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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.

Introduction: The presence of iron deficiency (ID) in patients with acute heart failure (AHF) is high. There are few studies on the characteristics of these patients and the safety of ferric carboxymaltose administration (FCM)., Objective: Study the differences among patients with AHF based on the presence and type of ID as well as the safety of FCM administration in these patients., Method: The AHF-ID study is a multicentre, analytical, prospective follow-up cohort including patients admitted to six Spanish hospitals for AHF. ID was defined as serum ferritin <100 μg/L (group A) or ferritin 100-299 μg/L with a TSAT <20% (group B). In cases receiving FCM the appearance of adverse events was analysed. Adjusted Cox regression was used to determine the association with 30-days reattendance for AHF after discharge., Results: A total of 221 patients were recruited; 191 (86.4%) presented ID, 121 (63.4%) group A and 70 (36.6%) group B. There were scarce differences between the groups analysed. No differences were found in 30-days reattendance for AHF. FCM was administered to 158 (71.5%) patients, with 8 (5.1%) presenting adverse events, the most frequent being digestive alterations. Treatment was not discontinued in any case., Conclusions: There are scarce differences between the presence and the type of ID in patients with AHF. The administration of FCM in patients with ID and AHF is safe., (© 2020 John Wiley & Sons Ltd.)

Objectives: This study investigated whether systemic corticosteroids (new onset) administered to patients with acute heart failure (AHF) have any association with outcomes, with differentiated analyses for patients with and without chronic obstructive pulmonary disease (COPD) as a comorbidity., Background: Patients with undiagnosed dyspnea frequently receive corticosteroids in emergency departments while determining a final diagnosis, but their effect on the outcomes of patients with AHF without overt COPD exacerbation is unknown., Methods: We selected patients with AHF from the EAHFE (Epidemiology of Acute Heart Failure in the Emergency Departments) registry, recording key data (new-onset corticosteroid therapy, COPD condition). Patients with and without COPD were analyzed separately. We calculated unadjusted and adjusted ratios for corticosteroid-treated compared with corticosteroid-untreated patients for 2 coprimary endpoints: 90-day all-cause mortality (from index episode) and 90-day post-discharge combined endpoint (all-cause mortality or readmission for AHF), with intermediate time-point estimations. Other secondary endpoints were calculated, and some sensitive and stratified analyses were performed., Results: We analyzed 11,356 patients: 8,635 without COPD (841 corticosteroid-treated, 9.7%) and 2,721 with COPD (753 corticosteroid-treated, 27.7%). There were several differences between treated and untreated patients, essentially because corticosteroid-treated patients were sicker. Although unadjusted outcomes were worse in corticosteroid-treated patients, especially in patients without COPD, these differences disappeared after adjustment: hazard ratios for 90-day mortality (without/with COPD) were 0.91 (95% confidence interval (CI): 0.76 to 1.10)/0.99 (95% CI: 0.78 to 1.26), and 1.09 (95% CI: 0.93 to 1.28)/1.02 (95% CI: 0.86 to 1.21) for the post-discharge combined endpoint. Analyses of intermediate time-point coprimary endpoints and secondary outcomes rendered similar estimations. Sensitivity and stratified analysis did not significantly modify these results., Conclusions: There is no evidence of harm related to the new onset of systemic corticosteroid therapy during an episode of AHF, either in patients with or without concomitant COPD., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Little is known about the prevalence and impact of risk of malnutrition on short-term mortality among seniors presenting with acute heart failure (AHF) in emergency setting. The objective was to determine the impact of risk of malnutrition on 30-day mortality risk among older patients who attended in Emergency Departments (EDs) for AHF., Material and Methods: We performed a secondary analysis of the OAK-3 Registry including all consecutive patients ≥65 years attending in 16 Spanish EDs for AHF. Risk of malnutrition was defined by the Mini Nutritional Assessment Short Form (MNA-SF) < 12 points. Unadjusted and adjusted logistic regression models were used to assess the association between risk of malnutrition and 30-day mortality., Results: We included 749 patients (mean age: 85 (SD 6); 55.8% females). Risk of malnutrition was observed in 594 (79.3%) patients. The rate of 30-day mortality was 8.8%. After adjusting for MEESSI-AHF risk score clinical categories (model 1) and after adding all variables showing a significantly different distribution among groups (model 2), the risk of malnutrition was an independent factor associated with 30-day mortality (adjusted OR by model 1 = 3.4; 95%CI 1.2-9.7; p = .020 and adjusted OR by model 2 = 3.1; 95%CI 1.1-9.0; p = .033) compared to normal nutritional status., Conclusions: The risk of malnutrition assessed by the MNA-SF is associated with 30-day mortality in older patients with AHF who were attended in EDs. Routine screening of risk of malnutrition may help emergency physicians in decision-making and establishing a care plan., (Copyright © 2019 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Objectives: To study the effectiveness and safety of vernakalant for restoration of sinus rhythm in patients with atrial fibrillation (AF) in routine hospital emergency department care, and to evaluate factors associated with a more effective response., Material and Methods: Prospective multicenter cohort study enrolling consecutive patients who were administered vernakalant for medical cardioversion of AF between September 2014 through March 2016 in 5 hospitals in the Spanish autonomous community of Valencia., Results: We studied 165 cases. The median (interquartile range) was 68 years (56-77) years. Cardioversion with vernakalant was effective in 77.6% (95% CI, 71.1%-84%). The median time to conversion was 8 ( 6-12) minutes after a first dose and 34 (22-62) minutes after a second dose. A prior history of cardiac insufficiency was nonsignificantly less common in patients who converted with vernakalant (6.3%) than in those who did not (18.9%) (adjusted odds ratio [OR], 0.45 [95% CI, 0.13-1.56]; P=.208). Having no prior history of AF was nonsignificantly related to greater effectiveness (in 54.7% vs in 35.1% with prior AF). Duration less than 12 hours was significantly associated with greater effectiveness (83.6% vs 59.5%; adjusted OR, 2.76 [95% CI, 1.12-6.80]; P=.028). Adverse events were reported for 30 patients. None of the events had clinically important consequences, and in only 2 cases (1.2%) was it necessary to suspend treatment., Conclusion: Vernakalant is effective and safe for restoring sinus rhythm in the hospital emergency department.

