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"en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Management of patients with AHF in the congestive phase.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">ARB: angiotensin II receptor blockers; MRA: mineralocorticoid receptor antagonist; ARNI: angiotensin receptor/neprilysin inhibitor; BiPAP: bilevel positive airway pressure; CPAP: continuous positive airway pressure; APE: acute pulmonary edema; ECG: electrocardiogram; TTE: transthoracic echocardiogram; HR: heart rate; eGFR: estimated glomerular filtration rate; HF: heart failure; AHF: acute heart failure; HFrEF: heart failure with reduced ejection fraction; ACEI: angiotensin-converting enzyme inhibitor; OTI: orotracheal intubation; NA: sodium; O<span class="elsevierStyleInf">2</span>: oxygen; BP: blood pressure; XR: x-ray; IV: intravenous; NIMV: non-invasive mechanical ventilation; P.O.; oral route of administration.</p>"
]
]
]
"textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0030" class="elsevierStylePara elsevierViewall">Acute heart failure (AHF) is defined as the rapid or gradual onset of signs or symptoms of HF which require urgent medical care and can lead to hospital admission. Patients who have an episode of AHF have a high risk of complications.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> In Spain, AHF is the leading cause of hospitalization in individuals >65 years.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> In-hospital mortality ranges from 4% to 10% and mortality at one year after discharge ranges from 25% to 30%.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> Likewise, it is important to note that the risk of readmission in patients hospitalized due to AHF is high, especially early readmission during the first month after discharge (around 13.4%), which is considered the period of greatest vulnerability.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><p id="par0035" class="elsevierStylePara elsevierViewall">In 2020, the Heart Failure and Atrial Fibrillation Group of the Spanish Society of Internal Medicine (SEMI, for its initials in Spanish) developed recommendations in the form of a protocol. The aim was to provide guidance on the most notable practical aspects of treatment and follow-up on these patients during a hospital admission as well as to standardize and optimize management to the greatest possible extent based on the available evidence.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Afterwards, new guidelines and important clinical trials were published, which have made it necessary to update these recommendations.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> As in the previous recommendations,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> this document focuses on the four main stages of hospitalization of a patient with AHF: admission, management of the congestive and the stable/stabilization phases, and hospital discharge. The executive summary is presented herein. The full recommendations can be viewed in the <a class="elsevierStyleCrossRef" href="#sec1010">supplementary material</a>.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patient admission</span><p id="par0045" class="elsevierStylePara elsevierViewall">Reaching an early diagnosis of AHF is fundamental in order to begin the most suitable treatment early. AHF can occur as the first manifestation of HF or as acute decompensation in a patient with chronic HF. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the main diagnostic tests that will be useful in both making a diagnosis and searching for possible causes of decompensation.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It should be noted that renal function and electrolyte abnormalities can limit the use of drugs and have prognostic implications.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">At the time of admission for an episode of decompensated HF, it is necessary to collect some basic information (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6</span></a> Furthermore, a comprehensive evaluation of congestion must be conducted in patients hospitalized due to HF through a multiparameter evaluation that includes signs and symptoms, biomarkers (natriuretic peptides and CA-125), and a clinical ultrasound.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Management of patients with AHF in the congestive phase</span><p id="par0055" class="elsevierStylePara elsevierViewall">The main aspects related to the management of patients with AHF in the congestive phase are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Non-invasive daily monitoring of the patient’s vital signs—including pulse oximetry, blood pressure, heart rate, respiratory rate, and diuresis—is essential for evaluating whether ventilation, peripheral perfusion, oxygenation, heart rate, and blood pressure are adequate.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Patients must be weighed daily and maintain fluid balance. Renal function must be strictly monitored, preferably with the periodic measurement of urea, creatinine, estimated glomerular filtration rate (eGFR), and electrolytes. The routine use of bladder catheters for the quantification of diuresis is not recommended.