Con en s lis s a ailable a ScienceDi ec
Eu opean Jou nal o In e nal Medicine
jou nal homepage: www.else ie .com/loca e/ejim
O iginal A icle
Influence o he leng h o hospi alisa ion in pos -discha ge ou comes in
pa ien s wi h acu e hea ailu e: Resul s o he LOHRCA s udy
Òsca Mi ó
a,b,⁎,1
, Joan Pad osa
a,1
, Koji Takagi
c
, É ienne Gaya
c
, Víc o Gil
a
, Pe e Llo ens
d
,
F ancisco Ja ie Ma ín-Sánchez
e,
, Pablo He e o-Puen e
g
, Ja ie Jacob
h
, Ma ía Mi Mon e o
i
,
Josep Tos
j
, Ma ía Pila López Díez
k
, Lisse e T a e ia
l
, Raquel To es-Gá a e
m
,
Ma ía Isabel Alonso
n
, Ca men Agüe a
o
, Ampa o Vale o
p
, Pa icia Ja aloyes
d
,
W. F ank Peacock
b,q
, Héc o Bueno
,
, Alexand e Mebazaa
b,c
, on behal o he ICA-SEMES
Resea ch G oup, Ma a Fuen es
s
, C is ina Gil
s
, Héc o Alonso
, Pablo Ga mila
,
Guille mo Llopis Ga cía
u
, Ma ía Cecilia Yáñez-Palma
u
, Se gio Iglesias López
u
, Rosa Escoda
,
Ca olina Xipell
, Ca olina Sánchez
, Josep Ma ía Gay an
, Ma ía José Pé ez-Du á
w
, E a Sal o
w
,
José Pa ón
x
, An onio No al
y
, José Manuel To es
z
, Ma ía Luisa López-G ima
aa
, Ampa o Vale o
aa
,
Ma ian Ángeles Juan
aa
, Al ons Agui e
ab
, Julián E as i Mo ales
ab
, Sil ia Mínguez Masó
ab
,
Ma ía Isabel Alonso
ac
, F ancisco Ruiz
ac
, José Miguel F anco
ad
, Ana Belén Mecina
ae
, Josep Tos
a
,
Susana Sánchez
ag
, Vi ginia Ca bajosa
ag
, Pascual Piñe a
ah
, José And és Sánchez Nicolás
ah
,
Raquel To es Ga a e
ai
, Ai o Alqueza
aj
, Miguel Albe o Rizzi
aj
, Se gio He e a
aj
, Alex Rose
ak
,
I ene Cabello
ak
, Fe nando Richa d
al
, José Ma ía Ál a ez Pé ez
al
, Ma ía Pila López Diez
al
,
Joaquín Vázquez Ál a ez
am
, Belén P ie o Ga cía
am
,
Ma ía Ga cía Ga cía yMa a Sánchez González
am
, Pa icia Ja aloyes
an
, Víc o Ma quina
an
,
Inmaculada Jiménez
an
, Nés o He nández
an
, Benjamín B ouze
an
, Se gio Ramos
an
, Ana López
an
,
Juan An onio Andueza
ao
, Rodol o Rome o
ap
, Ma ín Ruíz
aq
, Robe o Cal ache
aq
,
Ma ía Te esa Lo ca
a
, Luis Calde ón
a
, Bea iz Amo es A iaga
as
, Bea iz Sie a
as
,
En ique Ma ín Moja o
a
, Lise e T a e ía Bécque
au
, Guille mo Bu illo
au
, Lluís Llauge Ga cía
a
,
Ge a d Co ominas LaSalle
a
, Ca men Agüe a U bano
aw
, Ana Belén Ga cía So o
aw
,
Elisa Delgado Padial
aw
, Es e Soy Fe e
ax
, Manuel Ga ido
ay
, F ancisco Ja ie Lucas
az
,
Ru Gaya
ba
, Ca los Bibiano
bb
, Ma ía Mi
bb
, Bea iz Rod íguez
bb
, Na alia Sánchez
bb
,
José Luis Ca ballo
bc
, Es he Rod íguez-Ad ada
bd
, Belén Rod íguez
bd
a
Eme gency Depa men , Hospi al Clínic, Ba celona; “Eme gencies: p ocesses and pa hologies”Resea ch G oup, IDIBAPS, Uni e si y o Ba celona, Ba celona, Ca alonia,
Spain
b
The GREAT (Global REsea ch in Acu e Ca dio ascula Condi ions Team) Ne wo k, Rome, I aly
c
Depa men o Anes hesiology and C i ical Ca e Medicine, Sain Louis La iboisiè e Uni e si y Hospi al, Uni e si é Pa is Dide o , Pa is, F ance
d
Eme gency Depa men , Home Hospi aliza ion and Sho S ay Uni , Hospi al Gene al de Alican e, Alican e, Spain
e
Eme gency Depa men , Hospi al Clínico San Ca los, Mad id, Ins i u o de In es igación Sani a ia San Ca los (IdISSC), Uni e sidad Complu ense de Mad id, Spain
Cen o Nacional de In es igaciones Ca dio ascula es (CNIC), Mad id, Spain
g
Eme gency Depa men , Hospi al Uni e si a io Cen al de As u ias, O iedo, Spain
h
Eme gency Depa men , Hospi al Uni e si a i de Bell i ge, L'Hospi ale de Llob ega , Ba celona, Ca alonia, Spain
i
Eme gency Depa men , Hospi al Uni e si a io In an a Leono , Mad id, Spain
j
Eme gency Depa men , Hospi al de Te assa, Ba celona, Ca alonia, Spain
k
Eme gency Depa men , Hospi al Uni e si a io de Bu gos, Bu gos, Spain
l
Eme gency Depa men , Hospi al Uni e si a io de Cana ias, Tene i e, Spain
m
Eme gency Depa men , Hospi al Uni e si a io Se e o Ochoa, Leganés, Mad id, Spain
n
Eme gency Depa men , Hospi al Valme, Se illa, Spain
o
Eme gency Depa men , Hospi al Cos a del Sol, Ma bella, Málaga, Spain
h ps://doi.o g/10.1016/j.ejim.2019.08.007
⁎
Co esponding au ho a :Eme gency Depa men , Hospi al Clínic, Villa oel 170, Ba celona, Ca alonia 08036, Spain.
