Consensus on basic conduct during the hospital admission of patients with acute heart failure

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Fernández Rodríguez, J. Casado, F. Formiga, A. González-Franco, J.C. Arévalo, M. Beltrán, J.M. Cerqueiro González, P. Llàcer, L. Manzano, J.L. Morales-Rull, J. Pérez Silvestre, A. Conde-Martel" "autores" => array:12 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "Fernández Rodríguez" ] 1 => array:2 [ "nombre" => "J." "apellidos" => "Casado" ] 2 => array:2 [ "nombre" => "F." "apellidos" => "Formiga" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "González-Franco" ] 4 => array:2 [ "nombre" => "J.C." "apellidos" => "Arévalo" ] 5 => array:2 [ "nombre" => "M." "apellidos" => "Beltrán" ] 6 => array:2 [ "nombre" => "J.M." "apellidos" => "Cerqueiro González" ] 7 => array:2 [ "nombre" => "P." "apellidos" => "Llàcer" ] 8 => array:2 [ "nombre" => "L." "apellidos" => "Manzano" ] 9 => array:2 [ "nombre" => "J.L." "apellidos" => "Morales-Rull" ] 10 => array:2 [ "nombre" => "J. Pérez" "apellidos" => "Silvestre" ] 11 => array:2 [ "nombre" => "A." 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Prevalence clearly and significantly increases with age, reaching 16% in patients over the age of 75 years.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Acute heart failure (AHF), wherein symptoms come on or worsen suddenly, is associated with a higher degree of morbidity and mortality. Patients who experience an episode of AHF tend to experience subsequent complications that encompass everything from multi-organ damage to death.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>In Spain, AHF is the main cause for hospitalisation in patients over 65 years, representing more than 113,000 admissions per year, of which one quarter die within one year of admission.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> In recent years (2003–2013), a rising trend has been observed in hospitalisations due to AHF, an increase of 76.7%, particularly affecting patients ≥75 years and associated with an increase in comorbidities.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>In this context, it is important to highlight that the risk of readmission for patients hospitalised with AHF is high, particularly early readmission during the first month post-discharge (∼13.4%),<a class="elsevierStyleCrossRef" href="#bib0025">5</a> which is considered the most vulnerable period for patients hospitalised with AHF.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> In fact, hospital readmissions within 30 days also increased in the 2003–2013 period (from 17.6 to 22.1%) at a mean relative rate of 1.36% per year.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>Readmissions due to AHF have a significant impact in terms of both mortality and economic burden on the healthcare system. Patients with HF who are readmitted due to worsening illness or other non-cardiovascular causes have higher rates of mortality (12.7% and 13.3%, respectively) than patients admitted with HF for the first time (9.2%; P < .001). On the other hand, the economic cost of the disease, estimated to be 2.5 billion euros per year, is mainly associated with hospitalisations,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> with an average hospital stay of 7–10 days for patients admitted for AHF.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>MethodologyIn light of the aforementioned and the increasing availability of new relevant evidence related to the therapeutic management of AHF,<a class="elsevierStyleCrossRef" href="#bib0040">8</a> and due to recent guideline updates,<a class="elsevierStyleCrossRefs" href="#bib0045">9,10</a> the Heart Failure and Atrial Fibrillation Group of the Spanish Society of Internal Medicine (SEMI) has developed protocol recommendations with the aim of guiding specialists in the most important practical aspects of treatment and follow-up for these patients during hospital admission, as well as to standardise and optimise their treatment to the extent possible based on the available evidence.Likewise, the present document addresses the four main hospitalisation phases of a patient with AHF: admission, treatment during the congestive and stable phases, and discharge from hospital. The phases are defined as follows: 1) considerations upon admission, defined as the moment in which assessment is requested from Internal Medicine, either in the emergency department or in the hospital ward; 2) management of the congestive phase which encompasses admission through to starting to decrease diuretics; 3) management of the stable phase which starts with decreasing diuretics up until the day of discharge, and 4) considerations upon discharge, defined as the day of discharge (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>To draft the guidelines, the authors split into 4 work groups and each group was tasked with writing one chapter based on the published evidence and clinical experience. Following the completion of each chapter, an editing process was carried out to achieve a uniform document that was shared among the authors for revision and approval. The final results comprise a set of recommendations that are intended to be practical for the management of patients admitted for AHF.Patient admissionConsiderations when admitting patients with AHFWhen admitting a patient for an episode of decompensated HF, it is necessary to collect what is considered basic information, as set out in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Aspects to be taken into consideration include the patient’s epidemiological data, the presence or lack thereof of a caretaker, if he or she is educated on the disease, warning signs, substance abuse by the patient, and the presence or not of dementia. Seeing as how HF particularly affects elderly individuals, a comprehensive geriatric assessment (CGA) of the patient will also help improve understanding and prognosis.<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a> The minimum CGA, in addition to cognition, must incorporate the patient's capacity to perform basic activities of daily living (Barthel's index), whose prognostic value has been shown at both 3 months and one year from hospital admission for AHF.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a>The clinical progress of the disease must be studied in detail (hospital admissions for AHF in the past year, number of emergency department visits in the last 3 months, etc.). Since the current treatment recommendations, and to some degree the prognosis, are based on the type of ventricular dysfunction (reduced, intermediate, or preserved),<a class="elsevierStyleCrossRef" href="#bib0045">9</a> it is important to know the date of the last ultrasound which determined the left ventricular ejection fraction (LVEF).The onset of HF can be associated with structural, mechanical or electrical heart abnormalities. Likewise, HF can be due to ischaemic, metabolic, endocrine, immune, inflammatory, infectious, genetic, or neoplastic processes, among others.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Therefore, the aetiology of the patient’s HF must be noted. The relevance of amyloid cardiomyopathy has recently been brought to light; therefore, amyloidosis should also be investigated as a possible aetiological factor.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>Finding out the patient’s comorbidities is basic practice<a class="elsevierStyleCrossRef" href="#bib0080">16</a> and especially important in the HF patient group with preserved EF (pEF), in which the mean age exceeds 80 years, is predominantly made up of women, and comorbidities largely determine the disease prognosis.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> These patients frequently meet the criteria for polypathological patients, a condition that justifies internal medicine specialists participating in their treatment. Of the broad spectrum of comorbidities in HF patients,<a class="elsevierStyleCrossRef" href="#bib0085">17</a> some are strictly aetiological factors or factors that determine the course of the HF (diabetes mellitus, high blood pressure, atrial fibrillation [AF], thyroid disease and obesity). Others are the consequence of common aetiological factors, such as chronic obstructive pulmonary disease (COPD) and chronic kidney disease, or are associated with old age (dementia, anaemia) and obesity (hypoventilation, sleep apnoea syndrome), etc. Considering that some of these comorbidities can produce similar signs and symptoms as HF (COPD), can interfere with treatment (chronic kidney disease, COPD), or cause decompensation (hyperthyroidism, anaemia, high blood pressure or poorly controlled AF), properly identifying them and treating them is crucial from the time of admission.It is essential to be aware of the standard treatment when treating any admitted patient, and all the more so in HF patients. These patients frequently present with inadequate previous treatment for HF or other comorbidities and, on the other hand, an unwarranted excess of psychoactive drugs, analgesics, or anti-inflammatory agents.<a class="elsevierStyleCrossRefs" href="#bib0045">9,17</a> In addition to being polymedicated, they may also be “poorly medicated”. The most important medications to consider, particularly in HF with reduced EF (rEF), are also listed in the table. In addition, certain drugs should be taken into account due to how frequently they are used in these patients, such as digoxin, calcium channel blockers, antiplatelet drugs, anticoagulants, hypolipidemic agents, antiarrhythmic agents and others specifically associated with comorbidities.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>In terms of triggering factors, the following should be considered: infections, therapeutic non-compliance, dietary transgressions, anaemia, and cardiovascular (CV) factors (uncontrolled high blood pressure, arrhythmia and myocardial ischaemia), as well as toxic and pharmacological factors such as alcohol, non-steroidal anti-inflammatory drugs and non-dihydropyridine calcium channel blockers (verapamil and diltiazem).<a class="elsevierStyleCrossRefs" href="#bib0090">18,19</a>As a supplementary tool to chest radiography, lung ultrasound scans and scans of the inferior vena cava have gained prominence in recent years as parameters that contribute to quantifying the patient’s degree of congestion.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> Measuring plasma biomarkers such as carbohydrate antigen 125 (CA 125) can also contribute to identifying the patient’s degree of congestion and to titrating diuretic treatment.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> In addition, measuring natriuretic peptides is essential to ruling out HF due to their high negative predictive value: as prognostic markers, they should be ordered during any hospital admission.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Patient vitals, which are essential to clinical assessment and therapeutic decision-making, should also be recorded during the physical examination.Blood testing at admission should include a complete blood count, biochemical analysis with renal function (urea, creatinine), and electrolyte panel (sodium and potassium), as well as a urine sample with sodium and potassium. Renal function and electrolyte alterations can limit the use of certain drugs and have prognostic implications<a class="elsevierStyleCrossRef" href="#bib0045">9</a>: a urine sodium content of <50−70 mEq/L after 2 h of intravenous diuretic treatment indicates diuretic resistance.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> It is also essential to evaluate pH, oxygen saturation, and baseline albumin.Assessment of signs and symptoms of congestion using the EVEREST indexA thorough evaluation of the degree of congestion must be made in hospitalised HF patients. To do this, the systematic information set out in the EVEREST<a class="elsevierStyleCrossRef" href="#bib0115">23</a> index in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> can be of use.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Managing AHF patients in the congestive phaseThe main aspects related to managing AHF patients in the congestive phase are detailed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Non-invasive daily monitoringNon-invasive monitoring of the patient’s vital signs, including pulse oximetry, blood pressure, respiratory rate (RR), and diuresis, is essential to evaluate whether ventilation, peripheral infusion, oxygenation, heart rate, and blood pressure are adequate.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Heart rate monitoring helps us to optimise heart rate inhibitor treatment in patients with sinus rhythm. What’s more, since patients with HF and AF have a poorer prognosis,<a class="elsevierStyleCrossRef" href="#bib0120">24</a> we must bear in mind current guideline recommendations for maintaining HR between 60 and 100 beats per minute (bpm).Patients should be weighed daily, and a fluid balance chart should be maintained. Renal function should preferably be monitored with a daily measurement of blood urea nitrogen (BUN)/urea, creatinine, and electrolytes. Routine use of a urinary catheter for measuring diuresis is not recommended.Disease-modifying drugsTreatment with disease-modifying HF medications should be continued throughout admission, except in the presence of haemodynamic instability (symptomatic hypotension, hypoperfusion, bradycardia), hyperkalaemia, or severely impaired renal function. In these cases, the dosage of other drugs that affect blood pressure or renal function, or of the same disease-modifying HF drugs, should be reviewed or temporarily stopped and restarted once the patient is stabilised. Beta blockers can be continued except in the case of cardiogenic shock as their discontinuation is associated with significantly increased mortality and rehospitalisation.<a class="elsevierStyleCrossRef" href="#bib0125">25</a>Respiratory supportThe respiratory failure that accompanies AHF/APE (acute pulmonary oedema) requires O2 saturation (satO2) monitoring and, in the case of COPD or obesity hypoventilation syndrome (OHS), determining PCO2 and pH.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> The supply of an adapted flow of O2 is basic in cases of respiratory failure (PO2 < 60 mmHg or satO2 < 90%). Because O2 produces peripheral vasoconstriction and a decrease in cardiac output, its use is restricted to situations of hypoxia.<a class="elsevierStyleCrossRef" href="#bib0130">26</a>In the case of respiratory distress (RR > 25 bpm, satO2 < 90%) the recommendation is early application of noninvasive ventilation techniques (NIV),<a class="elsevierStyleCrossRef" href="#bib0045">9</a> CPAP model (continuous positive airway pressure) or Bi-PAP (bilevel positive airway pressure) model, which achieve better oxygenation through the recruitment of collapsed alveoli, the reversal of areas of atelectasis, and the injection of fluid into the interstitial space.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Bi-PAP is reserved for cases with hypercapnia (PCO2 > 50 mmHg), respiratory acidosis, or in which COPD or OHS coexist.<a class="elsevierStyleCrossRef" href="#bib0135">27</a> NIV reduces respiratory distress and prevents orotracheal intubation (OTI) in patients with AHF.<a class="elsevierStyleCrossRef" href="#bib0140">28</a>Reduced level of consciousness, severe respiratory acidosis (pH < 7.25), or the inability to guarantee adequate oxygenation despite the previous measures are indications for OTI and mechanical ventilation.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Haemodynamic supportTwo types of situations typically arise: hypertensive emergency and AHF which presents as hypotension or even cardiogenic shock.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>AHF precipitated by hypertensive emergency typically manifests as APE. The therapeutic target is 25% reduction of the initial BP in the first 2−4 h, so use of vasodilators in combination with the initial diuretic treatment is advised. They should be avoided or discontinued when systolic blood pressure (SPB) is less than 90 mmHg. Continuous infusion of intravenous nitroglycerin starting at 10−20 μg/min is recommended, up to a maximum dose of 200 μg/min.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>In the presence of hypotension, the haemodynamic profile should be evaluated, using as a guide the simultaneous presence of congestion and hypoperfusion. Reduction or discontinuation of concomitant hypotensive medication is mandatory. In patients with hypoperfusion, it must be considered whether excessive volume depletion exists, and in that case administer fluid therapy to reverse it.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Inotropic agents or vasopressors are recommended from the outset in patients with congestion and SBP < 90 mmHg (cold and wet profile), and if refractory to other measures it is also recommended in patients with SBP >90 mmHg.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>SBP figures aid in selecting the inotropic or vasopressor agent of choice. If SBP < 90 mmHg, treatment will be started with vasopressors. Due to their side effects, use will be limited until SBP > 90 mmHg is reached, at which time inotropic agents can be initiated. Norepinephrine use is preferred over (0.2−0.1 μg/kg/min) dopamine, at beta-adrenergic doses (3−5 μg/kg/min) because of its safety profile.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>In the case of SBP ≥ 90 mmHg, use of levosimendan (0.1−0.2 μg/kg/min) for 24 h or dobutamine (2−20 μg/kg/min) is recommended, though the former is preferable as its mechanism of action is not interfered with by the patient’s potential baseline beta-blockade and it has a lower arrhythmogenic capacity and possibility to induce myocardial ischaemia than classic beta-mimetic inotropes.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Decongestive treatment: diureticsDecongestive treatment is a first priority as it has been shown that early treatment with intravenous loop diuretics is associated with lower hospital mortality.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> As can be seen in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>, the starting diuretic dosage to be administered should be based on whether the patient is receiving furosemide treatment at home, and if so at what dosage.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>In the following 2–6 h it is important to evaluate the diuretic response obtained (specifically, the Na+ urine concentration [considering as an adequate value > 50−70 mEq/L] at 2 h and diuresis [considering as an adequate value > 100−150 mL/h] at 6 h), using both clinical and biochemical parameters for said evaluation.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> If the patient has not experienced any clinical improvement, the initially administered dose should be doubled, preferably with a 12 h protocol, though an 8 h protocol is also acceptable, or even continuous infusion (it is worth mentioning that the DOSE-AHF<a class="elsevierStyleCrossRef" href="#bib0150">30</a> study did not show differences in the primary endpoint according to whether the patients received furosemide as a bolus or via continuous infusion). If clinical improvement has been achieved, the initial dose with the potential protocols described should be maintained.Diuretic response will continue to be assessed after the next 24 h. The persistence of congestive signs and symptoms or diuresis <3 L/day will require the diuretic protocol to be intensified. There are various options for this, though the recommendation is a staged approach on successive days: there is evidence showing that staged therapeutic approaches depending on the decongestive response offer benefits in terms of fluid and weight loss, without compromising renal function.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> Therefore, if congestion and diuresis <3 L/day persist, the following options should be assessed in a phased manner: a) increasing the furosemide dose (maximum 400−600 mg); b) administering drugs for sequential nephron blockade (thiazides, aldosterone antagonists, or acetazolamide). Currently there are no specific recommendations regarding the priority of the second diuretic; urine potassium can be taken into account, prioritising thiazides when it is reduced and aldosterone antagonists when it is elevated. Acetazolamide may be preferable in cases of metabolic alkalosis. The results of the CLOROTIC study will offer more data on the effects of adding a thiazide to furosemide to improve the congestive symptoms of HF in a safe and effective manner<a class="elsevierStyleCrossRef" href="#bib0165">33</a>; c) hypertonic saline solution protocol (detailed in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>), and d) if no response is achieved, evaluate ultrafiltration.