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Emergencias 2015;27:11-22 ORIGINAL ARTICLE Characteristics and clinical course of patients with acute heart failure and the therapeutic measures applied in Spanish emergency departments: based on the EAHFE registry (Epidemiology of Acute Heart Failure in Emergency Departments) Pere Llorens1, Rosa Escoda2, Òscar Miró2, Pablo Herrero-Puente3, Francisco Javier Martín-Sánchez4, Javier Jacob5, José Manuel Garrido6, María José Pérez-Durá7, Cristina Gil8, Marta Fuentes8, Héctor Alonso9, Christian Muller10, Alexander Mebazaa11, en representación de los participantes del estudio del grupo de trabajo ICA-SEMES (Anexo 1) 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. Conclusions. 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. Keywords: Acute heart failure. Hospital emergency health services. Therapy. Clinical course. Registries. Características clínicas, terapéuticas y evolutivas de los pacientes con insuficiencia cardiaca aguda atendidos en servicios de urgencias españoles: Registro EAHFE Affiliation of authors: Emergency Service, Short Stay Unit and Home Care Unit, University Hospital General de Alicante, Alicante, Spain. 2 Emergency Service, Hospital Clinic of Barcelona, Research Group "ER: processes and pathologies", IDIBAPS, Barcelona, Spain. 3 Emergency Service, Hospital Universitario Central de Asturias, Research Group ER-HUCA, Oviedo, Spain. 4 Emergency Service and Short Stay Unit, Hospital Clinico San Carlos, Madrid, Spain. 5 Emergency Service, Hospital Universitario de Bellvitge, Barcelona, Spain. 6 Emergency Service, Hospital Virgen de la Macarena, Sevilla, Spain. 7 Emergency Department, Polytechnic Hospital La Fe, Valencia, Spain. 8 Emergency Service, Hospital Universitario de Salamanca, Salamanca, Spain. 9 Emergency Service, Hospital Marqués de Valdecilla, Santander, Spain. 10 Cardiology Department, University Hospital of Basel, Basel, Switzerland. 11 Department of Anaesthesia and Intensive Care, INSERM UMR 942, Lariboisière Hospital, University of Paris - Diderot, Paris, France. 1 Corresponding author: Pere Llorens General Emergency Service. General Hospital of Alicante C / Pintor Baeza 12. 03010 Alicante, Spain Email: [email protected] Item Information: Received: 11/11/2014 Accepted: 12/26/2014 Online: 02/11/2015 Objetivos. Presentación de los resultados del Registro EAHFE (Epidemiology of Acute Heart Failure in Emergency Departments) que recoge las características clínicas, de laboratorio, terapéuticas y la evolución de los pacientes con insuficiencia cardiaca aguda (ICA) atendidos en 29 servicios de urgencias hospitalarios (SUH) españoles. Se analizan los cambios de manejo a lo largo del tiempo; y se comparan los resultados con los de otros registros de ICA. Material y métodos. Estudio multicéntrico, de cohortes, prospectivo, de inclusión consecutiva, realizado en tres periodos (2007, 2009 y 2011). Se recogieron datos demográficos, clínicos, de laboratorio, del tratamiento farmacológi- 11 Llorens P, et al. Emergencias 2015;27:11-22 co previo y el administrado en SUH y variables evolutivas (mortalidad intrahospitalaria y a los 30 días y al año, reingreso a 30 días). Se analizaron los cambios terapéuticos y evolutivos a lo largo de estos 3 periodos. Se revisó la literatura para identificar registros previos de ICA de carácter nacional o internacional. Resultados. Se incluyeron 5.845 pacientes (2007: 948, 2009: 1.483, 2011: 3.414), con edad media de 79 años y 56% mujeres. Un 34,6% era un primer episodio de ICA. Presentaron elevada comorbilidad (82% hipertensión, 42,3% diabetes mellitus, 47,7% fibrilación auricular). Un 21,9% tenía dependencia funcional grave o total. El 57,3% tenía una disfunción sistólica (FEVI 38,3%). Los principales tratamientos administrados en urgencias consistieron en diuréticos (96,8%), nitroglicerina endovenosa (20,7%), ventilación no invasiva (6,4%) y fármacos inotrópicos o vasopresores (3,6%). El 57% presentaba una tasa de filtrado glomerular disminuida. Las troponinas y los péptidos natriuréticos se determinaron en urgencias en un 49,1% y 42,4% de casos, respectivamente. Las formas de presentación se clasificaron como: normotensiva (66,4%), hipertensiva (23,5%), hipotensiva (4,6%, 0,7% con shock). El 76,1% fue ingresado (1,9% en intensivos), con una mediana de estancia hospitalaria de 7 días, y el 23,9% dado de alta desde urgencias. La mortalidad intrahospitalaria fue 7,6%, a 30 días 9,4% y al año 29,5%. A lo largo del periodo estudiado, ha aumentado la solicitud de troponinas (p < 0,001) y péptidos natriuréticos (p < 0,001) en urgencias, ha disminuido el uso de diuréticos en perfusión (p < 0,001) y de inotropos/vasoconstrictores (p < 0,001) y ha disminuido el porcentaje de reconsulta a 30 días (p = 0,004). No se observaron cambios en la mortalidad intrahospitalaria y a los 30 días entre el periodo 2007-2011. Se han revisado 14 registros anteriores (8 prospectivos), y solo en 2 la inclusión de pacientes se hizo desde el SUH. Conclusiones. El Registro EAHFE describe las características de la ICA a partir de una cohorte que se aproxima al universo de pacientes con ICA. Con el paso del tiempo se observan cambios significativos en algunos aspectos del manejo de la ICA; las revisitas han disminuido, aunque la mortalidad no se ha modfiicado. Aparte del Registro EAHFE, solo existen otros 2 registros previos en el mundo que hayan incluido pacientes con ICA atendidos en urgencias. Palabras clave: Insuficiencia cardiaca aguda. Servicios de Urgencias Hospitalarios. Características. Manejo. Evolución. Registro. Introduction Acute heart failure (AHF) is one of the leading causes of hospitalization and represents a major economic and medical burden in any public health system. It is associated with increased hospital mortality after discharge, as well as high rates of readmission1. The diagnosis, management and treatment of AHF in routine clinical practice is based on data from different observational epidemiological studies, clinical trials and expert consensus documents. All this information is reflected in the guidelines of different societies and countries2-4. However, the