E-mail add ess: [email p o ec ed] (Ò. Mi ó).
Eu opean Jou nal o In e nal Medicine xxx (xxxx) xxx–xxx
0953-6205/ © 2019 Published by Else ie B.V. on behal o Eu opean Fede a ion o In e nal Medicine.
Please ci e his a icle as: Òsca Mi ó, e al., Eu opean Jou nal o In e nal Medicine, h ps://doi.o g/10.1016/j.ejim.2019.08.007
p
Eme gency Depa men , Hospi al Doc o Pese , València, Spain
q
Eme gency Depa men , Baylo College o Medicine, Ben Taub Gene al Hospi al, Hous on, USA
Ca diology Depa men , Uni e sidad Complu ense, Hospi al 12 de Oc ub e, Mad id, Spain
s
Hospi al Uni e si a io de Salamanca, Spain
Hospi al Ma qués de Valdecilla de San ande , Spain
u
Hospi al Clínico San Ca los de Mad id,Spain
Hospi al Clínic de Ba celona, Spain
w
Hospi al Poli énic La Fe de Valencia, Spain
x
Hospi al D . Neg ín de Las Palmas de G an Cana ia, Spain
y
Hospi al Insula de Las Palmas de G an Cana ia, Spain
z
Hospi al Reina So ía de Có doba, Spain
aa
Hospi al D . Pese de Valencia, Spain
ab
Hospi al del Ma de Ba celona, Spain
ac
Hospi al de Valme de Se illa, Spain
ad
Hospi al Miguel Se e de Za agoza, Spain
ae
Hospi al de Alco cón de Mad id, Spain
a
Conso ci Sani a i de Te assa, Spain
ag
Hospi al Rio O ega de Valladolid, Spain
ah
Hospi al Reina So ía de Mu cia, Spain
ai
Hospi al Se e o Ochoa de Mad id, Spain
aj
Hospi al de la San a C eu y San Pau de Ba celona, Spain
ak
Hospi al Uni e si a i de Bell i ge de Ba celona, Spain
al
Hospi al Uni e si a io de Bu gos, Spain
am
Hospi al Uni e si a io Cen al de As u ias de O iedo, Spain
an
Hospi al Gene al de Alican e, Spain
ao
Hospi al Gene al Uni e si a io G ego io Ma añón de Mad id, Spain
ap
Hospi al Ge a e de Mad id, Spain
aq
Hospi al de Hena es de Mad id, Spain
a
Hospi al del Tajo de Mad id, Spain
as
Hospi al Clínico Lozano Blesa de Za agoza, Spain
a
Hospi al San Pau i San a Tecla de Ta agona, Spain
au
Hospi al Uni e si a io de Cana ias de Tene i e, Spain
a
Hospi al Uni e si a i de Vic de Ba celona, Spain
aw
Hospi al Cos a del Sol de Ma bella de Málaga, Spain
ax
Hospi al Josep T ue a de Gi ona, Spain
ay
Hospi al Vi gen Maca ena de Se illa, Spain
az
Hospi al Gene al de Albace e, Spain
ba
Hospi al Juan XXIII de Ta agona, Spain
bb
Hospi al In an a Leono de Mad id, Spain
bc
Complejo Hospi ala io Uni e si a io de Ou ense, Spain
bd
Hospi al Rey Juan Ca los de Mos oles de Mad id, Spain
ARTICLE INFO
Keywo ds:
Acu e hea ailu e
Leng h o hospi alisa ion
Pos -discha ge ou comes
Vulne abili y phase
Mo ali y
Readmission
ABSTRACT
Objec i e: To in es iga e he ela ionship be ween leng h o hospi alisa ion (LOH) and pos -discha ge ou comes
in acu e hea ailu e (AHF) pa ien s and o asce ain whe he he e a e diffe en pa e ns acco ding o de-
pa men o ini ial hospi alisa ion.
Me hods: Consecu i e AHF pa ien s hospi alised in 41 Spanish cen es we e g ouped based on he LOH (< 6/6-
10/11-15/ > 15 days). Ou comes we e defined as 90-day pos -discha ge all-cause mo ali y, AHF eadmissions,
and he combina ion o bo h. Haza d a ios (HRs), adjus ed by ch onic condi ions and se e i y o decom-
pensa ion, we e calcula ed o g oups wi h LOH > 6 days s. LOH < 6 days ( e e ence), and s a ified by hos-
pi alisa ion in ca diology, in e nal medicine, ge ia ics, o sho -s ay uni s.
Resul s: We included 8563 pa ien s (mean age: 80 (SD = 10) yea s, 55.5% women), wi h a median LOH o 7 days
(IQR 4–11): 2934 (34.3%) had a LOH < 6 days, 3184 (37.2%) 6–10 days, 1287 (15.0%) 11–15 days, and 1158
(13.5%) > 15 days. The 90-day pos -discha ge mo ali y was 11.4%, eadmission 32.2%, and combined end-
poin 37.4%. Mo ali y was inc eased by 36.5% (95%CI = 13.0–64.9) when LOH was 11–15 days, and by 72.0%
(95%CI = 42.6–107.5) when > 15 days. Con e sely, no diffe ences we e ound in eadmission isk, and he
combined endpoin only inc eased 21.6% (95%CI = 8.4–36.4) o LOH > 15 days. S a ified analysis by hos-
pi alisa ion depa men s ende ed simila pos -discha ge ou comes, wi h all exhibi ing inc eased mo ali y o
LOH > 15 days and no significan inc emen s in eadmission isk.
Conclusions: Sho hospi alisa ions a e no associa ed wi h wo se ou comes. While pos -discha ge eadmissions
a e no affec ed by LOH, mo ali y isk inc eases as he LOH leng hens. These findings we e simila ac oss
hospi alisa ion depa men s.