Objectives: To identify factors associated with short hospital stays for patients admitted with acute heart failure (AHF) admitted to hospitals with short-stay units (SSU)., Material and Methods: Multicenter nonintervention study in a multipurpose cohort of patients with AHF to 10 Spanish hospitals with short-stay units; patients were followed prospectively. We recorded demographic data, medical histories, baseline cardiorespiratory and function variables on arrival in the emergency department, on admission, and at 30 days. The outcome variable was a short hospital stay (<= 4 days). We built receiver operating characteristic curves of simple and mixed predictive models for short stays and calculated the area under the curves., Results: A total of 1359 patients with a mean (SD) age of 78.7 (9.9) years (53.9% women) were included; 568 (41.8%) had short stays. Five hundred ninety patients (43.4%) were admitted to SSU and 769 (56.6%) were admitted to conventional wards. The variables associated with a short-stay according to the mixed regression model were hypertensive crisis (odds ratio [OR], 1.79; 95% CI, 1.17-2.73; P=.007) and admission to a SSU (OR, 16.6; 95% CI, 10.0-33.3; P<.001). Hypotensive AHF (OR, 0.49; 95% CI, 0.26-0.91; P=.025), hypoxemia (OR, 0.68; 95% CI, 0.53-0.88; P=.004); and admission on a Wednesday, Thursday, or Friday (OR, 0.62; 95% CI, 0.49-0.77; P<.001) were associated with a long stay. The area under the receiver operating characteristic curve was 0.827 (95% CI, 0.80-0.85; P<.001). Thirty-day mortality and readmission rates did not differ between patients with short vs long stays (mortality, 0.5% in both cases, P=.959; and readmission, 22.9% vs 27.7%, respectively; P=.059)., Conclusion: Both clinical and administrative factors are independently related to whether patients with AHF have short stays in the hospitals studied, and among therapy, it is remaslcasle the existence of a SSU.