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Treatment with HF-modifying drugs must continue during hospitalization, except in the presence of hemodynamic instability (symptomatic hypotension, hypoperfusion, bradycardia), hyperkalemia, or very deteriorated renal function. In these cases, the dose of other drugs that have effects on blood pressure or renal function or of the HF-modifying drugs themselves must be reviewed or they must be temporarily suspended and restarted after stabilization.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The respiratory failure that accompanies AHF/acute pulmonary edema (APE) requires O2 saturation (satO2) monitoring and, in the case of chronic obstructive pulmonary disease (COPD) or obesity hypoventilation syndrome (OHS), it is important to know the PCO<span class="elsevierStyleInf">2</span> and pH values.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> Providing adapted O<span class="elsevierStyleInf">2</span> flow is essential in cases of respiratory failure (PO<span class="elsevierStyleInf">2</span> <60 mmHg or satO<span class="elsevierStyleInf">2</span> <90%). In the event of respiratory distress (RR > 25 brpm, satO<span class="elsevierStyleInf">2</span> <90%), it is advised to implement non-invasive mechanical ventilation (NIMV),<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> continuous positive airway pressure (CPAP), or bilevel positive airway pressure (BiPAP) techniques early. A decrease in the level of consciousness, severe respiratory acidosis (pH < 7.25), or the inability to guarantee adequate oxygenation despite the previous measures is an indication for intubation and mechanical ventilation.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Patients mainly present with two types of situations from a hemodynamic point of view: hypertensive emergency and AHF with hypotension or even cardiogenic shock.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> AHF triggered by a hypertensive emergency typically manifests as APE. The treatment objective is a 25% reduction in the initial BP in the first two to four hours. To do so, the use of vasodilators in combination with the initial diuretic treatment is advised.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> When there is hypotension, the hemodynamic profile must be evaluated using the simultaneous presence of congestion and hypoperfusion as a guide. Starting inotropics or vasopressors is recommended in patients with congestion and SBP < 90 mmHg (wet-cold profile) and, if there is refractoriness to other measures, it is also recommended in patients with SBP > 90 mmHg.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Decongestive treatment is an initial priority. It has been demonstrated that early treatment with intravenous loop diuretics (in the first hour and at the appropriate dose) is associated with symptoms improvement and less in-hospital morbidity and mortality.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The initial diuretic dose should be based on whether the patient is receiving furosemide treatment at home and its dose with the aim of decreasing congestive symptoms and the onset of complications.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The diuretic regimen will be modified based on response until effective decongestion is achieved and then later progressively decreased. Ideally, the patient will be receiving the minimum effective dose orally for at least 24 h before hospital discharge (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Management of patients with AHF in the stable phase</span><p id="par0090" class="elsevierStylePara elsevierViewall">The main aspects related to the management of patients with AHF in the stable phase are shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>. This phase is the ideal time to start and/or adjust medication, especially evidence-based treatments in patients with heart failure with reduced ejection fraction (HFrEF). Diuretic treatment should be reduced until it can be given orally at the minimum effective dose or suspended.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Guidelines recommend maintaining prognosis-modifying drugs for HFrEF during hospitalization. In the case of <span class="elsevierStyleItalic">de novo</span> HFrEF, it is recommended to do everything possible to establish said treatments after the initial hemodynamic stabilization.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Clinical practice guidelines recommend considering starting sacubitril/valsartan before angiotensin-converting enzyme inhibitors (ACEI) in <span class="elsevierStyleItalic">de novo</span> or decompensated patients in order to reduce the risk of events (cardiovascular mortality and admissions due to HF) in the short term and to simplify management, thus avoiding titration of ACEI before later changing to sacubitril/valsartan.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,5</span></a> In order to start ACEI, in addition to hemodynamic stability, renal function and electrolytes must be evaluated. Beta blockers must be started when the patient is hemodynamically stable, euvolemic, and there are no contraindications. In sinus rhythm, a resting heart rate of between 50 and 70 bpm should be the target; the beta blocker dose should not be increased if the heart rate is less than 60 bpm.