records from different countries show discrepancies, sometimes substantial, between actual therapies and guideline indications5 and the results in terms of morbidity and mortality are often very different between hospital centers. In addition, geographical variations depending on the location of the study may include differences in age, race, ethnicity, culture, social and economic circumstances, health resources and health systems that affect the management and even the course of the disease6. Hospital emergency departments (EDs) and observation units (OU), where patients are usually located for periods of less than 24 hours, play a central role in the management of AHF. In Spain, as in most countries with a public health system, the vast majority of these patients are initially treated in the ED. The care provided there is a key factor, since rapid identification of the different scenarios and complications of AHF and its proper treatment determine short and medium term 12 prognosis4,7. Additionally, proper risk stratification in the ED may help select patients at low or intermediate risk, some of whom may be discharged directly from the ED thus avoiding unnecessary hospital admissions8. Data from different countries indicate that this percentage ranges between 20% and 40%9,10. EDs, on attending most patients with AHF, allow a more global view, which approximates the reality of the disease. However, most AHF records describe hospitalized patients or those managed in specialized units, which excludes the proportion of patients discharged directly from the ED10-24. In addition, most records are cross-sectional and analyze the management of AHF in a cohort of the population attended at a particular moment of time. This prevents assessing the degree of adherence of the professionals caring for AHF patients to current management guidelines, and the effect of training programs designed to correct deviations, which are only identifiable through studies with a longitudinal design25. For the first time, the present study describes overall results from the EAHFE Registry (Epidemiology of Acute Heart Failure in Emergency Departments), whose general objective was to remedy the above-mentioned limitations. In particular, the three specific objectives of this paper were: 1) to describe the clinical characteristics, laboratory findings, treatment and outcome of AHF patients seen in Spanish EDs; 2) to detect changes in the management of these patients in such EDs over time; and 3) compare the results of this registry with those of other published AHF registries. Llorens P, et al. Emergencias 2015;27:11-22 Method The EAHFE26 Registry is a multipurpose, multicenter, non-interventional analytical cohort study with prospective follow-up. The EAHFE Registry has had three phases of patient inclusion to date: the first (EAHFE-1), from April 15 to May 15, 2007 (1 month in 10 EDs); the second (EAHFE-2) was conducted between 1 and 30 June 2009 (1 month, 19 EDs) and the third (EAHFE-3) between November 7, 2011 and January 7, 2012 (2 months, 29 EDs). Participating hospitals are widely distributed in Spain and include university hospitals, referral hospitals and community hospitals (see list of centers in the Annex on participating centers). During these periods, participating EDs included all consecutive AHF patients. The diagnostic criteria are based on the presence of symptoms (dyspnea, orthopnea, paroxysmal nocturnal dyspnea) and acute signs of AHF (third heart sound, pulmonary rales, jugular venous pressure greater than 4 cm, sinus tachycardia at rest, edema, hepatomegaly, hepatojugular reflux) and radiological evidence of pulmonary congestion. The only exclusion criterion is a diagnosis of acute myocardial infarction with ST elevation as the primary diagnosis and concomitantly development of AHF. All participating EDs have a principal investigator, and all principal investigators meet one month before starting the inclusion period to agree and unify criteria. Subsequently, and prior to the patient inclusion period, each principal investigator meets with his/her ED physicians to explain the protocol, since they all participate in the detection of patients with AHF. When a case is detected, the principal investigator checks that the patient meets the inclusion criteria, in which case all the variables are recorded on a specific data sheet. The variables have not differed substantially between periods. This action protocol was the same in all three periods of recruitment for the EAHFE registry, and at no time was there any intervention, since all management is provided by the medical team responsible with their usual care procedures. The registry is prepared in accordance with the Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and patients give their informed consent to participate. The full protocol was approved by the ethics and clinical research committees of the participating hospitals. Part 1: Descriptive analysis of the EAHFE Registry Baseline patient data include demographics (age and sex), comorbidity (history of hypertension, diabetes mellitus, dyslipidemia, coronary artery disease, valvular heart disease, atrial fibrillation, chronic renal failure - creatinine higher than 2 mg / dL, stroke, chronic obstructive pulmonary disease -COPD-, peripheral artery disease, diagnosis of dementia and previous episodes of AHF), baseline functional status (functional dyspnea according to the New York Heart Association -NYHA-), echocardiographic data in the event of having had an echocardiogram performed in the year before the ED visit, baseline functional status, measured by the Barthel27 index, (0-20 points: total dependence; 21-60: severe dependence; 61-90: moderate dependence, 91-99: little or mild dependence, and 100: independence), and treatment prior to the ED visit (diuretics, beta blockers, angiotensin converting enzyme inhibitors – ACEI - angiotensin receptor antagonists of angiotensin II - ARA-II, calcium channel blockers, aldosterone inhibitors, anticoagulants, antiplatelet agents, digoxin and cardiac resynchronization therapy). Data from the acute