología, 11% en geriatría y 16% en otros servicios); de ellos, 3.241 (49%) permanecieron en observación en urgencias (grupo AOU) y 3.350 (51%) hospitalizaron sin observación previa (grupo no-AOU). La observación en urgencias se asoció con ser mujer, tener demencia o enfermedad pulmonar obstructiva crónica, recibir crónicamente fármacos específicos para insuficiencia cardiaca, mayor deterioro funcional basal y mayor gravedad de la descompensación. El grupo AOU más frecuentemente hospitalizó en medicina interna y corta estancia, y menos frecuentemente en cardiología, geriatría y cuidados intensivos. La mortalidad a 30 días fue del 12,6% (AOU = 13,7%, no-AOU = 11,4%, p = 0,004); la mortalidad intrahospitalaria fue del 10,4% (AOU = 11,1%, no-AOU = 9,6%, p = 0,044) y el ingreso prolongado del 50,0% (AOU = 48,7%, no-AOU = 51,2%, p = 0,046). Tras ajustar por las diferencias entre grupos, la estancia en observación en urgencias no se asoció con mortalidad a 30 días (HR = 1,14, IC 95% = 0,99-1,31), mortalidad intrahospitalaria (OR = 1,09, IC 95% = 0,92-1,29) o estancia prolongada (OR = 0,91, IC 95% = 0,82-1,01).Aunque los pacientes hospitalizados por ICA que permanecen en observación en urgencias presentan mayor mortalidad, esta asociación parece explicarse por su peor situación de base y la mayor gravedad del episodio de descompensación y no por su paso por el AOU.

To determine whether symptoms and levels of severity of intoxication from street drugs differ between adolescents and young adults who come to hospital emergency departments for treatment.We studied a consecutive cohort of adolescents (aged 12-17 years) and young adults (aged 18-30 years) who were treated in 11 hospital emergency departments belonging to the Drug Abuse Network of Spanish Hospital Emergency Departments (REDURHE). Sociodemographic and clinical characteristics and level of severity were recorded for comparison between between adolescents and young adults, adjusted for sex, alcohol co-ingestion, and type of drug used. An intoxication was recorded as severe if at least 1 of the following indicators was present: cardiac arrest, tracheal intubation, intensive care unit admission, and in-hospital death.We included a total of 2181 patients: 249 adolescents (11.4%) and 1932 young adults (88.6%). Alcohol coingestion and use of multiple drugs were less common in adolescents, who had significantly more events related to cannabis (in 81.1% vs 49.0% of young adults) and benzodiazepines (13.3% vs 5.5%). The adolescents had significantly fewer intoxications from the use of cocaine (10.8% vs 45.1%), amphetamines (17.3% vs 32.3%), ketamine (0.4% vs 6.0%) and gamma-hydroxybutyrate (0.4% vs 4.0%). A higher proportion of adolescents than young adults presented with diminished consciousness (23.0% vs 16.9%), but fewer manifested anxiety (15.9% vs 26.3%), palpitations (11.0% vs 19.5%), or chest pain (2.8% vs 9.2%). The pattern of associations was similar in the subgroup of intoxications due to cannabis. The adjusted model confirmed that the adolescents were more likely to have diminished consciousness, with an odds ratio (OR) of 1.851 (95% CI, 1.204-2.844) and less likely to have anxiety (OR, 0.529 (95% CI, 0.347-0.807). Intoxication was severe in 46 patients overall (2.1%); in adolescents and young adults the proportions were 0.8% and 2.3%, respectively (P = 0.129). In adolescents, the OR was 0.568 (95% CI, 0.131-2.468) for severity; for component indicators, the ORs were 0.494 (95% CI, 0.063-3.892) for intubation and 0.780 (95% CI, 0.175-3.475) for intensive care unit admission. No deaths occurred.Adolescents requiring emergency care for street drug intoxication had co-ingested alcohol or taken multiple drugs less often than young adults. Cannabis was the drug most often used by adolescents, who presented more often with diminished consciousness but less often with anxiety. We detected no differences related to event severity.Investigar si existen diferencias en las drogas, sintomatología y gravedad entre adolescentes y jóvenes atendidos por intoxicación por drogas en servicios de urgencias hospitalarios (SUH).Entre los pacientes consecutivos atendidos por consumo de drogas en los 11 SUH de la REDURHE (Red de estudio de Drogas en Urgencias Hospitalarios en España), se seleccionaron los adolescentes (edad = 12-17 años) y los jóvenes (edad = 18-30 años). Se compararon las características sociodemográficas, clínicas y la gravedad (evento adverso combinado –EAC–: parada cardiorrespiratoria, intubación endotraqueal, ingreso en cuidados intensivos o muerte intrahospitalaria) en adolescentes y jóvenes, ajustadas por sexo, coingesta de etanol y drogas involucradas.Se incluyeron 2.181 pacientes (adolescentes = 249, 11,4%; jóvenes = 1.932, 88,6%). En adolescentes, la coingesta de etanol y múltiples drogas fue menos frecuente. Hubo significativamente más asistencias por cannabis (81,1% vs 49,0%) y benzodiacepinas (13,3% vs 5,5%) y menos por cocaína (10,8% vs 45,1%), anfetamínicos (17,3% vs 32,3%), ketamina (0,4% vs 6,0%) y gamma-hidroxibutirato (0,4% vs 4,0%). Los adolescentes presentaron más disminución de consciencia (23,0% vs 16,9%) y menos ansiedad (15,9% vs 26,3%), palpitaciones (11,0% vs 19,5%) y dolor torácico (2,8% vs 9,2%). Estas asociaciones se mantuvieron al analizar el subgrupo de intoxicados por cannabis. En el modelo ajustado, los adolescentes presentan más disminución de consciencia con (OR = 1,851, IC 95%: 1,204-2,844) y menos ansiedad (OR = 0,529, IC 95%: 0,347-0,807). Se observó EAC en 46 pacientes (2,0%; 0,8% vs 2,3%, p = 0,129). La OR ajustada en adolescentes para EAC fue 0,568 (IC 95%: 0,131-2,468), y para intubación 0,494 (IC 95%: 0,063-3,892) y para ingreso en intensivos 0,780 (IC 95%: 0,175-3,475). No hubo fallecimientos.Los adolescentes intoxicados por drogas atendidos en SUH presentan con menor frecuencia coingesta de etanol o múltiples drogas. La droga más frecuentemente implicada es el cannabis, y presentan más disminución de consciencia y menos ansiedad. No detectamos diferencias en la gravedad entre adolescentes y jóvenes.