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>If the clinical decongestion parameters are adequate or diuresis higher than 3 L/day has been reached, the established therapy should be maintained until effective decongestion is achieved for subsequent progressive reduction. Ideally the patient will be receiving the minimum effective dose by oral route at least 24 h before discharge from hospital.Managing AHF patients in the stable phaseThe main aspects related to the management of AHF patients in the stable phase are detailed in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Management protocol in the stable phaseThis phase is the ideal moment to start and/or adjust medication, particularly evidence-based treatments (EBT) in patients with HFrEF. Diuretic treatment should be reduced until taken orally and at the minimum effective dose, or it should be withdrawn.Starting or adjusting disease-modifying drugsGuidelines recommend maintaining disease-modifying drugs for HFrEF during admission. In the case of new-onset HFrEF, the recommendation is to do everything possible to implement such treatments following initial haemodynamic stabilisation.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Therapeutic regimens in new-onset HF and continuation of established treatment in decompensated HF (in all cases with rEF)The following criteria have been established for both new-onset HF and for continuing with established treatment for decompensated HF:The new report from the expert consensus meeting of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) on clinical practice recommends considering starting sacubitril/valsartan before angiotensin-converting enzyme inhibitors (ACEI) in new-onset or decompensated patients to reduce the risk of short-term adverse events and to simplify management, thereby avoiding ACEI titration to later switch over to sacubitril/valsartan.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> Experts lean on the evidence provided by the PIONEER-HF<a class="elsevierStyleCrossRef" href="#bib0040">8</a> study, which demonstrates the superiority of sacubitril/valsartan over enalapril to reduce NT-proBNP and readmissions at 8 weeks, with a similar safety profile<a class="elsevierStyleCrossRef" href="#bib0040">8</a> in patients hospitalised without the use of intravenous inotropic agents in the last 24 h and without increasing the intravenous diuretics dosage or the use of intravenous vasodilators in the previous 6 h.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> In these cases, as the patients are already high-risk for events, it is not necessary to check the NT-proBNP levels prior to starting sacubitril/valsartan.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>The benefit of starting ACEI/ARB II (angiotensin II receptor blockers) during admission has also been demonstrated, with fewer readmissions and lower mortality at one year in observational studies,<a class="elsevierStyleCrossRef" href="#bib0180">36</a> although there are no randomised clinical trials showing this. When starting treatment, in addition to haemodynamic stability, renal function and electrolytes should be evaluated.Beta blockers should be started when the patient is haemodynamically stable, euvolemic, and they are not contraindicated. The benefit of starting beta blockers prior to discharge has been established with fewer admissions and lower mortality, with evidence fundamentally based on observational studies. In fact, the maximum increase in survival has been shown to be obtained with the sacubitril/valsartan and beta blocker combination.<a class="elsevierStyleCrossRef" href="#bib0185">37</a>Regarding aldosterone receptor antagonists (MRA), not all studies show the benefits of starting this in hospital. Various authors describe greater congestion relief, reduced admissions for HF, lower CV mortality, or a reduction in CV events following myocardial infarction,<a class="elsevierStyleCrossRef" href="#bib0185">37</a> while others do not confirm any benefits regarding reduced admission rates or mortality.<a class="elsevierStyleCrossRef" href="#bib0190">38</a> If prescribed, the patient should be closely watched at discharge, particularly in patients at risk of renal function impairment or hyperkalaemia. In any case, initiation during admission increases long-term use.In the case of ACEI, beta blockers, and MRAs, as the patient progresses from rEF to intermediate EF and to preserved EF, the beneficial effects indicated herein start to diminish.In terms of switching drugs within the same class, while the evidence is scarce, using drugs with proven evidence in HF is recommended.In HF with LVEF, no treatment to date has convincingly been shown to reduce morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Managing comorbiditiesType 2 diabetes mellitusDetermine HbA1c if not done in the previous 3 months. While admitted, hyperglycaemia should be treated with basal-bolus insulin and a correction protocol, withdrawing oral anti-diabetic drugs. The target blood sugar is 140−180 mg/dL.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> The safety and efficacy of dipeptidyl peptidase-4 inhibitors (iDPP-4) has been demonstrated (sitagliptin or linagliptin), alone or in combination with basal insulin.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> The HbA1c target should be personalised at discharge. Avoid saxagliptin, glitazones, and sulfonylureas. Based on the current evidence, no specific recommendation can be made regarding the use of sodium-glucose cotransporter-2 (SGLT2) inhibitors in patients with established HF, although their use could be evaluated in patients with type 2 diabetes mellitus and established CV disease or those at high risk of CV disease, to prevent or delay the start of hospitalisations for HF.<a class="elsevierStyleCrossRef" href="#bib0170">34</a>Arterial hypertensionThe blood pressure target is <140/90 mmHg, and if treatment is well-tolerated, preferably <130/80 mmHg.<a class="elsevierStyleCrossRef" href="#bib0200">40</a> Use disease-modifying drugs; if control still cannot be achieved, hydralazine can be considered which, together with isosorbide dinitrate, has been assessed in clinical trials on HF and rEF. The use of these is recommended in patients who do not tolerate ACEI, ARBs II or angiotensin receptor-neprilysin inhibitors (ARNI), or amlodipine and felodipine, which have been proven safe in patients with HFrEF.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Contraindicated in HFrEF: diltiazem, verapamil, and moxonidine.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>Iron deficiency and anaemiaImprovement in symptoms, exercise capacity, quality of life and reduced admissions have been shown with the administration of intravenous ferric carboxymaltose in patients with HF and rEF (not demonstrated in patients with pEF) and with iron deficiency (ferritin < 100 ng/mL or between 100 and 300 ng/mL a transferrin saturation [TS] < 20%), regardless of the presence or lack thereof of anaemia.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> It is important to investigate the cause of iron deficiency and anaemia when these are present.Atrial fibrillationThe CHA2DS2-VASc scale, based on a points system, can be used to assess a patient’s cardioembolic risk. It is described in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>.<elsevierMultimedia ident="tbl0030"></elsevierMultimedia>Anticoagulation is indicated if CHA2DS2-VASc ≥ 2.<a class="elsevierStyleCrossRef" href="#bib0205">41</a> In nonvalvular AF, the use of direct oral anticoagulants (DOACs) is preferable over vitamin K antagonists (VKA).<a class="elsevierStyleCrossRef" href="#bib0210">42</a> HR control: target HR between 60−100 bpm, and without better results with HR < 70 bpm. No reduction in morbidity and mortality has been shown with beta blockers in patients with AF and HFrEF. The recommendation is to control HR with beta blockers indicated for HFrEF and, if not possible, to add digoxin.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>COPDIn terms of treatment for COPD with AHF during hospitalisation, beta-mimetic nebulisers must be avoided and anticholinergics should be used, with the option to add corticoids if a) it is absolutely positive that there is a COPD or bronchospasm component related to the HF, and b) the patient has a preserved level of consciousness (whereas, if this is lowered, the patient probably has hypercapnia and high-flow nebulisation, particularly with O2, could worsen his/her ventilation condition). At discharge, bronchodilator treatment, preferably using long-acting bronchodilator drugs and starting with LAMA (long-acting muscarinic antagonists), although LABA (long-acting beta2 agonists) can be used. Use cardioselective beta blockers (bisoprolol, nebivolol, metoprolol) to treat HF in patients with COPD.EducationSelf careIn chronic HF, active patient participation through self care helps improve progress and reduce readmissions.<a class="elsevierStyleCrossRef" href="#bib0215">43</a> Both the European clinical practice guidelines for HF<a class="elsevierStyleCrossRef" href="#bib0045">9</a> as well as the American<a class="elsevierStyleCrossRef" href="#bib0050">10</a> recommend that patients be educated on self care before discharge.Key aspects in terms of education include information about HF, monitoring weight and preventing malnutrition, maintaining a low-sodium diet, avoiding excessive fluid intake and restricting this when indicated–generally in patients with severe HF to relieve congestion. Additionally, abstention from tobacco use and abstention or moderation in alcohol consumption. Regular physical activity has been shown to improve quality of life and reduce hospital admissions in patients with HF<a class="elsevierStyleCrossRef" href="#bib0220">44</a> and is recommended independently of the LVEF.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Flu and pneumonia vaccination should also be recommended.Warning signsAnother important component of education is to familiarise patients with warning signs, including increased dyspnoea, orthopnoea, onset of paroxysmal nocturnal dyspnoea, chest pain, weight gain and/or oedema or a feeling of fullness, so that when patients notice any of these symptoms they reach out or take action such as adjusting treatment, for example, increasing their diuretics dosage.MedicationThe patient must understand the indications and benefits of their prescribed medication and be aware of the possible side effects. It is important to review the medication list with the patient, evaluating therapeutic adherence and the difficulties of achieving this, and indicating which drugs should be avoided, such as non-steroidal anti-inflammatory drugs (NSAIDS) or drugs with high sodium content such as effervescent paracetamol.Managing the post-discharge transition periodThis section describes both considerations at discharge from hospital (summarised in the checklist in the following subsection) as well as management of the post-discharge transition period (<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>).<elsevierMultimedia ident="tbl0035"></elsevierMultimedia>Checklist used at hospital dischargeThe routine use of checklists has been confirmed in numerous processes both within and without the health care setting. Among the main virtues of this system, we can highlight the reduced number of errors and standardisation of a procedure performed by different individuals, with the resulting drop in interpersonal variety. The philosophy of this 10-point list is to help internists optimise the management of hospitalised HF patients, therefore reducing the number of early hospitalisations. These points are listed below<a class="elsevierStyleCrossRef" href="#bib0225">45</a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1Have the precipitating factors been identified and controlled?</li><li class="elsevierStyleListItem" id="lsti0010">2Have the comorbidities been assessed?</li><li class="elsevierStyleListItem" id="lsti0015">3Is the patient decongested? The EVEREST<a class="elsevierStyleCrossRef" href="#bib0115">23</a> criteria, classic signs of HF, or point-of-care ultrasound can be used.</li><li class="elsevierStyleListItem" id="lsti0020">4Is the LVEF known? Particularly important in patients with depressed LVEF (<40%), candidates for certain treatments that differ from those of patients with preserved LVEF.</li><li class="elsevierStyleListItem" id="lsti0025">5If LVEF < 40%, has treatment been optimised with sacubitril/valsartan, ACEI or ARBs II, beta blockers, and MRAs? These therapies have shown reduced mortality and readmission for HF with depressed LVEF.<a class="elsevierStyleCrossRef" href="#bib0230">46</a> In a network analysis, the most effective combinations for HFrEF were: 1) sacubitril/valsartan + beta blocker + MRA, and 2) ACEI+ beta blocker + MRA + ivabradine; reducing all-cause mortality (vs. placebo) by 62 and 59%, respectively, and all-cause hospitalisation by 42% for both combinations.<a class="elsevierStyleCrossRef" href="#bib0170">34</a></li><li class="elsevierStyleListItem" id="lsti0030">6Has the remaining medication been reviewed? The elimination of drugs with little intrinsic value is particularly important in polymedicated patients.</li><li class="elsevierStyleListItem" id="lsti0035">7Have renal function and electrolytes been assessed? Dosages for some drugs will be adjusted according to creatinine clearance, particularly anticoagulation therapy.<a class="elsevierStyleCrossRef" href="#bib0235">47</a></li><li class="elsevierStyleListItem" id="lsti0040">8Is the heart rhythm, rate, systolic blood pressure, and duration of the QRS complex known? In patients with AF, anticoagulation will be considered if there are no major contraindications.</li><li class="elsevierStyleListItem" id="lsti0045">9Has the patient and/or the caretaker been educated about the disease? Have instructions been given? Refers to the need for specific educational materials.</li><li class="elsevierStyleListItem" id="lsti0050">10Does the patient have an appointment scheduled soon with primary or specialised care? This appointment should always take place within one month from discharge, preferably within the first 10 days.</li></ul>Evaluating the risk for readmissionIn terms of evaluating readmission risk, it is essential to identify patients with greater probability of returning to hospital in order to establish closer follow-up and prevent new hospitalisations. This assessment is based on four fundamental components (<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>):<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0055">•Admissions or visits to the emergency department in the 3 months prior to the current admission. The risk of readmission following hospitalisation for HF is known to be higher in patients with frequent admissions or visits to the emergency department in the previous months, particularly among elderly patients.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> Therefore, it is important to detect this population and take advantage of the current admission to optimise treatment and thereby improve follow-up, coordination with the primary care specialist, and access to quick and effective care.</li><li class="elsevierStyleListItem" id="lsti0060">•Clinical assessment in relation to HF and decongestion. Low SBP, moderate hyponatremia, need for high dosage diuretics, and renal function impairment. All are aspects with proven relevance in terms of predicting poor prognosis and high risk of readmission.<a class="elsevierStyleCrossRef" href="#bib0240">48</a></li><li class="elsevierStyleListItem" id="lsti0065">•Presence of geriatric syndromes during hospitalisation.<a class="elsevierStyleCrossRef" href="#bib0245">49</a> Confusional syndromes, frailty, malnutrition, and sarcopenia not only extend hospital stays, but can also bring about a poor prognosis. Their presence during hospital admission will require closer follow-up, as well as implementation of measures to offset or at least lessen the aforementioned syndromes.</li><li class="elsevierStyleListItem" id="lsti0070">•Social factors related to the patient. Though sometimes not taken into account, in the case of deprivation, they are described as a risk factor for readmission<a class="elsevierStyleCrossRef" href="#bib0250">50</a> and should therefore be assessed in discharge planning.</li></ul>Care continuityThe change in paradigm in the management of chronic diseases like HF, with a focus on integral and multidisciplinary care, entails taking on as one of the essential pillars the transition of care and adequate post-hospitalisation follow-up. In other words, at the time of discharge, continuity of care should be guaranteed by focusing on two aspects (<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>):<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0075">1Define the patient’s treatment protocol, including the following aspects:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080">•Proper medication reconciliation should be carried out, with correctly noted dose and dosage to minimise errors.</li><li class="elsevierStyleListItem" id="lsti0085">•Indicate which drugs will require dose optimisation: sacubitril/valsartan, beta blockers, ACEI…</li><li class="elsevierStyleListItem" id="lsti0090">•Review the suitability of the indication, taking into account internationally recognised prescription criteria, such as the “do not do” recommendations of scientific societies,<a class="elsevierStyleCrossRef" href="#bib0255">51</a> the Beers criteria<a class="elsevierStyleCrossRef" href="#bib0260">52</a> or the STOPP/START criteria.<a class="elsevierStyleCrossRef" href="#bib0265">53</a></li></ul></li><li class="elsevierStyleListItem" id="lsti0095">2Define within the discharge report who will establish the patient’s next contact with the health care system and in what manner this will occur. The variability of each health care area makes it impossible to contemplate a single proposal. According to local characteristics, three options are suggested:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0100">•Contact with the primary care team: either through nursing staff, medical personnel, or both; at home or at the health care centre (depending on the patient’s condition), in the first 7 days post-discharge.</li><li class="elsevierStyleListItem" id="lsti0105">•Coordination according to specific local protocols wherein the role of case manager exists.<a class="elsevierStyleCrossRef" href="#bib0270">54</a></li><li class="elsevierStyleListItem" id="lsti0110">•Proactive telephone contact from the Unit/clinic nursing team within the first 72 h post-discharge.</li></ul></li></ul>Future perspectivesThis document aims to reduce variability and improve care for patients hospitalised with HF and promote systematic updates to HF patient care according to the most recent available evidence. Despite the existence of clear treatment recommendations for drugs that increase survival in patients with HFrEF, recent data from real-world records show that these drugs are under-used.<a class="elsevierStyleCrossRef" href="#bib0275">55</a> In the present protocol, though the entire hospitalisation process is addressed, the creation of a discharge checklist is of particular importance to systematically reviewing the many aspects that must be taken into account, thereby enabling better prescribing, education, and follow-up of the patient according to their needs. In fact, the American Society of Cardiology suggests creating a checklist at discharge, having shown that its implementation was associated with reduced admissions.<a class="elsevierStyleCrossRef" href="#bib0280">56</a> It would also make it possible to encourage quality clinical training on a pathology that is highly prevalent in Internal Medicine and to improve coordination between the various care levels post-discharge. If integrating said checklist into the electronic clinical history can ultimately be achieved, in addition to facilitating its use, it would also make it possible to exploit the data and discover the reality of HF patients in Spain.ConclusionsAHF patient admission<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0115">•It is essential to know the course of the disease in detail and to take an accurate case history and evaluation of signs and symptoms.</li><li class="elsevierStyleListItem" id="lsti0120">•Upon evaluating the patient, their comorbidities must be considered, as these greatly condition the disease prognosis, particularly in the group of HF patients with pEF.</li><li class="elsevierStyleListItem" id="lsti0125">•It is important to be aware of the HF patient’s standard treatment: diuretics, sacubitril/valsartan, ACEI or ARB II, beta blockers, MRAs, ivabradine, as well as others such as digoxin, hypolipidemic agents, antiarrhythmic agents, or anticoagulants.</li></ul>Management of the congestive phase<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0130">•Decongestive treatment is a priority during the first hours of hospital care.</li><li class="elsevierStyleListItem" id="lsti0135">•A diuretic readjustment protocol is recommended depending on the response over the first 24 h of hospital care.</li><li class="elsevierStyleListItem" id="lsti0140">•A staged therapeutic diuretic approach according to the decongestive response offers benefits in terms of fluid and weight loss, without compromising renal function.