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Background: Patients with atrial fibrillation (AF) and heart failure (HF) have a high risk of thromboembolism and other outcomes and anticoagulation is recommended., Hypothesis: This study was aimed to explore the risk factors associated with HF worsening in patients with AF and HF taking rivaroxaban in Spain., Methods: Multicenter, prospective, observational study that included adults with AF and chronic HF, receiving rivaroxaban ≥4 months before entering. HF worsening was defined as first hospitalization or emergency visit because of HF exacerbation., Results: A total of 672 patients from 71 Spanish centers were recruited, of whom 658 (97.9%) were included in the safety analysis and 552 (82.1%) in the per protocol analysis. At baseline, mean age was 73.7 ± 10.9 years, 64.9% were male, CHA 2 DS 2 -VASc was 4.1 ± 1.5, HAS-BLED was 1.6 ± 0.9% and 51.3% had HF with preserved ejection fraction. After 24 months of follow-up, 24.9% of patients developed HF worsening, 11.6% died, 2.9% had a thromboembolic event, 3.1% a major bleeding, 0.5% an intracranial bleeding and no patient had a fatal hemorrhage. Older age, the history of chronic obstructive pulmonary disease, the previous use of vitamin K antagonists, and restrictive or infiltrative cardiomyopathies, were independently associated with HF worsening. Only 6.9% of patients permanently discontinued rivaroxaban treatment., Conclusions: Approximately one out of four patients with HF and AF treated with rivaroxaban developed a HF worsening episode after 2 years of follow-up. The identification of those factors that increase the risk of HF worsening could be helpful in the comprehensive management of this population., (© 2023 The Authors. Clinical Cardiology published by Wiley Periodicals, LLC.)

Background: Heart failure (HF) and atrial fibrillation (AF) are common and coexistent conditions., Hypothesis: To investigate the adverse events and mortality risk factors in patients with AF and HF treated with rivaroxaban in Spain., Methods: Multicenter, prospective and observational study with a follow-up of 2 years, that included adults, with a diagnosis of nonvalvular AF and chronic HF, anticoagulated with rivaroxaban at least 4 months before being enrolled., Results: A total of 672 patients from 71 Spanish centers were recruited, of whom 658 (97.9%) were included in the safety analysis and 552 (82.1%) in the per protocol analysis. At baseline, the mean age was 73.7 ± 10.9 years, 65.9% were male, 51.3% had HF with preserved ejection fraction and 58.7% were on New York Heart Association functional class II. CHA 2 DS 2 -VASc was 4.1 ± 1.5. During the follow-up, 11.6% of patients died and around one-quarter of patients were hospitalized or visited the emergency department, being HF worsening/progression the main cause (51.1%), with a 2.9% of thromboembolic events and 2.0% of acute coronary syndromes. Major bleeding occurred in 3.1% of patients, with 0.5% experiencing intracranial bleeding but no fatalities. Compliance with HF treatment was associated with a lower risk of death (hazard ratio: 0.092; 95% confidence interval: 0.03-0.31)., Conclusions: Among patients with HF and AF anticoagulated with rivaroxaban, incidences of thromboembolic or hemorrhagic complications were low. The most important factor for improving survival was compliance with HF drugs, what strengths the need for early treatment with HF disease-modifying therapy and anticoagulation., (© 2023 The Authors. Clinical Cardiology published by Wiley Periodicals, LLC.)

Background: Carbohydrate antigen 125 (CA125) has emerged as a new biomarker in heart failure. The objective of the study is to determine whether serum CA125 levels predict total mortality and readmissions at one year in patients >70 years old with acute heart failure (AHF) and preserved ejection fraction (PEF)., Methods: Multicenter prospective observational study, which included 359 patients (mean age 81.5 years). The primary endpoint was total all-cause mortality and total readmissions for AHF at 1 year. A negative binomial regression technique was used to evaluate the association between CA125 and both endpoints., Results: At one year of follow-up, 87 deaths (24.2%) were registered. The patients in the lower quartile of CA125 had a lower crude mortality rate (14.4%, 26.7, 26.7, 29.2; p=0.09). After multivariate analysis, the CA125 value was positively associated with a higher risk (p=0.009). Such association was also positive but borderline significant for the risk of readmissions (p=0.089)., Conclusions: In a population older than 70 years hospitalized for AHF with PEF, elevated levels of CA125 are associated with an increased risk of death at one year of follow-up. The association with readmission for AHF was more uncertain. Low levels of CA125 identifies a subgroup at low-risk., (Copyright © 2021 Elsevier España, S.L.U. All rights reserved.)