The aim of this study was to conduct a meta-analysis of prospective studies assessing the relationship between bundle branch block (BBB) or wide QRS and risk of all-cause mortality in patients with acute heart failure (AHF).We searched the PubMed, Scopus and Web of Science database from inception to February 2022 to identify single centre or multicentre studies including a minimum of 400 patients and assessing the association between BBB or wide QRS and mortality in patients with AHF. Study-specific hazard ratio (HR) estimates were combined using a random-effects meta-analysis. Two meta-analyses were performed: (1) grouping by conduction disturbance and follow-up length and, (2) using the results from the longest follow-up for each study and grouping by the type of BBB. The meta-analysis included 21 publications with a total of 116,928 patients. Wide QRS (considering right (RBBB) and left (LBBB) altogether) was associated with a significant increment in the risk of all-cause mortality (pooled adjusted HR 1.112, 95% CI 1.065-1.160). The increased risk of death was also present when LBBB (HR 1.121, 95% CI 1.042-1.207) and RBBB (HR 1.187, 95% CI 1.045-1.348) were considered individually. There was no difference in risk between LBBB and RBBB (P for interaction = 0.533). Other outcomes including sudden death, rehospitalization and a combination of cardiovascular death or rehospitalization were also increased in patients with BBB or wide QRS.This meta-analysis suggests a modest increase in the risk of all-cause mortality among patients with AHF and BBB or wide QRS, irrespective of the type of BBB.

Aims To assess whether symptoms/signs of congestion and perfusion in acute heart failure (AHF) evaluated at patient arrival to the emergency department (ED) can predict the severity of decompensation and short-term outcomes. Methods and results We included patients from the Epidemiology of AHF Emergency Registry (EAHFE Registry). We registered seven clinical surrogates of congestion and five of hypoperfusion. Patients were grouped according to severity of congestion/hypoperfusion. We assessed the need for hospitalization, in-hospital all-cause mortality for patients needing hospitalization, and prolonged hospitalization for patients surviving the decompensation episode. Outcomes were adjusted for patient characteristics and the coexistence of congestion and hypoperfusion. We analysed 18 120 patients (median = 83 years, interquartile range = 76–88; women = 55.7%). Seventy-two per cent presented >2 signs/symptoms of congestion and 18% had at least 1 sign/symptom of hypoperfusion. Seventy-five per cent were hospitalized with in-hospital death in 9% and prolonged hospitalization in 47% discharged alive. The presence of congestion/hypoperfusion was independently associated with poorer outcomes. An increase in the number of signs/symptoms of congestion was associated with increased risk of hospitalization (P < 0.001) and prolonged stay (P = 0.011), but not mortality (P = 0.06). Increased signs/symptoms of hypoperfusion were associated with hospitalization (P < 0.001) and mortality (P < 0.001), but not prolonged stay (P = 0.227). In the combined model, including congestion and hypoperfusion, both had additive effects on hospitalization, in-hospital mortality was driven by hypoperfusion and no differences were observed for prolonged hospitalization. Conclusion The presence of congestion/hypoperfusion at ED arrival is a simple clinical marker associated with a higher risk of severity/adverse short-term outcomes.

