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Background: Congestion is an essential issue in patients with heart failure (HF). Standard treatments do not usually achieve decongestion, and various strategies have been proposed to guide treatment, such as determination of natriuresis. After starting treatment with loop diuretics, we postulate that initial natriuresis might help treatment titration, decongestion, and improve prognosis., Methods: It was a prospective and observational study. Patients admitted with the diagnosis of HF decompensation were eligible. An assessment of congestion was performed during the first 48 h., Results: A total of 113 patients were included. A poor diuretic response was observed in 39.8%. After the first 48 h, patients with a greater diuretic response on admission (NaU > 80 mmol/L) showed fewer pulmonary b lines (12 vs. 15; p = 0.084), a lower IVC diameter (18 mm vs. 22 mm; p = 0.009), and lower IAP figures (11 mmHg vs. 13 mmHg; p = 0.041). Survival analysis tests demonstrated significant differences showing a higher proportion of all-cause mortality (ACM) and HF rehospitalization in the poor-diuretic-response group (log-rank test = 0.020)., Conclusions: Up to 40% of the patients presented a poorer diuretic response at baseline, translating into worse outcomes. Patients with an optimal diuretic response showed significantly higher abdominal decongestion at 48 h and a better prognosis regarding ACM and/or HF rehospitalizations., Competing Interests: The authors declare no conflicts of interest.

Purpose of the Review: An efficient diuretic response is vital during cardiac decompensation in heart failure (HF) patients. The increase in intra-abdominal pressure (IAP) could be one of the keys for understanding cardiorenal syndrome and guiding diuretic treatment during hospitalization. In this review, we analyze the relationship between IAP and diuretic response in HF patients., Recent Findings: Increased IAP is associated with worsening renal function (WRF) in patients with advanced HF. Furthermore, the persistence of a rise in IAP after the first 72 h of intravenous diuretic treatment has been correlated with a worse diuretic response, a higher degree of congestion, and an impaired prognosis. The rise in IAP in HF patients has been associated with impaired renal function and a lower diuretic response. Nonetheless, more studies are needed to elucidate the actual role of IAP in congestive nephropathy and whether it may help guide diuretic therapy during acute decompensations., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Point of care lung ultrasound (POCUS) has been recently used to assess prognosis in COVID-19 patients. However, there are no data comparing POCUS and chest-X ray, a technique widely used., Patients and Methods: Retrospective analysis in stable COVID-19 patients. Schalekamp radiological lung scale and LUZ-Score ultrasound scale were compared. Primary end-point was in-hospital death and/or need for Intensive Care Unit admission., Results: A total of 138 patients were included. Median Schalekamp scale was 2 (2) and median LUZ-Score scale was 21 (10). No significant correlation was observed between both techniques. Patients with a LUZ-Score ≥ 21 points at admission had worse lung function and higher concentrations of LDH, CRP and Interleuquine-6. Schalekamp scale failed to identify patients at a higher risk at admission for the primary end-point. Addition of POCUS to a previous clinical model, improved risk prediction (AUC 0.805 [95% CI: 0.662-0.948]; P  = <0.001)., Conclusions: Chest X-ray and POCUS showed no correlation at admission in this analysis. Only POCUS identified a group of patients with greater clinical and analytical involvement. POCUS improved, previous clinical model, while chest X-ray did not add relevant predictive information for the primary endpoint., (© 2022 Elsevier España, S.L.U. All rights reserved.)

Introduction: Hospitalization for acute decompensation of heart failure (ADHF) is a frequent event associated with long‑term adverse effects. Prognosis is even worse if acute kidney injury (AKI) occurs during hospitalization., Objectives: The study aimed to determine whether kidney damage biomarkers neutrophil gelatinase‑associatedlipocalin (NGAL), kidney injury molecule 1 (KIM‑1), and interleukin18 (IL‑18) might predict AKI and have prognostic value in ADHF., Patients and Methods: Serum NGAL on admission and urine NGAL, KIM‑1, and IL‑18 on discharge were determined in 187 ADHF patients enrolled in a prospective, observational, unblinded study. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. Patients were followedfor 12 months to record all‑cause mortality., Results: A total of 22% patients died during the follow‑up, with 52.5% dying within 4 months after discharge. Serum NGAL (P <0.001), urine NGAL (P = 0.047), and urinary KIM‑1 (P = 0.014) levels were significantly higher in the deceased patients at discharge. After adjustment for estimated glomerular filtration rate (eGFR), only urinary KIM‑1 independently predicted mortality at month 4 (hazard ratio [HR], 3.166; 95% CI, 1.203-8.334; P = 0.020) and month 12 (HR, 1.969; 95% CI, 1.123-3.454; P = 0.018) in Cox regression models. In receiver operating characteristic (ROC) analysis urinary KIM‑1 (area under the ROC curve [AUC] = 0.830) outperformed other markers of renal function. The Kaplan-Meier survival analysis showed KIM‑1 predictive value as additive to that of AKI incidence and admission eGFR. Admission serum NGAL was higher in AKI patients (P ≤0.001) with a modest diagnostic performance (AUC = 0.667), below that of urea (AUC = 0.732), creatinine (AUC = 0.696), or cystatin C (AUC = 0.676)., Conclusions: Discharge urinary KIM‑1 was a strong and independent predictor of mortality, particularly during the most vulnerable period shortly after hospitalization. Admission serum NGAL was inferior to conventional renal function parameters in predicting AKI during ADHF.

