Papers by Manuel Montero Pérez-Barquero M
European Journal of Internal Medicine, 2019
To validate externally the CACE-HF clinical prediction rule, which predicts 1-year mortality in p... more To validate externally the CACE-HF clinical prediction rule, which predicts 1-year mortality in patients with heart failure (HF). Methods: We performed an external validation of the CACE-HF risk score in patients included in the RICA heart failure registry who had completed 1 year of follow-up, comparing the characteristics of the derivation and validation cohorts. The performance of the risk score was evaluated in terms of calibration, using calibration-inthe-large (a), calibration slope (b), and the Hosmer-Lemeshow test, and in terms of discrimination, using the area under the ROC curve. Results: In total, 3337 patients were included in the validation cohort. There were no significant differences between the derivation and validation cohorts in 1-year mortality (24.63% vs. 22.98%) or in the risk score and risk classes. The discrimination capacity in the validation cohort was slightly lower, 0.67 (95% CI: 0.65, 0.69), compared to that of the derivation cohort. Calibration results were a −0.05 (95% CI: −0.14, 0.03), indicating that the average predictions did not differ from the average outcome frequency, and b = 0.75 (95% CI: 0.64, 0.86), indicating a modest inconsistency in predictor effects. Observed mortality versus predicted mortality according to the deciles and risk classes were very similar in both cases, indicating good calibration. Conclusions: The results of the external validation of the CACE-HF risk score show that although the capacity for discrimination was slightly lower than in the derivation cohort, the calibration was excellent. This tool, therefore, can assist in decision-making in the management of these patients.
Journal of Geriatric Cardiology, Nov 28, 2022
Revista Clínica Española (English Edition), 2019
Introduction and objectives: Plasma c-reactive protein (CRP) has been tested as a prognostic mark... more Introduction and objectives: Plasma c-reactive protein (CRP) has been tested as a prognostic marker in acute heart failure (AHF). Whether its measurement really provides significant prognostic information when applied to elderly patients with AHF episodes remains unclear. Methods: We measured the plasma CRP values of patients admitted because of any type of AHF to internal medicine services. We evaluated the association of these values with the patients' baseline clinical characteristics and their 3-month post-discharge all-cause mortality or readmission rates. For comparison purposes, we divided the sample in tertiles of low, medium and high CRP values (<2.24 mg/L, 2.25-11.8 mg/L and >11.8 mg/L). Results: We included 1443 patients with a median age of 80 years (interquartile range 73-85); 680 (47%) were men, with a moderate comorbid burden. 60.1% had preserved left ventricular ejection fraction (>50%). Multivariate analysis confirmed an independent association between higher CRP values and the presence of respiratory infection, lower systolic blood pressure and deteriorated renal function upon admission. Three months after the index admission, a total of 142 patients (9.8%) had died, and 268 (18.6%) had either been readmitted or died. admission CRP values did not correlate with 3-month all-cause mortality (p = 0.79), 3-month all-cause readmission (p = 0.96) or the combination of both events (p = 0.96). However, higher CRP values were associated with a longer length of stay (p < 0.001).
Revista Clínica Española, 2016
gradecemos los comentarios de Llopis García et al.1 y Rizzi t al.2, respecto a nuestro artículo3.... more gradecemos los comentarios de Llopis García et al.1 y Rizzi t al.2, respecto a nuestro artículo3. Ambos señalan la exisencia de diferencias entre la cohorte del programa UMIPIC los pacientes que acuden a urgencias por insuficiencia carespecialistas es deseable. No estamos en desacuerdo con el punto de vista de Llopis García et al.1 de que estas unidades deberían tener un carácter más multidisciplinar, pero pensamos que el seguimiento de este tipo de paciente tiene que centrarse en un médico, requiriendo de otros consultores en ocasiones seleccionadas, evitando que de forma rutinaria el paciente tenga que ser evaluado, en presencia física, por facultativos de diferentes especialidades4,5. En nuestra opinión es mucho más eficiente y apreciado por el paciente que la atención sea ofrecida, en lo posible, directamente por el mismo médico. En este sentido, la medicina interna, por su polivalencia y compromiso con el paciente, puede servir de nexo de unión entre el paciente y otras especialidades que, sin duda, tienen una misión muy importante en el cuidado d
Revista Clínica Española (English Edition), 2022
OBJECTIVES This work aims to determine the prevalence, characteristics, and impact on prognosis o... more OBJECTIVES This work aims to determine the prevalence, characteristics, and impact on prognosis of right bundle branch block (RBBB) in a cohort of acute heart failure (AHF) patients. METHODS We prospectively analyzed 3,638 AHF patients included in the RICA registry (National Heart Failure Registry of the Spanish Internal Medicine Society). We independently analyzed the relationship between baseline and clinical characteristics and the presence of RBBB as well as the potential impact of RBBB on 1-year all-cause mortality and a composite endpoint of 90-day post-discharge hospitalization or death. RESULTS The prevalence of RBBB was 10.9%. Patients with RBBB were older, a higher proportion were male, had more pulmonary comorbidities, had higher left ventricular ejection fraction values, and had worse functional status. There were no differences in risk for patients with RBBB, with an adjusted hazard ratio (95% confidence interval) for 1-year mortality of 1.05 (0.83-1.32), and for the composite endpoint of 90-day post-discharge hospitalization or death of 0.97 (0.74-1.25). These results were consistent on the sensitivity analyses. CONCLUSIONS Few patients with AHF present with RBBB, which is consistently associated with advanced age, male sex, pulmonary comorbidities, preserved left ventricular ejection fraction, and worse functional status. Nonetheless, after considering these factors, RBBB in AHF patients is not associated with worse outcomes.