episode of AHF include vital signs on ED arrival (systolic blood pressure or SBP, heart rate – HR - and respiratory rate - RR), analytical data (hemoglobin with anemia defined according to recommendations of the WHO, glucose, creatinine, urea, estimated glomerular filtration test - eGF- using the abbreviated formula of the study Modification of Diet in Renal Disease MDRD28-, sodium, troponin and natriuretic peptides, although the latter are not available in all EDs), ECG data, treatment administered in the ED and the destination of the patient after ED care (discharge or admission, and the hospital department in the latter case). With existing clinical history data, the principal investigator of each center performed two independent classifications of the episode. On the one hand, the episode of AHF was classified as hypertensive, normotensive, hypotensive, pulmonary edema, cardiogenic shock and isolated right heart failure. This classification was performed with EAHFE patients included in periods 2 and 32. On the other hand, for the EAHFE periods 1 and 3, the researcher classified each episode depending on whether there was any trigger for the AHF, judging by the data collected and the comments made in the clinical history by the medical care team, and what this factor was. In the latter case, more than one episode triggering factor could be assigned. Finally, the EAHFE Register also collects data from patient follow-up, consisting of the total hospital stay when appropriate, hospital mortality and follow-up mortality, as well as ED revisits for a new episode of AHF within 30 days. This was done through a phone call or by consulting the clinical history or primary care consultation 3060 days after the index event. In addition, a new phone call or consultation within one year from the index event was used to assess the long-term mortality. Part 2: Evolutionary analysis To compare possible changes over time in the management of AHF in Spanish ED patients, we analyzed data from the 8 EDs who had participated in all three periods of recruitment: EAHFE-1 in 2007, EAHFE-2 in 2009 and EAHFE-3 in 2011 (Hospital Marqués de Valdecilla in Santander, University Hospital of Salamanca, Hospital de Bellvitge in L'Hospitalet de Llobregat, Hospital Clinic of Barcelona, Hospital Universitario Central de Asturias in Oviedo, Hospital Clinico San Carlos in Madrid, Hospital La Fe in Valencia and Alicante General Hospital). For each of these patients we analyzed the 13 Llorens P, et al. Emergencias 2015;27:11-22 emergency physicians approach to the application of troponin and natriuretic peptide in the ED, the treatment administered in such EDs, and patient willingness. Additionally, in these centers we investigated the evolution of in-hospital 30-day mortality and 30-day revisits to the ED. Part 3: Review of previous AHF records Se compararon las principales características de los pacWe compared the main characteristics of EAHFE registry patients with those reported in other published registries. Medline was used as a search engine, with the words "Acute Heart Failure" and "Registry" as descriptors for review of the literature. Abstracts of papers were reviewed and those that met all the following criteria were chosen: main registries, multicenter, nationwide or international collaboration in which AHF was the principal diagnosis, analysis of aspects of care in the ED or during hospitalization concerning the acute episode, and intensive care units (ICU) were not the primary destination of patients. Papers that met these criteria were reviewed in full text. In addition, cross-references that appeared in these articles were reviewed. Statistical analysis Qualitative variables are expressed as frequencies and percentages, and continuous variables as means and standard deviation (SD). Tables and survival curves were elaborated using Kaplan-Meier method. Chi-square test for linear trend was used to compare possible changes in the management of patients with AHF in the ED over time. Differences with a p value less than 0.05 were considered significant. All analyses were performed using SPSS 18.0.. Results Part 1: Patient characteristics Registry EAHFE The EAHFE registry included 5,845 patients with AHF (EAHFE-1: 948, EAHFE-2: 1,483, EAHFE-3: 3,414 patients). The average age was 79 years (SD 10) and 56% were women; 34.6% of the cases were first episodes of AHF (de novo). Regarding comorbidity, 82% had hypertension, 42.3% diabetes mellitus, 47.7% atrial fibrillation and 24.6% COPD. Almost a quarter (22.6%) were NYHA functional class I at baseline and 37.5% had functional independence (Barthel 100 points). At the other extreme, 25.1% of patients had a functional class NYHA III-IV and 21.9% had severe or total functional dependence (Barthel 60 points). 38.1% had an echocardiogram, which showed systolic dysfunction in 57.3% of cases. Left ventricle ejection fraction (LVEF) was 50.6% (38.3% for the subgroup of patients with systolic dysfunction). The main treatments that patients received chronically for their heart failure were loop diuretics 67.2% ACE inhibitors or ARBs 55.9% and beta-blockers 32.7%. Other baseline characteristics are shown in Table 1. 14 The data collected during the acute episode is reported in Table 2. Notably, we observed anemia in 57.1% of patients, blood glucose greater than 180 mg / dl in 20.6%, natremia lower than 135 mEq / L 20.8% and GFR lower than 60 mL / h / m2 1.73 in 57%. Troponins and natriuretic peptides were determined in the ED in 49.1% and 42.4% of patients, respectively. Regarding treatment, we would highlight the predominant use of diuretics (96.8%; mainly in bolus form) and noninvasive ventilation (NIV) in 6.4% and inotropes or vasopressors in 3.6%. The predominant form of presentation, observed in two thirds of cases, was normotensive AHF, followed by hypertensive AHF, which was observed in almost a quarter of patients. Only 0.7% of AHF presented with shock (Figure 1). In 523 cases (11%), the clinical diagnosis was acute pulmonary edema (EAP). Furthermore, in 77% of patients we were able to identify at least one trigger, most frequently infection (41.6% of patients where a triggering factor was identified). The remaining factors are detailed in Table 3. After treatment in the ED, 76.1% of patients with AHF were admitted to wards (1.9% admitted to ICU) and 23.9% were discharged directly from the ED or OU (Figure 2). The average stay for hospitalized patients was 9 (SD 15) days, with a median of 7 days (IQR: 7). Hospital mortality was7.6%, overall mortality at 30 days was 9.4% and the rate of revisits within 30 days was 20%. Figure 3 shows the survival curve for mortality at one year, reaching 29.5%. Part 2: Evolutionary analysis. Comparison between EAHFE Registries 1, 2 and 3 The 8 EDs that participated in the three EAHFE phases contributed a total of 2,865 patients (EAHFE 1: 825; EAHFE 2: 722; EAHFE 3: 1318). The determination of troponins and natriuretic peptides in the ED during the period increased (Table 4). As for treatment in the ED, we observed highlights a significant decrease in the use of diuretics in perfusion and inotropes and vasopressors. However, ED use of intravenous nitroglycerin has not changed significantly over time. The ratio of patients hospitalized and discharged from the ED has not changed significantly. Regarding follow-up data of these patients, neither in-hospital mortality nor 30-day mortality changed significantly over time changes, but the rate of return visits to the ED for AHF within 30 days showed a significant decrease (Figure 4). Part 3: Review of previous AHF records Of 76 studies initially identified, 13 met the criteria for inclusion. The complete review of these items resulted in four exclusions since they were sub-studies, so 9 studies were analyzed. In addition, through cross references, another 5 items were identified and finally included, so that 14 studies were finally reviewed (Table 5). Of these, 9 registries were prospective and 6 retrospective; in 12 of them, patients were hospitalized (6 Llorens P, et al. Emergencias 2015;27:11-22 Table 1. Baseline characteristics of patients with acute heart failure Total n (%) Table 2. Characteristics of acute episode of heart failure Total n (%) Epidemiological data Age, Edad,years años[mean [media(SD)] (DE)] 79.3 (10.4) Female sex Sexo mujer 3,304 (56.5) Medical history Hypertension Hipertensión arterial 4,824 (82.7) Diabetes mellitus 2,464 (42.3) Dyslipidemia Dislipemia 2,235 (38.3) Ischemic heart disease Cardiopatía isquémica 1,785 (30.6) Chronic renalrenal failure Insuficiencia crónica 1,302 (22.3) Cerebrovascular disease Enfermedad cerebrovascular 736 (12.6) AF Fibrilación auricular 2,780 (47.7) Valve disease Valvulopatía 1,536 (26.4) Peripheral disease Arteriopatíaartery periférica 467 (8.0) COPD EPOC 1,432 (24.6) Dementia Demencia 451 (7.7) Neoplasia 512 (8.8) Cirrhosis Cirrosis 66 (1.1) Previous heartcardiaca failure previa Insuficiencia 3,695 (65.4) Baseline data Cardiorespiratory (stage NYHA) Cardiorrespiratoria (estadio de la NYHA) II 1,220 (22.6) IIII 2,822 (52.3) IIIIII 1,261 (23.4) IVIV 92 (1.7) Functional(Índice (BarthelBarthel) Index) Funcional Functional independence (100puntos) points) Independencia funcional (100 1,931 (37.5) Mild dependence Dependencia leve(91-99 (91-99points) puntos) 269 (5.2) Moderate dependence (61-90 points) Dependencia moderada (61-90 puntos) 1,680 (32.6) Severe dependence Dependencia grave (21-60 (21-60 points) puntos) 944 (18.3) Total dependence Dependencia total(0-20 (0-20points) puntos) 332 (6.4) Type de echocardiographic dysfunction(n (n==2226) 2226) Tipo disfunción ecocardiográfica systolic Sistólica 1,275 (57.3) diastolic Diastólica 930 (41.8) mixed Mixta 21 (0.9) Left ventricular ejection fraction [mean (SD)] Fracción eyección del ventrículo izquierdo [media (DE)] All patients Todos los pacientes 50.6 (15.9) Patients with dysfunction Pacientes consystolic disfunción sistólica 38.3 (12.6) Pre-hospital treatment Diuretics ASA Diuréticos ASA 3,860 (67.2) ACE inhibitors and ARBs IECA-ARAII 3,266 (55.9) Beta blockers Betabloqueantes 1,878 (32.7) Aldosterone antagonists Antagonistas de la aldosterona 961 (16.7) Digoxin Digoxina 1,132 (19.7) CRT Dispositivos TRC 472 (8.2) SD: standard deviation; COPD, chronic obstructive pulmonary disease; NYHA, New York Heart Association; SBP, systolic blood pressure. ACEI ARBs: angiotensin converting enzyme / angiotensin-II receptor antagonists; CRT: cardiac resynchronization therapy. Vital Signs Systolic arterial blood pressure Presión sistólica (mmHg) [mean [media(SD)] (DE)] 142 (29) <140 < 140mmHg mmHg 2.775 (66.4) <120 < 120mmHg mmHg 1.167 (20) <100 < 100mmHg mmHg 271 (4.8) <80 < 80mmHg mmHg 23 (0.4) Diastolicarterial blood diastólica pressure (mmHg) Presión (mmHg)[mean [media(SD)] (DE)] 77 (17) Heart rate (bpm) [Mean Frecuencia cardiaca (lpm)(SD)] [media (DE)] 90,1 (24.7) Respiratory respiratoria rate (bpm) (rpm) [mean[media (SD)] (DE)] Frecuencia 23 (7) Oxygen saturation Saturación basal de on o] arrival (%) [mean (SD)] 92 (7) Electrocardiogram AF Fibrilación auricular 2.342 (40.1) Left ventricular hypertrophy Hipertrofia ventricular izquierda 293 (5) Left bundle branch block Bloqueo de rama izquierda 521 (8.9) Laboratory data Hemoglobina(g(g/dl) (DE)] 11,8 (2.0) Hemoglobin / dl) [media [mean (SD)] (< 12inenwomen mujeres, < 13 en hombres) 3.216 (57.1) Anemia (<12 <13 in men) Glucemia(mg (mg/dl) [media(SD)] (DE)] 143 (73) Glucose / dl) [mean 110 2.980 (64.2) >>110 140 1.519 (37.2) >>140 180 841 (20.6) >>180 Creatinina (mg (mg/dl) 1.3 (0.8) Creatinine / dl)[media [mean(DE)] (SD)] 2 [media (DE)] Filtrado glomerular (ml/min/1,73 m2) m ) [mean (SD)] 58.2 (26,4) Glomerular filtration rate (ml / min / 1.73 < 60 4.149 (57) <60 < 30 771 (14) <30 < 15 133 (2.4) <15 Sodio (mEq/L) (DE)] 137 (5) Sodium (mEq /[media L) [mean (SD)] < 135 1.152 (20.8) <135 < 130 330 (6.0) <130 < 125 114 (2) <125 < 115 13 (0.2) <115 Péptidos natriuréticos [mediana (RIC)] Natriuretic peptides [median (IQR)] NT-proBNP(pg (pg/mL) 4.010 (6.847) NT-proBNP / mL)(n (n==2.096) 2,096) BNP(pg (pg/mL) 698 (1.354) BNP / mL)(n (n==382) 382) Troponinas(n(n= =2,869) 2.869) Troponins Positivas* 1.309 (45) Positive * Positivastroponin de la troponina T de 4ª generación (n = 523 181 (34.6) Positive T 4th generation (n = 523) Positivasultrasensitive de la troponina T ultrasensible (n = 887) 724 (81.3) Positive troponin T (n = 887) Positivastroponin de la troponina I (n = 1.458) 404 (27.8) Positive I (n = 1,458) Treatment Oxygen Oxigenoterapia 4.519 (78.5) Non-invasive Ventilación noventilation invasiva 377 (6.4) Bolus intravenous diuretics Diuréticos intravenosos bolo 5.069 (86.7) Diuretics intravenousperfusión infusion Diuréticosbyintravenosos 591 (10.1) Intravenous nitroglycerin Nitroglicerina intravenosa 1.190 (20.7) Inotropic or ovasopressor treatment Inotrópicos vasopresores 207 (3.6) Digoxin Digoxina 1.014 (17.6) *Cut-off percentile 99. SD: standard deviation. cardiology, 1 internal medicine, and the rest in any ward) and 2 studies included patients seen in the ED. Mean age varied from 69-77 years and the percentage of women varied between 39% and 62.4%. Comorbidity was present in very different ways. So, for major comorbidities, ischemic heart disease was present in 28% to 65%, hypertension between 57.8 and 83.7%, diabetes mellitus between 31 and 45.3%, atrial fibrillation between 31 and 53.1%, and previous episodes of AHF between 37 and 88%. Regarding baseline data, between 51.3 to 72.5% of patients received chronic treatment with ACE inhibitors or ARBs and beta-blockers between 40 and 53.1%. Presentation in the form of acute pulmonary edema varied between 16 and 49.6%, and shock bet- ween 2 and 14.5%. The presence of an infection as a precipitating factor was recorded in 15-27%, although this was contained in only 4 of the 14 records. LVEF ranged between 34 and 42%. Mean SBP of acute episodes varied between 130 and 147 mmHg, HR between 88 and 110 bpm, creatinine between 0.76 and 1.8 mg / dL, anemia between 14.4 and 46% of patients and only 3 records showed the percentage of patients with hyponatremia, ranging between 5% (sodium <130 mmEq / L) and 45% (sodium <136 mmEq / L). The application of natriuretic peptides varied between 8 and 82%. As for treatments for AHF episodes, NIV was used in 8.9-36.1%, diuretics in 80-99%, vasodilators in 14.3-51.3% and inotropes in 10.5-29.8%. The average hospital stay for patients admitted varied bet- 15 Llorens P, et al. Emergencias 2015;27:11-22 858 patients; 15.1% 31 patients; 0.7% 265 patients; 4.7% 896 patients; 15.7% 134 patients; 2.8% 372 patients; 6.5% 125 patients; 2.6% 3,159 patients; 66.4% 1850 patients; 32.5% Normotensive AHF ICA normotensiva Hypertensive AHF ICA hipertensiva Hypertensive AHF (no shock) ICA hipotensiva (sin shock) Hypertensive AHF (with shock) ICA hipotensiva (con shock) ACS withinsuficiencia heart failurecardiaca SCA con Right heart failure Insuficiencia cardiaca derecha The main findings of this study can be summarized under three headings. First, we describe a large series of patients with AHF collected prospectively during care in the ED. If we accept that this is the scenario that most closely reflects the reality of patients with AHF, its findings can be considered representative and reliable for the global spectrum of this syndrome. In general, this is usually an aging and functionally dependent population compared to that often seen in clinical trials and even in other similar records. Their clinical management, both chronic and acute, is suboptimal in rela- tion to guideline recommendations. A quarter of patients are discharged from the ED without hospitalization, and their short and long term outcomes can clearly be improved. Second, this work shows discrete but significant changes over time in some aspects of the management of these patients in the ED. These changes tend to compliance with the treatment guidelines for AHF, but not optimally. They therefore deserve to be analyzed to identify areas for improvement in the treatment and prognosis of AHF. Third, analysis of the main published AHF records shows that most involved inpatients, the results are quite heterogeneous, and are not directly comparable with those of the EAHFE registry. Indeed, we only found 2 studies, the ADHERE-EM12 conducted in the US and the Canadian Cohort Study 24, which included ED patients. The EAHFE Registry com- Table 3. Distribution of episodes of acute heart failure depending on the trigger * 1.0 16.9% Total n (%) 16 981 (23.0) 3,287 (77.0) 1,370 (32.1) 637 (37.2) 263 (6.2) 255 (6.0) 167 (3.9) 112 (2.6) 802 (18.8) registries (n = 22.6% 0.8 Cumulative survival Time in days Presence of trigger No Yes Precipitating factors identified Infection Rapid atrial fibrillation Anemia Hypertensive emergency Therapeutic failure Coronary ischemia Other *The data were collected in EAHFE-1 and EAHFE-3 4,268). 9.4% 29.5% 0.6 0.4 6 Months Discussion Figure 2. Destination of patients with acute heart failure treated in the emergency department. ED: hospital emergency department. 3 Months ween 3.8 and 17.8 days, ICU admission between 17 and 69% and hospital mortality varied between 3.8 and 17.8%. 1357; 23.9% Direct discharge home desde from the ED a domicilio el SUH Alta directa Internal Medicinamedicine interna Cardiology Cardiología Short Unidadstay de unit corta estancia Geriatric Geriatría ward Intensive unit intensivos Unidad decare cuidados Other Otros 1 Month Figure 1. Distribution of episodes of acute heart failure in EAHFE-2 and EAHFE-3 registries (n = 4,753). AHF: acute heart failure. ACS: acute coronary syndrome. 