1. In oduc ion
Hea ailu e (HF) is a wo ld-wide pandemic associa ed wi h sig-
nifican mo bidi y, mo ali y, and cos bu den [1,2]. Fo e e y heal h
ca e sys em, he majo i y o HF cos s a e ela ed o hospi alisa ions
du ing acu e decompensa ions and a e p opo ional o he leng h o
hospi alisa ion (LOH) equi ed [3]. The e o e, many effo s ha e been
di ec ed a sho ening he LOH o pa ien s wi h acu e HF (AHF).
Mo eo e , his s a egy is po en ially beneficial due o a educ ion o
he haza ds associa ed wi h hospi alisa ion i sel , which include ex-
posu e o nosocomial in ec ion and complica ions, ia ogenic ha m, o
1
Òsca Mi ó and Joan Pad osa ha e equally con ibu ed o his s udy and
should bo h be conside ed as fi s au ho .
Ò. Mi ó, e al. Eu opean Jou nal o In e nal Medicine xxx (xxxx) xxx–xxx
2
he de elopmen o deli ium in he elde ly. Sho ening hospi alisa ion
could also impac he a es o pos -hospi al synd ome, which occu s in
ecen ly hospi alised pa ien s who a e no only eco e ing om hei
acu e illness, bu also expe ience a ansien pe iod o gene alised isk
o a wide ange o ad e se heal h e en s [4]. In his sense, da a on
pa ien s wi h AHF om he VERITAS ials demons a ed ha longe
LOH was associa ed wi h a highe a e o pos -discha ge mo ali y [5].
To mee he objec i e o limi ing he LOH o a minimum, some coun-
ies (e.g., Spain) ha e p omo ed he c ea ion o sho - e m uni s, he
pu pose o which is o p o ide quick, coo dina ed managemen o pa-
ien s who ha e no addi ional challenges o he han decompensa ion o
a ch onic condi ion, such as AHF [6,7].
None heless, while i has been p oposed ha sho ening LOH in
AHF is he bes way o mi iga e expendi u es and educe pos -discha ge
ad e se ou come isk [8], i is also easible ha i may wo sen sho -
e m ou comes. Ce ainly, esidual conges ion o unsol ed esidual
o gan damage is mo e likely o be p esen a hospi al discha ge in pa-
ien s wi h a e y sho pe iod o in-hospi al supe ised managemen
and ea men . In addi ion, while well-defined discha ge planning and
s uc u ed ou pa ien ollow-up imp o e AHF pa ien ou comes [9],
e y sho hospi alisa ions could in e e e wi h he comple e im-
plemen a ion o such measu es. To da e, he impac o LOH on pos -
discha ge ou comes has been poo ly explo ed in he eal wo ld sce-
na io. Al hough andomised clinical ials a e he gold s anda d o
unequi ocally demons a e he benefi o new ea men o disease
app oaches, inpa ien hospi al egis ies emain he p ima y sou ce o
eal-wo ld da a as hey include unselec ed pa ien s ep esen ing he ull
spec um o HF [10]. Ou pu pose was o explo e he ela ionship be-
ween he LOH and pos -discha ge ou comes in a la ge egis y o
consecu i e pa ien s admi ed o hospi al o AHF. Ou hypo hesis is
ha a sho du a ion o hospi alisa ion does no nega i ely impac
ou comes in AHF. An explo a o y s a ified analysis by he main hos-
pi alisa ion depa men s o AHF pa ien s was also pe o med.
2. Me hods
2.1. Se ing
The LOHRCA (Leng h O Hospi alisa ion and i s Rela ionship wi h
ou Comes in Acu e hea ailu e) s udy was an explo a o y, seconda y
analysis wi hin he EAHFE (Epidemiology o Acu e Hea Failu e in
Eme gency depa men s) Regis y. This egis y was ini ia ed in 2007
and e e y 2–3 yea s i ca ies ou a 1–2-mon h ec ui men pe iod o all
consecu i e pa ien s diagnosed wi h AHF in Spanish EDs pa icipa ing
in he p ojec . To da e, 5 ec ui men phases (in 2007, 2009, 2011,
2014, and 2016) ha e been pe o med wi h he pa icipa ion o 41 EDs
om communi y and uni e si y hospi als ac oss Spain ( ep esen ing
abou 13% o he hospi als belonging o he Spanish public heal hca e
sys em), en olling a o al o 13,791 AHF pa ien s. The LOHRCA s udy
used he 12,843 pa ien s ec ui ed in phases 2 o 5 since da a on LOH
was no eco ded in phase 1. De ails o pa ien inclusion ha e been
epo ed p e iously [11,12]. B iefly, he p incipal in es iga o s o each
eme gency depa men pa icipa ing in he EAHFE Regis y a end a
gene al mee ing held be o e e e y ec ui men phase in o de o
homogenize he logis ics, p o ocol defini ions, as well as he inclusion
and exclusion c i e ia. All p incipal in es iga o s a e p o ided wi h a
common dic iona y o e ms in o de o ha e s anda d defini ions a all
cen es (a ailable as Supplemen a y Table 1). The p incipal in-
es iga o s hen explain p o ocol ins uc ions o he eme gency physi-
cians o hei espec i e cen es du ing a weekly ED mee ing p eceding
pa ien ec ui men . Du ing he ec ui men ime ame, pa ien en ol-
men is done by any a ending eme gency physician in he pa icipa ing
EDs. These physicians a e esponsible o he de ec ion o po en ial
cases o pa ien s wi h AHF. All suspec ed cases a e confi med by he
p incipal in es iga o o each cen e o ensu e he pa ien s mee he
diagnos ic c i e ia o AHF based on he F amingham clinical c i e ia
[13]. I possible, he diagnosis is confi med by measu emen o plasma
na iu e ic pep ide and/o echoca diog aphy du ing ED o hospi al
s ay, ollowing he cu en ecommenda ions o he ESC guidelines
[14], and his is done in abou 92% o cases. The p incipal in es iga o
o each cen e is esponsible o he final diagnos ic adjudica ion o he
cases. The only exclusion c i e ion o he EAHFE Regis y is a con-
cu en p ima y diagnosis o ST-ele a ion myoca dial in a c ion
(STEMI), which occu s in abou 3% o AHF cases. The EAHFE Regis y
is only obse a ional, does no include any planned in e en ion, and
he managemen o pa ien s is en i ely based on he a ending ED
physician decisions.
