Nutritional intervention in chronic heart failure patients: A randomized controlled clinical trial.

BACKGROUND AND OBJECTIVES: Malnutrition is common in patients with heart failure (HF) and is associated with poor prognosis. We evaluated the prognostic and clinical impact of a nutritional intervention in malnourished patients with chronic HF. METHODS: A randomized controlled clinical trial was carried out in patients with chronic HF who were malnourished or at risk. Participants were randomized to receive an individualized nutritional intervention or conventional management. The primary endpoint was a composite of all-cause mortality or time-to-first HF hospitalizations at the 12-month follow-up. The secondary endpoints were changes in nutritional status and functional capacity. RESULTS: We screened 225 patients, 86 of whom had some degree of malnutrition and were randomized. At 12 months, the primary outcome occurred in 10 patients (23.8%) in the intervention group and in 22 patients (50.0%) in the control group (HR=0.39; 95% CI, 0.19-0.83). This effect was mainly related to a lower risk of hospitalization for HF in the intervention group: 8 patients (19.0%) versus 18 patients (40.9%) in the control group (HR=0.39; 95% CI=0.17-0.89). We observed an improvement in nutritional status and functional capacity in the intervention group versus the control group. CONCLUSIONS: In patients with chronic HF and some degree of malnutrition, individualized nutritional intervention may reduce the risk of all-cause mortality or HF hospitalisations and improve nutritional status and functional capacity. These results underline the need for further randomized controlled trials with this approach to confirm the potential prognostic benefit.

Basic action protocol for the outpatient management of chronic heart failure of the Spanish Society of Internal Medicine.

Chronic heart failure (CHF) represents a challenge for the healthy system due to its high prevalence, high burden of morbidity and mortality, and high consumption of health resources. To address this problem, it is necessary to develop efficient management strategies that include both hospital care and outpatient care. The primary objective is to stabilize the patient and prevent decompensation, with the consequent improvement in quality of life, reduction in hospital admissions and emergency department care, and, consequently, reduction in healthcare costs. In this context, the heart failure and atrial fibrilation working group of the Spanish Society of Internal Medicine has developed a protocol for the management of outpatient CHF, that addresses, from the perspective of Internal medicine, all the problems suffered by the patient with CHF. This protocol aims to optimize pharmacological treatment, control cardiovascular risk factors and various comorbidities, educate the patient and their environment about the disease, promote adherence to treatment and stablish follow-up adapted to their condition.

Impact of natriuresis on worsening renal function during episodes of acute heart failure.

INTRODUCTION AND OBJECTIVES: Worsening renal function (WRF) is a frequent complication in acute heart failure (AHF) with a controversial prognostic value. We aimed to study the usefulness of natriuresis to evaluate WRF. METHODS: We conducted an observational, prospective, multicenter study of patients with AHF who underwent a furosemide stress test. The patients were classified according to whether WRF was present or absent and according to the median natriuretic response. The main endpoint was the combination of mortality, rehospitalization due to HF, and heart transplant at 6 months of follow-up. RESULTS: One hundred and fifty-six patients were enrolled, and WRF occurred in 60 (38.5%). The patients were divided into 4 groups: a) 47 (30.1%) no WRF/low UNa (UNa ≤ 109 mEq/L); b) 49 (31.4%) no WRF/high UNa (UNa >109 mEq/L); c) 31 (19.9%) WRF/low UNa and d) 29 (18.6%) WRF/high UNa. The parameters of the WRF/low UNa group showed higher clinical severity and worse diuretic and decongestive response. The development of WRF was associated with a higher risk of the combined event (HR, 1.88; 95%CI, 1.01-3.50; P=.046). When stratified by natriuretic response, WRF was associated with an increased risk of adverse events in patients with low natriuresis (HR, 2.28; 95%CI, 1.15-4.53; P=.019), but not in those with high natriuresis (HR, 1.18; 95%CI, 0.26-5.29; P=.826). CONCLUSIONS: Natriuresis could be a useful biomarker for interpreting and prognosticating WRF in AHF. WRF is associated with a higher risk of adverse events only in the context of low natriuresis.

Left ventricular global longitudinal strain is associated with filling pressure and cardiac output in an outpatient setting: Insights from CardioMEMS™.