Aims: Increased intra-abdominal pressure (IAP) is now considered a potential contributor to organ damage and disease progression in acute heart failure (AHF). In this work, we aimed to determine if antigen carbohydrate 125 (CA125) is associated with IAP and to identify a cutpoint of CA125 useful for ruling out intra-abdominal hypertension (defined as IAP ≥ 12 mmHg)., Methods and Results: We prospectively evaluated a cohort of 53 patients admitted with AHF in which IAP was measured within the first 24-h of admission. The mean age was 80 ± 8 years, 31 (58.5%) were female, and 31 (58.5%) had left ventricular ejection fraction ≥50%. The median plasma levels of NT-proBNP and CA125 were 3830 pg/mL (2417-8929) and 45.8 U/mL (29.8-114.0), respectively. The median of IAP was 15 mmHg (11-17), and 39 (73%) patients had an IAP ≥ 12 mmHg. The diagnostic performance of CA125 for identifying an IAP ≥ 12 mmHg was tested using the receiving operating characteristic (ROC) curve. The cut-off for CA125 of 17.1 U/mL showed a sensitivity of 92%, a specificity of 50%, and an area under the ROC curve of 0.71. After multivariate adjustment, CA125 remained non-linearly and positively associated with higher IAP (P-value = 0.003), explaining almost 28% of the model's variability (R2: 27.6%)., Conclusions: Patients with AHF and intra-abdominal hypertension had higher CA125 plasma levels. A baseline concentration of CA125 below 17.1 U/mL will increase the odds of identifying a subset of patients with normal IAP., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Risk stratification of COVID-19 patients is fundamental to improving prognosis and selecting the right treatment. We hypothesized that a combination of lung ultrasound (LUZ-score), biomarkers (sST2), and clinical models (PANDEMYC score) could be useful to improve risk stratification., Methods: This was a prospective cohort study designed to analyze the prognostic value of lung ultrasound, sST2, and PANDEMYC score in COVID-19 patients. The primary endpoint was in-hospital death and/or admission to the intensive care unit. The total length of hospital stay, increase of oxygen flow, or escalated medical treatment during the first 72 h were secondary endpoints., Results: a total of 144 patients were included; the mean age was 57.5 ± 12.78 years. The median PANDEMYC score was 243 (52), the median LUZ-score was 21 (10), and the median sST2 was 53.1 ng/mL (30.9). Soluble ST2 showed the best predictive capacity for the primary endpoint (AUC = 0.764 (0.658-0.871); p = 0.001), towards the PANDEMYC score (AUC = 0.762 (0.655-0.870); p = 0.001) and LUZ-score (AUC = 0.749 (0.596-0.901); p = 0.002). Taken together, these three tools significantly improved the risk capacity (AUC = 0.840 (0.727-0.953); p ≤ 0.001)., Conclusions: The PANDEMYC score, lung ultrasound, and sST2 concentrations upon admission for COVID-19 are independent predictors of intra-hospital death and/or the need for admission to the ICU for mechanical ventilation. The combination of these predictive tools improves the predictive power compared to each one separately. The use of decision trees, based on multivariate models, could be useful in clinical practice.

Background: Malnutrition is frequent in patients with heart failure (HF) and contributes to increased systemic congestion, but also hinders its correct assessment, especially during decompensations. Estimating the degree of malnutrition and its relationship with systemic congestion is important to optimize treatment during decompensations., Material and Methods: Retrospective cohort study in patients with acute HF. The population was stratified according to CONUT (Controlling Nutritional Status) and PNI (Prognostic Nutritional Index) nutrition indices in order to analyse their relationship with objective parameters of congestion and the prognostic value of malnutrition., Results: 309 patients were included. More than half presented some degree of malnutrition upon admission. The degree of congestion was significantly higher in malnourished patients, with a higher proportion of «comet tail artifacts» and a higher relative plasma volume. NT-proBNP concentrations, both on admission and at discharge, were also significantly higher in malnourished patients, regardless of the scale used. The univariate analysis identified the CONUT and PNI index as factors associated with one-year mortality from any cause (HR 1.62 [1.22-2.14]; p = 0.001) and PNI (HR 65 [0.53-0.80]; p = < 0.001), respectively., Conclusions: A higher degree of malnutrition (determined by means of the CONUT and PNI indices) in patients with acute HF was associated with a higher presence of objective parameters of congestion and a higher one-year all-cause mortality., (Copyright © 2020 Elsevier España, S.L.U. All rights reserved.)