2.2. E hics
The EAHFE Regis y p o ocol was app o ed by a cen al E hics
Commi ee a he Hospi al Uni e si a io Cen al de As u ias (O iedo,
Spain) wi h he e e ence numbe s 49/2010, 69/2011, 166/13, and
160/15. Due o he non-in e en ional design o he egis y, Spanish
legisla ion allows cen al E hical Commi ee app o al, accompanied by
no ifica ion o he local E hical Commi ees. All pa icipa ing pa ien s
ga e in o med consen o be included in he egis y and o be con-
ac ed o ollow-up. The LOHRCA s udy was ca ied ou in s ic
compliance wi h he Decla a ion o Helsinki p inciples.
2.3. Design and a iables eco ded
All pa ien s hospi alised a e an ED diagnosis o AHF and dis-
cha ged ali e, in whom da a ega ding he LOH and mo ali y we e
a ailable, we e eligible o his s udy. The LOHRCA s udy was designed
o analyse ou comes in 4 LOH subg oups. G oups we e defined om a
p e ious analysis o ou come p e alence e sus ime (Fig. 1), and
consis ed o LOH ≤5, 6 o 10, 11 o 15, and > 15 days. The LOH was
defined as he calenda day ha pa ien s p esen ed o he ED un il he
calenda day ha hey we e discha ged om he hospi al.
In addi ion o he LOH (classifica o y a iable), ano he 22 in-
dependen a iables ega ding demog aphic da a (2 a iables), co-
mo bidi ies (12 a iables), baseline s a us (3 a iables) and ch onic
ea men s o HF (5 a iables) we e eco ded o delinea e he ch onic
unde lying isk p ofiles ha could po en ially impac on he p ima y
endpoin s. Wi h espec o he se e i y o he AHF episode i sel , we
es ima ed he isk o each pa ien using he p e iously de eloped
Fig. 1. P obabili y o ad e se ou comes plo ed agains day by day o leng h o
hospi alisa ion.
Ò. Mi ó, e al. Eu opean Jou nal o In e nal Medicine xxx (xxxx) xxx–xxx
3
MEESSI sco e
11
and EFFECT sco e [15], which assess he 30-day isk o
dea h in ED AHF and in hospi alised AHF pa ien s, espec i ely. Fo
bo h, he highe he sco e, he highe he isk. The ini ial depa men o
which he pa ien was ans e ed a e ED managemen was conside ed
esponsible o hospi alisa ion because, al hough he in e nal ans e
a e be ween diffe en depa men s is < 10% in Spanish hospi als, we
did no eco d u he depa men s o which a pa ien was mo ed when
he ini ial depa men was no he same as he final depa men om
which he pa ien was discha ged home.
2.4. Ou comes
We eco ded h ee main pos -discha ge ou comes, defined as
s a ing a he ime o discha ge om hospi alisa ion, and included 90-
day all-cause dea h, 90-day eadmission due o AHF, and he combined
endpoin . The 90-day pe iod was selec ed because i has been p oposed
as he ulne able pos -discha ge pe iod o pa ien s wi h AHF [16].
Follow-up was pe o med by elephone con ac and consul a ion o
medical eco ds.
2.5. S a is ical analysis
Con inuous a iables a e exp essed as mean and s anda d de ia ion
(SD) o median and in e qua ile ange (IQR) i no no mally dis-
ibu ed, and disc e e a iables as absolu e alues and pe cen ages.
Compa ison among g oups was ca ied ou using one-way ANOVA o
con inuous a iables and he chi squa e es o disc e e a iables.
Ou comes among he g oups o LOH we e compa ed by means o Cox
Fig. 2. Flow cha o pa ien inclusion.
LOS: leng h o s ay.
Table 1
O e all pa ien cha ac e is ics o he whole se ies and compa ison among he ou g oups de e mined by he leng h o hospi alisa ion.
To al
N= 8563
n (%)
Missing alues
n (%)
< 6 days
N= 2934
n (%)
6–10 days
N= 3184
n (%)
11–15 days
N= 1287
n (%)
> 15 days
N= 1158
n (%)
p alue
Demog aphic da a
Age (yea s) (mean (SD)) 80.2 (10.2) 10 (0.1) 80.9 (10) 80.2 (10.2) 80.1 (10.2) 78.7 (10.5) < 0.001
Female 4742 (55.5) 24 (0.3) 1664 (56.9) 1786 (56.3) 708 (55.1) 584 (50.6) 0.006
Como bidi ies
Hype ension 7215 (84.4) 16 (0.2) 2503 (85.5) 2684 (84.4) 1079 (83.9) 949 (82.2) 0.146
Diabe es melli us 3665 (42.9) 18 (0.2) 1213 (41.5) 1362 (42.8) 575 (44.7) 515 (44.6) 0.256
Ischaemic hea disease 2467 (28.9) 19 (0.2) 859 (29.3) 894 (28.1) 379 (29.5) 335 (29) 1.396
Hea al e disease 2282 (26.7) 17 (0.2) 789 (26.9) 819 (25.8) 347 (27) 327 (28.3) 0.746
A ial fib illa ion 4235 (49.6) 17 (0.2) 1544 (52.8) 1546 (48.6) 604 (47) 541 (46.9) < 0.001
Ch onic kidney ailu e (c ea inine > 2 mg/mL) 2298 (26.9) 16 (0.2) 719 (24.6) 863 (27.1) 382 (29.7) 334 (28.9) 0.002
Ce eb o ascula disease 1155 (13.5) 18 (0.2) 413 (14.1) 384 (12.1) 175 (13.6) 183 (15.9) 0.016
Pe iphe al a e y disease 839 (9.8) 19 (0.2) 281 (9.6) 296 (9.3) 136 (10.6) 126 (10.9) 0.648
Ch onic obs uc i e pulmona y disease 2105 (24.6) 23 (0.3) 681 (23.3) 786 (24.7) 336 (26.1) 302 (26.2) 0.228
Demen ia 993 (13) 938 (11) 324 (12.3) 389 (13.7) 161 (13.9) 119 (11.9) 0.488
