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Background: While the indication for noninvasive ventilation (NIV) in severely hypoxemic patients with acute heart failure (AHF) is often indicated and may improve clinical course, the benefit of early initiation before patient arrival to the emergency department (ED) remains unknown., Objective: This study aimed to assess the impact of early initiation of NIV during emergency medical service (EMS) transportation on outcomes in patients with AHF., Design: A secondary retrospective analysis of the EAHFE (Epidemiology of AHF in EDs) registry., Setting: Fifty-three Spanish EDs., Participants: Patients with AHF transported by EMS physician-staffed ambulances who were treated with NIV at any time during of their emergency care were included and categorized into two groups based on the place of NIV initiation: prehospital (EMS group) or ED (ED group)., Outcome Measures: Primary outcome was the composite of in-hospital mortality and 30-day postdischarge death, readmission to hospital or return visit to the ED due to AHF. Secondary outcomes included 30-day all-cause mortality after the index event (ED admission) and the different component of the composite primary endpoint considered individually. Multivariate logistic regressions were employed for analysis., Results: Out of 2406 patients transported by EMS, 487 received NIV (EMS group: 31%; EMS group: 69%). Mean age was 79 years, 48% were women. The EMS group, characterized by younger age, more coronary artery disease, and less atrial fibrillation, received more prehospital treatments. The adjusted odds ratio (aOR) for composite endpoint was 0.66 (95% CI: 0.42-1.05). The aOR for secondary endpoints were 0.74 (95% CI: 0.38-1.45) for in-hospital mortality, 0.74 (95% CI: 0.40-1.37) for 30-day mortality, 0.70 (95% CI: 0.41-1.21) for 30-day postdischarge ED reconsultation, 0.80 (95% CI: 0.44-1.44) for 30-day postdischarge rehospitalization, and 0.72 (95% CI: 0.25-2.04) for 30-day postdischarge death., Conclusion: In this ancillary analysis, prehospital initiation of NIV in patients with AHF was not associated with a significant reduction in short-term outcomes. The large confidence intervals, however, may preclude significant conclusion, and all point estimates consistently pointed toward a potential benefit from early NIV initiation., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The aim of the present study was to evaluate the impact of chronic treatment with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) on short-term clinical outcomes after an episode of AHF., Methods: A secondary analysis of patients included in the EAHFE (Epidemiology of Acute Heart Failure in Emergency Departments) cohort, which includes patients diagnosed with AHF in 45 Spanish Emergency Departments (EDs). The primary outcome was all-cause in-hospital mortality. The secondary outcomes were all-cause death within 7 days, need for hospital admission and prolonged hospitalisation defined as a stay longer than or equal to 7 days. Multiple regression and propensity-matching was used for multivariate adjustment., Results: Of the 17,920 patients, 10,041 (56 %) were receiving chronic treatment with ACEI/ARB. The mean age was 80.4 years and 55.7 % were women. Adjusted odds ratios (aOR) were 0.76 (95 % CI 0.71-0.82) for in-hospital mortality witch multiple regression and 0.74 (95 %CI 0.63-0.88) with propensity-matching. aOR were 0.72; (95 %CI 0.65-0.79) and 0.70 (95 %CI 0.57-0.87) for mortality at the 7-day follow-up, respectively. The sensitivity analysis ACEI/ARB were associated with few all-cause deaths in patients with elevated natriuretic peptides in the EDs (aOR 0.74; 95 % CI 0.68-0.80), patients requiring hospital admission (aOR 0.78; 95 % CI 0.73-0.84) and patients with a history of HF (aOR 0.72; 95 % CI 0.66-0.78)., Conclusions: Chronic use of ACEI/ARB was associated with better short-term outcomes in terms of all-cause in-hospital mortality in patients with AHF who attend an EDs., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Aims: To investigate whether seasonal influenza and COVID-19 vaccinations influence the severity of decompensations and long-term outcomes of patients