INTRODUCTION AND OBJECTIVES: Left ventricular global longitudinal strain (LVGLS) is an indicator of myocardial function in patients with heart failure with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). Nevertheless, it is not clear whether LVGLS correlates with filling pressures and cardiac output (CO) in an ambulatory setting. We aimed to assess whether LVGLS is associated with invasive pulmonary artery pressures (PAP) and CO in outpatients using the invasive remote monitoring CardioMEMS™ system. METHODS: This single-center, prospective observational study included patients with HFrEF undergoing remote monitoring using the CardioMEMS™ system, between January 2020 and December 2022. Repeated transthoracic echocardiography (TTE) studies were performed in each patient and invasive hemodynamic data were obtained during the TTE studies using the CardioMEMS™ system. Univariate and multivariate models were used to assess the potential association between LVGLS and invasive PAP and CO. RESULTS: Twelve patients were included and 46 TTE studies were analyzed. LVGLS was correlated with diastolic (d) PAP (r=0.403, p=0.041) and CO (r=-0.426, p=0.039) in the univariate analysis. In multivariate models, LVGLS was an independent predictor of dPAP and CO, but not mean PAP or systolic PAP. The variation of LVGLS between TTE studies was correlated with the variation of dPAP during follow-up (r=0.60, p=0.017). CONCLUSIONS: In a cohort of HFrEF patients under invasive hemodynamic remote monitoring, LVGLS was independently associated with invasive filling pressures and CO, in an outpatient setting. These findings reinforce the value of LVGLS for the management of outpatients with HFrEF.

Medication adherence and persistence in heart failure: A protocol for a systematic review and meta-analysis.

OBJECTIVE: To study medication adherence and persistence among heart failure patients, assess the methods utilised for estimating medication adherence, and identify optimal adherence thresholds and their impact on clinical outcomes. METHODS: A systematic search will be conducted in PubMed, Embase, CINAHL, Web of Science, and Scopus databases. Observational studies assessing medication adherence or persistence among heart failure patients via electronic healthcare databases will be included. A narrative synthesis will describe medication adherence and persistence reported and methods used to measure it. A meta-analysis will be attempted to evaluate the impact of secondary medication adherence (multiple and by drug class) on clinical outcomes, including hospitalisation, emergency visits, and mortality. The I2 statistic will be employed to study heterogeneity and the GRADE framework to evaluate evidence certainty. This protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines and is registered with the Prospective Register of Ongoing Systematic Reviews CRD42024509542. DISCUSSION: This study aims to evaluate medication adherence and persistence in heart failure management through electronic health databases, intending to explore widely used measurement methods and their limitations, and to identify adherence thresholds associated with improved clinical outcomes. By examining these aspects, we anticipate proposing enhancements for future research and establishing desired adherence goals. This approach highlights the expected significance of our findings in advancing patient care and research methodologies.

Prevalence of transthyretin cardiac amyloidosis in patients with heart failure with preserved ejection fraction: the PRACTICA study.

INTRODUCTION AND OBJECTIVES: Transthyretin cardiac amyloidosis (ATTR-CA) is a frequent cause of heart failure with preserved ejection fraction (HFpEF). This study sought to determine the prevalence of ATTR-CA among HFpEF patients in a multicenter nationwide study. METHODS: Consecutive ambulatory or hospitalized patients aged ≥ 50 years with HFpEF and left ventricle hypertrophy ≥ 12mm were studied at 20 Spanish hospitals. Screening for cardiac amyloidosis was initiated according to the usual clinical practice of each center. Positive scintigraphs were centrally analyzed. RESULTS: 422 patients were included, of whom 387 underwent further screening for cardiac amyloidosis. A total of 65 patients (16.8%) were diagnosed with ATTR-CA, none below 75 years. There was an increase of prevalence with age. Of them, 60% were male, with a mean age of 85.3±5.2 years, mean left ventricle ejection fraction of 60.3±7.6% and a mean maximum left ventricle wall thickness of 17.2 [12-25] mm. Most of the patients were New York Heart Association class II (48.4%) or III (46.8%). Besides being older than non-ATTR-CA patients, ATTR-CA patients had higher median NT-proBNP levels (3801 [2266-7132] vs 2391 [1141-4796] pg/mL; P=.003). There was no statistical difference in the prevalence of ATTR-CA by sex (19.7% for men and 13.8% for women, P=.085). A ∼7% (4/56) of the patients exhibited a genetic variant (ATTRv). CONCLUSIONS: This multicenter nationwide study found a prevalence of 16.8%, confirming that ATTR-CA is a significant contributor to HFpEF in male and female patients with left ventricle hypertrophy and more than 75 years.