Background: Pulmonary congestion (PC) is associated with an increased risk of hospitalization and death in patients with heart failure (HF). Lung ultrasound is highly sensitive for detecting PC. The aim of this study is to evaluate whether lung ultrasound-guided therapy improves 6-month outcomes in patients with HF. Methods: A randomized, multicenter, single-blind clinical trial in patients discharged after hospitalization for decompensated HF. Participants were assigned 1:1 to receive treatment guided according to the presence of lung ultrasound signs of congestion (semi-quantitative evaluation of B lines and the presence of pleural effusion) versus standard of care (SOC). The primary endpoint was the combination of cardiovascular death, readmission, or emergency department or day hospital visit due to worsening HF at 6 months. In September 2020, after an interim analysis, patient recruitment was stopped. Results: A total of 79 patients were randomized (mean age 81.2 +/− 9 years) and 41 patients (51.8%) showed a left ventricular ejection fraction >50%. The primary endpoint occurred in 11 patients (29.7%) in the SOC group and in 11 patients (26.1%) in the LUS group (log-rank = 0.83). Regarding nonserious adverse events, no significant differences were found. Conclusions: LUS-guided diuretic therapy after hospital discharge due to ADHF did not show any benefit in survival or a need for intravenous diuretics compared with SOC.

Despite currently available treatments, risk of death and hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF) remains high. The pathophysiology of HFrEF includes neurohormonal activation characterized by stimulation of deleterious pathways (i.e., sympathetic nervous and renin-angiotensin-aldosterone systems) and suppression of protective pathways such as nitric oxide-dependent pathways. Inhibition or stimulation of some, but not all, of these pathways is insufficient. In HFrEF, there is reduced nitric oxide, soluble guanylate cyclase, and cGMP activity, leading to deleterious effects in the myocardial, vascular, and renal systems. Vericiguat is able to stimulate the activity of this protective pathway. The VICTORIA study demonstrated that the addition of vericiguat to optimal medical treatment in patients with HFrEF and recent decompensation significantly reduced the incidence of the primary endpoint, a composite of cardiovascular death or HF hospitalization, with a number needed to treat of 24 patients and excellent tolerability., (Copyright © 2022 The Authors. Published by Elsevier España, S.L.U. All rights reserved.)

Aims: Heart failure (HF) and diabetes are 2 strongly associated diseases. The main objective of this work was to analyze changes in the prognosis of patients with diabetes who were admitted for heart failure in 2 time periods., Methods: This work is a prospective study comparing prognosis at one year of follow-up among patients with diabetes who were hospitalized for HF in either 2008-2011 or 2018. The patients are from the Spanish Society of Internal Medicine's National Heart Failure Registry (RICA, for its initials in Spanish). The primary endpoint was to analyze the composite outcome of total mortality and/or readmission due to HF in 12 months. A multivariate Cox regression model was used to evaluate the strength of association (hazard ratio [HR]) between diabetes and the outcomes between both periods., Results: A total of 936 patients were included in the 2018 cohort, of which 446 (48%) had diabetes. The baseline characteristics of the populations from the 2 periods were similar. In patients with diabetes, the composite outcome was observed in 233 (47.5%) in the 2008-2011 cohort and 162 (36%) in the 2018 cohort [HR 1.48; 95% confidence interval (95%CI) 1.18-1.85; p < .001]. The proportion of readmissions (HR 1.39; 95%CI 1.07-1.80; p = .015) and total mortality (HR 1.60; 95%CI 1.20-2.14; p < .001) were also significantly higher in patients with diabetes from the 2008-2011 cohort compared to the 2018 cohort., Conclusions: In 2018, an improvement was observed in the prognosis for all-cause mortality and readmissions over one year of follow-up in patients with diabetes hospitalized for HF compared to the 2008-2011 period., (Copyright © 2021 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

The relationship between diabetes and heart failure is complex and bidirectional. Nevertheless, the existence of a cardiomyopathy attributable exclusively to diabetes has been and is still the subject of controversy, due, among other reasons, to a lack of a consensus definition. There is also no unanimous agreement in terms of the physiopathogenic findings that need to be present in the definition of diabetic cardiomyopathy or on its classification, which, added to the lack of diagnostic methods and treatments specific for this disease, limits its general understanding. Studies conducted on diabetic cardiomyopathy, however, suggest a unique physiopathogenesis different from that of other diseases. Similarly, new treatments have been shown to play a potential role in this disease. The following review provides an update on diabetic cardiomyopathy., (Copyright © 2020 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Introduction: There are few data in the Spanish population about the causes of death in patients admitted to internal medicine departments for heart failure. Their study according to left ventricular ejection fraction (reduced: rEF, mid-range: mEF, and preserved: pEF) could improve the knowledge of patients and their prognosis., Methods: Prospective multicentre cohort study of 4144 patients admitted with heart failure to internal medicine departments. Their clinical characteristics, mortality rate and causes were classified according to pEF (≥ 50%), mEF (40%-49%) and rEF (<40%). Patients were followed-up for a median of one year., Results: There were 1198 deaths (29%). The cause of death was cardiovascular (CV) in 833 patients (69.5%), mainly heart failure (50%) and sudden cardiac death (7.5%). Non-cardiovascular (NoCV) causes were responsible for 365 deaths (30.5%). The most common NoCV causes were infections (13%). The most frequent and early cause in all groups was heart failure. Patients with pEF, compared to the other groups, had lower risk of sudden cardiac death and higher risk of infections (P <.05). The causes of death in patients with mrEF were closer to those with pEF., Conclusions: The causes of death in patients with heart failure were different depending on ejection fraction strata. Patients with mEF and pEF, due to their high comorbidity and higher frequency of NoCV death, would require comprehensive management by internal medicine., (Copyright © 2020 Elsevier España, S.L.U. All rights reserved.)