</li><li class="elsevierStyleListItem" id="lsti0145">•Disease-modifying treatment should be maintained to the extent possible.</li></ul>Management of the stable phase<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0150">•Starting and/or adjusting treatment should be considered, particularly for evidence-based treatments, in patients with HFrEF; in other words, sacubitril/valsartan (or ACEI/ARB II), beta blockers, and aldosterone antagonists.</li><li class="elsevierStyleListItem" id="lsti0155">•The various comorbidities should be assessed and controlled and the patient and/or family members educated on the disease to ensure their involvement in self care.</li></ul>Considerations at discharge from hospital<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0160">•It is recommended to consider the checklist information to optimise the management of hospitalised HF patients and to reduce the number of early hospitalisations.</li><li class="elsevierStyleListItem" id="lsti0165">•The four patient groups with higher risk of readmission should be identified.</li><li class="elsevierStyleListItem" id="lsti0170">•The 3 most efficient options for maintaining care continuity following hospital discharge should be addressed.</li></ul>Conflicts of interestJosé María Fernández has received support for consulting and conferences from Novartis, Boehringer-Lilly, Pfizer, Daiichi-Sankyo, and for attendance at congresses from Pfizer, Boehringer-Lilly.Jesús Casado has received support for consulting, conferences and attendance at congresses from Novartis and Rovi, and for consulting with Vifor and Pfizer.Francesc Formiga has support for consulting, conferences and attendance at congresses from Novartis and Rovi, and for consulting with Vifor and Pfizer.Álvaro González-Franco has received support for consulting, conferences or attendance at congresses from Novartis, Vifor, Daiichi, Pfizer and Esteve.José Carlos Arévalo has received support for consulting or attendance at congresses from Novartis, Esteve, Bayer and Bristol-Myers.Manuel Beltrán has received support for consulting, conferences, or attendance at congresses from Novartis, Astra, Novo Nordisk, Daichii, Boehringer, Lilly and Sanofi.José Manuel-Cerqueiro has received support from Novartis for conferences.Pau Llacer has received support for consulting, conferences or attendance at congresses from Novartis, Vifor, Boehringer, Rovi, Ferrer, Esteve, Pfizer, Astra Zeneca, Novo Nordisk.Luis Manzano has received support for consulting, conferences and attendance at congresses from Novartis and Rovi, and for consulting with Vifor and Pfizer.José Luis Morales-Rull has received support for consulting or conferences from Novartis, Orion Pharma, Esteve, Pharmanutra.José Pérez-Silvestre has received support for conferences, consulting, and/or attendance at congresses from Novartis, Rovi, Pfizer, Boehringer, Bayer, Esteve, Ferrer and Glaxo.Alicia Conde-Martel has received support for consulting or conferences from Pfizer, Novartis, Bristol Myers and Daiichi-Sankyo." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1509384" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1369266" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1509383" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1369265" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Patient admission" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Considerations when admitting patients with AHF" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Assessment of signs and symptoms of congestion using the EVEREST index" ] ] ] 7 => array:3 [ "identificador" => "sec0030" "titulo" => "Managing AHF patients in the congestive phase" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Non-invasive daily monitoring" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Disease-modifying drugs" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Respiratory support" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Haemodynamic support" ] 4 => array:2 [ "identificador" => "sec0055" "titulo" => "Decongestive treatment: diuretics" ] ] ] 8 => array:3 [ "identificador" => "sec0060" "titulo" => "Managing AHF patients in the stable phase" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Management protocol in the stable phase" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Starting or adjusting disease-modifying drugs" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Therapeutic regimens in new-onset HF and continuation of established treatment in decompensated HF (in all cases with rEF)" ] 3 => array:3 [ "identificador" => "sec0080" "titulo" => "Managing comorbidities" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Type 2 diabetes mellitus" ] 1 => array:2 [ "identificador" => "sec0090" "titulo" => "Arterial hypertension" ] 2 => array:2 [ "identificador" => "sec0095" "titulo" => "Iron deficiency and anaemia" ] 3 => array:2 [ "identificador" => "sec0100" "titulo" => "Atrial fibrillation" ] 4 => array:2 [ "identificador" => "sec0105" "titulo" => "COPD" ] ] ] 4 => array:3 [ "identificador" => "sec0110" "titulo" => "Education" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0115" "titulo" => "Self care" ] 1 => array:2 [ "identificador" => "sec0120" "titulo" => "Warning signs" ] 2 => array:2 [ "identificador" => "sec0125" "titulo" => "Medication" ] ] ] ] ] 9 => array:3 [ "identificador" => "sec0130" "titulo" => "Managing the post-discharge transition period" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0135" "titulo" => "Checklist used at hospital discharge" ] 1 => array:2 [ "identificador" => "sec0140" "titulo" => "Evaluating the risk for readmission" ] 2 => array:2 [ "identificador" => "sec0145" "titulo" => "Care continuity" ] ] ] 10 => array:2 [ "identificador" => "sec0150" "titulo" => "Future perspectives" ] 11 => array:3 [ "identificador" => "sec0155" "titulo" => "Conclusions" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0160" "titulo" => "AHF patient admission" ] 1 => array:2 [ "identificador" => "sec0165" "titulo" => "Management of the congestive phase" ] 2 => array:2 [ "identificador" => "sec0170" "titulo" => "Management of the stable phase" ] 3 => array:2 [ "identificador" => "sec0175" "titulo" => "Considerations at discharge from hospital" ] ] ] 12 => array:2 [ "identificador" => "sec0180" "titulo" => "Conflicts of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-09-21" "fechaAceptado" => "2020-01-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1369266" "palabras" => array:4 [ 0 => "Acute heart failure" 1 => "Recommendations" 2 => "Treatment" 3 => "Protocol" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1369265" "palabras" => array:4 [ 0 => "Insuficiencia cardiaca aguda" 1 => "Recomendaciones" 2 => "Tratamiento" 3 => "Protocolo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Acute heart failure (AHF) is a highly prevalent clinical entity in individuals older than 45 years in Spain. AHF is associated with significant morbidity and mortality and is the leading cause of hospitalisation for individuals older than 65 years in Spain, a quarter of whom die within 1 year of the hospitalisation. In recent years, there has been an upwards trend in hospitalisations for AHF, which increased 76.7% from 2003 to 2013. Readmissions at 30 days for AHF have also increased (from 17.6% to 22.1%), at a relative mean rate of 1.36% per year, with the consequent increase in the use of resources and the economic burden for the healthcare system. The aim of this document (developed by the Heart Failure and Atrial Fibrillation Group of the Spanish Society of Internal Medicine) is to guide specialists on the most important aspects of treatment and follow-up for patients with AHF during hospitalisation and the subsequent follow-up. The main recommendations listed in this document are as follows: 1) At admission, perform a comprehensive assessment, considering the patient’s standard treatment and comorbidities, given that these determine the disease prognosis to a considerable measure. 2) During the first few hours of hospital care, decongestive treatment is a priority, and a staged diuretic therapeutic approach based on the patient’s response is recommended. 3) To manage patients in the stable phase, consider starting and/or adjusting evidence-based drug treatment (e.g., sacubitril/valsartan or angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta blockers and aldosterone antagonists). 4) At hospital discharge, use a checklist to optimise the patient’s management and identify the most efficient options for maintaining continuity of care after discharge." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La insuficiencia cardiaca aguda (ICA) es una entidad clínica con una elevada prevalencia en la población de más de 45 años en España. Está asociada a una importante morbimortalidad, constituyendo la primera causa de hospitalización en mayores de 65 años en nuestro país, de los cuales una cuarta parte fallecen al año del ingreso. En los últimos años se ha observado una tendencia al alza en las hospitalizaciones por ICA, que aumentaron un 76,7% en el período de 2003 a 2013. Los reingresos a los 30 días por ICA también aumentaron (del 17,6 al 22,1%) a un ritmo medio relativo del 1,36% por año, con el consiguiente increment en el uso de recursos y en la carga económica para el sistema sanitario. Este documento, elaborado por el grupo de Insuficiencia Cardiaca y Fibrilación Auricular de la Sociedad Española de Medicina Interna, tiene como objetivo orientar al especialista en los aspectos más importantes del tratamiento y seguimiento de los pacientes con ICA durante el ingreso y el seguimiento posterior. Las principales recomendaciones recogidas son: 1) en el momento del ingreso, realizar una evaluación integral, considerando el tratamiento habitual y comorbilidades del paciente, ya que condicionan en gran medida el pronóstico de la enfermedad; 2) en las primeras horas de atención hospitalaria, el tratamiento descongestivo es prioritario y se recomienda un abordaje terapéutico diurético escalonado en función de la respuesta; 3) en el manejo de la fase estable, considerar el inicio y/o ajustar el tratamiento con fármacos basados en la evidencia, es decir, sacubitrilo/valsartán o IECA/ARA II, betabloqueantes y antialdosterónicos; 4) en el momento del alta hospitalaria, utilizar un checklist para optimizar el manejo del paciente hospitalizado e identificar las opciones más eficientes para mantener la continuidad de cuidados tras el alta." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Fernández Rodríguez JM, Casado J, Formiga F, González-Franco Á, Arévalo JC, Beltrán M, et al. Consenso de actuación básica durante el ingreso hospitalario por insuficiencia cardiaca aguda. Rev Clin Esp. 2021;221:283–296." ] ] "multimedia" => array:11 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 444 "Ancho" => 2157 "Tamanyo" => 95395 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Stages of hospitalisation due to heart failure." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ACEI: angiotensin-converting enzyme inhibitor; AHF: acute heart failure; ARB: angiotensin II receptor blocker; BMI: body mass index; BP: blood pressure; CKD: chronic kidney disease; COPD: chronic obstructive pulmonary disease; CPAP: Continuous Positive Airway Pressure; DOAC: direct oral anticoagulant; GF: glomerular filtration; Hb: haemoglobin; HF: heart failure; HPB: high blood pressure; HR: heart rate; JVD: jugular venous distention; LVEF: left ventricular ejection fraction; MRA: mineralocorticoid receptor antagonist; NT-proBNP: N-terminal pro b-type natriuretic peptide; NYHA: New York Heart Association scale; OHS: obesity hypoventilation syndrome; PND: paroxysmal nocturnal dyspnoea; SAHS: sleep apnoea-hypopnea syndrome." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202105110748283731"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2592339.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Considerations when admitting patients with AHF." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "JVD: jugular venous distention.A result of ≥1 is associated with a 10% increase in risk of readmission at 6 months.A result of ≥3 is associated with a 10% increase in all-cause mortality at 6 months." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Dyspnoea \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Orthopnoea \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">JVD \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Rales \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Oedemas \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Fatigue \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">None \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Seldom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Seldom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6−9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Slight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Seldom \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10−15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequent \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Marked \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2592333.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Assessment of signs and symptoms of congestion using the EVEREST score.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AA: aldosterone antagonist; ACEI: angiotensin-converting enzyme inhibitor; AHF: acute heart failure; ARB: angiotensin II receptor blocker; ARNI: angiotensin receptor-neprilysin inhibitor; BB: beta blocker, BiPAP: bilevel positive airway pressure; BP: blood pressure; CPAP: continuous positive airway pressure; ECG: electrocardiogram; eGFR: estimated glomerular filtration rate; HF: heart failure; HR: heart rate; MRA: mineralocorticoid receptor antagonist; NIMV: noninvasive mechanical ventilation; OTI: orotracheal intubation; rEF: reduced ejection fraction.aEvaluate bolus/8 h or continuous infusion." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202105110748283732"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2592334.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Managing the AHF patient in the congestive phase." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Furosemide: 250−500 mg/12 h/i.v. in 30 min.BoiK aspartic acid: 2 tablets every 8 h.Fluid restriction to 1000 cc daily.Daily renal function and electrolyte panel.150 cc HSS/12 h/i.v. in 30 min. Na+ concentration in infusion according to natremia.HSS: Hypertonic saline solution." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Infusion concentration \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Blood levels of Na+ \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preparation form \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypertonic saline solution at 4.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><125 mEq/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dilute 19 ampoules of NaCl 20% in 1000 mL saline solution 0.9% and administer 150 mL of the dilution in 30 min/12 h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypertonic saline solution at 3.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">126−135 mEq/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dilute 14 ampoules of NaCl 20% in 1000 mL saline solution 0.9% and administer 150 mL of the dilution in 30 min/12 h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypertonic saline solution at 2.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">136−145 mEq/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dilute 8 ampoules of NaCl 20% in 1000 mL saline solution 0.9% and administer 150 mL of the dilution in 30 min/12 h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypertonic saline solution at 1.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>145 mEq/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dilute 3 ampoules of NaCl 20% in 1000 mL saline solution 0.9% and administer 150 mL of the dilution in 30 min/12 h \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2592338.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Hypertonic saline solution protocol." ] ] 5 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin II receptor blocker; ARNI: angiotensin receptor-neprilysin inhibitor; BB: beta blocker; BP: blood pressure; bpm: beats per minute; HF: heart failure; HR: heart rate; MRA: mineralocorticoid receptor antagonist; NSAID: non-steroidal anti-inflammatory drug; rEF: reduced ejection fraction.aAs of yet no treatment has convincingly been shown to reduce morbidity and mortality in patients with LVEF > 40%." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202105110748283733"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2592336.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Managing AHF patients in the stable phase." ] ] 6 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Risk factor \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Congestive heart failure/Left ventricular dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age ≥ 75 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stroke/transitory ischaemic attack/thromboembolism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age 65−74 years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female sex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2592337.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "The ESC recommends anticoagulant treatment in patients with atrial fibrillation and CHA2DS2-VASc greater or equal to 2.(44)." ] ] ] "descripcion" => array:1 [ "en" => "CHA2DS2-VASc score. Evaluation of cardiovascular risk<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> based on a points system.<a class="elsevierStyleCrossRef" href="#bib0215">43</a>" ] ] 7 => array:8 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "eGFR: estimated glomerular filtration rate; SBP: systolic blood pressure." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Risk of readmission. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Identification of patients at higher risk of readmission: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">It is essential to identify patients with higher risk of readmission. The following items are proposed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• >2 admissions in the past 3 months or >2 visits to the emergency department in the last month \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Poor clinical condition at discharge: SBP < 100 mmHg, >120 mg of oral furosemide/day, Na+ < 130 mEq/L and/or eGFR < 30 mL/min/1.73 m2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Appearance of a geriatric syndrome during admission: confusional syndrome, frailty, malnutrition or sarcopenia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Poor social situation or risk of poor adherence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. Care continuity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Establish the patient’s therapeutic regimen at discharge and what is expected in primary care: drugs and dosages at discharge, proposal for optimisation where necessary and withdrawal of medication without evidence or counterproductive medications \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Contact with the health care system: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Contact with primary care \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Case management \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Proactive contact telephone \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2592335.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Managing the post-discharge transition period." ] ] 8 => array:5 [ "identificador" => "202105110748283731" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 4374 "Ancho" => 2167 "Tamanyo" => 539848 ] ] ] 9 => array:5 [ "identificador" => "202105110748283732" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx2.jpeg" "Alto" => 4128 "Ancho" => 2167 "Tamanyo" => 722173 ] ] ] 10 => array:5 [ "identificador" => "202105110748283733" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx3.jpeg" "Alto" => 3183 "Ancho" => 2167 "Tamanyo" => 547967 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:56 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Consenso para la mejora de la atención integral de los pacientes con Insuficiencia Cardiaca Aguda" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Grupo de trabajo de la SEC, SEMI y SEMES, para las recomendaciones en la mejora de la atención integral de los pacientes con Insuficiencia Cardíaca Aguda" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:2 [ "link" => "https://secardiologia.es/publicaciones/catalogo/documentos-de-consenso/5816-consenso-para-la-mejora-de-la-atencion-integral-de-los-pacientes-con-insuficiencia-cardiaca-aguda" "fecha" => "2014" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trajectories of risk after hospitalization for heart failure, acute myocardial infarction, or pneumonia: retrospective cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K. 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Consensus on basic conduct during the hospital admission of patients with acute heart failure