Parâmetros de Strain Diastólico Estão Associados à Mortalidade em Curto Prazo e à Reinternação em Pacientes com Insuficiência Cardíaca Avançada / Diastolic Strain Parameters are Associated with Short Term Mortality and Rehospitalization in Patients with Advanced Heart Failure

Resumo Fundamento A insuficiência cardíaca é uma das principais causas de hospitalização e mortalidade em todo o mundo e representa um grande fardo económico para os sistemas de saúde. A identificação de fatores prognósticos em pacientes com IC é de grande importância para estabelecer estratégias de manejo ideais e evitar procedimentos invasivos e dispendiosos desnecessários em pacientes em estágio terminal. Objetivos No presente estudo, nosso objetivo foi investigar a associação entre parâmetros de strain diastólico, incluindo E/e' SR, e resultados de curto prazo em pacientes com IC avançada. Métodos O estudo populacional incluiu 116 pacientes com insuficiência cardíaca avançada com fração de ejeção reduzida (ICFEr) avançada. Avaliações clínicas, laboratoriais e ecocardiográficas dos pacientes foram realizadas nas primeiras 24 horas de internação. Os pacientes foram acompanhados por um mês e qualquer reinternação por piora dos sintomas de IC e qualquer mortalidade foi registrada. O nível de significância adotado na análise estatística foi de 5%. Resultados A E/e' SR foi significativamente maior no grupo de pacientes em comparação ao grupo controle (p=0,001). Durante o acompanhamento de um mês, 13,8% dos pacientes morreram e 37,1% dos pacientes foram reinternados. NT-ProBNP sérico (p=0,034) e E/e' SR (p=0,033) foram considerados preditores independentes de mortalidade e o uso de IECA (p=0,027) e strain 3C apical (p=0,011) foram considerados independentes preditores de reinternação no grupo de pacientes. Conclusão Os resultados do presente estudo prospectivo demonstram que a E/e' SR medida pela ecocardiografia com speckle tracking é um preditor independente e sensível de mortalidade em curto prazo em pacientes com ICFEr avançada e pode ter um papel na identificação de pacientes com ICFEr em estágio terminal.

Abstract Background Heart failure (HF) is a leading cause of hospitalization and mortality worldwide and places a great economic burden on healthcare systems. Identification of prognostic factors in HF patients is of great importance to establish optimal management strategies and to avoid unnecessary invasive and costly procedures in end-stage patients. Objectives In the current study, we aimed to investigate the association between diastolic strain parameters including E/e' SR, and short-term outcomes in advanced HF patients. Methods The population study included 116 advanced HF with reduced ejection fraction (HFrEF) patients. Clinical, laboratory, and echocardiographic evaluations of the patients were performed within the first 24 hours of hospital admission. Patients were followed for one month and any re-hospitalization due to worsening of HF symptoms and any mortality was recorded. The level of significance adopted in the statistical analysis was 5%. Results E/e' SR was significantly higher in the patient group compared to the control group (p=0.001). During one-month follow-up, 13.8% of patients died and 37.1% of patients were rehospitalized. Serum NT-ProBNP (p=0.034) and E/e' SR (p=0.033) were found to be independent predictors of mortality and ACEİ use (p=0.027) and apical 3C strain (p=0.011) were found to be independent predictors of rehospitalization in the patient group. Conclusion Findings of the current prospective study demonstrate that E/e' SR measured by speckle tracking echocardiography is an independent and sensitive predictor of short-term mortality in advanced HFrEF patients and may have a role in the identification of end-stage HFrEF patients.

Análise Comparativa do ECG com o Holter na avaliação da Frequência Cardíaca na Insuficiência Cardíaca com Fração de Ejeção Reduzida e Ritmo Sinusal / Comparative Analysis of ECG and Holter Monitoring in the Assessment of Heart Rate in Heart Failure with Reduced Ejection Fraction and Sinus Rhythm

Resumo Fundamento A frequência cardíaca (FC) na insuficiência cardíaca com fração de ejeção reduzida (ICFEr) e ritmo sinusal apresenta valor prognóstico. Entretanto, o método de mensuração é debatido na literatura. Objetivos Comparar em pacientes com ICFEr e ritmo sinusal a FC no Holter com três eletrocardiogramas de repouso: ECG1, ECG2 e ECG3. Metodologia Estudo transversal com 135 pacientes portadores de insuficiência cardíaca com fração de ejeção ≤ 40% e ritmo sinusal. A FC foi avaliada por ECG e Holter. Análises incluíram o coeficiente de correlação intraclasse (CCI), regressão robusta, raiz do erro quadrático médio, Bland-Altman e a área sobre a curva ROC. Adotou-se nível de significância de 0,05 e o ajuste de Bonferroni-Holm para minimizar erros tipo I. Resultados As medianas [intervalo interquartil] de idade e fração de ejeção foram de 65 anos [16] e 30% [11], respectivamente. O CCI dos 3 ECG foi de 0,922 (intervalo de confiança de 95%: 0,892; 0,942). Os coeficientes de regressão robusta para ECG1 e ECG3 foram 0,20 (intervalo de confiança de 95%: 0,12; 0,29) e 0,21 (intervalo de confiança de 95%: 0,06; 0,36). O R2 robusto foi de 0,711 (intervalo de confiança de 95%: 0,628; 0,76). Na análise de concordância de Bland-Altman, os limites de concordância foram de −17,0 (intervalo de confiança de 95%: −19,0; −15,0) e 32,0 (intervalo de confiança de 95%: 30,0; 34,0). A área sob a curva ROC foi de 0,896 (intervalo de confiança de 95%: 0,865; 0,923). Conclusão A FC do ECG mostrou alta concordância com a FC do Holter, validando seu uso clínico em pacientes com ICFEr e ritmo sinusal. Contudo, a concordância foi subótima em um terço dos pacientes com FC inferior a 70 bpm pelo ECG, devendo ser considerada a realização de Holter neste contexto.