Objectives: To analyze data recorded in the EAHFE registry (Epidemiology of Acute Heart Failure in Emergency Departments), which collects information on the clinical characteristics and laboratory findings of patients with acute heart failure (AHF) treated in 29 Spanish hospital emergency departments (EDs) as well as therapies used and clinical course. We analyzed changes in management observed over time and compared the results with data recorded in other AHF registries., Material and Methods: Prospective multicenter cohort study of consecutive patients treated in 3 different years: 2007, 2009, and 2011. We collected demographic, clinical, and laboratory data; medications taken prior to the emergency and in the ED; and outcome variables (in-hospital and 30-day and 1-year mortality rates, readmissions within 30 days). Changes in therapy and course in the 3 years were analyzed. The literature was reviewed to find other national and international AHF registries., Results: A total of 5845 patients were included (2007, 948; 2009, 1483; 2011, 3414). The mean age was 79 years and 56% were women. The AHF episode registered was the first experienced by 34.6% of the patients. Comorbidity was high: 82% had hypertension, 42.3% had diabetes mellitus, and 47.7% had atrial fibrillation. Severe or total functional dependence was observed in 21.9%, and 57.3% had systolic dysfunction (left ventricular ejection fraction, 38.3%). The main treatments administered consisted in diuretics (96.8%), endovenous nitroglycerine (20.7%), noninvasive ventilation (6.4%), and inotropic agents or vasopressors (3.6%). The glomerular filtration rate was low in 57%. Troponin and natriuretic peptide levels were measured in the EDs in 49.1% and 42.4% of the cases, respectively. Patients presented as normotensive in 66.4% of the cases, hypertensive in 23.5%, and hypotensive in 4.6% (0.7% in shock); 76.1% were admitted (1.9% to the ICU). The median hospital stay was 7 days and 23.9% were discharged from the ED. In-hospital mortality was 7.6%; 30-day mortality was 9.4% and 1-year mortality 29.5%. Orders for troponin and natriuretic peptide determinations increased over the 3 study periods, and the intravenous infusion of diuretics and inotropic agents and vasoconstrictors decreased (P < 0.001, all comparisons). Revisits within 30 days also decreased (P = 0.004). No changes were observed in in-hospital or 30-day mortality rates between 2007 and 2011. We reviewed 14 previously published registry reports (8 compiled prospectively); only 2 of the registries included ED patients., Conclusion: The EAHFE registry describes the characteristics of AHF in a cohort that resembles the universe of our patients with AHF. Significant changes were observed over time in some aspects of AHF management. Revisits decreased, but mortality rates remained unchanged. Only 2 other previously analyzed registries included patients with AHF treated in hospital EDs.

Background: The mainstay of treatment for acutely decompensated heart failure (ADHF) is intravenous diuretic therapy either as a bolus or via continuous infusion., Objectives: We evaluated the clinical effects and safety of three strategies of intravenous furosemide administration used in emergency departments (EDs) for ADHF., Methods: We performed a multicentre, randomised, parallel-group study. Patients with ADHF were randomised within 2 h of ED arrival to receive furosemide by continuous infusion (10 mg/h, group 1) or boluses (20 mg/6 h, group 2; or 20 mg/8 h, group 3). The primary end point was total diuresis, and secondary end points were dyspnoea, orthopnoea, extension of rales and peripheral oedema, blood pressure, respiratory and heart rates, and pulse oximetry, which were measured at arrival and 3, 6, 12 and 24 h after treatment onset. We also measured serum creatinine, sodium and potassium levels at arrival and after 24 h., Results: Group 1 patients (n=36) showed greater 24 h diuresis (3705 mL) than those in groups 2 (n=37) and 3 (n=36) (3093 and 2670 mL, respectively; p<0.01), and this greater diuretic effect was observed earlier. However, no differences were observed among groups in the nine secondary clinical end points evaluated. Creatinine deterioration developed in 15.6% of patients, hyponatraemia in 9.2%, and hypokalaemia in 19.3%, with the only difference among groups observed in hypokalaemia (group 1, 36.3%; group 2, 13.5%; group 3, 8.3%; p<0.01)., Conclusions: In patients with ADHF attending the ED, boluses of furosemide have a smaller diuretic effect but provide similar clinical relief, similar preservation of renal function, and a lower incidence of hypokalaemia than continuous infusion., Trial Registration Number: This randomised trial was registered in the European Clinical Trial Database (EudraCT) with the reference number 2008-004488-20., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: To determine the characteristics and prognostic factors of early death in the very elderly with acute heart failure (AHF)., Patients and Methods: We performed a prospective, observational study of AHF patients attended in Emergency Departments (ED), analyzing 45 variables collected in ED and studying troponin, natriuretic peptides and echocardiographies, not always available in the ED. The patients were divided into 2 groups: nonagenarian (age ≥ 90 years) and controls (age < 90 years). The study variables were mortality and death or reconsultation to the ED for AHF within 30 days after inclusion., Results: We included 4700 patients (nonagenarians: 520, 11.1%). The 30-day mortality was 21.5% and 8.7% (p<0.01), respectively with a combined event of 33.3% and 26.7% (p=0.001). Age ≥ 90 years was maintained in all the models associated with death (OR: 1.94, CI 95%: 1.40-2.70). In nonagenarians, chronic kidney insufficiency (OR: 2.07, CI95%: 1.16-3.69), severe functional dependence (OR: 2.18, CI95%; 1.30-3.64) and basal oxygen saturation <90% (OR: 1.97, CI95%: 1.17-3.32) and hyponatremia <135 mEq/L (OR: 1.89, CI95%: 1.05-3.42) were predictive variables of mortality. We observed an association between elevated troponin levels and natriuretic peptide values > 5,180 pg/mL and mortality (OR: 4.26, CI95%: 1.83-9.89; and OR: 3.51, CI95%: 1.45-8.48; respectively)., Conclusions: The profile of nonagenarians with AHF differs from that of younger patients. Although very advanced age is an independent prognostic factor of mortality, these patients have fewer predictive factors of mortality, being only functional deterioration, basal kidney disease, hyponatremia and respiratory insufficiency on arrival at the ED and probably troponin values and elevated natriuretic peptides., (Copyright © 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.)