Consenso de actuación básica durante el ingreso hospitalario por insuficiencia cardiaca aguda

J.M. Fernández Rodrígueza, J. Casadob, F. Formigac, Á. González-Francod, J.C. Arévaloe, M. Beltránf, J.M. Cerqueiro Gonzálezg, P. Llàcerh, L. Manzanoi, J.L. Morales-Rullj, J. Pérez Silvestrek, A. Conde-Martell,

Corresponding author

alicia.conde@ulpgc.es

Corresponding author.

a Servicio de Medicina Interna, Hospital Carmen y Severo Ochoa, Cangas del Narcea, Asturias, Spain

b Servicio de Medicina Interna, Hospital Universitario de Getafe, Getafe, Madrid, Spain

c Servicio de Medicina Interna, IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain

d Unidad de Gestión Clínica de Medicina Interna, Hospital Universitario Central de Asturias, Oviedo, Spain

e Servicio de Medicina Interna, Hospital de Zafra, Zafra, Badajoz, Spain

f Medicina Interna, Hospital Virgen del Camino, Sanlúcar de Barrameda, Cádiz, Spain

g Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, Spain

h Servicio de Medicina Interna, Hospital de Manises, Valencia, Spain

i Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Departamento de Medicina y Especialidades Médicas, Facultad de Medicina y Ciencias de la Salud, Universidad de Alcalá, IRYCIS, Madrid, Spain

j Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Lleida, Spain

k Servicio de Medicina Interna, Unidad Insuficiencia Cardíaca Paciente Crónico y Edad Avanzada, Consorcio Hospital General Universitario de Valencia, Valencia, Spain

l Servicio de Medicina Interna, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas, Las Palmas de Gran Canaria, Spain