The objective of this study is to determine the prevalence of cognitive impairment (CogI) in patients hospitalized for congestive heart failure, and the influence of CogI on mortality and hospital readmission. This is a multicenter cohort study of patients hospitalized for congestive heart failure enrolled in the RICA registry. The patients were divided into 3 groups according to their Short Portable Mental Status Questionnaire score: 0-3 errors (no CogI or mild CogI), 4-7 (moderate CogI) and 8-10 (severe CogI). A total of 3845 patients with a mean (SD) age of 79 (8.6) years were included; 2038 (53%) were women. A total of 550 (14%) patients had moderate CogI and 76 (2%) had severe CogI. Factors independently associated with severe CogI were age (OR 1.09, 95% CI 1.05-1.14 p < 0.001), male sex (OR 0.57, 95% CI 0.34-0.95, p = 0.031), heart rate (OR 1.01, 95% CI 1.00-1.02, p = 0.004), Charlson index (OR 1.16, 95% CI 1.06-1.27, p = 0.002), and history of stroke (OR 2.67, 95% CI 1.60-4.44, p < 0.001). Severe CogI was associated with higher mortality after one year (HR 3.05, 95% CI 2.25-4.14, p < 0.001). The composite variable of death/hospital readmission was higher in patients with CogI (log rank p < 0.001). Patients with heart failure and severe CogI are older and have a higher comorbidity burden, lower survival, and a higher rate of death or readmission at 1 year, compared to patients with no CogI.

Aim: The heterogeneity of patients with heart failure and preserved ejection fraction (HFpEF) is high, thusthis entity tends to be grouped into phenotypes to act with precision. Within these groups, patients with type 2 diabetes mellitus (T2DM) hold this heterogeneity. Our aim is to describe subgroups of patients with HFpEF and T2DM based on other comorbidities., Material and Methods: Patients were recruited from the national registry of heart failure (RCIA). Patients with ejection fraction greater than or equal to 50% without valvular disease and with T2DM were included. A hierarchical agglomerative analysis was performed with Ward's method including the following variables: dyslipidemia, liver disease, Chronic obstructive pulmonary disease (COPD), dementia, cerebrovascular disease, arrhythmia, systolic blood pressure, body mass index (BMI), estimation of glomerular filtration and hemoglobin., Results: 1934 patients with ICFEP were included, of which 907 (46.9%) had T2DM with a predominance of women (60.9%) and with a BMI of 31.1 (5.9) Kg / m2. Four groups were obtained, two with high vascular risk (one with arrhythmia and the other without it) with 263 patients the first and 201 the second. A third group had a predominance of COPD (140 patients) and a last group with 303 patients older but with less comorbidity., Conclusions: In our patients with ICFEP and T2DM, obesity and female sex predominated. All four groups offered treatment chances to improve their prognosis not only based on the use of new antidiabetic drugs but also on other options that may be a starting point for further research., (Copyright © 2019 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Introduction: Acute heart failure (AHF) is a frequent epidemic in geriatrics. The main aim of this study was to evaluate the clinical and prognostic differences of very elderly patients with AHF compared to the rest, and evaluate the factors associated with 90-day mortality., Methods: We analyzed 3828 patients hospitalized for AHF with an age of ≥ 70 years. The population was divided into three groups: 70-79, 80-89 and ≥ 90 years old (nonagenarians). The baseline characteristics of patients nonagenarians were compared with the rest. In the group of nonagenarians, their clinical characteristics were analyzed according to the left ventricular ejection fraction (LVEF) and the factors associated with mortality at 90 days of follow-up., Results: Nonagenarians showed higher comorbidity and cognitive deterioration, worse basal functional status, and preserved LVEF. Alternatively, they presented a lower rate of diabetes mellitus, lower incidence of de novo AHF, and lower prescription of angiotensin-converting-enzyme inhibitors, aldosterone blockers, anticoagulants, and statins at hospital discharge. Of the total, 334 patients (9.3%) had died by 90 days. The 90-day mortality rate was highest in nonagenarians (7.1% vs 9.8% vs 17%; p = 0.001). Multivariate analysis showed that renal failure, New York Heart Association (NYHA) functional classifications of III-IV, and a more advanced functional deterioration at baseline are predictors of mortality within 90 days., Conclusions: The AHF in patients nonagenarians has a different clinical profile compared to younger patients and a higher mortality. In this subgroup of patients having a worse baseline functional status, higher NYHA classification (III-IV), and renal failure are predictors of 90-day mortality.