Aims To directly compare the diagnostic accuracy of high-sensitivity cardiac troponin (hs-cTn) T vs. hs-cTnI in the early non-invasive differentiation of Type 1 myocardial infarction (T1MI) due to plaque rupture and atherothrombosis from Type 2 myocardial infarction (T2MI) due to supply–demand mismatch. Methods and results In a prospective multicentre diagnostic study, two independent cardiologists centrally adjudicated the final diagnosis of T1MI vs. T2MI according to the fourth universal definition of myocardial infarction (MI), using all available clinical information including cardiac imaging in patients presenting with acute chest pain. Diagnostic accuracy was quantified by the area under the receiver operating characteristics curve (AUC). The most extensively validated hs-cTnT-Elecsys and hs-cTnI-Architect assays were measured at presentation, 1 h, and 2 h. Among 5887 patients, 1106 (19%) had a final diagnosis of MI, including 860 (78%) T1MI and 246 (22%) T2MI. The AUC of hs-cTnT-Elecsys to differentiate T1MI from T2MI was moderate and comparable to that provided by hs-cTnI-Architect: hs-cTnT-Elecsys AUC-presentation 0.67 [95% confidence interval (CI) 0.64–0.71], AUC-1 h 0.70 (95% CI 0.66–0.74), and AUC-2 h 0.71 (95% CI 0.66–0.75) vs. hs-cTnI-Architect AUC-presentation 0.71 (95% CI 0.67–0.74), AUC-1 h 0.72 (95% CI 0.68–0.76), and AUC-2 h 0.74 (95% CI 0.69–0.78), all P = not significant (NS). Similarly, the AUC of absolute changes was moderate and comparable for hs-cTnT-Elecsys and hs-cTnI-Architect (all P = NS). Cut-off concentrations achieving at least 90% specificity for the differentiation of T1MI vs. T2MI were >114 ng/L for hs-cTnT-Elecsys [odds ratio (OR) 4.2, 95% CI 2.7–6.6] and >371 ng/L for hs-cTnI-Architect (OR 4.0, 95% CI 2.6–6.2). Conclusion hs-cTnT-Elecsys and hs-cTnI-Architect provided comparable, albeit only moderate, diagnostic accuracy for the early differentiation of T1MI vs. T2MI. Clinical trial registration ClinicalTrials.gov number, NCT00470587, https://clinicaltrials.gov/ct2/show/NCT00470587.

Aims We investigated the incidence, risk factors, clinical characteristics, and outcomes of pulmonary embolism (PE) in patients with COVID-19 attending emergency departments (EDs), before hospitalization. Methods and Results We retrospectively reviewed all COVID-19 patients diagnosed with PE in 62 Spanish EDs (20% of Spanish EDs, case group) during the first COVID-19 outbreak. COVID-19 patients without PE and non-COVID-19 patients with PE were included as control groups. Adjusted comparisons for baseline characteristics, acute episode characteristics, and outcomes were made between cases and randomly selected controls (1:1 ratio). We identified 368 PE in 74 814 patients with COVID-19 attending EDs (4.92‰). The standardized incidence of PE in the COVID-19 population resulted in 310 per 100 000 person-years, significantly higher than that observed in the non-COVID-19 population [35 per 100 000 person-years; odds ratio (OR) 8.95 for PE in the COVID-19 population, 95% confidence interval (CI) 8.51–9.41]. Several characteristics in COVID-19 patients were independently associated with PE, the strongest being D-dimer >1000 ng/mL, and chest pain (direct association) and chronic heart failure (inverse association). COVID-19 patients with PE differed from non-COVID-19 patients with PE in 16 characteristics, most directly related to COVID-19 infection; remarkably, D-dimer >1000 ng/mL, leg swelling/pain, and PE risk factors were significantly less present. PE in COVID-19 patients affected smaller pulmonary arteries than in non-COVID-19 patients, although right ventricular dysfunction was similar in both groups. In-hospital mortality in cases (16.0%) was similar to COVID-19 patients without PE (16.6%; OR 0.96, 95% CI 0.65–1.42; and 11.4% in a subgroup of COVID-19 patients with PE ruled out by scanner, OR 1.48, 95% CI 0.97–2.27), but higher than in non-COVID-19 patients with PE (6.5%; OR 2.74, 95% CI 1.66–4.51). Adjustment for differences in baseline and acute episode characteristics and sensitivity analysis reported very similar associations. Conclusions PE in COVID-19 patients at ED presentation is unusual (about 0.5%), but incidence is approximately ninefold higher than in the general (non-COVID-19) population. Moreover, risk factors and leg symptoms are less frequent, D-dimer increase is lower and emboli involve smaller pulmonary arteries. While PE probably does not increase the mortality of COVID-19 patients, mortality is higher in COVID-19 than in non-COVID-19 patients with PE.