Objetivo: Analizar la relacion en pacientes mayores con insuficiencia cardiaca entre el autocuida... more Objetivo: Analizar la relacion en pacientes mayores con insuficiencia cardiaca entre el autocuidado y variables como calidad de vida, edad, sexo, indice de comorbilidad de Charlson y clasificacion funcional NYHA. Metodologia: Estudio descriptivo. Utilizacion del cuestionario de la salud percibida SF36 y el cuestionario EHFScBS (European Heart Failure Self-care Behaviour Scale). Analisis estadistico descriptivo e inferencial mediante contraste de hipotesis. Nivel de confianza p<0,05. Resultados: 22 pacientes Peor autocuidado: 59,1%. No hubo diferencias estadisticamente significativas entre peor y mejor autocuidado con las variables estudiadas. La edad fue la variable que mas se aproximo a la significacion: peor autocuidado 85,54 (2,5); mejor autocuidado 88,44 (3,9); p=0,07. Conclusion: No se encontro asociacion entre peor y mejor autocuidado con las variables estudiadas.
Revista Clínica Española, 2021
Resumen Antecedentes Los pacientes ancianos con insuficiencia cardiaca (IC) presentan una elevada... more Resumen Antecedentes Los pacientes ancianos con insuficiencia cardiaca (IC) presentan una elevada comorbilidad que conlleva una atencion fragmentada, con frecuentes hospitalizaciones y alta mortalidad. En este estudio se evaluo el beneficio de un modelo asistencial caracterizado por una atencion integral y continuada (programa UMIPIC), en pacientes con IC de edad avanzada. Metodos y resultados Se analizaron prospectivamente 2.862 pacientes con IC atendidos en servicios de Medicina Interna, procedentes del registro RICA. Se dividieron en 2 grupos: uno en seguimiento en el programa UMIPIC (grupo UMIPIC, n: 809) y otro atendido de forma convencional (grupo RICA, n: 2053). Se evaluaron los reingresos por IC durante 12 meses de seguimiento y la mortalidad total tras un episodio de hospitalizacion por IC. Los pacientes del grupo UMIPIC tuvieron mas edad, comorbilidades y fraccion de eyeccion preservada que los del grupo RICA. Sin embargo, el grupo UMIPIC tuvo una menor tasa de reingresos por IC (17 frente a 26%, p Conclusiones La implantacion del programa UMIPIC, basado en una atencion integral y continuada a pacientes ancianos con IC y elevada comorbilidad, disminuye significativamente los reingresos por IC y la mortalidad total.