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AHF is the main cause for hospitalisation in patients over 65 years&#44; representing more than 113&#44;000 admissions per year&#44; of which one quarter die within one year of admission&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> In recent years &#40;2003&#8211;2013&#41;&#44; a rising trend has been observed in hospitalisations due to AHF&#44; an increase of 76&#46;7&#37;&#44; particularly affecting patients &#8805;75 years and associated with an increase in comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this context&#44; it is important to highlight that the risk of readmission for patients hospitalised with AHF is high&#44; particularly early readmission during the first month post-discharge &#40;&#8764;13&#46;4&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> which is considered the most vulnerable period for patients hospitalised with AHF&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> In fact&#44; hospital readmissions within 30 days also increased in the 2003&#8211;2013 period &#40;from 17&#46;6 to 22&#46;1&#37;&#41; at a mean relative rate of 1&#46;36&#37; per year&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Readmissions due to AHF have a significant impact in terms of both mortality and economic burden on the healthcare system&#46; Patients with HF who are readmitted due to worsening illness or other non-cardiovascular causes have higher rates of mortality &#40;12&#46;7&#37; and 13&#46;3&#37;&#44; respectively&#41; than patients admitted with HF for the first time &#40;9&#46;2&#37;&#59; <span class="elsevierStyleItalic">P</span>&#8239;&#60;&#8239;&#46;001&#41;&#46; On the other hand&#44; the economic cost of the disease&#44; estimated to be 2&#46;5 billion euros per year&#44; is mainly associated with hospitalisations&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> with an average hospital stay of 7&#8211;10 days for patients admitted for AHF&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><p id="par0025" class="elsevierStylePara elsevierViewall">In light of the aforementioned and the increasing availability of new relevant evidence related to the therapeutic management of AHF&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and due to recent guideline updates&#44;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> the Heart Failure and Atrial Fibrillation Group of the Spanish Society of Internal Medicine &#40;SEMI&#41; has developed protocol recommendations with the aim of guiding specialists in the most important practical aspects of treatment and follow-up for these patients during hospital admission&#44; as well as to standardise and optimise their treatment to the extent possible based on the available evidence&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Likewise&#44; the present document addresses the four main hospitalisation phases of a patient with AHF&#58; admission&#44; treatment during the congestive and stable phases&#44; and discharge from hospital&#46; The phases are defined as follows&#58; 1&#41; considerations upon admission&#44; defined as the moment in which assessment is requested from Internal Medicine&#44; either in the emergency department or in the hospital ward&#59; 2&#41; management of the congestive phase which encompasses admission through to starting to decrease diuretics&#59; 3&#41; management of the stable phase which starts with decreasing diuretics up until the day of discharge&#44; and 4&#41; considerations upon discharge&#44; defined as the day of discharge &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">To draft the guidelines&#44; the authors split into 4 work groups and each group was tasked with writing one chapter based on the published evidence and clinical experience&#46; Following the completion of each chapter&#44; an editing process was carried out to achieve a uniform document that was shared among the authors for revision and approval&#46; The final results comprise a set of recommendations that are intended to be practical for the management of patients admitted for AHF&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patient admission</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Considerations when admitting patients with AHF</span><p id="par0040" class="elsevierStylePara elsevierViewall">When admitting a patient for an episode of decompensated HF&#44; it is necessary to collect what is considered basic information&#44; as set out in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Aspects to be taken into consideration include the patient&#8217;s epidemiological data&#44; the presence or lack thereof of a caretaker&#44; if he or she is educated on the disease&#44; warning signs&#44; substance abuse by the patient&#44; and the presence or not of dementia&#46; Seeing as how HF particularly affects elderly individuals&#44; a comprehensive geriatric assessment &#40;CGA&#41; of the patient will also help improve understanding and prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a> The minimum CGA&#44; in addition to cognition&#44; must incorporate the patient&#39;s capacity to perform basic activities of daily living &#40;Barthel&#39;s index&#41;&#44; whose prognostic value has been shown at both 3 months and one year from hospital admission for AHF&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The clinical progress of the disease must be studied in detail &#40;hospital admissions for AHF in the past year&#44; number of emergency department visits in the last 3 months&#44; etc&#46;&#41;&#46; Since the current treatment recommendations&#44; and to some degree the prognosis&#44; are based on the type of ventricular dysfunction &#40;reduced&#44; intermediate&#44; or preserved&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> it is important to know the date of the last ultrasound which determined the left ventricular ejection fraction &#40;LVEF&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The onset of HF can be associated with structural&#44; mechanical or electrical heart abnormalities&#46; Likewise&#44; HF can be due to ischaemic&#44; metabolic&#44; endocrine&#44; immune&#44; inflammatory&#44; infectious&#44; genetic&#44; or neoplastic processes&#44; among others&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Therefore&#44; the aetiology of the patient&#8217;s HF must be noted&#46; The relevance of amyloid cardiomyopathy has recently been brought to light&#59; therefore&#44; amyloidosis should also be investigated as a possible aetiological factor&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Finding out the patient&#8217;s comorbidities is basic practice<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and especially important in the HF patient group with preserved EF &#40;pEF&#41;&#44; in which the mean age exceeds 80 years&#44; is predominantly made up of women&#44; and comorbidities largely determine the disease prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> These patients frequently meet the criteria for polypathological patients&#44; a condition that justifies internal medicine specialists participating in their treatment&#46; Of the broad spectrum of comorbidities in HF patients&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> some are strictly aetiological factors or factors that determine the course of the HF &#40;diabetes mellitus&#44; high blood pressure&#44; atrial fibrillation &#91;AF&#93;&#44; thyroid disease and obesity&#41;&#46; Others are the consequence of common aetiological factors&#44; such as chronic obstructive pulmonary disease &#40;COPD&#41; and chronic kidney disease&#44; or are associated with old age &#40;dementia&#44; anaemia&#41; and obesity &#40;hypoventilation&#44; sleep apnoea syndrome&#41;&#44; etc&#46; Considering that some of these comorbidities can produce similar signs and symptoms as HF &#40;COPD&#41;&#44; can interfere with treatment &#40;chronic kidney disease&#44; COPD&#41;&#44; or cause decompensation &#40;hyperthyroidism&#44; anaemia&#44; high blood pressure or poorly controlled AF&#41;&#44; properly identifying them and treating them is crucial from the time of admission&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">It is essential to be aware of the standard treatment when treating any admitted patient&#44; and all the more so in HF patients&#46; These patients frequently present with inadequate previous treatment for HF or other comorbidities and&#44; on the other hand&#44; an unwarranted excess of psychoactive drugs&#44; analgesics&#44; or anti-inflammatory agents&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;17</span></a> In addition to being polymedicated&#44; they may also be &#8220;poorly medicated&#8221;&#46; The most important medications to consider&#44; particularly in HF with reduced EF &#40;rEF&#41;&#44; are also listed in the table&#46; In addition&#44; certain drugs should be taken into account due to how frequently they are used in these patients&#44; such as digoxin&#44; calcium channel blockers&#44; antiplatelet drugs&#44; anticoagulants&#44; hypolipidemic agents&#44; antiarrhythmic agents and others specifically associated with comorbidities&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In terms of triggering factors&#44; the following should be considered&#58; infections&#44; therapeutic non-compliance&#44; dietary transgressions&#44; anaemia&#44; and cardiovascular &#40;CV&#41; factors &#40;uncontrolled high blood pressure&#44; arrhythmia and myocardial ischaemia&#41;&#44; as well as toxic and pharmacological factors such as alcohol&#44; non-steroidal anti-inflammatory drugs and non-dihydropyridine calcium channel blockers &#40;verapamil and diltiazem&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">As a supplementary tool to chest radiography&#44; lung ultrasound scans and scans of the inferior vena cava have gained prominence in recent years as parameters that contribute to quantifying the patient&#8217;s degree of congestion&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> Measuring plasma biomarkers such as carbohydrate antigen 125 &#40;CA 125&#41; can also contribute to identifying the patient&#8217;s degree of congestion and to titrating diuretic treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> In addition&#44; measuring natriuretic peptides is essential to ruling out HF due to their high negative predictive value&#58; as prognostic markers&#44; they should be ordered during any hospital admission&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Patient vitals&#44; which are essential to clinical assessment and therapeutic decision-making&#44; should also be recorded during the physical examination&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Blood testing at admission should include a complete blood count&#44; biochemical analysis with renal function &#40;urea&#44; creatinine&#41;&#44; and electrolyte panel &#40;sodium and potassium&#41;&#44; as well as a urine sample with sodium and potassium&#46; Renal function and electrolyte alterations can limit the use of certain drugs and have prognostic implications<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#58; a urine sodium content of &#60;50&#8722;70&#8239;mEq&#47;L after 2&#8239;h of intravenous diuretic treatment indicates diuretic resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> It is also essential to evaluate pH&#44; oxygen saturation&#44; and baseline albumin&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Assessment of signs and symptoms of congestion using the EVEREST index</span><p id="par0085" class="elsevierStylePara elsevierViewall">A thorough evaluation of the degree of congestion must be made in hospitalised HF patients&#46; To do this&#44; the systematic information set out in the EVEREST<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> index in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> can be of use&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Managing AHF patients in the congestive phase</span><p id="par0090" class="elsevierStylePara elsevierViewall">The main aspects related to managing AHF patients in the congestive phase are detailed in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Non-invasive daily monitoring</span><p id="par0095" class="elsevierStylePara elsevierViewall">Non-invasive monitoring of the patient&#8217;s vital signs&#44; including pulse oximetry&#44; blood pressure&#44; respiratory rate &#40;RR&#41;&#44; and diuresis&#44; is essential to evaluate whether ventilation&#44; peripheral infusion&#44; oxygenation&#44; heart rate&#44; and blood pressure are adequate&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Heart rate monitoring helps us to optimise heart rate inhibitor treatment in patients with sinus rhythm&#46; What&#8217;s more&#44; since patients with HF and AF have a poorer prognosis&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> we must bear in mind current guideline recommendations for maintaining HR between 60 and 100 beats per minute &#40;bpm&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Patients should be weighed daily&#44; and a fluid balance chart should be maintained&#46; Renal function should preferably be monitored with a daily measurement of blood urea nitrogen &#40;BUN&#41;&#47;urea&#44; creatinine&#44; and electrolytes&#46; Routine use of a urinary catheter for measuring diuresis is not recommended&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Disease-modifying drugs</span><p id="par0105" class="elsevierStylePara elsevierViewall">Treatment with disease-modifying HF medications should be continued throughout admission&#44; except in the presence of haemodynamic instability &#40;symptomatic hypotension&#44; hypoperfusion&#44; bradycardia&#41;&#44; hyperkalaemia&#44; or severely impaired renal function&#46; In these cases&#44; the dosage of other drugs that affect blood pressure or renal function&#44; or of the same disease-modifying HF drugs&#44; should be reviewed or temporarily stopped and restarted once the patient is stabilised&#46; Beta blockers can be continued except in the case of cardiogenic shock as their discontinuation is associated with significantly increased mortality and rehospitalisation&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Respiratory support</span><p id="par0110" class="elsevierStylePara elsevierViewall">The respiratory failure that accompanies AHF&#47;APE &#40;acute pulmonary oedema&#41; requires O<span class="elsevierStyleInf">2</span> saturation &#40;satO<span class="elsevierStyleInf">2</span>&#41; monitoring and&#44; in the case of COPD or obesity hypoventilation syndrome &#40;OHS&#41;&#44; determining PCO<span class="elsevierStyleInf">2</span> and pH&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The supply of an adapted flow of O<span class="elsevierStyleInf">2</span> is basic in cases of respiratory failure &#40;PO<span class="elsevierStyleInf">2</span>&#8239;&#60;&#8239;60&#8239;mmHg or satO<span class="elsevierStyleInf">2</span>&#8239;&#60;&#8239;90&#37;&#41;&#46; Because O<span class="elsevierStyleInf">2</span> produces peripheral vasoconstriction and a decrease in cardiac output&#44; its use is restricted to situations of hypoxia&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">In the case of respiratory distress &#40;RR &#62;&#8239;25&#8239;bpm&#44; satO<span class="elsevierStyleInf">2</span>&#8239;&#60;&#8239;90&#37;&#41; the recommendation is early application of noninvasive ventilation techniques &#40;NIV&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> CPAP model &#40;continuous positive airway pressure&#41; or Bi-PAP &#40;bilevel positive airway pressure&#41; model&#44; which achieve better oxygenation through the recruitment of collapsed alveoli&#44; the reversal of areas of atelectasis&#44; and the injection of fluid into the interstitial space&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Bi-PAP is reserved for cases with hypercapnia &#40;PCO<span class="elsevierStyleInf">2</span>&#8239;&#62;&#8239;50&#8239;mmHg&#41;&#44; respiratory acidosis&#44; or in which COPD or OHS coexist&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> NIV reduces respiratory distress and prevents orotracheal intubation &#40;OTI&#41; in patients with AHF&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Reduced level of consciousness&#44; severe respiratory acidosis &#40;pH&#8239;&#60;&#8239;7&#46;25&#41;&#44; or the inability to guarantee adequate oxygenation despite the previous measures are indications for OTI and mechanical ventilation&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Haemodynamic support</span><p id="par0125" class="elsevierStylePara elsevierViewall">Two types of situations typically arise&#58; hypertensive emergency and AHF which presents as hypotension or even cardiogenic shock&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">AHF precipitated by hypertensive emergency typically manifests as APE&#46; The therapeutic target is 25&#37; reduction of the initial BP in the first 2&#8722;4&#8239;h&#44; so use of vasodilators in combination with the initial diuretic treatment is advised&#46; They should be avoided or discontinued when systolic blood pressure &#40;SPB&#41; is less than 90&#8239;mmHg&#46; Continuous infusion of intravenous nitroglycerin starting at 10&#8722;20&#8239;&#956;g&#47;min is recommended&#44; up to a maximum dose of 200&#8239;&#956;g&#47;min&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In the presence of hypotension&#44; the haemodynamic profile should be evaluated&#44; using as a guide the simultaneous presence of congestion and hypoperfusion&#46; Reduction or discontinuation of concomitant hypotensive medication is mandatory&#46; In patients with hypoperfusion&#44; it must be considered whether excessive volume depletion exists&#44; and in that case administer fluid therapy to reverse it&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Inotropic agents or vasopressors are recommended from the outset in patients with congestion and SBP&#8239;&#60;&#8239;90&#8239;mmHg &#40;cold and wet profile&#41;&#44; and if refractory to other measures it is also recommended in patients with SBP&#8239;&#62;90&#8239;mmHg&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">SBP figures aid in selecting the inotropic or vasopressor agent of choice&#46; If