Background: Lung ultrasound is feasible for assessing lung injury caused by coronavirus disease 2019 (COVID-19). However, the prognostic meaning and time-line changes of lung injury assessed by lung ultrasound in COVID-19 hospitalised patients are unknown., Methods: Prospective cohort study designed to analyse prognostic value of lung ultrasound in COVID-19 patients by using a quantitative scale (lung ultrasound Zaragoza (LUZ)-score) during the first 72 h after admission. The primary end-point was in-hospital death and/or admission to the intensive care unit. Total length of hospital stay, increase of oxygen flow and escalation of medical treatment during the first 72 h were secondary end-points., Results: 130 patients were included in the final analysis; mean±sd age was 56.7±13.5 years. Median (interquartile range) time from the beginning of symptoms to admission was 6 (4-9) days. Lung injury assessed by LUZ-score did not differ during the first 72 h (21 (16-26) points at admission versus 20 (16-27) points at 72 h; p=0.183). In univariable logistic regression analysis, estimated arterial oxygen tension/inspiratory oxygen fraction ratio (PAFI) (hazard ratio 0.99, 95% CI 0.98-0.99; p=0.027) and LUZ-score >22 points (5.45, 1.42-20.90; p=0.013) were predictors for the primary end-point., Conclusions: LUZ-score is an easy, simple and fast point-of-care ultrasound tool to identify patients with severe lung injury due to COVID-19, upon admission. Baseline score is predictive of severity along the whole period of hospitalisation. The score facilitates early implementation or intensification of treatment for COVID-19 infection. LUZ-score may be combined with clinical variables (as estimated by PAFI) to further refine risk stratification., Competing Interests: Conflict of interest: J. Rubio-Gracia has nothing to disclose. Conflict of interest: I. Giménez-López has nothing to disclose. Conflict of interest: V. Garcés-Horna has nothing to disclose. Conflict of interest: D. López-Delgado has nothing to disclose. Conflict of interest: J.L. Sierra-Monzón has nothing to disclose. Conflict of interest: L. Martínez-Lostao has nothing to disclose. Conflict of interest: C. Josa-Laorden has nothing to disclose. Conflict of interest: F. Ruiz-Laiglesia has nothing to disclose. Conflict of interest: J.I. Pérez-Calvo has nothing to disclose. Conflict of interest: S. Crespo-Aznarez has nothing to disclose. Conflict of interest: J. García-Lafuente has nothing to disclose. Conflict of interest: N. Peña-Fresneda has nothing to disclose. Conflict of interest: B. Amores Arriaga has nothing to disclose. Conflict of interest: B. Gracia-Tello has nothing to disclose. Conflict of interest: M. Sánchez-Marteles has nothing to disclose., (Copyright ©The authors 2021.)

Although several biomarkers have shown correlation to prognosis in COVID-19 patients, their clinical value is limited because of lack of specificity, suboptimal sensibility or poor dynamic behavior. We hypothesized that circulating soluble ST2 (sST2) could be associated to a worse outcome in COVID-19. In total, 152 patients admitted for confirmed COVID-19 were included in a prospective non-interventional, observational study. Blood samples were drawn at admission, 48-72 h later and at discharge. sST2 concentrations and routine blood laboratory were analyzed. Primary endpoints were admission at intensive care unit (ICU) and mortality. Median age was 57.5 years [Standard Deviation (SD: 12.8)], 60.4% males. 10% of patients ( n = 15) were derived to ICU and/or died during admission. Median (IQR) sST2 serum concentration (ng/mL) rose to 53.1 (30.9) at admission, peaked at 48-72 h (79.5(64)) and returned to admission levels at discharge (44.9[36.7]). A concentration of sST2 above 58.9 ng/mL was identified patients progressing to ICU admission or death. Results remained significant after multivariable analysis. The area under the receiver operating characteristics curve (AUC) of sST2 for endpoints was 0.776 ( p = 0.001). In patients admitted for COVID-19 infection, early measurement of sST2 was able to identify patients at risk of severe complications or death.

Background: The increase in intraabdominal pressure (IAP) has been correlated with increased creatinine levels in patients with heart failure with severely reduced left ventricular ejection fraction (HFrEF). However, IAP has not been examined in more stable patients or those with heart failure with preserved ejection fraction (HFpEF)., Patients and Method: We conducted an observational, prospective descriptive study that measured the IAP of patients hospitalised for decompensated heart failure (HF). The sample was stratified according to left ventricular ejection fraction (LVEF), with a cut-off of 50%. The objective was to analyse the IAP, the baseline characteristics and degree of congestion using clinical ultrasonography and impedance audiometry., Results: The study included 56 patients, 22 with HFrEF and 34 with HFpEF. The patients with HFrEF presented a higher prevalence of ischaemic heart disease (11% vs. 6%; p = 0.010) and chronic obstructive pulmonary disease/asthma (6% vs. 2%; p = 0.025). The IAP was higher in the patients with HFrEF (17.2 vs. 13.3 mmHg; p = 0.004), with no differences in renal function at admission according to the LVEF (CKD-EPI creatinine) (HFrEF 55.0 mL/min/1.73 m 2 [32.6-83.6] vs. HFpEF 55.0 mL/min/1.73 m 2 [44.0-74.9]; p = 0.485). The patients with HFrEF presented a more congestive profile determined through ultrasonography (inferior vena cava collapse [26% vs. 50%; p = 0.001]), impedance audiometry (total body water at admission, 46 L vs. 41 L; p = 0.052; and at 72 h, 50.2 L vs. 39.1 L; p = 0.038) and CA125 concentration (68 U/mL vs. 39 U/mL; p = 0.037)., Conclusions: During the decompensation episodes, the patients with HFrEF had a greater increase in IAP and a higher degree of systemic congestion., (Copyright © 2020 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Introduction and Objectives: There is great interest in better characterizing patients with heart failure (HF) with preserved ejection fraction (HF-PEF). The objective of this study is to determine the prevalence, progression over time and to describe the clinical and epidemiological characteristics of patients with HF-PEF., Methods: From the National Registry of Heart Failure (RICA, prospective multicentre cohort study) we analysed patients consecutively admitted for HF in Internal Medicine wards over a period of 11 years (2008-2018)., Results: 4752 patients were included, 2957 (62.2%) with preserved ejection fraction. This prevalence remained constant from 2008 to 2019. Compared to patients with HF and reduced ejection fraction (HF-REF) patients with HF-PEF are older, more are female, there is a higher prevalence of hypertensive and valvular aetiology, they have a profile of different comorbidities and worse functional status. A high proportion of patients receive disease-modifying treatment for IC-REF (renin-angiotensin-aldosterone system inhibitors and beta-blockers). The overall mortality after one-year follow-up was 24% and 30% in the HF-PEF and the HF-REF, respectively. In the multivariate analysis, the risk of death was higher in patients with HF-REF compared to HF-PEF (OR: 1.84; 95% CI: [1.43-2.36]). The length of hospital stay was also lower in the HF-PEF patients but there were no differences in re-hospitalizations., Conclusions: Sixty percent of patients in the RICA registry have preserved ejection fraction. These patients have a higher comorbidity burden and a worse functional status, but lower mortality compared with HF-REF patients., (Copyright © 2020 Elsevier España, S.L.U. All rights reserved.)