91 patients; 1.6% 12 Months 1,119 patients; 23.5% 186 patients; 3.9% 0.2 0.0 0 365 Timesurvival in days(days) Cumulative Figure 3. Survival curve corresponding to the mortality of patients enrolled in the EAHFE study. Llorens P, et al. Emergencias 2015;27:11-22 Table 4. Comparison of ED management of acute heart failure over time* Lab tests requested in the ED Determination of natriuretic peptides Determination of troponin ED treatment Oxygen Non-invasive ventilation Bolus intravenous diuretics Diuretics by intravenous infusion Intravenous nitroglycerin Inotropic-vasopressor treatment Destination Direct discharge from the ED * Results from 2865 patients with AHF corresponding EAHFE-1 N = 825 n (%) EAHFE-2 N = 722 n (%) EAHFE-3 N = 1318 n (%) 59 (7.2) 403 (48.8) 279 (38.6) 356 (49.3) 628 (47.6) 823 (62.4) < 0.001 < 0.001 675 (81.8) 26 (3.2) 687 (83.3) 169 (20.5) 176 (21.3) 36 (4.4) 570 (85.5) 43 (6) 631 (87.4) 69 (9.6) 173 (25.9) 26 (3.6) 1.049 (79.8) 59 (4.5) 1.146 (86.9) 84 (6.4) 307 (23.3) 43 (3.3) 0.13 0.24 < 0.05 < 0.001 0.389 < 0.001 167 (20.2) 168 (23.3) 282 (21.2) to the 8 hospitals participating in the EAHFE Records 1, 2 and 3. plements these and can be directly compared with them. Below we discuss this with the EAHFE findings. It is noteworthy that EAHFE Registry patients are those with a higher mean age (79 years), and in some cases by more than 10 years of age compared with other registries, especially those not conducted in EDs. The difference in age between the population with a disease and the population included in clinical trials has been highlighted in many studies29-33. In part this may be because the inclusion of patients in many cases is made from cardiology wards, where the age of patients admitted is usually lower. Therefore, this difference could be reduced in part with greater involvement and participation of EDs in clinical trials34,35. Advanced age possibly determines greater comorbidities, functional dependency and preserved LVEF, as found in the EAHFE Registry. This can influence the application of the results of clinical trials to the general population or sometimes give rise to unexpected results. The guidelines recommend troponin determination in all ED patients with AHF, to establish the prognosis Percentage p= 0.004 p= 0.87 p= 0.44 Hospital mortality Mortality at 30 days ED revisits within 30 days Figure 4. Comparison over time of mortality and revisits to the ED in 2,865 patients with acute heart failure corresponding to the 8 hospitals participating in the EAHFE Registries 1, 2 and 3. ED: hospital emergency department. p linear trend 0.60 and in some cases it may be diagnostic of the trigger if the clinical symptoms are compatible with acute coronary syndrome (ACS)36. This recommendation is not followed in more than half the cases. It is noteworthy that, when determined, the result is positive in 45% of cases. This percentage is high, possibly biased by the fact that troponin tests were perhaps requested in more severe cases or in patients with symptoms suggestive of ACS. In this regard, it is remarkable in those centers using the new ultrasensitive test, positivity exceeds 80%, and this poses a challenge in the differential diagnosis of ACS, since ischemic heart disease is present in a large number of cases of AHF, and although clinical symptoms are most useful, cardiac catheterization may be necessary in many cases for confirmation. The determination of natriuretic peptides in the ED in our study (34%) was very similar to that reported by the European ESC-HF Pilot registry19 and the Italian registry IN-HF21 (37% and 30% respectively), but well below that shown in the ADHERE 11 registry in the US (63%) or the French registry OFAHF23 (82%). However, these studies do not specify whether they were requested on ED arrival or during hospitalization, and the EAHFE registry did not include many of the patients with natriuretic peptide determination during hospitalization. In this case, the recommendation for urgent determination in the ED is not as strong as for troponins. However, their availability in the ED has been increasing, which has been associated with an increasing percentage of patients whose values are determined, as seen in this study. Thus, although it is routinely recommended during hospitalization of patients with AHF to stratify risk and as a prognostic marker37, the benefits of its determination in the ED in terms of indicating likely revisits or mortality are unclear38. We have seen that neither the determination of natriuretic peptides in an individual patient or the fact that ED have this test available is associated with better prognosis in terms of mortality or revisits, either for inpatients or those discharged from the ED39. This may be related to the absence of recommendations regarding the intensity or type of therapy to follow according to test values, or the degree or type of control to be performed 17 18 ND 79 45 32.5 33.5 8∞ 76 ND ND ND ND ND ND ND ND ND ND 89 1.8 ND ND ND 38 65 73 44 31 ND 30 65 53 70 48 28 ND ND ND ND ND 144 ND 1.8 ND ND 63 34 USA 143 87 1.8 ND ND 8 39 ND ND ND ND 15 51.3 65.7 53.1 23.4 46 71 41 31 28 19.6 88 USA OPTIMIZEDHF13 147 99 1.4 ND ND ND ND ND ND ND DD ND 60 45 40 20 33 71 34 40 9 A 37 Japan ATTEND14 AHEAD15 RO-AHFS16 EHFS I17 EHFS II18 ESC HF pilot19 ALARMHF20 IN-HF21 Italian S22 OFICA23 Canadian RICA24 Cohort Study10* EAHFE 135 90 1.2 35.1‡ 5** ND 37 14.5 18.4 3.8 36.2 ND 59.8 55 51 16.9 51 73.1 42.6 26.5 16.2 ND 41.7 143 98 1.3 ND ND ND 38 5 29 4 11.3 ND 52.9 69.3 44.5 35 61 67 33 44 ND ND 88 ND ND ND ND 20.5 20 ND <1 ND ND 19 17 ND ND ND ND 51”” 53 27 ND ND 18 83 135 95 ND 14.7¶ ND 16 38 4 16 3 30 17.6 63.1 71.2 43.2 26.6 53.6 62.5 32.8 38.7 19.3 16.8 62.9 141 97 1.7 46§ 45~ ND 37 72.5 81 32 ND 46 65.6 38.4 28.4 29.7 24.7 56 133 130 (novo) 130 (ICC) 134 88 107 (ICC) 110 (novo) 93 ND ND 1.5 31.4§ 14.4¶ 38.7§ ND ND 18.8~ 37 ND 30 40 (novo) 37 (ICC) 38 38 59 64 41 16 42.3 57.8 40.4 37.7 30.1 32.5 57 7.7 49.6 ND 33 ND 11.7 36.7 4.5 36.9 16.3 ND ND ND ND 30.7 70.2 45.3 24.4 24.8 21.4 63.8 2 27 9 13 ND 2 ND ND ND ND 60 68 62 21 51 62 35 44 ND 26 ND 130 89 1.5 ND ND 82 42 6 38 6 13 27 ND ND ND ND 44 62 31 38 20.9 15 72 146 89 0.76 ND ND ND ND ND ND ND ND ND 58.2 54.5 46.4 18.7 51.8 63.8 38.2 ND 22.2 ND ND ND ND ND 45.1§ ND ND 50 ND ND ND ND ND 80.3ˆ 85.4ˆ 57.4ˆ 28.8ˆ 28 83.7 44.7 53.1 27.5 59.2 66.6 142 90 1.3 57.1‡ 5.9**; 20.8~ 34 50 0.7 11 2.6 2.8 32.1 55.9 67.2 32.7 19.7 30.5 82.5 42.2 47.6 24.5 22.3 63.2 Czech Rumania Europe Europe Europe Europa, Turkey, Italy Italy Italy Canada Spain Spain Republic Australia, Mexico 274 83 259 32 7 13 115 133 136 668 61 206 170 86 52 29 2001-4 (36) 2004-5 (21) 2003-4 (22) 2007-9 (27) 2006-9 (38) 2008-9 (12) 2000-1 (1.5) 2004-5 (10) 2009-10 (8) 2006-7 (6) 2007-9 (23) 2004 (3) 2009 (1 day) 2004-7 (36) 2008-9 (10) 2007-11 (4) R R R P R P P P P R P P P R P P Hosp. SUH