Objective: We determined the clinical-epidemiological characteristics and prognostic factors of early mortality and re-consultation in an elderly population attending the hospital emergency department (HED) for acute heart failure (AHF)., Patients and Methods: A prospective, observational, non interventional study including all the patients with AHF attended in the Spanish's HED. Two groups were defined: elderly (≥ 80 years) and controls (< 80 years)., Variables: demographic characteristics, comorbidity, degree of cardiac involvement, previous treatment, symptoms and signs of the AHF episode, precipitating factors, treatment in the HED and outcome., Outcome Variables: mortality and re-consultation within 30 days., Results: Of the 942 patients included, 455 of whom were elderly (48.3%). In this elderly population female sex, auricular fibrillation and a history of ictus and a poor functional status predominated. The type of ventricular dysfunction was unknown in 70%. No main differences in the presentation of AHF were found between the two groups. Mortality and re-consultation to the HED within 30 days were similar in both groups. While several factors were identified to be related to mortality or re-consultation in control group, in the elderly group it was more difficult to identify patients who will die or re-consult to the HED within the following 30 days. Only respiratory insufficiency on arrival to the HED was found to predict a greater probability of death (OR 3.55; CI95% 1.39-9.11)., Conclusions: AHF in elderly patients presents some differential characteristics and, most importantly, it is more difficult to identify which of these patients will die or re-consult in the short-term., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: Patients with acute heart failure (AHF) are frequently evaluated in the Emergency Departments (ED) and discharged from their observation units (OU) without hospital admission. We examined direct discharge rates from the ED OU, risk factors for returning to the ED, and returning and mortality rates., Patients and Methods: This prospective, longitudinal, noninterventional, population-based cohort study included all the patients with AHF consecutively attended in seven Spanish EDs who were directly discharged without hospital admission. Reattendance (dependent variable) was accepted if occurred during the next 30 days after discharge. Twenty-nine independent variables were recorded, covering epidemiological, clinical, and functional data., Results: Two hundred and fifty-nine of 740 patients (35%) diagnosed with AHF were entirely managed in the ED OU and discharged home (mean stay: 18.8 h); 26.7% of them were reattended. Only three variables were independently associated with the chance of reattendance: functional impairment predicted adverse outcomes [odds ratio (OR): 4.0, 95% confidence interval (95% CI): 1.7-9.1], while past history of hypertension and a systolic blood pressure greater than 160 mmHg at ED arrival decreased the risk of ED return (OR: 0.4, 95% CI: 0.2-0.9; and OR: 0.3; 95% CI: 0.1-0.9; respectively). An overall mortality of 4.7% was recorded during the next 30 days., Conclusion: One-third of the patients consulting at the ED for an episode of AHF can be directly discharged from the OU of ED, with relatively low rates of reattendance (26.7%) and mortality (4.7%). Emergency physicians should be especially cautious discharging patients with functional dependence because they are at increased risk of returning.

Introduction and Objectives: To investigate factors associated with short-term mortality in elderly patients seen in emergency departments for an episode of acute heart failure., Methods: A prospective, non-interventional, multicenter, cohort study was carried out in patients aged 65 years and older who were treated in the emergency department of one of eight tertiary hospitals in Spain. Twenty-eight independent variables that could influence mortality at 30 days were assessed. They covered epidemiological and clinical factors and daily functioning. Data were obtained by reviewing medical records or by interviewing the patient or a relative. Multivariate logistic regression analysis was performed., Results: The study included 623 patients, 42 of whom (6.7%) died within 30 days of visiting the emergency department. Four variables were significantly associated with higher mortality: functional dependence at baseline (i.e., Barthel index=60; odds ratio [OR]=2.9; 95% confidence interval [CI], 1.2-6.5), New York Heart Association class III-IV (OR=3; 95% CI, 1.3-7), systolic blood pressure <100 mmHg (OR=4.8; 95% CI, 1.6-14.5) and blood sodium <135 mEq/l (OR=4.2; 95% CI, 1.8-9.6)., Conclusions: Several factors evaluated on initial assessment in the emergency department, including the level of functional dependence, were found to determine a poor short-term prognosis in elderly patients who present with an episode of acute heart failure.