Background: A physical examination has limited performance in estimating systemic venous congestion and predicting mortality in patients with heart failure. We have evaluated the usefulness of the N-terminal prohormone of brain natriuretic peptide (NT-proBNP), cancer antigen 125 (CA125), lung ultrasound findings, relative plasma volume (rPV) estimation, and the urea/creatinine ratio as surrogate parameters of venous congestion and predictors of mortality., Methods: This work is a retrospective study of 203 patients admitted for acute heart failure in a tertiary hospital's internal medicine department with follow-up in a specialized outpatient clinic between 2013 and 2018. Clinical data were collected from hospital records. Treatment was decided upon according to the clinical judgment of each patient's attending physician. The main outcome measure was all-cause mortality at one year of follow-up., Results: Patients' mean age was 78.8 years and 47% were male. A total of 130 (65%) patients had chronic heart failure, 51 (26.2%) patients were in New York Heart Association class III-IV, and 116 (60%) patients had preserved left ventricular ejection fraction. During follow-up, 42 (22%) patients died. Values ??of NT-proBNP≥3,804pg/mL (HR 2.78 [1.27-6.08]; p=.010) and rPV ≥-4.54% (HR 2.74 [1.18-6.38]; p=.019) were independent predictors of all-cause mortality after one year of follow-up., Conclusions: NT-proBNP and rPV are independent predictors of one-year mortality among patients hospitalized for decompensated heart failure., (Copyright © 2020 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

The latest acute heart failure consensus document from the Spanish Society of Cardiology, Spanish Society of Internal Medicine, and Spanish Society of Emergency Medicine was published in 2015, which made an update covering the main novelties regarding acute heart failure from the last few years necessary. These include publication of updated European guidelines on heart failure in 2016, new studies on the pharmacological treatment of patients during hospitalization, and other recent developments regarding acute heart failure such as early treatment, intermittent treatment, advanced heart failure, and refractory congestion. This consensus document was drafted with the aim of updating all aspects related to acute heart failure and to create a document that comprehensively describes the diagnosis, treatment, and management of this disease., (Copyright © 2020 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Background: Diagnosis of acute kidney injury (AKI) during acute decompensations of heart failure (ADHF) remain challenging. We analysed the incidence and prognosis of AKI, and the significance of small increases of creatinine, during ADHF and after stabilization., Patients and Methods: Patients admitted for ADHF were prospectively included. Creatinine was measured at admission, 48h thereafter and 24h before discharge. AKI was diagnosed when creatinine increased≥50% in 7 days (RIFLE criteria) or≥0.3mg/dL in 48h (AKIN criteria) during admission. Changes between baseline creatinine (measured within 3-month before admission) and one month after discharge were assessed, to seek for residual impairment of renal function and its significance., Results: Two hundred and four patients were included. Incidence of AKI was 28.4% (n=58). Creatinine peaked by day 5 in patients with AKI vs. non-AKI (1.9 vs. 1.1mg/dL; P<.000) and remained significantly higher among patients with AKI 3 months after discharge (increase of 20 vs. 4%; P=.013). Twelve-months mortality was associated with increases in cystatin C, NT-proBNP and AKI (15.5 vs. 44.8%, P<.000), being the latter the most powerful independent predictor of death ?Exp(B)=5.34; P=.009?. Minor increases in creatinine (20% or 0.2mg/dL) during admission associated lesser 12-months survival (P=.033 and P=.019, respectively). Increases in creatinine≥10% between baseline and one month after discharge are associated with higher mortality (12.6 vs. 22.5%, P=.044)., Conclusions: AKI is a strong predictor of mortality after ADHF. Minor increments in creatinine concentrations, below the accepted threshold for AKI definition, are prognostically meaningful., (Copyright © 2019 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Systemic congestion is one of the mechanisms involved in acute decompensated heart failure (ADHF). Increased intra-abdominal pressure (IAP), elicited by abdominal congestion, has been related to acute kidney injury and prognosis. Nonetheless, the link between diuretic response, surrogate markers of congestion and renal function remains poorly understood. We measured IAP in 43 patients from a non-interventional, exploratory, prospective, single center study carried out in patients admitted for ADHF. IAP was measured with a calibrated electronic manometer through a catheter inserted in the bladder. Normal IAP was defined as < 12 mmHg. At baseline, median IAP was 15 mmHg, with a reduction over the next 72 h to a median of 12 mmHg. A higher IAP at admission was associated with higher baseline blood urea (83 mg/dL [62-138] vs. 50 mg/dL [35-65]; p = 0.007) and creatinine (1.30 mg/dL vs. 0.95 mg/dL; p = 0.027), and with poorer diuretic response 72 h after admission, either measured by diuresis (14.4 mL/mg vs. 21.6 mL/mg; [p = 0.005]) or natriuresis (1.2 mEqNa/mg vs. 2.0 mEqNa/mg; [p = 0.008]). A higher incidence for 1-year all-cause mortality (45.0% vs. 16.7%; log-rank test = 0.041) was observed among those patients with IAP > 12 mmHg at 72 h. In patients with ADHF, higher IAP at admission is associated with poorer baseline renal function and impaired diuretic response. The persistence of IAP at 72 h above 12 mmHg associates to longer length of hospital stay and higher 1-year all-cause mortality.