with acute heart failure (AHF)., Methods and Results: We included consecutive AHF patients attended at 40 Spanish emergency departments during November and December 2022. They were grouped according to whether they had received seasonal influenza and COVID-19 vaccination. The severity of heart failure (HF) decompensation was assessed with the MEESSI scale, need for hospitalization, intensive care unit (ICU) admission, and in-hospital mortality. Long-term outcomes were 90-day and 1-year all-cause mortality. Associations between vaccination, HF decompensation severity, and long-term outcomes were investigated. Subgroup analyses were executed for 16 patient characteristics and their relationship with vaccination and 1-year mortality. We analysed 4243 patients (median age 85 years; interquartile range 77-90; 57% female): 1841 (43%) had received influenza vaccination, 3139 (74%) COVID-19 vaccination, 1773 (41.8%) received both vaccines (full vaccination) and 1036 (24.4%) none. Previous episodes of AHF, chronic obstructive pulmonary disease and chronic treatment with diuretics were associated with vaccination (either influenza, COVID-19 and full vaccination). High or very-high risk decompensation occurred in 18.6%; hospitalization in 72.3%, ICU admission in 1.1%, and in-hospital mortality in 8.4%. Influenza vaccination was associated with lower hospitalization rates (adjusted odds ratio [OR] 0.746, 95% confidence interval [CI] 0.636-0.876) and in-hospital mortality (OR 0.761, 95% CI 0.583-0.992), while COVID-19 vaccination was associated with increased hospitalizations (OR 1.215, 95% CI 1.016-1.454). Overall, 90-day and 1-year mortality were 20.3% and 34.4%. Both were decreased in influenza-vaccinated patients (adjusted hazard ratio [HR] 0.831, 95% CI 0.709-0.973; and HR 0.885, 95% CI 0.785-0.999, respectively) but only at 90 days in COVID-19 vaccinated patients (HR 0.829, 95% CI 0.702-0.980). Full vaccination achieved even greater reductions in in-hospital, 90-day, and 1-year mortality (HR 0.638, 95% CI 0.479-0.851; HR 0.702, 95% CI 0.592-0.833; and HR 0.815, 95% CI 0.713-0.931, respectively). Subgroup analysis based on patient-related characteristics demonstrated the consistence of vaccination with long-term survival., Conclusion: In HF patients, seasonal influenza vaccination appears to be associated with less severe decompensation and lower 1-year mortality, while no firm conclusions can be drawn from the results of the present study regarding the benefits of COVID-19 vaccination. Full vaccination is associated with the greatest reduction in short- and long-term mortality., (© 2024 European Society of Cardiology.)

Objective: To study factors associated with hospitalization in an unselected population of patients aged 65 years or older treated for syncope in Spanish hospital emergency departments (EDs). To determine the prevalence of adverse events at 30 days in patients discharged home and the factors associated with such events., Methods: We included all patients aged 65 years or older who were diagnosed with syncope during a single week in 52 Spanish EDs, recording patient clinical and ED case management data. We compared the findings between hospitalized patients and those discharged home, following the latter for 30 days. In discharged patients, we explored predictors of a composite adverse-event outcome (occurrence of any of the following: ED revisits, hospitalization related to the index visit, or any-cause death)., Results: A total of 477 patients with syncope were identified; 67 (14%) were admitted, and 5 (7.5%) died. The median (interquartile range) length of hospital stay was 6 days (3-11 days). Comorbidity increased the probability of hospitalization (odds ratio, 2.172; 95% CI, 1.013-4.655). Among the 410 patients (86%) discharged home from the ED, 9.2% experienced an adverse event within 30 days (ED revisits, 8.,1%; hospitalization, 2.2%; death, 1.5%). No factors were associated with the 30-day composite outcome., Conclusions: The majority of patients aged 65 years or older are discharged home from EDs, and 30-day adverse events, while infrequent, are difficult to predict. Hospitalization was related to comorbidity and an absence of cognitive decline.