Abstract Background Heart rate (HR) has shown prognostic value in patients with heart failure with reduced ejection fraction (HFrEF) and sinus rhythm. However, the method of measurement is debated in the literature. Objectives To compare HR on Holter with 3 resting electrocardiograms (ECG1, ECG2, and ECG3) in patients with HFrEF and sinus rhythm. Methods This was a cross-sectional study with 135 patients with heart failure with ejection fraction ≤ 40% and sinus rhythm. HR was assessed by ECG and Holter. Analyses included intraclass correlation coefficient (ICC), robust regression, root mean squared error, Bland-Altman, and area under the receiver operating characteristic (ROC) curve. A significance level of 0.05 and Bonferroni-Holm adjustment were adopted to minimize type I errors. Results The median [interquartile range] age and ejection fraction were 65 years [16] and 30% [11], respectively. The ICC of the 3 ECGs was 0.922 (95% confidence interval: 0.892; 0.942). The robust regression coefficients for ECG1 and ECG3 were 0.20 (95% confidence interval: 0.12; 0.29) and 0.21 (95% confidence interval: 0.06; 0.36). The robust R2 was 0.711 (95% confidence interval: 0.628; 0.76). In the Bland-Altman agreement analysis, the limits of agreement were −17.0 (95% confidence interval: −19.0; −15.0) and 32.0 (95% confidence interval: 30.0; 34.0). The area under the ROC curve was 0.896 (95% confidence interval: 0.865; 0.923). Conclusion The HR on ECG showed high agreement with the HR on Holter, validating its clinical use in patients with HFrEF and sinus rhythm. However, agreement was suboptimal in one third of patients with HR below 70 bpm on ECG; thus, 24-hour Holter monitoring should be considered in this context.

Cardiac amyloidosis worsens prognosis in patients with heart failure: findings from the PREVAMIC study.

BACKGROUND AND OBJECTIVES: Cardiac amyloidosis (CA) is a common pathology in elderly patients that usually presents as heart failure (HF). However, it is not clear whether CA associated with HF has a worse prognosis compared with HF due to other etiologies. MATERIAL AND METHODS: Prospective, observational cohort study that recruited patients ≥65 years of age with HF in 30 Spanish centers. The cohort was divided according to whether the patients had AC or not. Patients were followed for 1 year. RESULTS: A total of 484 patients were included in the analysis. The population was elderly (median 86 years) and 49% were women CA was present in 23.8 % of the included patients. In the CA group, there was a lower prevalence of diabetes mellitus and valvular disease. At one year of follow-up, mortality was significantly more frequent in patients with CA compared to those without (33.0 vs.14.9%, p < 0.001). However, there were no differences between both groups in visits to the emergency room or readmissions. In the multivariate analysis, the variables that were shown to predict all-cause mortality at one year of follow-up were chronic kidney disease (HR 1.75 (1.01-3.05) p 0.045), NT-proBNP levels (HR 2.51 (1.46-4.30) p < 0.001), confusion (HR 2.05 (1.01-4.17), p 0.048), and the presence of CA (HR 1.77 (1.11-2.84), p 0.017). CONCLUSION: The presence of CA in elderly patients with HF is related to a worse prognosis at one year of follow-up. Early diagnosis of the pathology and multidisciplinary management can help improve patient outcomes.

The relationship between heart failure and smoking, and development of urethral stricture.

OBJECTIVE: To evaluate the relationship between heart failure (HF), chronic obstructive pulmonary disease (COPD), and smoking with the development of urethral stricture (US) by examining the patients who underwent transurethral prostate resection procedure, with and without the development of US in their follow-ups. METHODS: Among the patients who underwent transurethral resection of the prostate, 50 patients who developed US during their follow-ups formed group 1, while a total of 50 patients who did not develop US and were selected by lot formed group 2. The relationship between the patients' data on HF, COPD and smoking status and the development of US was investigated. RESULTS: The mean number of cigarettes smoked was statistically significantly high in the group with stricture (p = 0.007). Furthermore, pulmonary function test parameters of patients such as forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), and FEV1/FVC were found to be statistically significantly higher in Group 2 (p < 0.001, p < 0.001, and p = 0.008, respectively). In the logistic regression analysis, being a smoker was found to be the strongest predictor (p = 0.032). CONCLUSION: Our study concluded that smoking, HF, and COPD significantly increase the risk of developing stricture after transurethral resection of the prostate.