The relationship between diabetes and heart failure is complex and bidirectional. Nevertheless, the existence of a cardiomyopathy attributable exclusively to diabetes has been and is still the subject of controversy, due, among other reasons, to a lack of a consensus definition. There is also no unanimous agreement in terms of the physiopathogenic findings that need to be present in the definition of diabetic cardiomyopathy or on its classification, which, added to the lack of diagnostic methods and treatments specific for this disease, limits its general understanding. Studies conducted on diabetic cardiomyopathy, however, suggest a unique physiopathogenesis different from that of other diseases. Similarly, new treatments have been shown to play a potential role in this disease. The following review provides an update on diabetic cardiomyopathy., (Copyright © 2020 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Aims: To validate externally the CACE-HF clinical prediction rule, which predicts 1-year mortality in patients with heart failure (HF)., Methods: We performed an external validation of the CACE-HF risk score in patients included in the RICA heart failure registry who had completed 1 year of follow-up, comparing the characteristics of the derivation and validation cohorts. The performance of the risk score was evaluated in terms of calibration, using calibration-in-the-large (a), calibration slope (b), and the Hosmer-Lemeshow test, and in terms of discrimination, using the area under the ROC curve., Results: In total, 3337 patients were included in the validation cohort. There were no significant differences between the derivation and validation cohorts in 1-year mortality (24.63% vs. 22.98%) or in the risk score and risk classes. The discrimination capacity in the validation cohort was slightly lower, 0.67 (95% CI: 0.65, 0.69), compared to that of the derivation cohort. Calibration results were a -0.05 (95% CI: -0.14, 0.03), indicating that the average predictions did not differ from the average outcome frequency, and b = 0.75 (95% CI: 0.64, 0.86), indicating a modest inconsistency in predictor effects. Observed mortality versus predicted mortality according to the deciles and risk classes were very similar in both cases, indicating good calibration., Conclusions: The results of the external validation of the CACE-HF risk score show that although the capacity for discrimination was slightly lower than in the derivation cohort, the calibration was excellent. This tool, therefore, can assist in decision-making in the management of these patients., (Copyright © 2019 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Aim: Hyponatremia is very often associated with renal disease in patients with heart failure (HF) and, when present, determines a poor outcome. We investigated the role of hyponatremia in HF patients in whom the presence or absence renal insufficiency was accurately predefined., Methods: This was a cohort study based on the Spanish National Registry on Heart Failure (RICA), a multicenter, prospective registry that enrolls patients admitted for decompensated HF who were subsequently followed up for 1 year. We classified patients into 4 groups according to the presence or absence of renal disease defined by the hematocrit, urea, and gender formula (HUGE) and then according to the presence of hyponatremia (Na ≤135 mEq/L)., Results: A total of 3,478 patients were included. Hyponatremia was more prevalent in the group with renal disease (22.1%) than without (18.4%). During admission, both groups with hyponatremia had more complications than those with normal serum sodium. During the 1-year follow-up, patients with hyponatremia and renal disease had a significantly worse outcome (HF mortality and readmission), HR 1.87, 95% CI 1.54-2.29, p < 0.001, compared to those with hyponatremia without renal disease, HR 1.01, 95% CI 0.79-1.3, p = 0.94., Conclusions: Hyponatremia is more prevalent in patients with renal insufficiency, and outcome is poorest when both renal disease and hyponatremia coexist. Patients with hyponatremia without renal disease show no differences in outcome compared to those without hyponatremia., (© 2019 S. Karger AG, Basel.)

Atrial fibrillation (AF) in the elderly is a complex condition due to the high number of frequently associated comorbidities, such as cardiovascular and kidney disease, cognitive disorders, falls and polypharmacy. Except when contraindicated, anticoagulation is necessary for preventing thromboembolic events in this population. Both vitamin K antagonists and direct oral anticoagulants (dabigatran, rivaroxaban and apixaban) are indicated in this context. Renal function should be closely monitored for this age group when these drugs are used. In recent years, various clinical practice guidelines have been published on patients with AF. The majority of these guidelines make specific recommendations on the clinical characteristics and treatment of elderly patients. In this update, we review the specific comments on the recommendations concerning antithrombotic treatment in elderly patients with nonvalvular AF., (Copyright © 2014 Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI). All rights reserved.)