Objectives: To determine the prevalence, characteristics, timing of implementation and prognosis of patients with left bundle branch block (LBBB) and acute heart failure (AHF) treated with cardiac resynchronization therapy (CRT) in a real-life registry., Methods: We analysed the characteristics of patients with AHF and LBBB at the time of inclusion in the EAHFE (Epidemiology Acute Heart Failure Emergency) cohort to determine the indication for CRT, the timing of implementation and its impact on 10-year all-cause mortality., Results: 729 patients with a median age of 82 years and there was a high burden of comorbidities and functional dependence. The median left-ventricle ejection fraction (LVEF) was 40%. Forty-six (6%) patients were treated with CRT at some point during follow-up, with a median time of delay for CRT implementation of 960 (IQR=1,147 days) and at least 108 more untreated patients fulfilled criteria for CRT. Patients receiving CRT were younger, had different comorbidities, less functional dependence (higher Barthel index) and lower LVEF values. The median follow-up was 5.7 years (95% CI: 5.6-5.8) and CRT was not associated with changes in 10-year mortality (adjusted HR 1.33, 95% CI: 0.72-2.48; p-value 0.4). When compared with untreated patients fulfilling criteria for CRT, very similar results were observed (adjusted HR 1.34, 95% CI: 0.67-2.68). , Conclusions: CRT implementation was delayed and underused in patients with AHF and LBBB. Under these circumstances, CRT is not associated with a reduction in all-cause mortality in the long term., Competing Interests: Conflicts of interest: The authors declare that they have no conflict of interest., (Copyright © 2023 Colombia Medica.)

Objective: To investigate the association of corrected QT (QTc) interval duration and short-term outcomes in patients with acute heart failure (AHF)., Methods: We analyzed AHF patients enrolled in 11 Spanish emergency departments (ED) for whom an ECG with QTc measurement was available. Patients with pace-maker rhythm were excluded. Primary outcome was 30-day all-cause mortality and secondary outcomes were need of hospitalization, in-hospital mortality and prolonged hospitalization (> 7 days). Association between QTc and outcomes was explored by restricted cubic spline (RCS) curves. Results were expressed as odds ratios (OR) and 95%CI adjusted by patients baseline and decompensation characteristics, using a QTc = 450 ms as reference., Results: Of 1800 patients meeting entry criteria (median age 84 years (IQR = 77-89), 56% female), their median QTc was 453 ms (IQR = 422-483). The 30-day mortality was 9.7%, while need of hospitalization, in-hospital mortality and prolonged hospitalization were 77.8%, 9.0% and 50.0%, respectively. RCS curves found longer QTc was associated with 30-day mortality if > 561 ms, OR = 1.86 (1.00-3.45), and increased up to OR = 10.5 (2.25-49.1), for QTc = 674 ms. A similar pattern was observed for in-hospital mortality; OR = 2.64 (1.04-6.69), for QTc = 588 ms, and increasing up to OR = 8.02 (1.30-49.3), for QTc = 674 ms. Conversely, the need of hospitalization had a U-shaped relationship: being increased in patients with shorter QTc [OR = 1.45 (1.00-2.09) for QTc = 381 ms, OR = 5.88 (1.25-27.6) for the shortest QTc of 200 ms], and also increasing for prolonged QTc [OR = 1.06 (1.00-1.13), for QTc = 459 ms, and reaching OR = 2.15 (1.00-4.62) for QTc = 588 ms]. QTc was not associated with prolonged hospitalization., Conclusion: In ED AHF patients, initial QTc provides independent short-term prognostic information, with increasing QTc associated with increasing mortality, while both, shortened and prolonged QTc are associated with need of hospitalization., (© 2023. The Author(s).)