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Regarding mineralocorticoid receptor antagonists, not all studies show benefits to starting them during hospitalization. If they are prescribed, patients should be closely monitored upon discharge, especially patients with a risk of renal function deterioration or hyperkalemia. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are one of the pillars of HFrEF treatment.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Vericiguat should be established after discharge as a second-line treatment after establishment of first-line treatments in patients with recent HF worsening.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> A <span class="elsevierStyleItalic">post-hoc</span> analysis of the SHIFT study showed that patients treated with ivabradine who had a recent hospitalization due to HF were found to have a lower risk of readmission.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> On the other hand, in appropriately selected patients, cardiac resynchronization therapy has been demonstrated to reduce HF mortality and hospitalizations as well as to improve heart function and quality of life.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In regard to HF with preserved ejection fraction (HFpEF), until the publication of the EMPEROR-Preserved<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and DELIVER<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> studies, there had been no convincing evidence from clinical trials that there was any treatment that reduced morbidity and mortality. In fact, the most recent European HF guidelines only recommended the use of diuretics for the treatment of congestive symptoms as well as the appropriate approach to comorbidities.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, after the publication of these studies, SGLT2 inhibitors are the only drugs that have unequivocally been demonstrated to reduce the risk of complications in patients in HFpEF. They must be started as soon as possible after the patient has been stabilized.</p><p id="par0110" class="elsevierStylePara elsevierViewall">On the other hand, education for patients and family members is very important with the intention of providing adequate tools for managing future decompensation episodes on three levels: self-care (information about HF; weight monitoring; avoiding malnutrition, high sodium intake, and excessive fluid intake), early detection of alarm signs, and a flexible regimen of diuretics and medication (evaluate adherence, side effects, drugs to be avoided).</p><p id="par0115" class="elsevierStylePara elsevierViewall">The appropriate approach to comorbidities is another key aspect.</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Type 2 diabetes mellitus</span><p id="par0120" class="elsevierStylePara elsevierViewall">HbA1c should be determined if it has not been measured in the previous three months. During hospitalization, hyperglycemia should be treated with basal-bolus insulin with a correction factor. Oral antidiabetic agents should be suspended. The glucose target is 140–180 mg/dL.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> SGLT2 inhibitors should form part of the basic treatment of HF regardless of LVEF and any medical history of diabetes. In patients with type 2 diabetes and stable HF, metformin can be continued if the glomerular filtration rate is >30 mL/min/1.73 m<span class="elsevierStyleSup">2</span>, but it should be avoided in the case of instability or hospitalization due to HF. Although the cardiovascular safety of DPP-4 inhibitors has been demonstrated in patients with HF, saxagliptin should be avoided. Similarly, the use of glitazones and sulfonylureas should be avoided in subjects with diabetes and HF.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Hypertension</span><p id="par0125" class="elsevierStylePara elsevierViewall">The general blood pressure target is <140/90 mmHg and, if treatment is well tolerated, preferably <130/80 mmHg.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Disease-modifying drugs (sacubitril/valsartan/ACEI/ARB/beta blockers/aldosterone antagonists/SGLT2 inhibitors) should be used with the dual objective of controlling blood pressure and improving the cardiovascular prognosis.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,13</span></a> Diltiazem, verapamil, and moxonidine are contraindicated in heart failure with reduced ejection fraction (HFrEF).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Iron deficiency and anemia</span><p id="par0130" class="elsevierStylePara elsevierViewall">Approximately 58%–83% of patients with AHF present with iron deficiency, even in the absence of anemia. Improvements in symptoms, exercise capacity, quality of life, and reduction in hospitalizations have been demonstrated with the administration of intravenous ferric carboxymaltose in patients with HF and LVEF < 50% (not demonstrated in patients with HFpEF) who have iron deficiency regardless of the presence of anemia. Furthermore, it is important to investigate the cause of anemia when it is present.