OBJETIVO: Evaluar la relación de la insuficiencia cardiaca, la enfermedad pulmonar obstructiva crónica y el tabaquismo con el desarrollo de estenosis de uretra en pacientes sometidos a resección transuretral de próstata con y sin desarrollo de estenosis de uretra en su seguimiento. MÉTODO: Cincuenta pacientes que desarrollaron estenosis de uretra durante su seguimiento formaron el grupo 1, y 50 pacientes que no desarrollaron estenosis de uretra y fueron seleccionados por lote formaron el grupo 2. Se investigó la relación de los datos de los pacientes sobre insuficiencia cardiaca, enfermedad pulmonar obstructiva crónica y tabaquismo con el desarrollo de estenosis uretral. RESULTADOS: La media de cigarrillos fumados fue significativamente más alta en el grupo con estenosis (p = 0.007). Además, se encontró que los parámetros de las pruebas de función pulmonar de los pacientes, como FEV1, FVC y FEV1/FVC, eran significativamente más altos en el grupo 2 (p < 0.001, p < 0.001 y p = 0.008, respectivamente). CONCLUSIONES: El tabaquismo, la insuficiencia cardiaca y la enfermedad pulmonar obstructiva crónica aumentan significativamente el riesgo de desarrollar estenosis después de una resección transuretral de próstata.

Hypertonic saline and heart failure: "sodium-centric" or "chlorine-centric"?

Up to 50% of patients admitted for heart failure (HF) have congestion at discharge despite diagnostic and therapeutic advances. Both persistent congestion and diuretic resistance are associated with worse prognosis. The combination of hypertonic saline and loop diuretic has shown promising results in different studies. However, it has not yet achieved a standardized use, partly because of the great heterogeneity in the concentration of sodium chloride, the dose of diuretic or the amount of sodium in the diet. Classically, the movement of water from the intracellular space due to an increase in extracellular osmolarity has been postulated as the main mechanism involved. However, chloride deficit is postulated as the main up-regulator of plasma volume changes, and its correction may be the main mechanism involved. This "chloride centric" approach to heart failure opens the door to therapeutic strategies that would include diuretics to correct hypochloremia, as well as sodium free chloride supplementation.

Role of spot urinary sodium in outpatients with heart failure.

INTRODUCTION AND OBJECTIVES: Spot determination of urinary sodium (UNa+) has emerged as a useful tool for monitoring diuretic response in patients with acute heart failure (AHF). However, the evidence in outpatients is scarce. We aimed to examine the relationship between spot UNa+ levels and the risk of mortality and worsening heart failure (WHF) events in individuals with chronic HF. METHODS: This observational and ambispective study included 1145 outpatients with chronic HF followed in a single center specialized HF clinic. UNa+ assessment was carried out 1-5 days before each visit. The endpoints of the study were the association between UNa+ and risk of a) long-term death and b) AHF-hospitalization and total WHF events (including AHF-hospitalization, emergency department visits or parenteral loop-diuretic administration in HF clinic), assessed by multivariate Cox and negative binomial regressions. RESULTS: The mean±standard deviation of age was 73±11 years, 670 (58.5%) were men, 902 (78.8%) were on stable NYHA class II, and 595 (52%) had LFEF ≥50%. The median (interquartile range) UNa+ was 72 (51-94) mmol/L. Over a median follow-up of 2.63 (1.70-3.36) years, there were 293 (25.6%) deaths and 382 WHF events (244 AHF-admissions) in 233 (20.3%) patients. After multivariate adjustment, baseline UNa+ was inverse and linearly associated with the risk of total WHF (IRR, 1.07; 95%CI, 1.02-1.12; P=.007) and AHF-admissions (IRR, 1.08; 95%CI, 1.02-1.14; P=.012) and borderline associated with all-cause mortality (HR, 1.04; 95%CI, 0.99-1.09; P=.068). CONCLUSIONS: In outpatients with chronic HF, lower UNa+ was associated with a higher risk of recurrent WHF events.

Beyond clinical trials - The cost saving associated with dapagliflozin use in Portugal hospital clinical practice.