Ac i e neoplasia 1068 (14) 941 (11) 348 (13.3) 398 (14) 162 (14) 160 (16) 0.424
P io episodes o acu e hea ailu e 5088 (60.5) 148 (1.7) 1784 (61.8) 1850 (59.2) 763 (60.3) 691 (60.9) 0.44
Baseline s a us
Ba hel Index (poin s) (mean (SD)) 79.16 (24.56) 969 (11.3) 80.55 (23.54) 78.91 (24.58) 78.01 (26.65) 77.47 (25.72) 0.001
NYHA class III-IV 2029 (25.1) 478 (5.6) 622 (22.3) 747 (24.8) 330 (27.5) 330 (30.5) < 0.001
Le en icula ejec ion ac ion (%) (mean (SD)) 50.98 (15.16) 3877 (45.3) 51.11 (15.12) 51.27 (14.96) 50.97 (14.96) 49.93 (15.92) 0.278
Ch onic ea men s a home
Diu e ics (any) 6363 (76) 194 (2.3) 2184 (75.7) 2354 (75.8) 951 (75.7) 874 (77.8) 1.018
Renin-angio ensin sys em inhibi o s 4792 (57.3) 195 (2.3) 1695 (58.7) 1807 (58.2) 695 (55.3) 595 (53) 0.006
Be a-blocke s 3416 (40.8) 196 (2.3) 1276 (44.2) 1188 (38.3) 506 (40.3) 446 (39.7) < 0.001
Mine aloco icoid- ecep o an agonis s 1428 (17.1) 193 (2.3) 480 (16.6) 511 (16.5) 209 (16.6) 228 (20.3) 0.046
Digoxin 1295 (15.5) 203 (2.4) 460 (16) 487 (15.7) 177 (14.1) 171 (15.2) 0.928
Se e i y o cu en hea ailu e decompensa ion
MEESSI sco e (mean (SD)) −2.69 (1.13) 3526 (41.2) −2.83 (1.09) −2.66 (1.14) −2.58 (1.12) −2.52 (1.16) < 0.001
EFFECT sco e (mean (SD)) 115.7 (25.1) 3865 (45.1) 113.7 (24.6) 116.6 (25.2) 117.1 (25.9) 117.6 (24.8) < 0.001
MEESSI sco e es ima es he 30-day mo ali y isk and includes 13 pa ame e s: age, Ba hel index, NYHA class, decompensa ion associa ed wi h acu e co ona y
synd ome, low ou pu signs and symp oms, sys olic blood p essu e, espi a o y a e, oxygen sa u a ion, po assium, NT-p oBNP, oponin, c ea inine, and le en-
icula hype ophy in ECG. The highe he sco e, he highe he isk.
EFFECT sco e es ima es he 30-day mo ali y isk and includes 10 pa ame e s: age, ce eb o ascula disease, demen ia, ch onic obs uc i e pulmona y disease, hepa ic
ci hosis, cance , espi a o y a e, sys olic blood p essu e, u ea ni ogen and sodium. The highe he sco e, he highe he isk.
Ò. Mi ó, e al. Eu opean Jou nal o In e nal Medicine xxx (xxxx) xxx–xxx
4
eg ession analysis and exp essed as haza d a ios (HRs) wi h 95%
confidence in e als (95% CI) using he sho es LOH s ay g oup
(< 6 days) as he e e ence s anda d. Cu es depic ing unadjus ed
p opo ional haza ds we e made. Haza d a ios we e adjus ed o all
independen a iables o ch onic s a us wi h a p< 0.10 in he uni-
a ia e analysis, and by decompensa ion se e i y de e mined by he
MEESSI and EFFECT sco es. Addi ional models o adjus men we e
c ea ed by a combina ion o he abo e. Missing alues we e eplaced
using he mul iple impu a ion echnique, gene a ing 5 da ase s wi h no
missing alues o he a iables included in he adjus men . As sensi-
i i y analysis, hospi alisa ions ≤10 days we e analysed in 1-day pe -
iods, wi h LOH o 0–3 days as he e e ence s anda d, in o de o de ec
isks in g oups in he sho es LOH. We also planned a s a ified analysis
o he h ee ou comes o he ou main admission wa ds in pa ien s
hospi alised due o AHF: ca diology, in e nal medicine, ge ia ics and
sho -s ay uni . S a is ical significance was accep ed i he 95% con-
fidence in e al (CI) o he excluded he alue 1, o he p alue
was < 0.05. Since his was an explo a o y s udy, a p e-hoc sample size
calcula ion was no made.
3. Resul s
O he 12,843 pa ien s included in he EAHFE 2 o 5 egis ies, 9674
we e hospi alised and 8563 we e discha ged ali e and had enough da a
a ailable o be included in he LOHRCA s udy (Fig. 2). O e all, he
mean age was 80 (SD 10) yea s, and 55.5% we e women. Como bidi ies
we e common, wi h he mos equen being hype ension (84.4%),
a ial fib illa ion (49.6%) and diabe es melli us (42.9%) (Table 1). Wi h
espec o baseline s a us, he mean Ba hel index was 79 (SD 25), le
en icula ejec ion ac ion 51% (SD 15), and 25.1% we e NYHA class
III o IV. A p io episode o AHF was eco ded in 60.5% o pa ien s, and
57.3% and 40.8% we e ecei ing ch onic ea men wi h enin-angio-
ensin sys em inhibi o s and be a-blocke s, espec i ely. Table 1 shows
he emaining da a ega ding baseline and ch onic s a us. Wi h ega d
o se e i y o decompensa ion, he MEESSI and EFFECT sco es
we e −2.69 (SD 1.13), and 116 (SD 25), espec i ely (Supplemen a y
Fig. 1).
The median LOH was 7 days (IQR 4–11). The LOH was < 6 days in
2934 pa ien s (34.3%), 6–10 in 3184 (37.2%), 11–15 in 1287 (15.0%),
and > 15 in 1158 (13.5%). These g oups we e diffe en in 10 ou o 22
ch onic o baseline s a us a iables (Table 1). They also diffe ed in he
MEESSI and he EFFECT sco es, and he highe he se e i y o he acu e
episode (assessed by ei he sco e), he longe he LOH (Table 1).