Introduction and objectives: Release kinetics of high-sensitivity cardiac troponin (hs-cTn) T and I in patients with acute myocardial infarction (AMI) are incompletely understood. We aimed to assess whether hs-cTnT/I release in early AMI is near linear. Methods: In a prospective diagnostic multicenter study the acute release of hs-cTnT and hs-cTnI within 1 and 2 hours from presentation to the emergency department was quantified using 3 hs-cTnT/I assays in patients with suspected AMI. The primary endpoint was correlation between hs-cTn changes from presentation to 1 hour vs changes from presentation to 2 hours, among all AMI patients and different prespecified subgroups. The final diagnosis was adjudicated by 2 independent cardiologists, based on serial hs-cTnT from the serial study blood samples and additional locally measured hs-cTn values. Results: Among 2437 patients with complete hs-cTnT data, AMI was the adjudicated diagnosis in 376 patients (15%). For hs-cTnT, the correlation coefficient between 0- to 1-hour change and 0- to 2 hour change was 0.931 (95%CI, 0.916-0.944), P

RESUMEN Objetivo Conocer el enfoque terapéutico que se realiza en los servicios de urgencias hospitalarios (SUH) españoles a los pacientes con sospecha de infección de transmisión sexual (ITS), analizándolo según tamaño del hospital, afluencia en urgencias y comunidad autónoma. Material y métodos Encuesta estructurada a los responsables de los 282 SUH públicos que atienden adultos 24 horas/día. Se preguntó sobre rutinas asistenciales en urgencias en la atención a pacientes con sospecha de ITS. Los resultados se comparan mediante odds ratio (OR) e intervalo confianza del 95% (IC95%) según tamaño del hospital (grande vs mediopequeño: ≥500 vs. 60% en Cataluña y País Vasco, más en hospitales grandes (OR=2,65, IC95%=1,46-4,82) y SUH con alta afluencia (OR=3,49, IC95%=2,03-5,98)]. El 70% de SUH frecuentemente o casi siempre realizan tomas de exudados (>80% en Cataluña, Madrid, Castilla-La Mancha, Aragón, Navarra y País Vasco), el 44% serologías de ITS (>60% en Madrid) y el 35% serología VIH [(>60% en Navarra y Baleares; más en hospitales grandes (OR=2,43, IC95%=1,34-4,42) y SUH con alta afluencia (OR=1,94, IC95%=1,15-3,29)]. Al alta, remiten al paciente para seguimiento a dispositivos hospitalarios el 53% de SUH [>60% en Cataluña, Comunidad Valenciana, Murcia, CastillaLa Mancha, País Vasco, Asturias; más en hospitales grandes (OR=2,45, IC95%=1,31-4,57) y SUH de alta afluencia (OR=2,25, IC95%=1,35-3,76)] y a atención primaria el 28% (>80% en Cantabria). En el 55% de SUH los pacientes frecuentemente o casi siempre son dados de alta con visita de seguimiento programada (>80% en Extremadura, La Rioja y Navarra) y en el 32% esta visita es el siguiente día hábil [>60% en País Vasco; más en hospitales grandes (OR=3,43, IC95%=1,87-6,30) y SUH de alta afluencia (OR=3,63, IC95%=2,08-6,37)]. Conclusión La atención al paciente con sospecha de ITS no es homogénea en los SUH españoles y se detectan áreas de mejora, especialmente en la necesidad de protocolos de diagnósticos y seguimientos específicos.