Hosp. Hosp. Hosp./Card. Hosp./Card. Hosp. Hosp. Hosp./Card. Hosp. Hosp./Card.Hosp./Card.Hosp./Card. SUH Hosp./MI SUH 105,388 10,984 48,612 2,867 4,153 3,224 46,788 3,580 1,892 4,953 1,855 2,807 1,648 12,591 1,172 5,845 72 (14) 73 (14) 73 (14) 73 (14) 71 (12) 69 (22) 71 (ND) 71 (ND) 70 (13) 66-70 70 (13) 73 (11) 76 (13) 75 (11) 77 (8) 79 (10) 52 52.2 52 41 42.4 44 47 39 37 62.4 40 39.5 46 48.5 54.9 56.5 USA ADHEREEM12 Treatment of acute episode (%) NIV VNI ND ND ND 36.1 8.9 ND ND 13.9 ND 9.6 ND ND 12.4 ND ND 6.4 Diuretics Diuréticos ND ND ND 80.4 ND 80 ND 84.4 84.6 89.7 99 95.3 ND ND ND 96.8 Vasodilators Vasodilatores 21 ND 14.3 45.8 ND 33 ND 38.7 18.5 41.1 29.9 51.3 ND ND ND 20.7 Inotropics Inotrópicos 15 ND 10.9 20.7 22.3 18 ND 29.8 10.5 39 19.4 24.6 13.8 ND ND 2.1 Evolution Días hospitalizado (mediana/media) 4.3/ND ND/ND 4/5.7 21/31 7.1/ND ND/8.4 11/ND ND/9 ND/ND 6/ND 10/ND 9/ND 13/ND ND/ND ND/ND 7/9.4 Inpatient days (median / mean) ICU admission (%)(%) Ingreso en la UCI 18.7 ND ND ND ND ND ND 51 48 17 51.9 69 43 ND ND 1.9 Hospital Mortality (%) Mortalidad Intrahospitalaria (%) 4 5.8 3.8 7.7 12.7 7.7 6.9 7.3 3.8 17.8 6.4 7.3 8.2 ND† ND 7.6 CHF: chronic heart failure. R: Retrospective. P: Prospective. Hosp .: hospital. Card .: cardiology. ED: hospital emergency department. IM: internal medicine. NA: data not reported in the study. COPD, chronic obstructive pulmonary disease. ACEI / ARBs angiotensin converting enzyme inhibitors / angiotensin-II receptor blockers. LVEF, Left ventricular ejection. SBP, systolic blood pressure. HR: heart rate. BNP: natriuretic peptides. NIV: noninvasive ventilation. ICU: intensive care unit. * Data were obtained from the sum of the derivation cohort and the validation cohort. † Mortality at 7 days: 2%. ‡ Hemoglobin <12 in men and <13 g / dl in men. §Hemoglobin <12 g / dl. ¶limit unavailable. ** Sodium <130 mmEq / L. ~ Sodium <136 mmEq / L. ∞ Chronic dialysis. Estimated glomerular filtration rate <60 ml / min. Medication at discharge. ¥ Data obtained from a substudy. "" History of stable or unstable angina. ⁺Serum creatinine 150 µmol / l: 16% 200 µmol / l: 20%. ⁺⁺16% men and 23% women, hemoglobin <11 g / dl. ⁺⁺⁺Sodium <135 mmEq / L. ⁿFEVI <40% in 45% of cases. Participating centers Centros participantes Year of study (total months) Año del estudio (meses totales) Type of study Tipo de estudio Scope Ámbito Patients Pacientesincluded incluidos Age, Edad,years, años,mean media(SD) (DE) Women (%) Comorbidity (%) Ischemic heart disease Cardiopatía isquémica Hypertension Hipertensión Diabetes mellitus AF Fibrilación auricular COPD EPOC Chronic kidney disease Enfermedad renal crónica Chronic heartcardiaca failure crónica Insuficiencia Usual care (%) ACEI / ARBs IECA/ARA-II Diuretics Diuréticos Beta-blockers Beta-bloqueantes Digoxin Digoxina Presentation (%) Shock cardiogénico Cardiogenic shock Acute Edemapulmonary agudo de edema pulmón Right heart failure Insuficiencia cardiaca derecha Acute coronary syndrome Síndrome coronario agudo Infection Precipitating factor Physical and laboratory findings SBP PAS (mmHg) (mmHg) (average) (media) HR (bpm)(media) (mean) Fc (lpm) Creatinine / dL)(media) (mean) Creatinina (mg (mg/dL) Anemia Anemia (%) (%) Hyponatremia (%) Hiponatremia (%) BNP BNP (%) realizado (%) Mean LVEF (%) Epidemiology Country ADHERE11 Table 5. Comparison of the EAHFE Register with other major registries of acute heart failure Llorens P, et al. Emergencias 2015;27:11-22 Llorens P, et al. Emergencias 2015;27:11-22 after discharge (early follow-up, specialized consultations, phone monitoring, telemonitoring). Regarding the treatment performed in the ED, the use of NIV was lower (6.5%) than in other studies, with 8.9% in AHEAD15 and 9.6% in ALARM-HF20 and up to 36% in the Japanese study ATTEND14. And despite the various benefits of using NIV39,40, we have not observed an increase in use over time. We believe the percentage of utilization is low, because the EAHFE Registry itself provides 11% of patients with the classic form of acute pulmonary edema. As for treatment with intravenous nitrates, these are considered the most rational therapy in the management of the AHF4. Their use in the EAHFE study (20.7%) was similar to the North American ADHERE11 21% and OPTIMIZE-HF13 14.3% and the European ESF HF pilot study19 with 18.5%), and less than the Italian S22 (51%). ED Your prescription has remained without significant changes over time in Spain. We believe that this may be partly related to the limited evidence of its effect on the improvement in dyspnea or evolutionary parameters3. Again, this percentage must be considered low, as the hypertensive form of AHF involves 23.5% of patients and the normotensive form with SBP above 120 mmHg involves 63.3% of all normotensive forms. So, overall, 57.6% of patients in the EAHFE registry present a clinical picture where vasodilators clearly have a therapeutic role. Inotropes and vasopressors were used in our EDs much less than elsewhere, probably due to the inclusion of all patients attending the ED, including those that are discharged. Furthermore, our results show progressively less use over time. This may reflect special caution (or fear) for use in the ED because their frequent use has been associated with worse prognosis in these patients and the occurrence of adverse events2. Currently, in the ED, we should limit its use as a bridge to transplantation therapy or myocardial recovery, as palliative treatment in non-transplant candidates or in patients with hemodynamic instability4. Furosemide deserves special mention, as it is the most common treatment. Although its use is recommended to ensure infusion plasma level and a continuous effect, and it may be less damaging to the kidney, the fact is that its use is low (10.1%) and has decreased over time (from 20.5% to 6.4%). The fact that recent clinical trials have shown limited utility41-43 may have contributed to this decline, as well as patient discomfort, increased workload and nursing time, and the difficulty of moving the patient to a general ward which involves the use of continuous infusion equipment. The rates of ED discharge home of patients