Medicina Clínica, 2016
Fundamento y objetivo: Validar el cuestionario de satisfacción Anti-Clot Treatment Scale (ACTS) e... more Fundamento y objetivo: Validar el cuestionario de satisfacción Anti-Clot Treatment Scale (ACTS) en pacientes con fibrilación auricular no valvular (FANV) en tratamiento con anticoagulantes orales atendidos en consultas de Medicina Interna y Neurología de España. Métodos: Estudio transversal, multicéntrico, en el que se incluyeron 1.337 sujetos ≥ 18 años con FANV, en tratamiento con anticoagulantes orales ≥ 3 meses, atendidos en consultas de Medicina Interna o Neurología en España. Los pacientes completaron los cuestionarios ACTS, Self-Assessment of Treatment Questionnaire (SAT-Q) y EuroQol-5 dimensions (5Q-5D). La escala ACTS es un instrumento de satisfacción específico para la evaluación de la carga (mayor puntuación, menor carga) y beneficios (mayor puntuación, mayor beneficio) con el tratamiento anticoagulante. Se evaluaron las propiedades psicométricas del cuestionario de acuerdo con la teoría clásica de los test. Resultados: El tiempo medio en cumplimentar el cuestionario fue 8,99 ± 6,06 min y el 63,70% de los pacientes precisaron ayuda para la cumplimentación del mismo. Existió una elevada concordancia entre las puntuaciones del test y el retest. La fiabilidad total (alfa de Cronbach) fue 0,95 en la escala Carga y 0,82 en la escala Beneficio. El modelo factorial resultó pertinente. Todas las correlaciones con el cuestionario SAT-Q fueron positivas, moderadas y estadísticamente significativas. Con respecto al cuestionario EQ-5D-3L, estas fueron positivas, bajas y estadísticamente significativas. La satisfacción de los pacientes fue mayor cuando estaban siendo tratados con anticoagulantes orales de acción directa. Conclusiones: En pacientes con FANV en tratamiento con anticoagulantes orales, la versión en español del cuestionario ACTS fue fiable, válida y factible.
European Journal of Heart Failure, 2015
We have read with great interest the article of Filippatos et al.1 about the rational and design ... more We have read with great interest the article of Filippatos et al.1 about the rational and design of a new registry in heart failure, called International Registry to asses medical Practice with longitudinal observation for treatment of heart failure (REPORT-HF). In this article, authors cite several national and international registries, emphasizing the limitations of these previous observational studies and justifying the need of a new registry that collects information regarding long-term disease progression, including transition from acute to chronic situation. We would like to comment about another national registry conducted in Spain, similar to REPORT-HF, coordinated by the Working Group of Heart Failure of the Spanish Society of Internal Medicine RICA registry is a multicentre, prospective, cohort study of patients hospitalized for heart failure, that explores patient clinical characteristics, treatment and outcome over 1 year follow-up after discharge. From March 2008 until April 2015, 4200 patients were enrolled from 52 centres. Our registry has different characteristics from other registries, including a cohort that closely represent the real world: patients are elderly (78 years old), mainly women (53%), with a high prevalence of comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (diabetes 47%, chronic pulmonary disease 27%, atrial fibrillation 54%, peripheral arterial disease 14%) and with a mean baseline left ventricular ejection fraction of 51%.2 On the basis of RICA data, we have published articles concerning different topics as mortality, rehospitalizations, prognosis and treatment, that in our opinion provide relevant insights about heart failure in the real world.3–6
European Journal of Internal Medicine, 2014
Background: Elevated troponin in heart failure has been associated with worse prognosis, but ther... more Background: Elevated troponin in heart failure has been associated with worse prognosis, but there are differences in the design and results of published studies. Our objective was to determine the association of troponin T with mortality and readmissions in patients with acute heart failure in clinical practice conditions. Methods: We included patients from the RICA registry who were hospitalized for acute heart failure. They were classified into 3 groups according to troponin T levels: normal, intermediate and high (b 0.02, 0.02-0.049 and ≥0.05 ng/mL, respectively). Survival was studied by Kaplan-Meier curves and the association of variables was tested by Cox regression analysis. Results: A total of 406 patients was included. Average age was 76.9 (76.0-77.7) years. Hypertensive heart disease was the most common etiology. Left ventricular ejection fraction was b 45% in 22.1% of the patients. The group with elevated troponin T had higher proportions of women, systolic dysfunction, renal failure and anemia, a lower body mass index and longer hospital stay. At one year, patients with elevated troponin T had higher mortality than patients with normal troponin (35.5 vs. 13.9%, p b 0.001). The composite event (mortality and readmissions) was also more frequent (51.6 vs. 30.9%, p b 0.001), but there were no differences in readmissions alone. Troponin T ≥0.02 ng/mL was independently associated with mortality. Conclusions: Elevated troponin T levels are common in patients with heart failure in clinical practice and are associated with increased mortality and events after one year of follow-up.