Du ing he 90-day pos -discha ge pe iod, 975 (11.4%) pa ien s died,
2760 (32.2%) we e eadmi ed, and 3202 (37.4%) achie ed he com-
bined endpoin (Fig. 3). Wi h espec o pa ien s wi h a LOH o < 6
days, unadjus ed HRs o mo ali y showed s a is ically significan in-
c eases o 50.8% and 86.6% i hospi alised 11–15 days and > 15 days,
espec i ely. Unadjus ed HRs o 90-day eadmission showed a s a is-
ically significan inc ease o 15.4% o pa ien s wi h LOH > 15 days,
and he 90-day combined endpoin showed s a is ically significan in-
c eases o 9.0%, 12.3% and 31.0% o coho s wi h LOH o 6–10,
11–15, and > 15 days, espec i ely (Fig. 3and Table 2). The models
wi h p og essi e adjus men showed simila esul s o 90-day mo -
ali y, and s a is ically significan inc eases we e main ained wi h he
comple e adjus men (model 6) o mo ali y in pa ien s wi h LOH
11–15 days (36.5% inc ease s. LOH < 6 days; 95% CI 13.0% o 64.9%)
and > 15 days (72.0% inc ease s. LOH < 6 days, 95% CI 42.5% o
107.5%). On he o he hand, LOH had a neu al effec on 90-day
eadmission a e comple e adjus men (model 6), while pa ien s wi h
LOH > 15 days had significan ly highe a es o he combined endpoin
(22% inc ease s. LOH < 6 days, 95% CI 9% o 37%) (Table 2). The
Fig. 3. Unadjus ed cu es co esponding o p opo ional haza ds o he ou leng h o hospi alisa ion g oups o he h ee ou comes e alua ed in he p esen s udy.
Ò. Mi ó, e al. Eu opean Jou nal o In e nal Medicine xxx (xxxx) xxx–xxx
5

de ailed daily analysis o LOH du ing he fi s 10 days showed no di -
e ences in adjus ed HRs o mo ali y, al hough he e we e inc eases in
he adjus ed HR o eadmissions and he composi e endpoin in pa-
ien s wi h a LOH o 8 and 9 days compa ed wi h 0–3 days (Fig. 4).
S a ified analysis was pe o med acco ding o whe he pa ien s had
ini ially been admi ed o ca diology (1911 pa ien s, 22.3%), in e nal
medicine (4716, 43.4%), ge ia ics (620, 7.2%) o a sho s ay uni
(1408, 16.4%). Wi h ew excep ions, simila pa e ns o HRs we e ob-
se ed in pos -discha ge ou comes o he ou depa men s (Fig. 5).
Inc eased mo ali y was obse ed in pa ien s hospi alised > 15 days,
i espec i e o he ini ial admission depa men , wi h inc emen s an-
ging om 66% (in e nal medicine) o 216% (ge ia ics). Con e sely,
he e was no inc eased eadmission isk, and only a significan inc e-
men in isk o combined endpoin was obse ed in pa ien s ini ially
hospi alised in ca diology o sho -s ay uni s o > 15 days (29% and
98%, espec i ely).
4. Discussion
The esul s o he LOHRCA s udy we e ob ained om a consecu i e
coho wi h p ospec i e collec ion o clinical da a o pa ien s hospi a-
lised o AHF in 41 Spanish hospi als and p o ide h ee main findings.
Fi s , sho hospi alisa ions we e no associa ed wi h an inc eased isk
o ad e se pos -discha ge ou comes du ing he subsequen 90 days,
while he isk o p esen ing an ad e se e en inc eased in pa ien s
hospi alised o > 15 days. Second, while mo ali y inc eased wi h a
longe LOH, eadmission did no . And hi d, he depa men whe e he
pa ien had ini ially been hospi alised did no seem o influence he
p e ious wo findings.
Ou esul s sugges ha sho hospi alisa ions a e a sa e and e en a
ecommendable op ion o pa ien s wi h AHF, since a e adjus ing o
po en ial diffe ences in baseline and ch onic s a us as well as o he
se e i y o decompensa ion, nei he mo ali y no eadmission in-
c eased when he LOH was 10 o less days. A e his ime poin , we
ound ha mo ali y p og essi ely inc eased wi h a leng hening in he
LOH, wi h a 73% inc ease in pa ien s in whom he LOH su passed
15 days compa ed o hose no su passing 5 days. This finding is in line
wi h ecen da a om a Polish s udy o 765 pa ien s discha ged om 32
ca diology wa ds. In his s udy, mo ali y inc eased 120% du ing an
a e age 414-day ollow-up in pa ien s wi h an index hospi alisa ion
exceeding 21 days compa ed o pa ien s hospi alised < 7 days [17].
Simila ly, Sud e al. epo ed a 28% inc ease in 30-day all-cause mo -
ali y in 58,230 AHF pa ien s admi ed o any hospi al wa d (no only
ca diology) in On a io, Canada o 9 days o mo e compa ed wi h hose
wi h a LOH o 5–6 days [18]. The e o e, ou da a confi m and expand
he di ec ela ionship be ween LOH and he isk o dea h epo ed in
such s udies. As we p ospec i ely eco ded clinical da a (in con as
wi h p e ious s udies ha we e based on adminis a i e da a
Table 2
Unadjus ed and adjus ed haza d a ios (HR) o ad e se ou comes pe leng h o hospi alisa ion g oup.