SBP&#8239;&#60;&#8239;90&#8239;mmHg&#44; treatment will be started with vasopressors&#46; Due to their side effects&#44; use will be limited until SBP&#8239;&#62;&#8239;90&#8239;mmHg is reached&#44; at which time inotropic agents can be initiated&#46; Norepinephrine use is preferred over &#40;0&#46;2&#8722;0&#46;1&#8239;&#956;g&#47;kg&#47;min&#41; dopamine&#44; at beta-adrenergic doses &#40;3&#8722;5&#8239;&#956;g&#47;kg&#47;min&#41; because of its safety profile&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In the case of SBP&#8239;&#8805;&#8239;90&#8239;mmHg&#44; use of levosimendan &#40;0&#46;1&#8722;0&#46;2&#8239;&#956;g&#47;kg&#47;min&#41; for 24&#8239;h or dobutamine &#40;2&#8722;20&#8239;&#956;g&#47;kg&#47;min&#41; is recommended&#44; though the former is preferable as its mechanism of action is not interfered with by the patient&#8217;s potential baseline beta-blockade and it has a lower arrhythmogenic capacity and possibility to induce myocardial ischaemia than classic beta-mimetic inotropes&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Decongestive treatment&#58; diuretics</span><p id="par0155" class="elsevierStylePara elsevierViewall">Decongestive treatment is a first priority as it has been shown that early treatment with intravenous loop diuretics is associated with lower hospital mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> As can be seen in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#44; the starting diuretic dosage to be administered should be based on whether the patient is receiving furosemide treatment at home&#44; and if so at what dosage&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In the following 2&#8211;6&#8239;h it is important to evaluate the diuretic response obtained &#40;specifically&#44; the Na<span class="elsevierStyleSup">&#43;</span> urine concentration &#91;considering as an adequate value&#8239;&#62;&#8239;50&#8722;70&#8239;mEq&#47;L&#93; at 2&#8239;h and diuresis &#91;considering as an adequate value&#8239;&#62;&#8239;100&#8722;150&#8239;mL&#47;h&#93; at 6&#8239;h&#41;&#44; using both clinical and biochemical parameters for said evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> If the patient has not experienced any clinical improvement&#44; the initially administered dose should be doubled&#44; preferably with a 12&#8239;h protocol&#44; though an 8&#8239;h protocol is also acceptable&#44; or even continuous infusion &#40;it is worth mentioning that the DOSE-AHF<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> study did not show differences in the primary endpoint according to whether the patients received furosemide as a bolus or via continuous infusion&#41;&#46; If clinical improvement has been achieved&#44; the initial dose with the potential protocols described should be maintained&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Diuretic response will continue to be assessed after the next 24&#8239;h&#46; The persistence of congestive signs and symptoms or diuresis &#60;3&#8239;L&#47;day will require the diuretic protocol to be intensified&#46; There are various options for this&#44; though the recommendation is a staged approach on successive days&#58; there is evidence showing that staged therapeutic approaches depending on the decongestive response offer benefits in terms of fluid and weight loss&#44; without compromising renal function&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Therefore&#44; if congestion and diuresis &#60;3&#8239;L&#47;day persist&#44; the following options should be assessed in a phased manner&#58; a&#41; increasing the furosemide dose &#40;maximum 400&#8722;600&#8239;mg&#41;&#59; b&#41; administering drugs for sequential nephron blockade &#40;thiazides&#44; aldosterone antagonists&#44; or acetazolamide&#41;&#46; Currently there are no specific recommendations regarding the priority of the second diuretic&#59; urine potassium can be taken into account&#44; prioritising thiazides when it is reduced and aldosterone antagonists when it is elevated&#46; Acetazolamide may be preferable in cases of metabolic alkalosis&#46; The results of the CLOROTIC study will offer more data on the effects of adding a thiazide to furosemide to improve the congestive symptoms of HF in a safe and effective manner<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a>&#59; c&#41; hypertonic saline solution protocol &#40;detailed in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#44; and d&#41; if no response is achieved&#44; evaluate ultrafiltration&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">If the clinical decongestion parameters are adequate or diuresis higher than 3&#8239;L&#47;day has been reached&#44; the established therapy should be maintained until effective decongestion is achieved for subsequent progressive reduction&#46; Ideally the patient will be receiving the minimum effective dose by oral route at least 24&#8239;h before discharge from hospital&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Managing AHF patients in the stable phase</span><p id="par0175" class="elsevierStylePara elsevierViewall">The main aspects related to the management of AHF patients in the stable phase are detailed in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Management protocol in the stable phase</span><p id="par0180" class="elsevierStylePara elsevierViewall">This phase is the ideal moment to start and&#47;or adjust medication&#44; particularly evidence-based treatments &#40;EBT&#41; in patients with HFrEF&#46; Diuretic treatment should be reduced until taken orally and at the minimum effective dose&#44; or it should be withdrawn&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Starting or adjusting disease-modifying drugs</span><p id="par0185" class="elsevierStylePara elsevierViewall">Guidelines recommend maintaining disease-modifying drugs for HFrEF during admission&#46; In the case of new-onset HFrEF&#44; the recommendation is to do everything possible to implement such treatments following initial haemodynamic stabilisation&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Therapeutic regimens in new-onset HF and continuation of established treatment in decompensated HF &#40;in all cases with rEF&#41;</span><p id="par0190" class="elsevierStylePara elsevierViewall">The following criteria have been established for both new-onset HF and for continuing with established treatment for decompensated HF&#58;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The new report from the expert consensus meeting of the Heart Failure Association &#40;HFA&#41; of the European Society of Cardiology &#40;ESC&#41; on clinical practice recommends considering starting sacubitril&#47;valsartan before angiotensin-converting enzyme inhibitors &#40;ACEI&#41; in new-onset or decompensated patients to reduce the risk of short-term adverse events and to simplify management&#44; thereby avoiding ACEI titration to later switch over to sacubitril&#47;valsartan&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Experts lean on the evidence provided by the PIONEER-HF<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> study&#44; which demonstrates the superiority of sacubitril&#47;valsartan over enalapril to reduce NT-proBNP and readmissions at 8 weeks&#44; with a similar safety profile<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> in patients hospitalised without the use of intravenous inotropic agents in the last 24&#8239;h and without increasing the intravenous diuretics dosage or the use of intravenous vasodilators in the previous 6&#8239;h&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> In these cases&#44; as the patients are already high-risk for events&#44; it is not necessary to check the NT-proBNP levels prior to starting sacubitril&#47;valsartan&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The benefit of starting ACEI&#47;ARB II &#40;angiotensin II receptor blockers&#41; during admission has also been demonstrated&#44; with fewer readmissions and lower mortality at one year in observational studies&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> although there are no randomised clinical trials showing this&#46; When starting treatment&#44; in addition to haemodynamic stability&#44; renal function and electrolytes should be evaluated&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Beta blockers should be started when the patient is haemodynamically stable&#44; euvolemic&#44; and they are not contraindicated&#46; The benefit of starting beta blockers prior to discharge has been established with fewer admissions and lower mortality&#44; with evidence fundamentally based on observational studies&#46; In fact&#44; the maximum increase in survival has been shown to be obtained with the sacubitril&#47;valsartan and beta blocker combination&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Regarding aldosterone receptor antagonists &#40;MRA&#41;&#44; not all studies show the benefits of starting this in hospital&#46; Various authors describe greater congestion relief&#44; reduced admissions for HF&#44; lower CV mortality&#44; or a reduction in CV events following myocardial infarction&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> while others do not confirm any benefits regarding reduced admission rates or mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> If prescribed&#44; the patient should be closely watched at discharge&#44; particularly in patients at risk of renal function impairment or hyperkalaemia&#46; In any case&#44; initiation during admission increases long-term use&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In the case of ACEI&#44; beta blockers&#44; and MRAs&#44; as the patient progresses from rEF to intermediate EF and to preserved EF&#44; the beneficial effects indicated herein start to diminish&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">In terms of switching drugs within the same class&#44; while the evidence is scarce&#44; using drugs with proven evidence in HF is recommended&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">In HF with LVEF&#44; no treatment to date has convincingly been shown to reduce morbidity and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Managing comorbidities</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Type 2 diabetes mellitus</span><p id="par0230" class="elsevierStylePara elsevierViewall">Determine HbA1c if not done in the previous 3 months&#46; While admitted&#44; hyperglycaemia should be treated with basal-bolus insulin and a correction protocol&#44; withdrawing oral anti-diabetic drugs&#46; The target blood sugar is 140&#8722;180&#8239;mg&#47;dL&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> The safety and efficacy of dipeptidyl peptidase-4 inhibitors &#40;iDPP-4&#41; has been demonstrated &#40;sitagliptin or linagliptin&#41;&#44; alone or in combination with basal insulin&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> The HbA1c target should be personalised at discharge&#46; Avoid saxagliptin&#44; glitazones&#44; and sulfonylureas&#46; Based on the current evidence&#44; no specific recommendation can be made regarding the use of sodium-glucose cotransporter-2 &#40;SGLT2&#41; inhibitors in patients with established HF&#44; although their use could be evaluated in patients with type 2 diabetes mellitus and established CV disease or those at high risk of CV disease&#44; to prevent or delay the start of hospitalisations for HF&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Arterial hypertension</span><p id="par0235" class="elsevierStylePara elsevierViewall">The blood pressure target is &#60;140&#47;90&#8239;mmHg&#44; and if treatment is well-tolerated&#44; preferably &#60;130&#47;80&#8239;mmHg&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> Use disease-modifying drugs&#59; if control still cannot be achieved&#44; hydralazine can be considered which&#44; together with isosorbide dinitrate&#44; has been assessed in clinical trials on HF and rEF&#46; The use of these is recommended in patients who do not tolerate ACEI&#44; ARBs II or angiotensin receptor-neprilysin inhibitors &#40;ARNI&#41;&#44; or amlodipine and felodipine&#44; which have been proven safe in patients with HFrEF&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Contraindicated in HFrEF&#58; diltiazem&#44; verapamil&#44; and moxonidine&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Iron deficiency and anaemia</span><p id="par0240" class="elsevierStylePara elsevierViewall">Improvement in symptoms&#44; exercise capacity&#44; quality of life and reduced admissions have been shown with the administration of intravenous ferric carboxymaltose in patients with HF and rEF &#40;not demonstrated in patients with pEF&#41; and with iron deficiency &#40;ferritin&#8239;&#60;&#8239;100&#8239;ng&#47;mL or between 100 and 300&#8239;ng&#47;mL a transferrin saturation &#91;TS&#93;&#8239;&#60;&#8239;20&#37;&#41;&#44; regardless of the presence or lack thereof of anaemia&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> It is important to investigate the cause of iron deficiency and anaemia when these are present&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Atrial fibrillation</span><p id="par0245" class="elsevierStylePara elsevierViewall">The CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc scale&#44; based on a points system&#44; can be used to assess a patient&#8217;s cardioembolic risk&#46; It is described in <a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#46;</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0250" class="elsevierStylePara elsevierViewall">Anticoagulation is indicated if CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc&#8239;&#8805;&#8239;2&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> In nonvalvular AF&#44; the use of direct oral anticoagulants &#40;DOACs&#41; is preferable over vitamin K antagonists &#40;VKA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> HR control&#58; target HR between 60&#8722;100&#8239;bpm&#44; and without better results with HR&#8239;&#60;&#8239;70&#8239;bpm&#46; No reduction in morbidity and mortality has been shown with beta blockers in patients with AF and HFrEF&#46; The recommendation is to control HR with beta blockers indicated for HFrEF and&#44; if not possible&#44; to add digoxin&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">COPD</span><p id="par0255" class="elsevierStylePara elsevierViewall">In terms of treatment for COPD with AHF during hospitalisation&#44; beta-mimetic nebulisers must be avoided and anticholinergics should be used&#44; with the option to add corticoids if a&#41; it is absolutely positive that there is a COPD or bronchospasm component related to the HF&#44; and b&#41; the patient has a preserved level of consciousness &#40;whereas&#44; if this is lowered&#44; the patient probably has hypercapnia and high-flow nebulisation&#44; particularly with O2&#44; could worsen his&#47;her ventilation condition&#41;&#46; At discharge&#44; bronchodilator treatment&#44; preferably using long-acting bronchodilator drugs and starting with LAMA &#40;long-acting muscarinic antagonists&#41;&#44; although LABA &#40;long-acting beta2 agonists&#41; can be used&#46; Use cardioselective beta blockers &#40;bisoprolol&#44; nebivolol&#44; metoprolol&#41; to treat HF in patients with COPD&#46;</p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Education</span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Self care</span><p id="par0260" class="elsevierStylePara elsevierViewall">In chronic HF&#44; active patient participation through self care helps improve progress and reduce readmissions&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a> Both the European clinical practice guidelines for HF<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> as well as the American<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> recommend that patients be educated on self care before discharge&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">Key aspects in terms of education include information about HF&#44; monitoring weight and preventing malnutrition&#44; maintaining a low-sodium diet&#44; avoiding excessive fluid intake and restricting this when indicated&#8211;generally in patients with severe HF to relieve congestion&#46; Additionally&#44; abstention from tobacco use and abstention or moderation in alcohol consumption&#46; Regular physical activity has been shown to improve quality of life and reduce hospital admissions in patients with HF<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">44</span></a> and is recommended independently of the LVEF&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Flu and pneumonia vaccination should also be recommended&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Warning signs</span><p id="par0270" class="elsevierStylePara elsevierViewall">Another important component of education is to familiarise patients with warning signs&#44; including increased dyspnoea&#44; orthopnoea&#44; onset of paroxysmal nocturnal dyspnoea&#44; chest pain&#44; weight gain and&#47;or oedema or a feeling of fullness&#44; so that when patients notice any of these symptoms they reach out or take action such as adjusting treatment&#44; for example&#44; increasing their diuretics dosage&#46;</p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Medication</span><p id="par0275" class="elsevierStylePara elsevierViewall">The patient must understand the indications and benefits of their prescribed medication and be aware of the possible side effects&#46; It is important to review the medication list with the patient&#44; evaluating therapeutic adherence and the difficulties of achieving this&#44; and indicating which drugs should be avoided&#44; such as non-steroidal anti-inflammatory drugs &#40;NSAIDS&#41; or drugs with high sodium content such as effervescent paracetamol&#46;</p></span></span></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Managing the post-discharge transition period</span><p id="par0280" class="elsevierStylePara elsevierViewall">This section describes both considerations at discharge from hospital &#40;summarised in the checklist in the following subsection&#41; as well as management of the post-discharge transition period &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Checklist used at hospital discharge</span><p