Macrophages show remarkable phenotypic plasticity in response to environmental signals. Although it is generally less considered, cytoskeletal changes in macrophages influence their phenotype, including phagocytosis and secretion of soluble cytokines. Influenza virus NS1A-binding protein (Ivns1abp) belongs to the Kelch family of proteins that play a central role in actin cytoskeleton dynamics by directly associating with F-actin and by protecting against actin derangement. Due to its role in cytoskeleton preservation, the Ivns1abp gene might be a critical regulator of the macrophage phenotype and function under inflammatory conditions. In this study, we determine that the modulation of the Ivns1abp gene in macrophages could modify resistance to macrophages against inflammation and maintain functional phagocytosis. Our results indicate that inflammatory insults inhibit the Ivns1abp gene, whereby phagocytosis is inhibited and the ability of macrophages to induce proliferation and repair of damaged cells is compromised. Furthermore, our results show that inflammatory insults alter the activity of the transcription factor c-myc, a factor which directly modulates the expression of the Ivns1abp gene. In conclusion, this study demonstrates a central role of lvns1abp in promoting and preserving a reparative macrophage phenotype and resistance to this inflammatory environment.

Background: Despite advances in the diagnosis and treatment of heart failure (HF), the condition still has high morbidity and mortality. Health education and the treatment of comorbidities have been shown to be effective, as has multidisciplinary care in specialised units, although this involves organisational and structural efforts that are not always feasible. We present the results of a simple outpatient consultation, focused on the specialised care of HF., Patients and Methods: The consultation included patients discharged after hospitalisation (index hospitalisation) for decompensated HF from an internal medicine department. The follow-up was conducted by internists especially dedicated (not exclusively) to HF and a nurse partially dedicated to HF. The follow-up consisted of fixed visits 1, 3, 6 and 12 months after the discharge, with more visits on demand if needed., Results: A total of 250 patients were included with a minimum follow-up of 1 year. The reduction in hospitalisations and emergency department visits was 56% and 61% (P<.05), respectively, for HF and 46% and 40% (P<.05), respectively, for any cause. Treatment optimisation was also achieved, with a significant increase in the evidence-based drug prescription rate and the reduction of other drugs, such as calcium antagonists., Conclusion: A simple model based on a specialised care consultation for HF is effective in reducing readmissions and optimising the treatment. The lack of healthcare resources should not be an obstacle for specialised care for patients with HF., (Copyright © 2019 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Background: The increase in intraabdominal pressure (IAP) has been correlated with increased creatinine levels in patients with heart failure with severely reduced left ventricular ejection fraction (HFrEF). However, IAP has not been examined in more stable patients or those with heart failure with preserved ejection fraction (HFpEF)., Patients and Method: We conducted an observational, prospective descriptive study that measured the IAP of patients hospitalised for decompensated heart failure (HF). The sample was stratified according to left ventricular ejection fraction (LVEF), with a cut-off of 50%. The objective was to analyse the IAP, the baseline characteristics and degree of congestion using clinical ultrasonography and impedance audiometry., Results: The study included 56 patients, 22 with HFrEF and 34 with HFpEF. The patients with HFrEF presented a higher prevalence of ischaemic heart disease (11% vs. 6%; p = 0.010) and chronic obstructive pulmonary disease/asthma (6% vs. 2%; p = 0.025). The IAP was higher in the patients with HFrEF (17.2 vs. 13.3 mmHg; p = 0.004), with no differences in renal function at admission according to the LVEF (CKD-EPI creatinine) (HFrEF 55.0 mL/min/1.73 m 2 [32.6-83.6] vs. HFpEF 55.0 mL/min/1.73 m 2 [44.0-74.9]; p = 0.485). The patients with HFrEF presented a more congestive profile determined through ultrasonography (inferior vena cava collapse [26% vs. 50%; p = 0.001]), impedance audiometry (total body water at admission, 46 L vs. 41 L; p = 0.052; and at 72 h, 50.2 L vs. 39.1 L; p = 0.038) and CA125 concentration (68 U/mL vs. 39 U/mL; p = 0.037)., Conclusions: During the decompensation episodes, the patients with HFrEF had a greater increase in IAP and a higher degree of systemic congestion., (Copyright © 2020 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Objectives: To characterise the comorbidities of heart failure (HF) in men and women, to explore their clustering into multimorbidity patterns, and to measure the impact of such patterns on the risk of hospitalisation and mortality., Design: Observational retrospective population study based on electronic health records., Setting: EpiChron Cohort (Aragón, Spain)., Participants: All the primary and hospital care patients of the EpiChron Cohort with a diagnosis of HF on 1 January 2011 (ie, 8488 women and 6182 men). We analysed all the chronic diseases registered in patients' electronic health records until 31 December 2011., Primary Outcome: We performed an exploratory factor analysis to identify the multimorbidity patterns in men and women, and logistic and Cox proportional-hazards regressions to investigate the association between the patterns and the risk of hospitalisation in 2012, and of 3-year mortality., Results: Almost all HF patients (98%) had multimorbidity, with an average of 7.8 chronic diseases per patient. We identified six different multimorbidity patterns, named cardiovascular, neurovascular, coronary, metabolic, degenerative and respiratory. The most prevalent were the degenerative (64.0%) and cardiovascular (29.9%) patterns in women, and the metabolic (49.3%) and cardiovascular (43.2%) patterns in men. Every pattern was associated with higher hospitalisation risks; and the cardiovascular, neurovascular and respiratory patterns significantly increased the likelihood of 3-year mortality., Conclusions: Multimorbidity is the norm rather than the exception in patients with heart failure, whose comorbidities tend to cluster together beyond simple chance in the form of multimorbidity patterns that have different impact on health outcomes. This knowledge could be useful to better understand common pathophysiological pathways underlying this condition and its comorbidities, and the factors influencing the prognosis of men and women with HF. Further large scale longitudinal studies are encouraged to confirm the existence of these patterns as well as their differential impact on health outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Congestive symptoms are the key to recognising decompensated heart failure, whose treatment is based on reducing the congestion until a clinical situation has been reached that allows the patient to be discharged to continue outpatient treatment. The important aspect is not the degree of congestion at admission but rather the congestion that persists after energetic diuretic therapy. The persistence of congestive signs following an apparently correct and effective therapy has been called residual congestion and is associated with a poor prognosis. The tools for determining this condition are still rudimentary. Methods therefore need to be developed that enable a more accurate assessment., (Copyright © 2019 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Background: An increase in intraabdominal pressure (IAP) during acute heart failure, seems to be directly related to worsening renal function, which leads to worse clinical outcomes. We aimed to analyze the relationship between IAP and determinants of renal function during admission for acute decompensation of heart failure (ADHF) in a conventional Internal Medicine Ward., Patients and Methods: Descriptive and prospective study. Patients admitted for ADHF with an estimated glomerular filtration rate > 30mL/min/1.73 m 2 , willing to participate and who gave their informed consent were included. Ethics Committee of Aragon approved the protocol (PI 15 0227)., Results: We hereby report the results of an interim analysis of the first 28 patients included. Patients were divided in 2groups according to the median of IAP measured during the first 24h after admission for ADHF, namely high IAP (IAP>15mmHg) and low (IAP< 15mmHg). Fourteen patients were included in each group. No differences were found in baseline clinical characteristics, comorbidities or treatment between both groups. Patients with IAP above 15mmHg, showed a significant lower baseline estimated glomerular filtration rate (70.7 vs. 44.4mL/min/1.73 m 2 with p=0.004], blood urea 36 vs. 83mg/dL with p=0.002]; serum creatinine 0.87 vs. 1.3mg/dL with p=0.004 and cystatin C 1.2 vs. 1.94mg/dL with p= 0.002. Additionally, these patients had higher uric acid (5.7 vs. 8.0, p=0.046), lower hemoglobin concentrations (11.7 vs. 10.5g/L, p=0.04) and longer length of hospital stay (6.5 vs. 9.6 days, p=0.017)., Conclusions: The increase in IAP seems to be a frequent finding in patients admitted for ADHF. Patients share similar clinical profile irrespective of IAP, although the increase in IAP is associated with a significant baseline impairment of renal function., (Copyright © 2018 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Background: Worsening renal function is associated with an adverse prognosis for patients with acute heart failure (AHF). Urea-creatinine ratio (U:C ratio) might be useful for measuring renal function and could help stratify patients with AHF., Material and Methods: An observational and prospective study was conducted to analyse the prognostic value of the U:C ratio, measured during the first 24-28 hours of admission, for patients hospitalised for decompensated Heart failure, and its relationship with estimated glomerular filtration rate (eGFR) and acute kidney injury (AKI)., Results: The study included 204 patients, with a mean age of 79.3 years, and a median eGFR of 55 mL/min/1.73m 2 . In the multivariate analysis, an U:C ratio above the median (50) was related to the development of AKI (36.5% vs. 21.9%) and to increased mortality, both overall (OR 2.75) and by HF (OR 3.50) in long term. In combination with eGFR, the U:C ratio showed prognostic value in patients with normal eGFR (mortality of 4.4% for an U:C ratio ≤ 50 vs. 22% for U:C ratio > 50; p=0.01), as well as a better predictive capacity for AKI than each of them separately (AUC, 0.718; 95% CI 0.643-0.793; p>.000)., Conclusions: An U:C ratio > 50 is a predictor of increased long-term mortality for patients hospitalised for decompensated HF and with normal eGFR. Given the simplicity of this biomarker, its use in clinical practice should be more systematic., (Copyright © 2018 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Background: Congestion is the main reason for hospital admission for acute decompensated heart failure (ADHF). A better understanding of the clinical course of congestion and factors associated with decongestion are therefore important. We studied the clinical course, predictors and prognostic value of congestion in a cohort of patients admitted for ADHF by including different indirect markers of congestion (residual clinical congestion, brain natriuretic peptides (BNP) trajectories, hemoconcentration or diuretic response)., Methods and Results: We studied the prognostic value of residual clinical congestion using an established composite congestion score (CCS) in 1572 ADHF patients. At baseline, 1528 (97.2%) patients were significantly congested (CCS ≥ 3), after 7 days of hospitalization or discharge (whichever came first), 451 (28.7%) patients were still significantly congested (CCS ≥ 3), 751 (47.8%) patients were mildly congested (CCS = 1 or 2) and 370 (23.5%) patients had no signs of residual congestion (CCS = 0). The presence of significant residual congestion at day 7 or discharge was independently associated with increased risk of re-admissions for heart failure by day 60 (HR [95%CI] = 1.88 [1.39-2.55]) and all-cause mortality by day 180 (HR [95%CI] = 1.54 [1.16-2.04]). Diuretic response provided added prognostic value on top of residual congestion and baseline predictors for both outcomes, yet gain in prognostic performance was modest., Conclusion: Most patients with acute decompensated heart failure still have residual congestion 7 days after hospitalization. This factor was associated with higher rates of re-hospitalization and death. Decongestion surrogates, such as diuretic response, added to residual congestion, are still significant predictors of outcomes, but they do not provide meaningful additive prognostic information., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background and Objective: An inverse relationship has been described between blood pressure and the prognosis in heart failure (HF). The characteristics of this relationship are not well unknown. The objective of this study was to determine if this relationship is maintained in a non-selected cohort of patients with HF and if it can be modified by treatment., Material and Methods: Prospective study of cohorts including patients hospitalized for decompensated HF in Internal Medicine departments and followed as outpatients in a monographic consultation. Patients were classified according to their levels of systolic (SBP) and diastolic blood pressure (DBP). Clinical characteristics, all-cause mortality and readmissions after the first, third and sixth month of follow-up were analysed., Results: Two hundred and twenty-one patients were included after their admission to the hospital for acute HF. Mean patient age was 79.5 years(SD 8.09); 115 patients were male. No significant differences between SBP quartiles and basal characteristics were found. Patients with lower SBP (Q1) had higher mortality rates (20%, P<.05). No significant differences between mortality/readmissions and DBP were found. However, the Kaplan-Meier analysis showed higher all-cause mortality rates for the group of patients with lower SBP and DBP (log-rank=0.011 and 0.041, respectively). The pharmacological treatment did not differ significantly between both study groups., Conclusion: For non-selected patients suffering HF, higher SBP upon the admission is associated with significantly lower all-cause mortality rates during follow-up. Pharmacological treatment of HF does not seem to influence this inverse relationship between SBP at admission and patient mortality., (Copyright © 2017 Elsevier España, S.L.U. All rights reserved.)

Renal function is one of the most consistent prognostic determinants in heart failure. The prognostic information it provides is independent of the ejection fraction and functional status. This article reviews the various renal function assessment measures, with special emphasis on the fact that the patient's clinical situation and response to the heart failure treatment should be considered for the correct interpretation of the results. Finally, we review the literature on the performance of tubular damage biomarkers., (Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Systemic venous congestion has gained significant importance in the interpretation of the pathophysiology of acute heart failure, especially in the development of renal function impairment during exacerbations. In this study, we review the concept, clinical characterisation and identification of venous congestion. We update current knowledge on its importance in the pathophysiology of acute heart failure and its involvement in the prognosis. We pay special attention to the relationship between abdominal congestion, the pulmonary interstitium as filtering membrane, inflammatory phenomena and renal function impairment in acute heart failure. Lastly, we review decongestion as a new therapeutic objective and the measures available for its assessment., (Copyright © 2016 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Hepatocyte growth factor (HGF) plays a role in the improvement of cardiac function and remodeling. Their serum levels are strongly related with mortality in chronic systolic heart failure (HF). The aim of this study was to study prognostic value of HGF in acute HF, interaction with ejection fraction, renal function, and natriuretic peptides. We included 373 patients (age 76 ± 10 years, left ventricular ejection fraction [LVEF] 46 ± 14%, 48% men) consecutively admitted for acute HF. Blood samples were obtained at admission. All patients were followed up until death or close of study (>1 year, median 371 days). HGF concentrations were determined using a commercial enzyme-linked immunosorbent assay (human HGF immunoassay). The predictive power of HGF was estimated by Cox regression with calculation of Harrell C-statistic. HGF had a median of 1,942 pg/ml (interquartile rank 1,354). According to HGF quartiles, mortality rates (per 1,000 patients/year) were 98, 183, 375, and 393, respectively (p <0.001). In Cox regression analysis, HGF (hazard ratio1SD = 1.5, 95% confidence interval 1.1 to 2.1, p = 0.002) and N-terminal pro b-type natriuretic peptide (NT-proBNP; hazard ratio1SD = 1.8, 95% confidence interval 1.2 to 2.6, p = 0.002) were independent predictors of mortality. Interaction between HGF and LVEF, origin, and renal function was nonsignificant. The addition of HGF improved the predictive ability of the models (C-statistic 0.768 vs 0.741, p = 0.016). HGF showed a complementary value over NT-proBNP (p = 0.001): mortality rate was 490 with both above the median versus 72 with both below. In conclusion, in patients with acute HF, serum HGF concentrations are elevated and identify patients at higher risk of mortality, regardless of LVEF, ischemic origin, or renal function. HGF had independent and