< 6 days 6–10 days 11–15 days > 15 days
90-day all-cause mo ali y
Unadjus ed HR 1 (Re e ence) 1.081 (0.921–1.265) [0.339] 1.508 (1.250–1.820) [ < 0.001] 1.866 (1.553–2.242) [ < 0.001]
Adjus ed HR (model 1) 1 (Re e ence) 1.064 (0.906–1.249) [0.447] 1.441 [1.193–1.740) [ < 0.001] 1.850 (1.536–2.227) [ < 0.001]
Adjus ed HR (model 2) 1 (Re e ence) 0.996 (0.847–1.171) [0.958] 1.351 (1.118–1.631) [0.002] 1.651 (1.371–1.989) [ < 0.001]
Adjus ed HR (model 3) 1 (Re e ence) 1.049 (0.893–1.232) [0.562] 1.455 (1.206–1.756) [ < 0.001] 1.847 (1.537–2.219) [ < 0.001]
Adjus ed HR (model 4) 1 (Re e ence) 0.986 (0.839–1.158) [0.862] 1.325 (1.097–1.599) [0.003] 1.600 (1.329–1.928) [ < 0.001]
Adjus ed HR (model 5) 1 (Re e ence) 1.040 (0.885–1.222) [0.635] 1.407 (1.164–1.699) [ < 0.001] 1.797 (1.490–2.167) [ < 0.001]
Adjus ed HR (model 6) 1 (Re e ence) 1.009 (0.859–1.186) [0.911] 1.365 (1.130–1.649) [0.001] 1.720 (1.426–2.075) [ < 0.001]
Adjus ed HR (by p opensi y sco e ma ching) 1 (Re e ence) 0.985 (0.829–1.170)
[0.860]
1.480 (1.174–1.864)
[ < 0.001]
1.830 (1.441–2.324)
[ < 0.001]
90-day eadmission due o AHF
Unadjus ed HR 1 (Re e ence) 1.070 (0.980–1.167) [0.131] 1.030 (0.915–1.158) [0.628] 1.154 (1.019–1.307) [0.024]
Adjus ed HR (model 1) 1 (Re e ence) 1.057 (0.968–1.154) [0.213] 1.001 (0.889–1.126) [0.992] 1.103 (0.973–1.250) [0.127]
Adjus ed HR (model 2) 1 (Re e ence) 1.052 (0.964–1.148) [0.256] 1.005 (0.893–1.130) [0.939] 1.121 (0.990–1.270) [0.073]
Adjus ed HR (model 3) 1 (Re e ence) 1.063 (0.974–1.160) [0.173] 1.024 (0.910–1.152) [0.696] 1.148 (1.014–1.300) [0.030]
Adjus ed HR (model 4) 1 (Re e ence) 1.052 (0.964–1.149) [0.256] 0.993 (0.883–1.118) [0.911] 1.091 (0.962–1.237) [0.175]
Adjus ed HR (model 5) 1 (Re e ence) 1.050 (0.962–1.147) [0.276] 0.993 (0.889–1.126) [0.997] 1.103 (0.974–1.251) [0.123]
Adjus ed HR (model 6) 1 (Re e ence) 1.046 (0.958–1.142) [0.316] 0.987 (0.877–1.111) [0.830] 1.083 (0.955–1.228) [0.215]
Adjus ed HR (by p opensi y sco e ma ching) 1 (Re e ence) 1.019 (0.928–1.119)
[0.690]
0.982 (0.856–1.128
[0.799]
1.026 (0.883–1.192)
[0.883–1.192]
90-day combined endpoin
Unadjus ed HR 1 (Re e ence) 1.090 (1.002–1.175) [0.044] 1.123 (1007–1.252) [0.038] 1.310 (1.170–1.467) [ < 0.001]
Adjus ed HR (model 1) 1 (Re e ence) 1.075 (0.988–1.169) [0.092] 1.087 (0.974–1.213) [0.136] 1.248 (1.113–1.400) [ < 0.001]
Adjus ed HR (model 2) 1 (Re e ence) 1.064 (0.978–1.156) [0.148] 1.084 (0.972–1.209) [0.149] 1.256 (1.120–1.407) [ < 0.001]
Adjus ed HR (model 3) 1 (Re e ence) 1.080 (0.993–1.173) [0.072] 1.115 (0.999–1.173) [0.052] 1.301 (1.162–1.457) [ < 0.001]
Adjus ed HR (model 4) 1 (Re e ence) 1.062 (0.977–1.155) [0.157] 1.069 (0.958–1.193) [0.235] 1.222 (1.090–1.369) [0.001]
Adjus ed HR (model 5) 1 (Re e ence) 1.065 (0.979–1.159) [0.141] 1.077 (0.979–1.202) [0.184] 1.232 (1.099–1.382) [ < 0.001]
Adjus ed HR (model 6) 1 (Re e ence) 1.058 (0.973–1.151) [0.190] 1.066 (0.955–1.190) [0.256] 1.216 (1.084–1.364) [0.001]
Adjus ed HR (by p opensi y sco e ma ching) 1 (Re e ence) 1.031 (0.943–1.127)
[0.596]
1.066 (0.936–1.231)
[0.335]
1.174 (1.022–1.347)
[0.023]
AHF: acu e hea ailu e.
Bold numbe s deno e compa isons wi h p alues < 0.05.
Model 1: adjus ed o diffe ences in ch onic s a us (age and sex; a ial fib illa ion, ch onic kidney disease and ce eb o ascula disease as como bidi ies; baseline
Ba hel index and NYHA class; and ch onic ea men wi h enin-angio ensin sys em inhibi o s be a-blocke s and mine alco icos e oid- ecep o an agonis s).
Model 2: adjus ed o he MEESSI sco e.
Model 3: adjus ed o he EFFECT sco e.
Model 4: adjus ed o diffe ences in ch onic s a us and he MEESSI sco e.
Model 5: adjus ed o diffe ences in ch onic s a us and he EFFECT sco e.
Model 6: adjus ed o diffe ences in ch onic s a us, he MEESSI and he EFFECT sco e.
P opensi y sco e ma ching compa isons we e made be ween 2688, 1257 and 1091 pai s o he compa ison be ween he e e ence g oup (< 6 days) and he 6–10,
11–15 and > 15 days g oups, espec i ely.
Ò. Mi ó, e al. Eu opean Jou nal o In e nal Medicine xxx (xxxx) xxx–xxx
6
collec ion), we we e able o include he se e i y o decompensa ion in
he adjus men o ou es ima ions. Howe e , al hough ou esul s we e
e y consis en in all he adjus ed models we de eloped, an inc ease in
mo ali y wi h a leng hening o LOH may jus signal a mo e ulne able
popula ion equi ing longe hospi alisa ion and a highe isk o pos -
discha ge dea h a he han demons a ing a di ec influence o LOH in
he isk o dea h.