Objectives: To analyze the consistency between decisions to discharge or admit patients with acute heart failure (AHF) treated in emergency departments (EDs) and the level of risk of adverse events, and to analyze the impact of decisions to discharge patients., Material and Methods: Prospective study of baseline clinical data collected from patients diagnosed with AHF in 16 Spanish emergency departments. Patients were stratified by severity of decompensated AHF based on MEESSI assessment (Multiple Estimation of Risk Based on the Spanish Emergency Department Score). The distribution of severity was described for patients who were hospitalized (overall and for departments receiving the largest number of admissions) and for discharged patients. We analyzed the data for discharged patients for associations with the following quality-of-care indicators: all-cause mortality of less than 2% at 30 days, revisits to the ED for AHF in less than 10% of patients within 7 days of discharge, and revisits to the ED or admission for AHF in less than 20% within 30 days of discharge., Results: We included 2855 patients with a median (interquartile range) age of 84 (76-88) years. Fifty-four percent were women, 1042 (36.5%) were classified as low risk, 1239 (43.4%) as intermediate risk, 301 (10.5%) as high risk, and 273 (9.6%) as very high risk. Thirty-day mortality rates by level of low to very high risk were 1.9%, 9.3%, 15.3%, and 38.4%, respectively. One-year mortality rates by risk level were 15.4%, 35.6%, 52.0%, and 74.2%. Admission rates by risk level were 62.2%, 77.4%, 87.0%, and 88.3%. Overall, 47.1% o patients discharged from the ED were in the 3 higher-risk categories (intermediate to very high), and 30.7% were in the lowest risk category. The 5 hospital areas receiving the most admissions, in order of lowest-to-highest risk classification, were internal medicine, the short-stay unit, cardiology, intensive care, and geriatrics. Rates and 95% CIs for quality-of-care indicators in patients discharged from EDs were as follows: 30-day mortality, 4.3% (3.0%-6.1%); ED revisits within 7 days, 11.4% (9.2%-14.0%), and ED revisits or admissions within 30 days, 31.5% (28.0%-35.1%). In patients classified as low risk on ED discharge, these percentages were lower, as follows, respectively: 0.5% (0.1%-1.8%), 10.5% (7.6%-14.0%), and 29.5% (26.6%-32.6%)., Conclusion: We detected disparity between severity of AHF decompensation and the decision to discharge or admit patients. Outcomes in patients discharged from EDs do not reach the recommended quality-of-care standards. Reducing inconsistencies between severity of decompensation and ED decisions could help to improve quality targets.

Short stay unit (SSU) is an alternative to conventional hospitalization in patients with acute heart failure (AHF), but the prognosis is not known compared to direct discharge from the emergency department (ED). To determine whether direct discharge from the ED of patients diagnosed with AHF is associated with early adverse outcomes versus hospitalization in SSU. Endpoints, defined as 30-day all-cause mortality or post-discharge adverse events, were evaluated in patients diagnosed with AHF in 17 Spanish EDs with an SSU, and compared by ED discharge vs. SSU hospitalization. Endpoint risk was adjusted for baseline and AHF episode characteristics and in patients matched by propensity score (PS) for SSU hospitalization. Overall, 2358 patients were discharged home and 2003 were hospitalized in SSUs. Discharged patients were younger, more frequently men, with fewer comorbidities, had better baseline status, less infection, rapid atrial fibrillation and hypertensive emergency as the AHF trigger, and had a lower severity of AHF episode. While their 30-day mortality rate was lower than in patients hospitalized in SSU (4.4% vs. 8.1%, p < 0.001), 30-day post-discharge adverse events were similar (27.2% vs. 28.4%, p = 0.599). After adjustment, there were no differences in the 30-day risk of mortality of discharged patients (adjusted HR 0.846, 95% CI 0.637-1.107) or adverse events (1.035, 0.914-1.173). In 337 pairs of PS-matched patients, there were no differences in mortality or risk of adverse event between patients directly discharged or admitted to an SSU (0.753, 0.409-1.397; and 0.858, 0.645-1.142; respectively). Direct ED discharge of patients diagnosed with AHF provides similar outcomes compared to patients with similar characteristics and hospitalized in a SSU., (© 2023. The Author(s).)