INTRODUCTION AND OBJECTIVES: Heart failure (HF) is a clinical syndrome associated with substantial morbidity, mortality, and healthcare costs. Dapagliflozin has proven efficacy in reducing the risk of death and hospitalization in HF patients, regardless of left ventricular ejection fraction (LVEF). This paper aimed to project the potential impact of dapagliflozin on healthcare costs related to HF subsequent hospitalizations (HFHs) in Portuguese hospitals. METHODS: The total number of HF-related hospitalizations (hHF), HFHs, and the average length of stay for patients with a primary diagnosis of HF from six Portuguese hospitals, between January 2019 and December 2021, were collected and aggregated by hospital classification. Costs associated with HFHs were calculated according to Portuguese legislation and considering conservative, average, and complex approaches. Cost-saving projections were based on extrapolations from hHF risk reductions reported in dapagliflozin clinical trials. RESULTS: Considering a 26% risk reduction in hHF reported on pooled-analysis of DAPA-HF and DELIVER as the expected reduction in HFHs, the use of dapagliflozin would be associated with cost savings ranging from EUR 1612851.54 up to EUR 6587360.09, when considering all hospitals and the different approaches, between 2019 and 2021. A similar projection is observed based on 24% RRR derived by weighting DAPA-HF and DELIVER sub-analyses and PORTHOS epidemiological data. CONCLUSIONS: In this projection, dapagliflozin use in all eligible hHF patients is associated with a significant reduction in direct costs. Our data support that, in addition to the improvements in HF-related outcomes, dapagliflozin may have a significant economic impact on healthcare costs in Portuguese hospitals.

[Self-care education during Cardiac Rehabilitation programs for patients with Heart Failure with preserved Ejection Fraction: a Delphi Study]. / Educación en autocuidado durante programas de rehabilitación cardiaca para pacientes con insuficiencia cardiaca con fracción de eyección preservada: estudio Delphi.

OBJECTIVES: To develop a decalogue of self-care competencies to manage educational intervention during Cardiac Rehabilitation (CR) programs in Heart Failure with preserved Ejection Fraction (HFpEF) patients through multidisciplinary consensus. DESIGN: 3-round e-Delphi study using an initial questionnaire of 23 competencies based on the main recommendations of the CR and self-care guidelines. SITE: It was framed under the ethics of a randomised clinical trial developed at the Regional Hospital of Malaga. The survey was designed and disseminated as an online questionnaire. PARTICIPANTS: The expert panel comprised two patients with HFpEF and 13 healthcare professionals from Internal Medicine (n=3), Cardiology (n=2), Physiotherapy (n=3), Nursing (n=3) and Occupational Therapy (n=2). METHOD: The analysis of results included the content validity index, the percentage of agreement, and the concordance using Fleiss Kappa and Krippendorff's alpha. RESULTS: After the third round, 20 self-care competencies were identified, grouped into 12 domains, with sufficient consensus for their inclusion in the decalogue. CONCLUSIONS: The decalogue of self-care competencies generated from the multidisciplinary consensus guides education in patients with HFpEF, systematically addressing educational content tailored to patients for clinical practice in CR programs.

Loop diuretic discontinuation in chronic heart failure patients: A retrospective study.

INTRODUCTION AND OBJECTIVES: The use of loop diuretics is central in managing congestion in heart failure (HF), but their impact on prognosis remains unclear. In euvolemic patients, dose reduction is recommended, but there is no recommendation on their discontinuation. This study aims to assess the impact of loop diuretic discontinuation on the prognosis of outpatients with HF with reduced ejection fraction. METHODS: This retrospective cohort study collected data from medical records of patients followed in an outpatient HF clinic at a university hospital center. Patients were included if they had been on loop diuretics and these were discontinued. Demographic, clinical and laboratory data were collected, and number and type of congestive events during the one-year period after discontinuation were recorded. RESULTS: Among 265 patients on loop diuretics, almost half (129) discontinued them at some point. Patients had optimized medical therapy, low median age, low New York Heart Association class, low B-type natriuretic peptide values, normal blood pressure, controlled heart rate and kidney function within normal limits. Among 122 patients with one year of follow-up, 18 (14.8%) had a congestive event. Fifteen events (83.3%) were low-dose diuretic reinitiation at a scheduled visit. There were only three worsening heart failure events (2.5%) during the one-year period. A significant improvement in kidney function from discontinuation to the one-year follow-up appointment was also observed. CONCLUSIONS: In our cohort, loop diuretic discontinuation was possible and safe in a large proportion of patients. The results should be interpreted with caution and cannot be extrapolated to a broader population of HF patients.

[Translated article] Therapeutic management, adherence, and clinical outcomes of heart failure in Andalucía. ANDALIC Protocol.