additive information over NT-proBNP., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The purpose of this consensus document was to reach an agreement among experts on the multidisciplinary care of patients with acute heart failure. Starting with a narrative review of the care provided to these patients and a critical analysis of the healthcare procedures, we identified potential shortcomings and improvements and formalised a document on recommendations for optimising the clinical and therapeutic approach for acute heart failure. This document was validated through an in-person group session guided using participatory techniques. The process resulted in a set of 36 recommendations formulated by experts of the Spanish Society of Cardiology, the Spanish Society of Internal Medicine and the Spanish Society of Urgent and Emergency Care. The recommendations are designed to optimise the healthcare challenge presented by the care of patients with acute heart failure in the context of Spain's current National Health System., (Copyright © 2016 Elsevier España, S.L.U. and Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Objectives: To assess the utility of measuring the diameter and collapse of the inferior vena cava (IVC) in acute heart failure (AHF), its relationship with the prognosis and serum biomarkers of congestion., Patients and Methods: An observational prospective study was conducted that included 85 patients with AHF, classifying them into 4 groups according to IVC diameter (≤ or >20mm) and inspiratory collapse (< or ≥50%) at admission. The endpoints were mortality due to HF and the combined event of mortality and readmission for HF at 180 days., Results: Some 24.7% of the patients had an undilated IVC and ≥50% collapse (group 1); 20% had an undilated IVC and <50% collapse (group 2), 5.9% had a dilated IVC and ≥50% collapse (group 3); and 49.4% had a dilated IVC and <50% collapse (group 4). The lack of inspiratory collapse but not IVC dilation was related to higher concentrations of urea (P=.007), creatinine (P=.004), uric acid (P=.008), NT-proBNP (P=.009) and CA125 (P=.005). Survival free of the combined event at 180 days was lower in those patients with no IVC collapse., Conclusions: Dilation and the absence of the inspiratory collapse of the IVC are common in the context of AHF. The lack of inspiratory collapse of the IVC during the decompensation phase identifies a subgroup of patients with poorer prognosis at 6 months., (Copyright © 2015 Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Unlabelled: Cystatin C (CysC) is a protease encoded by housekeeping genes. Although its prognostic value in heart failure (HF) is well known, it is debatable whether this value is due to the greater accuracy of CysC in calculating the glomerular filtration rate or to its involvement in pathological ventricular remodelling. The aim of this study was to determine whether CysC expression changes in the myocardium of foetuses of different ages and in the myocardium of adults with various cardiovascular diseases, as well as to analyse the correlation between its serum concentrations and cardiac structure and morphology in a patient group with HF., Patients and Methods: We analysed the correlations (Pearson's r and Spearman's test) between the serum CysC levels and echocardiographic parameters of 351 patients with HF. We also performed immunohistochemical staining for CysC, metalloproteinase-9 (MMP-9) and desmin in 9 cardiac tissue samples from autopsies of 4 foetuses of different gestational ages and 5 healthy adults or adults with cardiovascular disease., Results: For the patients with HF, there was no correlation between the CysC concentrations and the cardiac parameters measured by 2D echocardiography. The immunohistochemistry showed a weak background staining for CysC in all samples, regardless of age and the presence or absence of cardiovascular diseases., Conclusions: Our results suggest that CysC does not have a significant role in the pathological remodelling of the left ventricle in HF., (Copyright © 2015 Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI). All rights reserved.)

Introduction: The objective was to assess the prognostic importance of various glycaemic control measures on hospital mortality., Material and Methods: Retrospective, analytical cohort study that included patients hospitalised in internal medicine departments with a diagnosis related to diabetes mellitus (DM), excluding acute decompensations. The clinical endpoint was hospital mortality. We recorded clinical, analytical and glycaemic control-related variables (scheduled insulin administration, plasma glycaemia at admission, HbA1c, mean glycaemia (MG) and in-hospital glycaemic variability and hypoglycaemia). The measurement of hospital mortality predictors was performed using univariate and multivariate logistic regression., Results: A total of 384 patients (50.3% men) were included. The mean age was 78.5 (SD, 10.3) years. The DM-related diagnoses were type 2 diabetes (83.6%) and stress hyperglycaemia (6.8%). Thirty-one (8.1%) patients died while in hospital. In the multivariate analysis, the best model for predicting mortality (R(2)=0.326; P<.0001) consisted, in order of importance, of age (χ(2)=8.19; OR=1.094; 95% CI 1.020-1.174; P=.004), Charlson index (χ(2)=7.28; OR=1.48; 95% CI 1.11-1.99; P=.007), initial glycaemia (χ(2)=6.05; OR=1.007; 95% CI 1.001-1.014; P=.014), HbA1c (χ(2)=5.76; OR=0.59; 95% CI 0.33-1; P=.016), glycaemic variability (χ(2)=4.41; OR=1.031; 95% CI 1-1.062; P=.036), need for corticosteroid treatment (χ(2)=4.03; OR=3.1; 95% CI 1-9.64; P=.045), administration of scheduled insulin (χ(2)=3.98; OR=0.26; 95% CI 0.066-1; P=.046) and systolic blood pressure (χ(2)=2.92; OR=0.985; 95% CI 0.97-1.003; P=.088)., Conclusion: An increase in initial glycaemia and in-hospital glycaemic variability predict the risk of mortality for hospitalised patients with DM., (Copyright © 2015 Elsevier España, S.L.U. y Sociedad Española de Medicina Interna (SEMI). All rights reserved.)