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Atrial fibrillation</span><p id="par0135" class="elsevierStylePara elsevierViewall">Atrial fibrillation (AF) is common in patients with HF. Patients with AF and HF have a high risk of presenting with thromboembolic complications. In general, anticoagulation is recommended in patients with AF and HF. The use of direct oral anticoagulants is preferred over vitamin K antagonists. To control HR, an initial target of <110 bpm is recommended and a stricter target is advised if the patient has symptoms of HF and LVEF deterioration. It is recommended to control the HR with beta blockers that are indicated for HFrEF and, if this is not possible, to add digoxin.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">COPD</span><p id="par0140" class="elsevierStylePara elsevierViewall">During hospitalization, nebulizations of β2 mimetics should be avoided and anticholinergics should be used. Glucocorticoids can be added if a) healthcare providers are convinced that there is a component of COPD or bronchospasm associated with HF and b) the patient’s level of consciousness is preserved. In regard to bronchodilator treatment, the use of long-acting bronchodilating drugs and starting long-acting anticholinergic bronchodilators (LAMA) is preferential upon discharge, although long-acting β2 adrenergic bronchodilators (LABA) can be used. Use cardioselective beta blockers (bisoprolol, nebivolol, metoprolol) in patients with HF and COPD.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Nutritional status</span><p id="par0145" class="elsevierStylePara elsevierViewall">A deterioration in nutritional status in patients with HF is associated with a worse prognosis. In patients with HF, it is necessary to perform a nutritional screening followed by an individualized nutritional support strategy.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Finally, in chronic HF, the active participation of the patient and his/her family in self-care allows for improving progress and reducing readmissions.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Both European<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and American<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> HF clinical practice guidelines recommend that patients receive education on self-care before discharge. It is important that the patient is able to identify alarm signs as well as use a flexible diuretic regimen. Likewise, the patient and his/her family must understand the indications and benefits of the prescribed medication as well as recognize the main side effects.</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Management of the post-discharge transition period</span><p id="par0155" class="elsevierStylePara elsevierViewall">This section describes both the considerations at the time of hospital discharge as well management of the post-discharge transition period (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows a ten-point checklist aimed at optimizing the management of patients hospitalized due to HF. These points should be considered at the time of hospital discharge in order to reduce the number of early readmissions. In post-discharge follow-up, an early evaluation (within three to seven days) in primary care is important, especially for patients at high risk of readmission, as well as a coordinated approach among the different levels of care.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Regarding the evaluation of readmission risk, it is essential to identify patients with a greater probability of returning to the hospital in order to provide closer follow-up and avoid new hospitalizations. This evaluation is based on four fundamental aspects: admissions or visits to the emergency room in the three months prior to the current hospitalization, a clinical evaluation related to HF and decongestion, presence of geriatric symptoms during the hospitalization, and social factors related to the patient.</p><p id="par0170" class="elsevierStylePara elsevierViewall">At the time of discharge, continuity of care must be guaranteed with a comprehensive, multidisciplinary healthcare perspective, placing emphasis on two aspects (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>): establishing the patient’s treatment regimen and recording in the discharge summary how, with whom, and in what manner the patient’s next contact with the healthcare system will be, as follows:<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0175" class="elsevierStylePara elsevierViewall">Contact with the primary care team either through the nursing department, medical personnel, or both and either at home or at the health center (according to the patient’s condition) in the first three to seven days following discharge.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0180" class="elsevierStylePara elsevierViewall">Coordination according to specific local protocols in which there is the figure of a case manager. Proactive telephone contact by the nursing department of the specialized unit/clinic in the first 72 h following discharge.