QJM, 2010
Objectives: To determine the relationship between admission blood pressure (BP) and prognosis in ... more Objectives: To determine the relationship between admission blood pressure (BP) and prognosis in patients hospitalized for acute decompensated heart failure (HF). Background: The relationship between BP admission blood pressure and outcomes in decompensated HF is controversial. It has been suggested that this presentation may be a specific disorder, but their mechanisms and clinical relationships are poorly defined. Methods: We evaluated the association between initial BP (systolic, diastolic and mean BP) with readmission and mortality, as well as potential interactions with age, clinical characteristics, renal function, left ventricular dysfunction, comorbidities and treatment. By using Cox regression models the association between each outcome and BP was tested. Results: A total of 581 patients (77.5-years-old, range 51-100) were included. At admission, mean BP in quartiles was 77.09 mm Hg (53.3-85.0) (Q1); 91.46 mm Hg (85.0-96.7) (Q2); 103.41 mm Hg (96.7-109.9) (Q3) and 124.79 mm Hg (109.9-209.0) (Q4). Median duration of follow-up was 8 months [95% confidence interval (CI) 5.2-11.1]. Mortality was 15.5% (Q1), 9.2% (Q2), 12.6% (Q3) and 7.3% (Q4). Interquartile hazard ratio (95% CIs) for mortality was 0.40 (0.19-0.85) P = 0.017. Body mass index (BMI) was higher in Q4 29.59 k/ m 2 than in Q1 28.25 k/m 2 (P = 0.018). There were no differences in age, clinical antecedents, renal function, comorbidities or severity of HF between groups. Conclusions: Higher mean BP at admission is associated with significantly lower mortality during follow-up, in patients hospitalized for HF. With the exception of BMI, positively correlated with blood pressure, this relationship is independent of other clinical factors and medications.
Emergencias, 2015
La insuficiencia cardiaca aguda (ICA) supone un elevado uso de recursos, carga económica y morbim... more La insuficiencia cardiaca aguda (ICA) supone un elevado uso de recursos, carga económica y morbimortalidad, tanto en los servicios de urgencias como durante la hospitalización o durante su control ambulatorio. La variabilidad actual existente en el diagnóstico, tratamiento y la continuidad asistencial ha inducido que diferentes sociedades científicas (cardiología, medicina interna y urgencias) redacten este documento de consenso sobre recomendaciones prácticas que den soporte a todos los profesionales intervinientes en el manejo de la ICA y permita homogeneizar la toma de decisiones. El enfoque de estas recomendaciones, basadas en la revisión de la literatura y la experiencia clínica, se ha realizado abarcando diferentes puntos críticos del proceso asistencial de los pacientes con ICA: en el servicio de urgencias, en cuanto a la evaluación inicial del paciente con clínica sugestiva de ICA, orientación diagnóstica, primeras decisiones terapéuticas, monitorización, evaluación del pronóstico y criterios de derivación; durante la hospitalización, con el desarrollo de un protocolo básico terapéutico; tras el alta, con la definición de objetivos de manejo y tratamiento de la ICA al alta del paciente; y de forma global, mediante la mejora o creación de una organización en la atención multidisciplinar y la continuidad asistencial en la ICA. Palabras clave: Atención integral. Insuficiencia cardiaca aguda. Servicio de Urgencias. Consensus on improving the care integrated of patients with acute heart failure Acute heart failure (AHF) requires considerable use of resources, is an economic burden, and is associated with high complication and mortality rates in emergency departments, on hospital wards, or outpatient care settings. Diagnosis, treatment, and continuity of care are variable at present, leading 3 medical associations (for cardiology, internal medicine, and emergency medicine) to undertake discussions and arrive at a consensus on clinical practice guidelines to support those who manage AHF and encourage standardized decision making. These guidelines, based on a review of the literature and clinical experience with AHF, focus on critical points in the care pathway. Regarding emergency care, the expert participants considered the initial evaluation of patients with signs and symptoms that suggest AHF, the initial diagnosis, first decisions about therapy, monitoring, assessment of prognosis, and referral criteria. For care of the hospitalized patient, the group developed a protocol for essential treatment. Objectives for the management and treatment of AHF on discharge were also covered through the creation or improvement of multidisciplinary care systems to provide continuity of care.