Objective: To investigate whether the existence of heart failure units (HFU) and link nurse units (LNU) in the hospital improve short-term outcomes of acute heart failure (AHF) episodes., Methods: Patients with AHF diagnosed in 45 Spanish emergency departments were analysed according to whether the hospital had a complete development of follow-up units (HFU + LNU), partial (HFU or LNU) or none. The outcomes were: 30-day mortality, hospitalization, in-hospital mortality, >7 days admission, and adverse event (death, rehospitalisation, or reconsultation to the emergency department) at 30 days post-discharge. Outcomes were adjusted for baseline and AHF episode characteristics., Results: 19,947 patients were included, median age was 82 years (IQR 76--87), women were 55%. It was 20% of patients attended in hospitals with null development, 28% with partial development and 52% with complete development. Mortality at 30 days was 10.1% (null/partial/complete development: 10.5%/9.5%/10.4%; p=0.880), hospitalization 74.6% (72.7%/72.7%/75.7%; p<0.001), in-hospital mortality 7.4% (7.6%/7.0%/7.5%; p=0.995), prolonged hospitalization 47.4% (51.1%/52.4%/43.5%; p<0.001) and adverse events 30 days post-hospitalization 30.3% (36.2%/28.9%/30.3%; p < 0.001). In the adjusted analysis, hospital with complete development of follow-up units was not associated with mortality, but with increased hospitalization (OR= 1.172; 95%CI 1.069-1.285) and lower prolonged hospitalization (OR = 0.725; 95%CI 0.660-0.797) and adverse events at 30 days post-discharge (OR=0.831; 95%CI 0.755-0.916). Partial development was only associated with decreased post-discharge adverse events (OR= 0.782; 95%CI 0.702-0.871)., Conclusion: The development of follow-up units is not associated with 30-day mortality, but is associated with less prolonged hospitalization and fewer post-discharge adverse events in patients with AHF., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Objectives: To describe the sociodemographic characteristics of and the health care resources used to treat patients aged 65 years or older who come to hospital emergency departments (EDs) in Spain, according to age groups., Material and Methods: We studied the phase-1 data for the EDEN cohort (Emergency Department and Elder Needs). Forty Spanish EDs collected data on all patients aged 65 years or older who were treated on the first 7 days in April 2019. We registered information on 6 sociodemographic and 5 function variables for all patients. For health resource use we used 6 diagnostic, 13 therapeutic, and 5 physical structural variables, for a total of 24 variables. Differences were analyzed according to age in blocks of 5 years., Results: A total of 18 374 patients with a median age of 78 years were included; 55% were women. Twenty-seven percent arrived by ambulance, 71% had not previously been seen by a physician, and 13% lived alone without assistance. Ten percent had a high level of functional dependence, and 14% had serious comorbidity. Resources used most often were blood analysis (in 60%) and radiology (59%), analgesics (25%), intravenous fluids (21%), antibiotics (14%), oxygen (13%), and bronchodilators (11%). Twenty-six percent were kept under observation in the ED, 26% were admitted to wards, and 2% were admitted to intensive care units (ICUs). The median stay in the ED was 3.5 hours, and the median hospital stay was 7 days. Sociodemographic characteristics changed according to age. Functional dependence worsened with age, and resource requirements increased in general. However, benzodiazepine use was unaffected, while the use of nonsteroidal anti-inflammatory drugs and ICU admission decreased., Conclusion: The functional dependence of older patients coming to EDs increases with age and is associated with a high level of health care resource use, which also increases with age. Planners should take into consideration the characteristics of the older patients and the proportion of the caseload they represent when arranging physical spaces and designing processes for a specific ED.

Objectives: 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., Material and Methods: 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)., Results: 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)., Conclusion: 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.

Introduction and Objectives: To determine whether structural/organizational characteristics of hospitals and emergency departments (EDs) affect acute heart failure (AHF) outcomes., Methods: We performed a secondary analysis of the EAHFE Registry. Six hospital/ED characteristics were collected and were related to 7 postindex events and postdischarge outcomes, adjusted by the period of patient inclusion, baseline patient characteristics, AHF episode features, and hospital and ED characteristics. The relationship between discharge directly from the ED (DDED) and outcomes was assessed, and interaction was analyzed according to the hospital/ED characteristics., Results: We analyzed 17 974 AHF episodes included by 40 Spanish EDs. Prolonged stays were less frequent in high-technology hospitals and those with hospitalization at home and with high-inflow EDs, and were more frequent in hospitals with a heart failure unit (HFU) and an ED observation unit. In-hospital mortality was lower in high-technology hospitals (OR, 0.78; 95%CI, 0.65-0.94). Analysis of 30-day postdischarge outcomes showed that hospitals with a short-stay unit (SSU) had higher hospitalization rates (OR, 1.19; 95%CI, 1.02-1.38), high-inflow EDs had lower mortality (OR, 0.73; 95%CI, 0.56-0.96) and fewer combined events (OR, 0.87; 95%CI, 0.76-0.99), while hospitals with HFU had fewer ED reconsultations (OR, 0.83; 95%CI, 0.76-0.91), hospitalizations (OR, 0.85; 95%CI, 0.75-0.97), and combined events (OR, 0.84; 95%CI, 0.77-0.92). The higher the percentage of DDED, the fewer the prolonged stays. Among other interactions, we found that more frequent DDED was associated with more 30-day postdischarge reconsultations, hospitalizations and combined events in hospitals without SSUs, but not in hospitals with an SSU., Conclusions: AHF outcomes were significantly affected by the structural/organizational characteristics of hospitals and EDs and their aggressiveness in ED management., (Copyright © 2020 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.)