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0185" class="elsevierStylePara elsevierViewall">Contact with the specialized hospital clinic in the first 14 days.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0190" class="elsevierStylePara elsevierViewall">Evaluation of the possibility of support from telemedicine systems.</p></li></ul></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0195" class="elsevierStylePara elsevierViewall">This document intends to decrease the variability and improve the care of patients hospitalized due to HF and promote an updated system of care for patients with HF according to the most recent available evidence. Despite clear recommendations on treatment with drugs that increase survival in patients with HFrEF, they are underused in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although the entire hospitalization process is addressed in the protocol presented herein, completing a checklist upon discharge is especially important in order to systematically review the numerous aspects to take into account. It allows for improving prescribing, education, and follow-up on the patient according to his/her needs. Indeed, completing a checklist upon discharge improves the approach to patients, reducing hospital readmissions. It would also promote high quality clinical training on a very important disease in internal medicine departments and improve coordination among levels of care following discharge. If it were ultimately incorporated into the electronic medical record, in addition to facilitating its use, this checklist would allow for taking advantage of data on and determining the reality of patients with HF in Spain.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0200" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Admission of a patient with AHF</span><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0205" class="elsevierStylePara elsevierViewall">It is essential to know the disease progress in detail, take a proper case history, and evaluate signs and symptoms.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0210" class="elsevierStylePara elsevierViewall">A patient’s comorbidities must be determined upon evaluation, given that they condition the disease's prognosis to a great extent, especially in patients with HFpEF.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0215" class="elsevierStylePara elsevierViewall">It is important to know the usual treatment taken by patients with HF: diuretics; sacubitril/valsartan; ACEI or ARB; beta blockers; mineralocorticoid receptor antagonists; SGLT2 inhibitors; ivabradine, vericiguat; and others such as digoxin, lipid lowering drugs, antiarrhythmic drugs, or anticoagulants.</p></li></ul></p><p id="par0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Management of the congestive phase</span><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">•</span><p id="par0225" class="elsevierStylePara elsevierViewall">Decongestive treatment is a priority in the first hours of hospital care.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">•</span><p id="par0230" class="elsevierStylePara elsevierViewall">A diuretic adjustment phase based on response in the first six to 24 h of hospital care is recommended.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">•</span><p id="par0235" class="elsevierStylePara elsevierViewall">A stepwise diuretic treatment approach based on the decongestive response offers benefits in terms of fluid and weight loss without compromising renal function.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">•</span><p id="par0240" class="elsevierStylePara elsevierViewall">Disease-modifying treatment should be maintained to the extent it is possible.</p></li></ul></p><p id="par0245" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Management of the stable phase</span><ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">•</span><p id="par0250" class="elsevierStylePara elsevierViewall">Starting and/or adjusting treatment—especially evidence-based drug treatment—should be considered in both patients with HFrEF (namely sacubitril/valsartan (or ACEI/ARB if sacubitril/valsartan are not tolerated), beta blockers, antialdosterones, and SGLT2 inhibitors) and in patients with HFpEF (namely SGLT2 inhibitors).</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">•</span><p id="par0255" class="elsevierStylePara elsevierViewall">The various comorbidities must be evaluated and controlled and the patient and/or family members must be educated on the disease to ensure their involvement in self-care.</p></li></ul></p><p id="par0260" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Considerations upon hospital discharge</span><ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">•</span><p id="par0265" class="elsevierStylePara elsevierViewall">It is recommended to consider the information from the checklist in order to optimize management of patients hospitalized due to HF and reduce the number of early hospitalizations.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">•</span><p id="par0270" class="elsevierStylePara elsevierViewall">Groups of patients at greater risk of readmission must be identified.