Heart failure is a prevalent syndrome with high mortality rates, representing a significant economic burden in terms of healthcare. The lack of systematic information about the treatment and adherence of patients with heart failure limits the understanding of these aspects and potentially the improvement of clinical outcomes. OBJECTIVE: To describe the clinical characteristics, therapeutic management, adherence, persistence, and clinical results, as well as the association between these variables, in a cohort of patients with heart failure in Andalusia. DESIGN: This study will be an observational, population-based, retrospective cohort study. Data of patients discharged from an Andalusian hospital with a diagnosis of heart failure between 2014 and 2023 will be extracted from the Andalusian population health database. ANALYSIS: The statistical analysis will incorporate the following strategies: (1) Descriptive analysis of the characteristics of the population cohort, adherence measures, and clinical outcomes. (2) Bivariate analyses to study the association of covariates with adherence, persistence, and clinical results. (3) Multivariate logistic regression and Cox regression analysis including relevant covariates. (4) To evaluate changes over time, multivariate Poisson regression models will be used. By conducting this comprehensive study, we aim to gain valuable insights into the clinical characteristics, treatment management, and adherence of heart failure patients in Andalusia, as well as to identify factors that may influence clinical outcomes. These findings could be critical both for the development of optimised strategies that improve medical care and quality of life of patients and for mitigating the health burden of HF in the region.

NT-proBNP in systemic right ventricles: a new cutoff level for risk stratification?

INTRODUCTION AND OBJECTIVES: The role of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in the risk prediction of patients with systemic right ventricles (sRV) is not well defined. The aim of this study was to analyze the prognostic value of NT-proBNP in patients with an sRV. METHODS: The prognostic value of NT-proBNP was assessed in 98 patients from the SERVE trial. We used an adjusted Cox proportional hazards model, survival analysis, and c-statistics. The composite primary outcome was the occurrence of clinically relevant arrhythmia, heart failure, or death. Correlations between baseline NT-proBNP values and biventricular volumes and function were assessed by adjusted linear regression models. RESULTS: The median age [interquartile range] at baseline was 39 [32-48] years and 32% were women. The median NT-proBNP was 238 [137-429] ng/L. Baseline NT-proBNP concentrations were significantly higher among the 20 (20%) patients developing the combined primary outcome compared with those who did not (816 [194-1094] vs 205 [122-357]; P=.003). In patients with NT-proBNP concentrations> 75th percentile (> 429 ng/L), we found an exponential increase in the sex- and age-adjusted hazard ratio for the primary outcome. The prognostic value of NT-proBNP was comparable to right ventricular ejection fraction and peak oxygen uptake on exercise testing (c-statistic: 0.71, 0.72, and 0.71, respectively). CONCLUSIONS: In patients with sRVs, NT-proBNP concentrations correlate with sRV volumes and function and may serve as a simple tool for predicting adverse outcomes.

Outcomes of patients with heart failure followed in units accredited by the SEC-Excelente-IC quality program according to the type of unit.

INTRODUCTION AND OBJECTIVES: The development of specific heart failure (HF) units has improved the management of patients with this disease due to improved organization and resource management. The Spanish Society of Cardiology (SEC) has defined 3 types of HF units (community, specialized, and advanced) based on their complexity and service portfolio. Our aim was to compare the characteristics, treatment, and outcomes of patients with HF according to the type of unit. METHODS: We analyzed data from the SEC-Excelente-IC quality accreditation program registry, with 1716 patients consecutively included in two 1-month cutoffs (March and October) from 2019 to 2021 by 45 SEC-accredited HF units. We compared the characteristics, treatment and 1-year outcomes between the 3 types of units. RESULTS: Of the 1716 patients, 13.2% were treated in community units, 65.9% in specialized units, and 20.9% in advanced units. The rates of mortality (27.5 vs 15.5/100 patients-year; P<.001), admissions for HF (39.7 vs 29.2/100 patients-year; P=.019), total decompensations (56.1 vs 40.5/100 patients-year; P=.003), and combined death/admission for HF (45.2 vs 31.4/100 patients-year; P=.005) were higher in community units than in specialized/advanced units. Follow-up in a community unit was an independent predictor of higher mortality and admissions at 1 year. CONCLUSIONS: Compared with follow-up by more specialized units, follow-up in a community unit was associated with a higher decompensation rate and increased 1-year mortality.