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., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Objective: To identify patients at risk of in-hospital mortality and adverse outcomes during the vulnerable post-discharge period after the first acute heart failure episode (de novo AHF) attended at the emergency department., Methods: This is a secondary review of de novo AHF patients included in the prospective, multicentre EAHFE (Epidemiology of Acute Heart Failure in Emergency Department) Registry. We included consecutive patients with de novo AHF, for whom 29 independent variables were recorded. The outcomes were in-hospital all-cause mortality and all-cause mortality and readmission due to AHF within 90 days post-discharge. A follow-up check was made by reviewing the hospital medical records and/or by phone., Results: We included 3422 patients. The mean age was 80 years, 52.1% were women. The in-hospital mortality was 6.9% and was independently associated with dementia (OR = 2.25, 95% CI = 1.62-3.14), active neoplasia (1.97, 1.41-2.76), functional dependence (1.58, 1.02-2.43), chronic treatment with beta-blockers (0.62, 0.44-0.86) and severity of decompensation (6.38, 2.86-14.26 for high-/very high-risk patients). The 90-day post-discharge combined endpoint was observed in 19.3% of patients and was independently associated with hypertension (HR = 1.40, 1.11-1.76), chronic renal insufficiency (1.23, 1.01-1.49), heart valve disease (1.24, 1.01-1.51), chronic obstructive pulmonary disease (1.22, 1.01-1.48), NYHA 3-4 at baseline (1.40, 1.12-1.74) and severity of decompensation (1.23, 1.01-1.50; and 1.64, 1.20-2.25; for intermediate and high-/very high-risk patients, respectively), with different risk factors for 90-day post-discharge mortality or rehospitalisation., Conclusions: The severity of decompensation and some baseline characteristics identified de novo AHF patients at increased risk of developing adverse outcomes during hospitalisation and the vulnerable post-discharge phase, without significant differences in these risk factors according to patient age at de novo AHF presentation.

Objectives: To study the effect of high-risk criteria on 30-day outcomes in frail older patients with acute heart failure (AHF) discharged from an emergency department (ED) or an ED's observation and short-stay areas., Material and Methods: Secondary analysis of discharge records in the Older AHF Key Data registry. We selected frail patients (aged > 70 years) discharged with AHF from EDs. Risk factors were categorized as modifiable or nonmodifiable. The outcomes were a composite endpoint for a cardiovascular event (revisits for AHF, hospitalization for AHF, or cardiovascular death) and the number of days alive out-of-hospital (DAOH) within 30 days of discharge., Results: We included 380 patients with a mean (SD) age of 86 (5.5) years (61.2% women). Modifiable risk factors were identified in 65.1%, nonmodifiable ones in 47.8%, and both types in 81.6%. The 30-day cardiovascular composite endpoint occurred in 83 patients (21.8%). The mean 30-day DAOH observed was 27.6 (6.1) days. Highrisk factors were present more often in patients who developed the cardiovascular event composite endpoint: the rates for patients with modifiable, nonmodifiable, or both types of risk were, respectively, as follows in comparison with patients not at high risk: 25.0% vs 17.2%, P = .092; 27.6% vs 16.7%, P = .010; and 24.7% vs 15.2%, P = .098). The 30-day DAOH outcome was also lower for at-risk patients, according to type of risk factor present: modifiable, 26.9 (7.0) vs 28.4 (4.4) days, P = .011; nonmodifiable, 27.1 (7.0) vs 28.0 (5.0) days, P = .127; and both, 27.1 (6.7) vs 28.8 (3.4) days, P = .005). After multivariate analysis, modifiable risk remained independently associated with fewer days alive (adjusted absolute difference in 30-day DAOH, -1.3 days (95% CI, -2.7 to -0.1 days). Nonmodifiable factors were associated with increased risk for the 30-day cardiovascular composite endpoint (adjusted absolute difference, 10.4%; 95% CI, -2.1% to 18.7%)., Conclusion: Risk factors are common in frail elderly patients with AHF discharged home from hospital ED areas. Their presence is associated with a worse 30-day prognosis.