id="par0285" class="elsevierStylePara elsevierViewall">The routine use of checklists has been confirmed in numerous processes both within and without the health care setting&#46; Among the main virtues of this system&#44; we can highlight the reduced number of errors and standardisation of a procedure performed by different individuals&#44; with the resulting drop in interpersonal variety&#46; The philosophy of this 10-point list is to help internists optimise the management of hospitalised HF patients&#44; therefore reducing the number of early hospitalisations&#46; These points are listed below<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a>&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0290" class="elsevierStylePara elsevierViewall">Have the precipitating factors been identified and controlled&#63;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0295" class="elsevierStylePara elsevierViewall">Have the comorbidities been assessed&#63;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0300" class="elsevierStylePara elsevierViewall">Is the patient decongested&#63; The EVEREST<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> criteria&#44; classic signs of HF&#44; or point-of-care ultrasound can be used&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0305" class="elsevierStylePara elsevierViewall">Is the LVEF known&#63; Particularly important in patients with depressed LVEF &#40;&#60;40&#37;&#41;&#44; candidates for certain treatments that differ from those of patients with preserved LVEF&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0310" class="elsevierStylePara elsevierViewall">If LVEF&#8239;&#60;&#8239;40&#37;&#44; has treatment been optimised with sacubitril&#47;valsartan&#44; ACEI or ARBs II&#44; beta blockers&#44; and MRAs&#63; These therapies have shown reduced mortality and readmission for HF with depressed LVEF&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> In a network analysis&#44; the most effective combinations for HFrEF were&#58; 1&#41; sacubitril&#47;valsartan&#8239;&#43;&#8239;beta blocker&#8239;&#43;&#8239;MRA&#44; and 2&#41; ACEI&#43;&#8239;beta blocker&#8239;&#43;&#8239;MRA&#8239;&#43;&#8239;ivabradine&#59; reducing all-cause mortality &#40;vs&#46; placebo&#41; by 62 and 59&#37;&#44; respectively&#44; and all-cause hospitalisation by 42&#37; for both combinations&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6</span><p id="par0315" class="elsevierStylePara elsevierViewall">Has the remaining medication been reviewed&#63; The elimination of drugs with little intrinsic value is particularly important in polymedicated patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7</span><p id="par0320" class="elsevierStylePara elsevierViewall">Have renal function and electrolytes been assessed&#63; Dosages for some drugs will be adjusted according to creatinine clearance&#44; particularly anticoagulation therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8</span><p id="par0325" class="elsevierStylePara elsevierViewall">Is the heart rhythm&#44; rate&#44; systolic blood pressure&#44; and duration of the QRS complex known&#63; In patients with AF&#44; anticoagulation will be considered if there are no major contraindications&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9</span><p id="par0330" class="elsevierStylePara elsevierViewall">Has the patient and&#47;or the caretaker been educated about the disease&#63; Have instructions been given&#63; Refers to the need for specific educational materials&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10</span><p id="par0335" class="elsevierStylePara elsevierViewall">Does the patient have an appointment scheduled soon with primary or specialised care&#63; This appointment should always take place within one month from discharge&#44; preferably within the first 10 days&#46;</p></li></ul></p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Evaluating the risk for readmission</span><p id="par0340" class="elsevierStylePara elsevierViewall">In terms of evaluating readmission risk&#44; it is essential to identify patients with greater probability of returning to hospital in order to establish closer follow-up and prevent new hospitalisations&#46; This assessment is based on four fundamental components &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0345" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Admissions or visits to the emergency department in the 3 months prior to the current admission&#46;</span> The risk of readmission following hospitalisation for HF is known to be higher in patients with frequent admissions or visits to the emergency department in the previous months&#44; particularly among elderly patients&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> Therefore&#44; it is important to detect this population and take advantage of the current admission to optimise treatment and thereby improve follow-up&#44; coordination with the primary care specialist&#44; and access to quick and effective care&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0350" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Clinical assessment in relation to HF and decongestion&#46;</span> Low SBP&#44; moderate hyponatremia&#44; need for high dosage diuretics&#44; and renal function impairment&#46; All are aspects with proven relevance in terms of predicting poor prognosis and high risk of readmission&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0355" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Presence of geriatric syndromes during hospitalisation</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">49</span></a> Confusional syndromes&#44; frailty&#44; malnutrition&#44; and sarcopenia not only extend hospital stays&#44; but can also bring about a poor prognosis&#46; Their presence during hospital admission will require closer follow-up&#44; as well as implementation of measures to offset or at least lessen the aforementioned syndromes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8226;</span><p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Social factors related to the patient&#46;</span> Though sometimes not taken into account&#44; in the case of deprivation&#44; they are described as a risk factor for readmission<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> and should therefore be assessed in discharge planning&#46;</p></li></ul></p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Care continuity</span><p id="par0365" class="elsevierStylePara elsevierViewall">The change in paradigm in the management of chronic diseases like HF&#44; with a focus on integral and multidisciplinary care&#44; entails taking on as one of the essential pillars the transition of care and adequate post-hospitalisation follow-up&#46; In other words&#44; at the time of discharge&#44; continuity of care should be guaranteed by focusing on two aspects &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">1</span><p id="par0370" class="elsevierStylePara elsevierViewall">Define the patient&#8217;s treatment protocol&#44; including the following aspects&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0375" class="elsevierStylePara elsevierViewall">Proper medication reconciliation should be carried out&#44; with correctly noted dose and dosage to minimise errors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8226;</span><p id="par0380" class="elsevierStylePara elsevierViewall">Indicate which drugs will require dose optimisation&#58; sacubitril&#47;valsartan&#44; beta blockers&#44; ACEI&#8230;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8226;</span><p id="par0385" class="elsevierStylePara elsevierViewall">Review the suitability of the indication&#44; taking into account internationally recognised prescription criteria&#44; such as the &#8220;do not do&#8221; recommendations of scientific societies&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a> the Beers criteria<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a> or the STOPP&#47;START criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a></p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">2</span><p id="par0390" class="elsevierStylePara elsevierViewall">Define within the discharge report who will establish the patient&#8217;s next contact with the health care system and in what manner this will occur&#46; The variability of each health care area makes it impossible to contemplate a single proposal&#46; According to local characteristics&#44; three options are suggested&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8226;</span><p id="par0395" class="elsevierStylePara elsevierViewall">Contact with the primary care team&#58; either through nursing staff&#44; medical personnel&#44; or both&#59; at home or at the health care centre &#40;depending on the patient&#8217;s condition&#41;&#44; in the first 7 days post-discharge&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8226;</span><p id="par0400" class="elsevierStylePara elsevierViewall">Coordination according to specific local protocols wherein the role of case manager exists&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a></p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8226;</span><p id="par0405" class="elsevierStylePara elsevierViewall">Proactive telephone contact from the Unit&#47;clinic nursing team within the first 72&#8239;h post-discharge&#46;</p></li></ul></p></li></ul></p></span></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Future perspectives</span><p id="par0410" class="elsevierStylePara elsevierViewall">This document aims to reduce variability and improve care for patients hospitalised with HF and promote systematic updates to HF patient care according to the most recent available evidence&#46; Despite the existence of clear treatment recommendations for drugs that increase survival in patients with HFrEF&#44; recent data from real-world records show that these drugs are under-used&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a> In the present protocol&#44; though the entire hospitalisation process is addressed&#44; the creation of a discharge checklist is of particular importance to systematically reviewing the many aspects that must be taken into account&#44; thereby enabling better prescribing&#44; education&#44; and follow-up of the patient according to their needs&#46; In fact&#44; the American Society of Cardiology suggests creating a checklist at discharge&#44; having shown that its implementation was associated with reduced admissions&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">56</span></a> It would also make it possible to encourage quality clinical training on a pathology that is highly prevalent in Internal Medicine and to improve coordination between the various care levels post-discharge&#46; If integrating said checklist into the electronic clinical history can ultimately be achieved&#44; in addition to facilitating its use&#44; it would also make it possible to exploit the data and discover the reality of HF patients in Spain&#46;</p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Conclusions</span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">AHF patient admission</span><p id="par0415" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0420" class="elsevierStylePara elsevierViewall">It is essential to know the course of the disease in detail and to take an accurate case history and evaluation of signs and symptoms&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0425" class="elsevierStylePara elsevierViewall">Upon evaluating the patient&#44; their comorbidities must be considered&#44; as these greatly condition the disease prognosis&#44; particularly in the group of HF patients with pEF&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0430" class="elsevierStylePara elsevierViewall">It is important to be aware of the HF patient&#8217;s standard treatment&#58; diuretics&#44; sacubitril&#47;valsartan&#44; ACEI or ARB II&#44; beta blockers&#44; MRAs&#44; ivabradine&#44; as well as others such as digoxin&#44; hypolipidemic agents&#44; antiarrhythmic agents&#44; or anticoagulants&#46;</p></li></ul></p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Management of the congestive phase</span><p id="par0435" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0440" class="elsevierStylePara elsevierViewall">Decongestive treatment is a priority during the first hours of hospital care&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0445" class="elsevierStylePara elsevierViewall">A diuretic readjustment protocol is recommended depending on the response over the first 24&#8239;h of hospital care&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8226;</span><p id="par0450" class="elsevierStylePara elsevierViewall">A staged therapeutic diuretic approach according to the decongestive response offers benefits in terms of fluid and weight loss&#44; without compromising renal function&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8226;</span><p id="par0455" class="elsevierStylePara elsevierViewall">Disease-modifying treatment should be maintained to the extent possible&#46;</p></li></ul></p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Management of the stable phase</span><p id="par0460" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8226;</span><p id="par0465" class="elsevierStylePara elsevierViewall">Starting and&#47;or adjusting treatment should be considered&#44; particularly for evidence-based treatments&#44; in patients with HFrEF&#59; in other words&#44; sacubitril&#47;valsartan &#40;or ACEI&#47;ARB II&#41;&#44; beta blockers&#44; and aldosterone antagonists&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8226;</span><p id="par0470" class="elsevierStylePara elsevierViewall">The various comorbidities should be assessed and controlled and the patient and&#47;or family members educated on the disease to ensure their involvement in self care&#46;</p></li></ul></p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Considerations at discharge from hospital</span><p id="par0475" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0480" class="elsevierStylePara elsevierViewall">It is recommended to consider the checklist information to optimise the management of hospitalised HF patients and to reduce the number of early hospitalisations&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0485" class="elsevierStylePara elsevierViewall">The four patient groups with higher risk of readmission should be identified&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8226;</span><p id="par0490" class="elsevierStylePara elsevierViewall">The 3 most efficient options for maintaining care continuity following hospital discharge should be addressed&#46;</p></li></ul></p></span></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Conflicts of interest</span><p id="par0495" class="elsevierStylePara elsevierViewall">Jos&#233; Mar&#237;a Fern&#225;ndez has received support for consulting and conferences from Novartis&#44; Boehringer-Lilly&#44; Pfizer&#44; Daiichi-Sankyo&#44; and for attendance at congresses from Pfizer&#44; Boehringer-Lilly&#46;</p><p id="par0500" class="elsevierStylePara elsevierViewall">Jes&#250;s Casado has received support for consulting&#44; conferences and attendance at congresses from Novartis and Rovi&#44; and for consulting with Vifor and Pfizer&#46;</p><p id="par0505" class="elsevierStylePara elsevierViewall">Francesc Formiga has support for consulting&#44; conferences and attendance at congresses from Novartis and Rovi&#44; and for consulting with Vifor and Pfizer&#46;</p><p id="par0510" class="elsevierStylePara elsevierViewall">&#193;lvaro Gonz&#225;lez-Franco has received support for consulting&#44; conferences or attendance at congresses from Novartis&#44; Vifor&#44; Daiichi&#44; Pfizer and Esteve&#46;</p><p id="par0515" class="elsevierStylePara elsevierViewall">Jos&#233; Carlos Ar&#233;valo has received support for consulting or attendance at congresses from Novartis&#44; Esteve&#44; Bayer and Bristol-Myers&#46;</p><p id="par0520" class="elsevierStylePara elsevierViewall">Manuel Beltr&#225;n has received support for consulting&#44; conferences&#44; or attendance at congresses from Novartis&#44; Astra&#44; Novo Nordisk&#44; Daichii&#44; Boehringer&#44; Lilly and Sanofi&#46;</p><p id="par0525" class="elsevierStylePara elsevierViewall">Jos&#233; Manuel-Cerqueiro has received support from Novartis for conferences&#46;</p><p id="par0530" class="elsevierStylePara elsevierViewall">Pau Llacer has received support for consulting&#44; conferences or attendance at congresses from Novartis&#44; Vifor&#44; Boehringer&#44; Rovi&#44; Ferrer&#44; Esteve&#44; Pfizer&#44; Astra Zeneca&#44; Novo Nordisk&#46;</p><p id="par0535" class="elsevierStylePara elsevierViewall">Luis Manzano has received support for consulting&#44; conferences and attendance at congresses from Novartis and Rovi&#44; and for consulting with Vifor and Pfizer&#46;</p><p id="par0540" class="elsevierStylePara elsevierViewall">Jos&#233; Luis Morales-Rull has received support for consulting or conferences from Novartis&#44; Orion Pharma&#44; Esteve&#44; Pharmanutra&#46;</p><p id="par0545" class="elsevierStylePara elsevierViewall">Jos&#233; P&#233;rez-Silvestre has received support for conferences&#44; consulting&#44; and&#47;or attendance at congresses from Novartis&#44; Rovi&#44; Pfizer&#44; Boehringer&#44; Bayer&#44; Esteve&#44; Ferrer and Glaxo&#46;</p><p id="par0550" class="elsevierStylePara elsevierViewall">Alicia Conde-Martel has received support for consulting or conferences from Pfizer&#44; Novartis&#44; Bristol Myers and Daiichi-Sankyo&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">Acute heart failure &#40;AHF&#41; is a highly prevalent clinical entity in individuals older than 45 years in Spain&#46; AHF is associated with significant morbidity and mortality and is the leading cause of hospitalisation for individuals older than 65 years in Spain&#44; a quarter of whom die within 1 year of the hospitalisation&#46; In recent years&#44; there has been an upwards trend in hospitalisations for AHF&#44; which increased 76&#46;7&#37; from 2003 to 2013&#46; Readmissions at 30 days for AHF have also increased &#40;from 17&#46;6&#37; to 22&#46;1&#37;&#41;&#44; at a relative mean rate of 1&#46;36&#37; per year&#44; with the consequent increase in the use of resources and