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">•</span><p id="par0275" class="elsevierStylePara elsevierViewall">The most efficient options should be proposed in order to maintain continuity of care following hospital discharge.</p></li></ul></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0280" class="elsevierStylePara elsevierViewall">Content Ed Net (Madrid, Spain) provided editorial assistance in the writing of this manuscript, funded by the <span class="elsevierStyleGrantSponsor" id="gs0005">Spanish Foundation of Internal Medicine</span> (FEMI, for its initials in Spanish) through an unconditional grant from Boehringer Ingelheim (BI). BI had the opportunity to review the manuscript to verify its medical and scientific accuracy in regard to drugs from BI as well as intellectual property considerations.</p></span><span id="sec1080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1100">Conflict of interest</span><p id="par1280" class="elsevierStylePara elsevierViewall">José María Fernández has received support for consultingand presentations from Novartis, Alianza Boehringer-Ingelheim/Lilly, Pfizer, Daiichi-Sankyo and for attendingconferences from Pfizer, Alianza Boehringer-Ingelheim/Lilly.Jesús Casado has received support for consulting, presentations, and attending conferences from Novartis andRovi and for consulting from Vifor and Pfizer. Francesc Formiga has received support for consulting, presentations, and attending conferences from Novartis and Roviand for consulting from Vifor and Pfizer. Álvaro González-Franco has received support for consulting, presentations,or attending conferences from Novartis, Vifor, Daiichi-Sankyo, Pfizer, and Esteve. José Carlos Arévalo has received support for consulting, presentations, or attending conferences from Novartis, Esteve, Bayer, and Bristol-Myers. Manuel Beltrán has received support for consulting, presentations, or attending conferences from Novartis, Astra,Novo Nordisk, Daichii-Sankyo, Boehringer-Ingelheim, Lilly,and Sanofi. José Manuel Cerqueiro has received suppor for presentations from Novartis. Pau Llàcer has received support for consulting, presentations, or attending conferences from Novartis, Vifor, Boehringer-Ingelheim, Rovi,Ferrer, Esteve, Pfizer, Astra Zeneca, and Novo Nordisk. Luis Manzano has received support for consulting, presentations, and/or attending conferences from Novartis and Rovi andfor consulting from Vifor and Pfizer. José Luis Morales-Rull has received support for consulting or presentations from Novartis, Orion Pharma, Esteve, and Pharma Nutra. José Pérez-Silvestre has received support for presentations, consulting, and/or attending conferences from Novartis,Rovi, Pfizer, Boehringer-Ingelheim, Bayer, Esteve, Ferrer,and Glaxo. Alicia Conde-Martel has received support for consulting or presentations from Pfizer, Novartis, Bristol Myers,and Daiichi-Sankyo.</p></span></span>"
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"titulo" => "Management of patients with AHF in the congestive phase"
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"titulo" => "Management of patients with AHF in the stable phase"
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1 => array:2 [
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"fechaRecibido" => "2023-05-31"
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0 => array:4 [
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1 => "Recommendations"
2 => "Treatment"
3 => "Protocol"
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0 => "Insuficiencia cardiac aguda"
1 => "Recomendaciones"
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"resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Acute heart failure (AHF) is associated with significant morbidity and mortality and it stands as the primary cause of hospitalization for individuals over the age of 65 in Spain. This document outlines the main recommendations as follows: (1) Upon admission, it is crucial to conduct a comprehensive assessment, taking into account the patient’s standard treatment and comorbidities, as these factors determine the prognosis of the disease. (2) During the initial hours of hospital care, prioritizing decongestive treatment is essential. It is recommended to adopt an early staged diuretic therapeutic approach based on the patient's response. (3) In order to manage patients in the stable phase, it is advisable to consider initiating and/or adjusting evidence-based drug treatments such as sacubitril/valsartan or angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta blockers, aldosterone antagonists, and SGLT2 inhibitors. (4) Upon hospital discharge, utilizing a checklist is recommended to optimize the patient's management and identify the most efficient options for ensuring continuity of care post-discharge.</p></span>"
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"titulo" => "Resumen"
"resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La insuficiencia cardiaca aguda (ICA) está asociada a una importante morbimortalidad, constituyendo la primera causa de hospitalización en mayores de 65 años en nuestro país. Las principales recomendaciones recogidas son: 1) al ingreso, se recomienda realizar una evaluación integral, considerando el tratamiento habitual y comorbilidades, ya que condicionan el pronóstico; 2) en las primeras horas de atención hospitalaria, el tratamiento descongestivo es prioritario y se recomienda un abordaje terapéutico diurético precoz y escalonado en función de la respuesta; 3) durante la fase estable, se recomienda considerar el inicio y/o titulación del tratamiento con fármacos basados en la evidencia, es decir, sacubitrilo/valsartán o inhibidores de la enzima convertidora de angiotensina/antagonistas de los receptores de angiotensina II, betabloqueantes, antialdosterónicos e inhibidores SGLT2; 4) en el momento del alta hospitalaria, es recomendable utilizar un listado --tipo <span class="elsevierStyleItalic">check-list</span>-- para optimizar el manejo del paciente hospitalizado e identificar las opciones más eficientes para mantener la continuidad de cuidados tras el alta.</p></span>"
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"apendice" => "<p id="par2120" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
"etiqueta" => "Appendix A"
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"en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Considerations upon admission of a patient with HF.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">DOAC: direct oral anticoagulants; ARB: angiotensin II receptor blockers; MRA: mineralocorticoid receptor antagonists; CPAP: continuous positive airway pressure; PND: paroxysmal nocturnal dyspnea; COPD: chronic obstructive pulmonary disease; CKD: chronic kidney disease; HF: heart failure; eGFR: estimated glomerular filtration rate; LVEF: left ventricular ejection fraction; GF: glomerular filtration; Hb: hemoglobin; HT: hypertension; HF: heart failure; AHF: acute heart failure; ACEI: angiotensin-converting enzyme inhibitor; BMI: body mass index; SGLT2I: sodium-glucose cotransporter 2 inhibitors; JVD: jugular venous distention; NT-proBNP: N-terminal prohormone of brain natriuretic peptide; NYHA: New York Heart Association scale; BP: blood pressure; OSAHS: obstructive sleep apnea hypopnea syndrome; Y/N: yes/no; OHS: obesity hypoventilation syndrome.</p>"
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"en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Management of patients with AHF in the congestive phase.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">ARB: angiotensin II receptor blockers; MRA: mineralocorticoid receptor antagonist; ARNI: angiotensin receptor/neprilysin inhibitor; BiPAP: bilevel positive airway pressure; CPAP: continuous positive airway pressure; APE: acute pulmonary edema; ECG: electrocardiogram; TTE: transthoracic echocardiogram; HR: heart rate; eGFR: estimated glomerular filtration rate; HF: heart failure; AHF: acute heart failure; HFrEF: heart failure with reduced ejection fraction; ACEI: angiotensin-converting enzyme inhibitor; OTI: orotracheal intubation; NA: sodium; O<span class="elsevierStyleInf">2</span>: oxygen; BP: blood pressure; XR: x-ray; IV: intravenous; NIMV: non-invasive mechanical ventilation; P.O.; oral route of administration.</p>"
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"en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Management of patients with AHF in the stable phase.</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">NSAID: non-steroidal anti-inflammatory drug; ARB: angiotensin II receptor blockers; MRA: mineralocorticoid receptor antagonist; ARNI: angiotensin receptor/neprilysin inhibitor; BB: beta blocker; AF: atrial fibrillation; HR: heart rate; pEF: preserved ejection fraction; rEF: reduced ejection fraction; HF: heart failure; ACEI: angiotensin-converting enzyme inhibitor; bpm: beats per minute; BP: blood pressure; SR: sinus rhythm.</p>"
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"en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Management of the post-discharge transition period.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">PC: primary care; HR: heart rate; eGFR: estimated glomerular filtration rate; HF: heart failure; IM: internal medicine; SBP: systolic blood pressure.</p>"
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"en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Post-discharge transition and coordination of care.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">PC: primary care.</p>"
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"leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">eGFR: estimated glomerular filtration rate.</p>"