Background: The multiple estimation of risk based on the emergency department Spanish score in patients with acute heart failure (MEESSI-AHF) is a risk score designed to predict 30-day mortality in acute heart failure patients admitted to the emergency department. Using a derivation cohort, we evaluated the performance of the MEESSI-AHF risk score to predict 11 different short-term outcomes., Methods: Patients with acute heart failure from 41 Spanish emergency departments (n=7755) were recruited consecutively in two time periods (2014 and 2016). Logistic regression models based on the MEESSI-AHF risk score were used to obtain c-statistics for 11 outcomes: three with follow-up from emergency department admission (inhospital, 7-day and 30-day mortality) and eight with follow-up from discharge (7-day mortality, emergency department revisit and their combination; and 30-day mortality, hospital admission, emergency department revisit and their two combinations with mortality)., Results: The MEESSI-AHF risk score strongly predicted mortality outcomes with follow-up starting at emergency department admission (c-statistic 0.83 for 30-day mortality; 0.82 for inhospital death, P=0.121; and 0.85 for 7-day mortality, P=0.001). Overall, mortality outcomes with follow-up starting at hospital discharge predicted slightly less well (c-statistic 0.80 for 7-day mortality, P=0.011; and 0.75 for 30-day mortality, P<0.001). In contrast, the MEESSI-AHF score predicted poorly outcomes involving emergency department revisit or hospital admission alone or combined with mortality (c-statistics 0.54 to 0.62)., Conclusions: The MEESSI-AHF risk score strongly predicts mortality outcomes in acute heart failure patients admitted to the emergency department, but the model performs poorly for outcomes involving hospital admission or emergency department revisit. There is a need to optimise this risk score to predict non-fatal events more effectively., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Objective: Experts recommended that direct discharge without hospitalization (DDWH) for emergency departments (EDs) able to observe acute heart failure (AHF) patients should be >40%, and these discharged patients should fulfil the following outcome standards: 30-day all-cause mortality <2% (outcome A); 7-day ED revisit due to AHF < 10% (outcome B); and 30-day ED revisit/hospitalization due to AHF < 20% (outcome C). We investigated these outcomes in a nationwide cohort and their relationship with the ED DDWH percentage., Methods: We analyzed the EAHFE registry (includes about 15% of Spanish EDs), calculated DDWH percentage of each ED, and A/B/C outcomes of DDWH patients, overall and in each individual ED. Relationship between ED DDWH and outcomes was assessed by linear and quadratic regression models, non-weighted and weighted by DDWH patients provided by each ED., Results: Among 17,420 patients, 4488 had DDWH (25.8%, median ED stay = 0 days, IQR = 0-1). Only 12.9% EDs achieved DDWH > 40%. Considering DDWH patients altogether, outcomes A/C were above the recommended standards (4.3%/29.4%), while outcome B was nearly met (B = 10.1%). When analyzing individual EDs, 58.1% of them achieved the outcome B standard, while outcomes A/C standards were barely achieved (19.3%/9.7%). We observed clinically relevant linear/quadratic relationships between higher DDWH and worse outcomes B (weighted R 2  = 0.184/0.322) and C (weighted R 2  = 0.430/0.624), but not with outcome A (weighted R 2  = 0.002/0.022)., Conclusions: The EDs of this nationwide cohort do not fulfil the standards for AHF patients with DDWH. High DDWH rates negatively impact ED revisit or hospitalization but not mortality. This may represent an opportunity for improvement in better selecting patients for early ED discharge and in ensuring early follow-up after ED discharge., (Copyright © 2020. Published by Elsevier Ltd.)