the economic burden for the healthcare system&#46; The aim of this document &#40;developed by the Heart Failure and Atrial Fibrillation Group of the Spanish Society of Internal Medicine&#41; is to guide specialists on the most important aspects of treatment and follow-up for patients with AHF during hospitalisation and the subsequent follow-up&#46; The main recommendations listed in this document are as follows&#58; 1&#41; At admission&#44; perform a comprehensive assessment&#44; considering the patient&#8217;s standard treatment and comorbidities&#44; given that these determine the disease prognosis to a considerable measure&#46; 2&#41; During the first few hours of hospital care&#44; decongestive treatment is a priority&#44; and a staged diuretic therapeutic approach based on the patient&#8217;s response is recommended&#46; 3&#41; To manage patients in the stable phase&#44; consider starting and&#47;or adjusting evidence-based drug treatment &#40;e&#46;g&#46;&#44; sacubitril&#47;valsartan or angiotensin-converting enzyme inhibitors&#47;angiotensin II receptor blockers&#44; beta blockers and aldosterone antagonists&#41;&#46; 4&#41; At hospital discharge&#44; use a checklist to optimise the patient&#8217;s management and identify the most efficient options for maintaining continuity of care after discharge&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0125" class="elsevierStyleSimplePara elsevierViewall">La insuficiencia cardiaca aguda &#40;ICA&#41; es una entidad cl&#237;nica con una elevada prevalencia en la poblaci&#243;n de m&#225;s de 45 a&#241;os en Espa&#241;a&#46; Est&#225; asociada a una importante morbimortalidad&#44; constituyendo la primera causa de hospitalizaci&#243;n en mayores de 65 a&#241;os en nuestro pa&#237;s&#44; de los cuales una cuarta parte fallecen al a&#241;o del ingreso&#46; En los &#250;ltimos a&#241;os se ha observado una tendencia al alza en las hospitalizaciones por ICA&#44; que aumentaron un 76&#44;7&#37; en el per&#237;odo de 2003 a 2013&#46; Los reingresos a los 30 d&#237;as por ICA tambi&#233;n aumentaron &#40;del 17&#44;6 al 22&#44;1&#37;&#41; a un ritmo medio relativo del 1&#44;36&#37; por a&#241;o&#44; con el consiguiente increment en el uso de recursos y en la carga econ&#243;mica para el sistema sanitario&#46; Este documento&#44; elaborado por el grupo de Insuficiencia Cardiaca y Fibrilaci&#243;n Auricular de la Sociedad Espa&#241;ola de Medicina Interna&#44; tiene como objetivo orientar al especialista en los aspectos m&#225;s importantes del tratamiento y seguimiento de los pacientes con ICA durante el ingreso y el seguimiento posterior&#46; Las principales recomendaciones recogidas son&#58; 1&#41; en el momento del ingreso&#44; realizar una evaluaci&#243;n integral&#44; considerando el tratamiento habitual y comorbilidades del paciente&#44; ya que condicionan en gran medida el pron&#243;stico de la enfermedad&#59; 2&#41; en las primeras horas de atenci&#243;n hospitalaria&#44; el tratamiento descongestivo es prioritario y se recomienda un abordaje terap&#233;utico diur&#233;tico escalonado en funci&#243;n de la respuesta&#59; 3&#41; en el manejo de la fase estable&#44; considerar el inicio y&#47;o ajustar el tratamiento con f&#225;rmacos basados en la evidencia&#44; es decir&#44; sacubitrilo&#47;valsart&#225;n o IECA&#47;ARA II&#44; betabloqueantes y antialdoster&#243;nicos&#59; 4&#41; en el momento del alta hospitalaria&#44; utilizar un <span class="elsevierStyleItalic">checklist</span> para optimizar el manejo del paciente hospitalizado e identificar las opciones m&#225;s eficientes para mantener la continuidad de cuidados tras el alta&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Ferna&#769;ndez Rodr&#237;guez JM&#44; Casado J&#44; Formiga F&#44; Gonza&#769;lez-Franco &#193;&#44; Are&#769;valo JC&#44; Beltra&#769;n M&#44; et al&#46; Consenso de actuaci&#243;n b&#225;sica durante el ingreso hospitalario por insuficiencia cardiaca aguda&#46; Rev Clin Esp&#46; 2021&#59;221&#58;283&#8211;296&#46;</p>"
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                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Absent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Seldom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Seldom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#8722;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Slight&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Seldom&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#8722;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Continuous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Continuous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Marked&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Continuous&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2592333.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Assessment of signs and symptoms of congestion using the EVEREST score&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
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        "mostrarFloat" => true
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0020"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">AA&#58; aldosterone antagonist&#59; ACEI&#58; angiotensin-converting enzyme inhibitor&#59; AHF&#58; acute heart failure&#59; ARB&#58; angiotensin II receptor blocker&#59; ARNI&#58; angiotensin receptor-neprilysin inhibitor&#59; BB&#58; beta blocker&#44; BiPAP&#58; bilevel positive airway pressure&#59; BP&#58; blood pressure&#59; CPAP&#58; continuous positive airway pressure&#59; ECG&#58; electrocardiogram&#59; eGFR&#58; estimated glomerular filtration rate&#59; HF&#58; heart failure&#59; HR&#58; heart rate&#59; MRA&#58; mineralocorticoid receptor antagonist&#59; NIMV&#58; noninvasive mechanical ventilation&#59; OTI&#58; orotracheal intubation&#59; rEF&#58; reduced ejection fraction&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span>Evaluate bolus&#47;8&#8239;h or continuous infusion&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="202105110748283732"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Managing the AHF patient in the congestive phase&#46;</p>"
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      4 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0025"
            "detalle" => "Table "
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Furosemide&#58; 250&#8722;500&#8239;mg&#47;12&#8239;h&#47;i&#46;v&#46; in 30&#8239;min&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">BoiK aspartic acid&#58; 2 tablets every 8&#8239;h&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Fluid restriction to 1000 cc daily&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Daily renal function and electrolyte panel&#46;</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">150 cc HSS&#47;12&#8239;h&#47;i&#46;v&#46; in 30&#8239;min&#46; Na<span class="elsevierStyleSup">&#43;</span> concentration in infusion according to natremia&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">HSS&#58; Hypertonic saline solution&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Infusion concentration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Blood levels of Na<span class="elsevierStyleSup">&#43;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preparation form&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypertonic saline solution at 4&#46;6&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;125 mEq&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dilute 19 ampoules of NaCl 20&#37; in 1000&#8239;mL saline solution 0&#46;9&#37; and administer 150&#8239;mL of the dilution in 30&#8239;min&#47;12 h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypertonic saline solution at 3&#46;5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">126&#8722;135 mEq&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dilute 14 ampoules of NaCl 20&#37; in 1000&#8239;mL saline solution 0&#46;9&#37; and administer 150&#8239;mL of the dilution in 30&#8239;min&#47;12 h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypertonic saline solution at 2&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136&#8722;145 mEq&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dilute 8 ampoules of NaCl 20&#37; in 1000&#8239;mL saline solution 0&#46;9&#37; and administer 150&#8239;mL of the dilution in 30&#8239;min&#47;12 h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypertonic saline solution at 1&#46;4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;145 mEq&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dilute 3 ampoules of NaCl 20&#37; in 1000&#8239;mL saline solution 0&#46;9&#37; and administer 150&#8239;mL of the dilution in 30&#8239;min&#47;12 h&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Hypertonic saline solution protocol&#46;</p>"
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      5 => array:8 [
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        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0030"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">ACEI&#58; angiotensin-converting enzyme inhibitor&#59; ARB&#58; angiotensin II receptor blocker&#59; ARNI&#58; angiotensin receptor-neprilysin inhibitor&#59; BB&#58; beta blocker&#59; BP&#58; blood pressure&#59; bpm&#58; beats per minute&#59; HF&#58; heart failure&#59; HR&#58; heart rate&#59; MRA&#58; mineralocorticoid receptor antagonist&#59; NSAID&#58; non-steroidal anti-inflammatory drug&#59; rEF&#58; reduced ejection fraction&#46;</p><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span>As of yet no treatment has convincingly been shown to reduce morbidity and mortality in patients with LVEF&#8239;&#62;&#8239;40&#37;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><elsevierMultimedia ident="202105110748283733"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Managing AHF patients in the stable phase&#46;</p>"
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      6 => array:8 [
        "identificador" => "tbl0030"
        "etiqueta" => "Table 6"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0035"
            "detalle" => "Table "
            "rol" => "short"
          ]
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        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Risk factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Congestive heart failure&#47;Left ventricular dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#8805; 75 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diabetes mellitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Stroke&#47;transitory ischaemic attack&#47;thromboembolism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vascular disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age 65&#8722;74 years&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Female sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc score&#46; Evaluation of cardiovascular risk<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> based on a points system&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a></p>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">1&#46; Risk of readmission&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Identification of patients at higher risk of readmission&#58;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">It is essential to identify patients with higher risk of readmission&#46; The following items are proposed&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8226; &#62;2 admissions in the past 3 months or &#62;2 visits to the emergency department in the last month&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8226; Poor clinical condition at discharge&#58; SBP&#8239;&#60;&#8239;100&#8239;mmHg&#44; &#62;120&#8239;mg of oral furosemide&#47;day&#44; Na<span class="elsevierStyleSup">&#43;</span>&#8239;&#60;&#8239;130&#8239;mEq&#47;L and&#47;or eGFR&#8239;&#60;&#8239;30&#8239;mL&#47;min&#47;1&#46;73&#8239;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8226; Appearance of a geriatric syndrome during admission&#58; confusional syndrome&#44; frailty&#44; malnutrition or sarcopenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8226; Poor social situation or risk of poor adherence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46; Care continuity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8226; Establish the patient&#8217;s therapeutic regimen at discharge and what is expected in primary care&#58; drugs and dosages at discharge&#44; proposal for optimisation where necessary and withdrawal of medication without evidence or counterproductive medications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#8226; Contact with the health care system&#58;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Contact with primary care&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Case management&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Proactive contact telephone&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Managing the post-discharge transition period&#46;</p>"
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                    0 => array:2 [
                      "titulo" => "Consenso para la mejora de la atenci&#243;n integral de los pacientes con Insuficiencia Cardiaca Aguda"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Grupo de trabajo de la SEC&#44; SEMI y SEMES&#44; para las recomendaciones en la mejora de la atenci&#243;n integral de los pacientes con Insuficiencia Card&#237;aca Aguda"
                          ]
                        ]
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Trajectories of risk after hospitalization for heart failure&#44; acute myocardial infarction&#44; or pneumonia&#58; retrospective cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "K&#46; Dharmarajan"
                            1 => "A&#46;F&#46; Hsieh"
                            2 => "V&#46;T&#46; Kulkarni"
                            3 => "Z&#46; Lin"
                            4 => "J&#46;S&#46; Ross"
                            5 => "L&#46;I&#46; Horwitz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.h411"
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                        "fecha" => "2015"
                        "volumen" => "350"
                        "paginaInicial" => "h411"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25656852"
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                      "titulo" => "Influence of nonfatal hospitalization for heart failure on subsequent mortality in patients with chronic heart failure"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;D&#46; Solomon"
                            1 => "J&#46; Dobson"
                            2 => "S&#46; Pocock"
                            3 => "H&#46; Skali"
                            4 => "J&#46;J&#46; McMurray"
                            5 => "C&#46;B&#46; Granger"
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                    ]
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                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Circulation&#46;"
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                        "volumen" => "116"
                        "paginaInicial" => "1482"
                        "paginaFinal" => "1487"
                      ]
                    ]
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                      "titulo" => "Trends and characteristics of hospitalization for heart failure in a population setting from 2003 to 2013"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46;L&#46; Fernandez Gasso"
                            1 => "L&#46; Hernando-Arizaleta"
                            2 => "J&#46;A&#46; Palomar-Rodriguez"
                            3 => "F&#46; Soria-Arcos"
                            4 => "D&#46;A&#46; Pascual-Figal"
                          ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.rec.2017.03.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Cardiol &#40;Engl Ed&#41;&#46;"
                        "fecha" => "2017"
                        "volumen" => "70"
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                0 => array:2 [
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                      "titulo" => "Length of stay and risk of very early readmission in acute heart failure"
                      "autores" => array:1 [
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "G&#46; Minana"
                            1 => "M&#46;J&#46; Bosch"
                            2 => "E&#46; Nunez"
                            3 => "A&#46; Mollar"
                            4 => "E&#46; Santas"
                            5 => "E&#46; Valero"
                          ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.ejim.2017.04.003"
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                        "tituloSerie" => "Eur J Intern Med&#46;"
                        "fecha" => "2017"
                        "volumen" => "42"
                        "paginaInicial" => "61"
                        "paginaFinal" => "66"
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                  "contribucion" => array:1 [
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                      "titulo" => "Trends&#44; causes and timing of 30-day readmissions after hospitalization for heart failure&#58; 11-year population-based analysis with linked data"
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                          "etal" => false
                          "autores" => array:5 [
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                            3 => "M&#46;V&#46; Abell&#225;n-P&#233;rez"
                            4 => "D&#46;A&#46; Pascual-Figal"
                          ]
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Cardiol&#46;"
                        "fecha" => "2017"
                        "volumen" => "248"
                        "paginaInicial" => "246"
                        "paginaFinal" => "251"
                      ]
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                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Epidemiolog&#237;a de la insuficiencia card&#237;aca aguda"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2020.01.010

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