with AHF vary widely. In ADHEREEM 12 , this was 7% of 11,258 patients, and in Lee et al. 10 it was 30% of 12,591 patients which is closer to our rate (23.9%). These oscillations reflect differences in health systems, health resources and ED organization. Regarding the latter, there are countries where there is a time limit of ED stay (the 4-hour rule in the UK, for example), making it harder to decide on discharge home44. Indeed, the possibility of an ED discharge is mainly affected by two characteristics: the availability of an observation unit in the ED (which facilitate longer ED stay and allow this observation by emergency physicians) and the selection of patients suitable for discharge after a short period of observation (less than 24 hours). Different studies show a continuous increase in readmission rates, between 24-27% at 30 days and approximately 30% at 60-90 days after discharge45. In our series, revisits to the ED during the first 30 days after discharge for a new episode of AHF was 20% and there has been a decrease in this percentage over time. In this regard, there are few studies (including those in which a rapid improvement in dyspnea, decreased episodes of worsening, or mortality)46 that have shown an effect on readmissions within 30-60 days of the index episode. The possible reasons for not being able to reduce revisits are manifold: rapid reduction of dyspnea and preventing worsening of heart failure may induce faster discharge, which shortens the hospital stay but negatively affect readmissions. However, we believe that aspects of the medical organization dealing with AHF may also play an important role. Many patients with AHF leave the hospital or ED without appropriate recommendations on what to do: they do not get the disease modifying drugs (or the doses are not properly titrated), they do not receive adequate education regarding important aspects of their disease (alarm symptoms, treatments, prognosis) and there may not be good coordination among the various professionals who treat patients with AHF8. In this regard, ambulatory control programs for chronic patients should improve many of these issues and result in better outpatient and home control and, to some extent, reduce ED visits and hospital admissions47,48. This study has certain limitations. First, AHF management policies (therapeutic protocols, discharge or admission criteria - in OU, wards or ICUs, requests for laboratory tests) may differ in each center, despite adherence to treatment guidelines at all times, as each center has an AHF coordinator. Second, the EAHFE data come from Spanish EDs and may not represent management in other countries. Third, although the inclusion of patients was consecutive, some patients may have been missed. Fourth, the classification of AHF presentation, as well as determining the existence of a trigger, were retrospectively analyzed by the principal investigator, so there may have been some overlapping or misclassified cases. Fifth, the diagnosis of AHF was based on clinical data without laboratory data for confirmation in some cases, so this is a possible source of error, but it also the dynamics of ED care in general. However, we believe the EAHFE Register provides reliable data about a population of patients with AHF, concerning both the acute episode and ED management trends, which probably includes most of the spectrum of this syndrome. Assessed in the context of other major published registries, it can contribute to better identify areas for improvement and steps to improve the 19 Llorens P, et al. Emergencias 2015;27:11-22 management of the AHF in the ED as well as in outpatient or hospital contexts. Financing This study was partially funded by the projects PI10 / 01918 and PI11 / 01021 of the Institute of Health Carlos III and FEDER funds. The Research Group "ED: processes and pathologies", IDIBAPS, receives funding from the Government of Catalonia for consolidated research groups (GRC 2009-2013 and 2014-2016). The AHF-SEMES group has received unconditional support from Orion Pharma, Otsuka and Novartis. Conflict of interest The author declares no conflict of interest in relation to the present article. Acknowledgements We thank Alicia Diaz for invaluable assistance in the administration and maintenance of the database. Addendum Co-investigadores del Registro EAHFE-Grupo de Trabajo de Insuficiencia Cardiaca Aguda de la Sociedad Española de Emergencias (Grupo ICA-SEMES): Cristina Gil (Hospital Universitario de Salamanca). José Vallés (Hospital La Fe de Valencia).Víctor Gil (Hospital Clinic de Barcelona). José Pavón, Ana Bella Álvarez (Hospital Dr. Negrín de Las Palmas de Gran Canaria). Antonio Noval (Hospital Insular de Las Palmas de Gran Canaria). José M. Torres (Hospital Reina Sofía de Córdoba). María Luisa López-Grima, Amparo Valero (Hospital Dr. Peset de Valencia). Alfons Aguirre (Hospital del Mar de Barcelona). María Isabel Alonso, Helena Sancho, Francisco Ruiz (Hospital de Valme de Sevilla). Antonio Giménez, José Miguel Franco (Hospital Miguel Servet de Zaragoza). Sergio Pardo (Hospital San Juan de Alicante). Ana Belén Mecina (Hospital de Alcorcón). Josep Tost (Consorci Sanitari de Terrassa). Jordi Fabregat (Hospital Mutua de Terrasa). Francisco Epelde (Consorci Sanitari i Universitari Parc Taulí en Sabadell). Susana Sánchez (Hospital Río Ortega de Valladolid). Pascual Piñera (Hospital Reina Sofía de Murcia). Raquel Torres Gárate (Hospital Severo Ochoa). Aitor Alquezar, Miguel Alberto Rizzi (Hospital San Pau de Barcelona). Fernando Richard (Hospital de Burgos). Javier Lucas (Hospital General de Albacete). Irene Cabello (Hospital Universitari de Bellvitge, Barcelona). References 1 Fonarow GC, Corday E; ADHERE Scientific Advisory Committee. Overview of acutely decompensated congestive heart failure (ADHF): a report from the ADHERE registry. Heart Fail Rev. 2004;9:179-85. 2 Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJV, Ponikowski P, Poole-Wilson PA, et al; ESC Committee for Practice Guidelines (CPG). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008. 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