Objective: To describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU)., Method: We included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge., Results: The study included 1473 patients (HH/IM/SSU: 68/979/384). The HH rate was 4.7% (95% CI, 3.8-6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5-12), similar to that of IM (median stay, 8 days; IQR, 5-13; p=.106) and longer than that of SSU (median stay, 4 days; IQR, 3-7; p<.001). The all-cause mortality at 1 year for HH did not differ from that of IM (HR, 0.91; 95% CI, 0.73-1.14) or SSU (HR, 0.77; 95% CI, 0.46-1.27); however, the emergency department readmission rate during the 30 days postdischarge was lower than that of IM (HR, 0.50; 95% CI, 0.25-0.97) and SSU (HR, 0.37; 95% CI, 0.19-0.74). There were no differences in the need for new hospitalisations or in the 30-day mortality rate., Conclusions: Direct transfer from the emergency department to HH is infrequent despite being a safe option for a certain patient profile with AHF., (Copyright © 2020 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Objective: To describe the frequency, clinical characteristics and outcomes of patients with acute heart failure (AHF) transferred directly from emergency departments to home hospitalisation (HH) and to compare them with those hospitalised in internal medicine (IM) or short-stay units (SSU)., Method: We included patients with AHF transferred to HH by hospitals that considered this option during the Epidemiology of Acute Heart Failure in Spanish Emergency Departments (EAHFE) 4-5-6 Registries and compared them with patients admitted to IM or SSU in these centres. We compared the adjusted all-cause mortality at 1 year and adverse events 30 days after discharge., Results: The study included 1473 patients (HH/IM/SSU:68/979/384). The HH rate was 4.7% (95% CI 3.8-6.0%). The patients in HH had few differences compared with those hospitalised in IM and SSUs. The HH mortality was 1.5%, and the HH median stay was 7.5 days (IQR, 4.5-12), similar to that of IM (median stay, 8 days; IQR, 5-13; p = .106) and longer than that of SSU (median stay, 4 days; IQR, 3-7; p < .001). The all-cause mortality at 1 year for HH did not differ from that of IM (HR, 0.91; 95% CI 0.73-1.14) or SSU (HR, 0.77; 95% CI 0.46-1.27); however, the emergency department readmission rate during the 30 days postdischarge was lower than that of IM (HR, 0.50; 95% CI 0.25-0.97) and SSU (HR, 0.37; 95% CI 0.19-0.74). There were no differences in the need for new hospitalisations or in the 30-day mortality rate., Conclusions: Direct transfer from the emergency department to HH is infrequent despite being a safe option for a certain patient profile with AHF., (Copyright © 2020 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Objective: To compare the clinical characteristics and outcomes of patients with acute heart failure (AHF) according to clinical profiles based on congestion and perfusion determined in the emergency department (ED)., Methods and Results: Overall, 11 261 unselected AHF patients from 41 Spanish EDs were classified according to perfusion (normoperfusion = warm; hypoperfusion = cold) and congestion (not = dry; yes = wet). Baseline and decompensation characteristics were recorded as were the main wards to which patients were admitted. The primary outcome was 1-year all-cause mortality; secondary outcomes were need for hospitalisation during the index AHF event, in-hospital all-cause mortality, prolonged hospitalisation, 7-day post-discharge ED revisit for AHF and 30-day post-discharge rehospitalisation for AHF. A total of 8558 patients (76.0%) were warm + wet, 1929 (17.1%) cold + wet, 675 (6.0%) warm + dry, and 99 (0.9%) cold + dry; hypoperfused (cold) patients were more frequently admitted to intensive care units and geriatrics departments, and warm + wet patients were discharged home without admission. The four phenotypes differed in most of the baseline and decompensation characteristics. The 1-year mortality was 30.8%, and compared to warm + dry, the adjusted hazard ratios were significantly increased for cold + wet (1.660; 95% confidence interval 1.400-1.968) and cold + dry (1.672; 95% confidence interval 1.189-2.351). Hypoperfused (cold) phenotypes also showed higher rates of index episode hospitalisation and in-hospital mortality, while congestive (wet) phenotypes had a higher risk of prolonged hospitalisation but decreased risk of rehospitalisation. No differences were observed among phenotypes in ED revisit risk., Conclusions: Bedside clinical evaluation of congestion and perfusion of AHF patients upon ED arrival and classification according to phenotypic profiles proposed by the latest European Society of Cardiology guidelines provide useful complementary information and help to rapidly predict patient outcomes shortly after ED patient arrival., (© 2019 The Authors. European Journal of Heart Failure © 2019 European Society of Cardiology.)