STROBE document. (DOCX 34 kb)
Medicina Clínica, 2022
INTRODUCTION There are few data in the Spanish population about the causes of death in patients a... more INTRODUCTION There are few data in the Spanish population about the causes of death in patients admitted to internal medicine departments for heart failure. Their study according to left ventricular ejection fraction (reduced: rEF, mid-range: mEF, and preserved: pEF) could improve the knowledge of patients and their prognosis. METHODS Prospective multicentre cohort study of 4144 patients admitted with heart failure to internal medicine departments. Their clinical characteristics, mortality rate and causes were classified according to pEF (≥ 50%), mEF (40%-49%) and rEF (<40%). Patients were followed-up for a median of one year. RESULTS There were 1198 deaths (29%). The cause of death was cardiovascular (CV) in 833 patients (69.5%), mainly heart failure (50%) and sudden cardiac death (7.5%). Non-cardiovascular (NoCV) causes were responsible for 365 deaths (30.5%). The most common NoCV causes were infections (13%). The most frequent and early cause in all groups was heart failure. Patients with pEF, compared to the other groups, had lower risk of sudden cardiac death and higher risk of infections (P <.05). The causes of death in patients with mrEF were closer to those with pEF. CONCLUSIONS The causes of death in patients with heart failure were different depending on ejection fraction strata. Patients with mEF and pEF, due to their high comorbidity and higher frequency of NoCV death, would require comprehensive management by internal medicine.
Internal and Emergency Medicine, 2020
Modes of death in patients with heart failure (HF) have been well characterized in randomized stu... more Modes of death in patients with heart failure (HF) have been well characterized in randomized studies, but data from real-life are scarce, especially in the elderly, women and in HF with mid-range or preserved left ventricular ejection fraction (LVEF). Our purpose was to examine modes of death in HF patients according to age, sex and LVEF. We analysed the mode of death of HF patients from two prospective multicentre contemporary Spanish registries conducted by cardiologists (REDINSCOR, n = 2150) and by internists (RICA, n = 1396). Mode of death was pre-specified. Out of 3546 patients, 485 (13.7%) died during the 9-month follow-up. Cardiovascular (CV) causes were the most frequent, regardless of the age, sex and LVEF. More than half of patients died due to worsening HF in both groups of patients, followed by other non-CV causes in those attended by internists, and sudden cardiac death in those cared by cardiologists. Stroke was more common among elderly patients, women and HF with preserved LVEF. Non-CV causes, particularly infectious diseases, accounted for a remarkable proportion of deaths, especially in the elderly and in HF patients with preserved LVEF. Functional class, age and anaemia had a strong influence on both CV and non-CV death. CV death due to refractory HF was the most prevalent among our population, irrespective of age, sex or LVEF. However, a significant proportion of HF patients died from non-CV causes, particularly elderly with mid-range and preserved LVEF. These patients could benefit significantly from a multidisciplinary follow-up.
Internal and Emergency Medicine, 2020
The objective of this study is to determine the prevalence of cognitive impairment (CogI) in pati... more The objective of this study is to determine the prevalence of cognitive impairment (CogI) in patients hospitalized for congestive heart failure, and the influence of CogI on mortality and hospital readmission. This is a multicenter cohort study of patients hospitalized for congestive heart failure enrolled in the RICA registry. The patients were divided into 3 groups according to their Short Portable Mental Status Questionnaire score: 0-3 errors (no CogI or mild CogI), 4-7 (moderate CogI) and 8-10 (severe CogI). A total of 3845 patients with a mean (SD) age of 79 (8.6) years were included; 2038 (53%) were women. A total of 550 (14%) patients had moderate CogI and 76 (2%) had severe CogI. Factors independently associated with severe CogI were age (OR 1.09, 95% CI 1.05-1.14 p < 0.001), male sex (OR 0.57, 95% CI 0.34-0.95, p = 0.031), heart rate (OR 1.01, 95% CI 1.00-1.02, p = 0.004), Charlson index (OR 1.16, 95% CI 1.06-1.27, p = 0.002), and history of stroke (OR 2.67, 95% CI 1.60-4.44, p < 0.001). Severe CogI was associated with higher mortality after one year (HR 3.05, 95% CI 2.25-4.14, p < 0.001). The composite variable of death/hospital readmission was higher in patients with CogI (log rank p < 0.001). Patients with heart failure and severe CogI are older and have a higher comorbidity burden, lower survival, and a higher rate of death or readmission at 1 year, compared to patients with no CogI.
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Papers by Manuel Montero Pérez-Barquero M