O Efeito da Administração Precoce de Solução Salina Hipertônica na Insuficiência Cardíaca Descompensada Aguda / The Effect of Early Administration of Hypertonic Saline Solution İn Acute Decompensated Heart Failure

Resumo Fundamento Não houve evidência científica sobre o tratamento inicial com solução salina hipertônica (SSH) na insuficiência cardíaca agudamente descompensada (ICAD). Objetivos Este estudo avaliou o impacto do uso de SSH junto com um diurético de alça (DA) como o primeiro tratamento diurético para ICAD, com foco na função renal, níveis de eletrólitos e resultados clínicos. Métodos Neste estudo retrospectivo de caso-controle, 171 pacientes adultos (93 mulheres/78 homens) com ICAD foram incluídos entre 1º de janeiro de 2022 e 31 de dezembro de 2022. Os pacientes foram alocados em dois grupos: combinação inicial de SSH+DA e DA padronizada. O desfecho primário foi piora da função renal (PFR). A hospitalização por IC e a mortalidade por todas as causas foram avaliadas durante 6 meses de acompanhamento. O nível de significância adotado na análise estatística foi de 5%. Resultados Os grupos exibiram semelhanças nas características basais. Diurese significativamente maior no 1º dia (3975 [3000-5150] vs. 2583 [2000-3250], p=0,001) e natriurese na 2ª hora (116,00 [82,75-126,00] vs. 131,75-140,00] vs. 94,00-103,25] vs. 99,00 [96,00-103,00], p=0,295), TFG (48,50 [29,75-72,50 vs. 50,00[35,50-63,50, p=0,616) e creatinina (1,20 [0,90-1,70] vs. 1,20 [1,00-1,50], p=0,218) permaneceu estável no grupo SSH combinado inicial quando comparado ao grupo DA padronizado (Cl-: 102,00[99,00-106,00] vs. 98,00[95,00-103,00], p=0,001, TFGe: 56,00 [41,00-71,00] vs. 55,00[35,00-71,00], p=0,050, creatinina: 1,10[0,90-1,40] vs. 1,20 [0,90-1,70], p=0,009). A piora da função renal (16,1% vs. 35,5%, p = 0,007) e o tempo de internação hospitalar (4 dias [3-7] vs. 5 dias [4-7], p = 0,004) foram menores na combinação inicial SSH+DA em comparação com o DA padronizado. A mortalidade hospitalar, a hospitalização por IC e a mortalidade por todas as causas foram semelhantes entre os dois grupos. Conclusão SSH como terapia inicial, quando combinada com DA, pode proporcionar uma diurese segura e eficaz sem prejudicar a função renal na ICAD. Portanto, a SSH pode levar a um menor tempo de internação hospitalar para esses pacientes.

Abstract Background There was no scientific evidence about the initial treatment of hypertonic saline solution (HSS) in acutely decompensated heart failure (ADHF). Objectives This study assessed the impact of using HSS along with a loop diuretic (LD) as the first diuretic treatment for ADHF, focusing on renal function, electrolyte levels, and clinical outcomes. Methods In this retrospective case-control study, 171 adult patients (93 females/78 males) with ADHF were included between January 1, 2022, and December 31, 2022. Patients were allocated into two groups: upfront combo HSS+LD and standardized LD. The primary endpoint was worsening renal function (WRF). Hospitalization for HF and all-cause mortality were evaluated during 6 months of follow-up. The significance level adopted in the statistical analysis was 5%. Results The groups exhibited similarities in baseline characteristics.A significantly higher diuresis on the 1st day (3975 [3000-5150] vs. 2583 [2000-3250], p=0.001) and natriuresis on the 2nd hour (116.00 [82.75-126.00] vs. 68.50 [54.00-89.75], p=0.001) in the initial upfront combo HSS+LD were found in comparison with the standardized LD.When compared to the standardized LD, the utilization of HSS led to an increase in serum Na+ (137.00 [131.75-140.00] vs. 140.00 [136.00-142.25], p=0.001 for upfront combo HSS, 139.00 [137.00-141.00] vs. 139.00 [136.00-140.00], p=.0470 for standardized LD), while chloride (99.00 [94.00-103.25] vs. 99.00[96.00-103.00], p=0.295), GFR (48.50 [29.75-72.50 vs. 50.00 [35.50-63.50, p=0.616), and creatinine (1.20 [0.90-1.70] vs. 1.20 [1.00-1.50], p=0.218) remained stable in the upfront combo HSS group when compared to standardized LD group (Cl-: 102.00 [99.00-106.00] vs. 98.00 [95.00-103.00], p=0.001, eGFR: 56.00 [41.00-71.00] vs. 55.00 [35.00-71.00], p=0.050, creatinine:1.10 [0.90-1.40] vs. 1.20 [0.90-1.70], p=0.009). Worsening renal function (16.1% vs 35.5%, p=0.007), and length of stay in the hospital (4 days [3-7] vs. 5 days [4-7], p=0.004) were lower in the upfront combo HSS+LD in comparison with the standardized LD. In-hospital mortality, hospitalization for HF, and all-cause mortality were similar between the two groups. Conclusion HSS as an initial therapy, when combined with LD, may provide a safe and effective diuresis without impairing renal function in ADHF. Therefore, HSS may lead to a shorter length of stay in the hospital for these patients.