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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">Tests to be performed \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">To identify/rule out \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">Electrocardiogram \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">Cardiac arrhythmias, myocardial ischemia \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">Oximetry \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">Respiratory failure \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">Chest x-ray \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">Congestion, lung infection \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">Pulmonary ultrasound \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">Congestion \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">Echocardiogram \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">Congestion, cardiac dysfunction, mechanical causes \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">Natriuretic peptides \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">Increase in filling pressures and congestion (NT-proBNP >450 pg/mL for individuals aged <50 years, >900 pg/mL for individuals aged 50–75 years, and >1800 pg/mL for individuals >75 years) or BNP > 400 pg/mL \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">Blood test Hemoglobin Creatinine/eGFR Urea Sodium, potassium, chloride Transferrin/ferritin TSH D-dimer Lactate Albumin pH Ca 125 Albuminuria Urine electrolytes (sodium and potassium) \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">AnemiaRenal dysfunctionRenal dysfunction/volume statusElectrolyte abnormalitiesIron depletionThyroid abnormalitiesPulmonary embolism and deep vein thrombosisLactic acidosisNutritional statusMetabolic/respiratory acidosis/alkalosisCongestion, inflammationCongestion and endothelial damageDiuretic response \t\t\t\t\t\t\n
\t\t\t\t</td></tr></tbody></table>
"""
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"leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">ARB: Angiotensin II receptor blockers; MRA: mineralocorticoid receptor antagonists; ARNI: angiotensin receptor/neprilysin inhibitor; BB: beta blockers; HR: heart rate; eGFR: estimated glomerular filtration rate; LVEF: left ventricular ejection fraction; ACEI: angiotensin-converting enzyme inhibitor; SGLT2I: sodium-glucose cotransporter 2 inhibitors; SBP: systolic blood pressure; NP: natriuretic peptides.</p>"
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<table border="0" frame="\n
\t\t\t\t\tvoid\n
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\t\t\t\t" scope="col" style="border-bottom: 2px solid black">Considerations before discharge \t\t\t\t\t\t\n
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\t\t\t\t">1. Have the triggering factors been identified and controlled? \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. Have comorbidities been evaluated? \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
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\t\t\t\t">3. Is the patient decongested? \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
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\t\t\t\t">4. Is the LVEF known? \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
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\t\t\t\t">5. If LVEF is <40% (evaluate if <50%), has treatment with the following been started or considered: \t\t\t\t\t\t\n
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\t\t\t\t\ttable-entry\n
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\t\t\t\t"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0005" class="elsevierStylePara elsevierViewall">ARNI (if it cannot be used, substitute with ACEI/ARB)</p></li></ul> \t\t\t\t\t\t\n
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\t\t\t\t"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0010" class="elsevierStylePara elsevierViewall">BB</p></li></ul> \t\t\t\t\t\t\n
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\t\t\t\t"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0015" class="elsevierStylePara elsevierViewall">MRA</p></li></ul> \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"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0020" class="elsevierStylePara elsevierViewall">SGTL2 inhibitors (dapagliflozin/empagliflozin) regardless of LVEF</p></li></ul> \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
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\t\t\t\t"><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0025" class="elsevierStylePara elsevierViewall">Vericiguat: consider if LVEF < 45% (eGFR >15 mL/min and NP < 8000 pg/mL)</p></li></ul> \t\t\t\t\t\t\n
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\t\t\t\t\ttable-entry\n
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\t\t\t\t">6. Has the rest of the medication been reviewed? \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
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\t\t\t\t">7. Have renal function and electrolytes been evaluated? \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
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\t\t\t\t">8. Are SBP, heart rhythm, HR, and QRS interval known? \t\t\t\t\t\t\n
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\t\t\t\t\ttable-entry\n
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\t\t\t\t">9. Has the patient/caregiver been educated on the disease and have recommendations been made? \t\t\t\t\t\t\n
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\t\t\t\t\ttable-entry\n
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\t\t\t\t">10. Does the patient have an early appointment scheduled with primary care and/or specialists?<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n
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