Editorial
New challenges in acute heart failure. Beyond hospital care
Nuevos retos en insuficiencia cardíaca aguda. Más allá de la atención hospitalaria
Instituto Clínico Cardiovascular, Hospital Clínic Barcelona, IDIBAPS. Barcelona, Spain
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Beyond hospital care" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "26" "paginaFinal" => "27" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "T. López-Sobrino, R. Andrea" "autores" => array:2 [ 0 => array:2 [ "nombre" => "T." "apellidos" => "López-Sobrino" ] 1 => array:4 [ "nombre" => "R." "apellidos" => "Andrea" "email" => array:1 [ 0 => "randrea@clinic.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Instituto Clínico Cardiovascular, Hospital Clínic Barcelona, IDIBAPS. Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nuevos retos en insuficiencia cardíaca aguda. Más allá de la atención hospitalaria" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute heart failure (AHF), which has a prevalence of 1–2% and an incidence of 5–10 cases per 1000<span class="elsevierStyleHsp" style=""></span>people/year in the West,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> is one of the main reasons for consultation in hospital emergency departments (HED). It generates up to 80,000 admissions per year in Spain<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and uses significant resources. Public health systems like ours have developed resources to improve efficiency in the face of the pressure that HED face. One of these resources is home hospitalization (HH), a type of care whose initial references in Spain date back to 1981.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of the Revista Clínica Española, Miró et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> have published a study on the use of HH in patients who come to the HED for AHF. They included 1473 patients who consulted for AHF in the HED of six hospitals that participated in the multicenter prospective EAHFE Registry between 2014 and 2018.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> They evaluated adjusted adverse events at 30 days and mortality at one year based on whether the patients were transferred directly to HH versus those admitted to internal medicine wards (IM) or short-stay units (SSU). HH was the smallest group, with 4.7% of all admitted patients. The duration of stay in HH was the same as for those in IM and longer than those in SSU. Mortality at one year of follow-up did not differ among the three groups (HH with respect to IM: HR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.91; 95% CI: 0.73–1.14 and with respect to SSU: HR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.77; 95% CI: 0.46–1.27). There were also no differences in mortality or readmission at 30 days. A decrease in HED readmissions was observed in the HH group with respect to the other two (HH-IM, HR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.50; 95% CI: 0.25–0.97 and HH-SSU, HR<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.37; 95% CI: 0.19–0.74).</p><p id="par0015" class="elsevierStylePara elsevierViewall">The authors conclude that there are few centers that offer HH (only six of the 45 participating centers in the registry) and that it is an underutilized resource. According to the mortality and adverse events outcomes, HH is a safe resource for patients attended to for AHF in HED compared to other types of hospitalization, decreasing short-term readmissions to these departments.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The population studied includes patients with AHF without acute coronary syndrome who were not candidates for invasive interventions; thus, they were patients who were frail, with comorbidities, elderly, or with terminal heart failure. The progressive aging of the population in our setting, in which 19.1% of the population is older than 65 years and 6.1% is older than 80 years,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> means that this type of patient is responsible for a large number of AHF consultations in HED, an aspect that makes this study highly interesting.</p><p id="par0025" class="elsevierStylePara elsevierViewall">This work seems to reinforce the safety of the HH option as well as its potential for decreasing HED readmissions, a finding that has previously been described.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This type of hospitalization requires an active attitude on the part of the patient and their social environment, promotes healthcare education, and very likely contributes to improving the transition process between hospital care and the posterior rehabilitation process upon discharge. Treatment compliance and lifestyle habits are fundamental at home. In this regard, HH allows for supervised training on hygienic and dietary measures, such as control of diuresis and weight, which are key factors for preventing future decompensations.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A meta-analysis carried out by Malik et al. described a significant decrease in mortality and readmissions (22% vs. 16%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05) in patients with AHF when they developed at-home support strategies after hospital discharge.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">A population involved in basic healthcare practices and knowledgeable about the early signs of AHF decompensation will very likely have a greater perception of control and well-being when less invasive types of hospitalization, such as HH, are indicated. Minimizing the institutionalization of these elderly patients during hospitalizations can prevent complications; for example, lower rates of nosocomial infections associated with HH have been observed.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">However, one of the fundamental limitations of this study lies in the heterogeneity of the three groups. Patients in the HH strategy were older, had a worse functional class, and a lower left ventricular ejection fraction (LVEF). The patients in this group received higher doses of oxygen therapy and loop diuretics in perfusion in the HED and more beta blockers upon discharge. On the contrary, there was a higher percentage of patients hospitalized in IM who had new-onset heart failure and they presented with more severe decompensations (mortality predicted by the MEESSI scale). It should be noted that patients in IM, whose baseline characteristics could suggest a more acute, severe profile, received less intensive treatment than patients in HH, a fact that could have had an influence on the worse progress of these patients.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Also of note is the low implementation of optimal treatment upon discharge in the three groups with respect to beta blockers (45%), angiotensin-converting enzyme inhibitors (52%), and aldosterone antagonists (14%). This is concordant with the high percentage of AHF and preserved LVEF represented in the study (mean LVEF in the HH group 48%, IM 53%, SSU 56%), in which there is less evidence that pharmacological treatment modifies prognosis. Treatment of hypertension and congestive symptoms as well as heart rate control when there is atrial fibrillation must be prioritized.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, this study supports the HH strategy in patients with AHF, especially in those with preserved LVEF and advanced age who are not candidates for interventional therapies. New lines of research should be proposed regarding its cost-effectiveness, but its main benefits (such as the reduction in nosocomial infections, better adaptation to hospitalization, incorporation of educational measures, and the active participations of patients and those around them) favor a better reincorporation into normal life after discharge.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Though they do not show an impact on mortality, these findings could explain the lower number of readmissions to HED.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In parallel, we must not forget the need to strengthen other multidisciplinary integrated care units,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> the shift of healthcare processes toward outpatient procedures, the creation of day hospitals, and remote follow-up with telemonitoring tools<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> that allow for maintaining the benefits and preventing readmissions over longer periods of time.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López-Sobrino T, Andrea R. Nuevos retos en insuficiencia cardíaca aguda. Más allá de la atención hospitalaria. Rev Clin Esp. 2021;221:26–27.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical epidemiology of heart failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Mosterd" 1 => "A.W. 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