Con e sely, we did no de ec an inc ease in 90-day eadmission
a es ela ed o LOH. This finding is in con as wi h p e ious s udies
assessing he ela ionship be ween LOH and pos -discha ge eadmission
[18–21]. While wo Ame ican s udies ha e demons a ed ha only
longe hospi alisa ions a e ela ed o all-cause and HF- ela ed ead-
missions [19,20], he Canadian Sud e al. s udy epo ed he same
finding o all-cause eadmission bu wi h a U-shape ela ionship o
HF- ela ed eadmission, wi h pa ien s wi h bo h he he sho es and
longes LOH being a inc eased isk [18]. By con as , analysis o he
6827 pa ien s om 27 coun ies included in he ASCEND-HF ial
showed ha a longe LOH was associa ed wi h a lowe isk in ead-
mission [21]. The e o e, ou findings a e ema kably diffe en om
hose ob ained in hese p e ious s udies, as we ailed o de ec any
ela ionship be ween LOH and he isk o pos -discha ge eadmission.
Hypo he ically, he ac ha we accoun ed o he se e i y o he epi-
sode could ha e con ibu ed o his absence o ela ionship. Re-
ma kably, only HF- ela ed eadmission was aken in o accoun in he
LOHRCA s udy. None heless, om all he in o ma ion cu en ly a ail-
able, i seems e iden ha while he ela ionship be ween LOH and
pos -discha ge mo ali y is clea and di ec , he exis ence and he way
o he ela ionship wi h pos -discha ge eadmission isk is s ill unclea
and needs u he s udies.
I is o no e ha we ound a ela i ely uni o m inc ease in mo ali y
in long hospi alisa ions ac oss he mos equen depa men s and
special ies in ol ed in in-hospi al AHF ca e. While ou esul s a e un-
ique in ha his app oach o in es iga e he effec on pos -discha ge
ou comes in indi idual depa men s has no p e iously been pe o med
by o he au ho s, hey a e con a y o many findings sugges ing ha he
managemen o AHF by ca diologis s may ha e be e ou comes
[22–24]. I should be no ed ha he esul s o he LOHRCA s udy
canno be in e p e ed as a esul o diffe ences in he pe o mance o
hese speciali ies managing AHF pa ien s du ing admission, bu a he
e e o ou comes ob ained du ing he ulne able phase ollowing pa-
ien discha ge. As p e iously commen ed, one possible explana ion is
ha an inc eased LOH is jus a ma ke o pa ien s wi h he highes isk,
Fig. 4. Compa a i e haza d a ios o he ully adjus ed model (adjus ed o diffe ences in baseline and ch onic s a us, he MEESSI sco e and he EFFECT sco e) o
he h ee ou comes e alua ed in he s udy: 90-day mo ali y (up), eadmission (middle) and combined endpoin (down). Analysis is p esen ed o he ou p edefined
leng h o hospi alisa ion g oups (le ) and de ailed day by day o he fi s 10 days ( igh ).
As e isks indica e p< 0.05 espec o e e ence g oup (Re .)
Ò. Mi ó, e al. Eu opean Jou nal o In e nal Medicine xxx (xxxx) xxx–xxx
7
and does no di ec ly cause he inc ease in mo ali y obse ed. We ha e
ied o limi his possibili y by making mul iple adjus men s, he eby
minimizing he po en ial effec o he diffe en ch onic o acu e pa ien
p ofiles, al hough unknown con ounde s may pe sis . I is well known
ha o pa ien s expe iencing an episode o AHF, he a e age su i al is
2 yea s, and he mos ulne able pe iod is he 3-mon h window im-
media ely a e discha ge [16,25]. Reducing pe sis en subclinical
conges ion, inc easing he use o disease-modi ying hea ailu e
he apies, and ensu ing op imal ansi ions o ca e a e hospi al dis-
cha ge ha e been desc ibed as essen ial s eps in imp o ing ou comes
o AHF pa ien s [24]. None heless, ou findings sugges ha inc eases
in LOH do no achie e g ea e o be e implemen a ion o hese key
s eps.
Again, a simila pa e n o eadmission was ound o he ou de-
pa men s, wi h no inc ease o eadmission isk associa ed wi h a longe
LOH. Only he combined endpoin occu ed mo e o en in pa ien s in-
i ially managed in he ca diology depa men o in he sho -s ay uni s
and who had a LOH > 15 days. One limi a ion which migh explain his
finding is ha we do no know how equen discha ge plans we e
implemen ed by each depa men . A ecen me a-analysis o 41 an-
domised ials es ing ansi ional ca e in e en ions demons a ed ha
implemen a ion o ansi ional plans a AHF pa ien discha ge achie es
a significan educ ion o 8% and 29% in he isk o ehospi alisa ion
and ED isi s, espec i ely [26]. As shown by ou esul s on mo ali y, i
Fig. 5. S a ified analysis o he effec o leng h o hospi alisa ion on 90-day ou comes acco ding o he depa men o hospi alisa ion ( ully adjus ed model).
Bold numbe s in he igh columns deno e p alue < 0.05.
Ò. Mi ó, e al. Eu opean Jou nal o In e nal Medicine xxx (xxxx) xxx–xxx
8
is clea ha a longe LOH wi h a g ea e oppo uni y o in e en ion
was no success ul in changing ou comes. Albei no s a is ically sig-
nifican , ou finding o a highe inc emen o eadmission (49%) in
pa ien s hospi alised longe han 15 days and who we e ini ially ad-
mi ed o sho -s ay uni s (on op o he 143% o inc ease in mo ali y)
p obably con ibu ed o he significan inc emen (98%) in he com-
bined endpoin in he same g oup o pa ien s. Many au ho s ha e un-
de lined he impo ance o candida e selec ion o define which pa ien s
should be admi ed o sho -s ay uni s, as ailu e o do his usually leads
o p olonged hospi alisa ions [7,8,27,28].
Ou s udy has some limi a ions. Fi s , his is a seconda y analysis
limi ed o hypo hesis gene a ion ha equi es confi ma ion in u u e
ials. Second, since he e was no sample size calcula ion due o he
explo a o y na u e o he s udy, a ype-II e o canno be excluded in
some o he es ima ions made, especially in he s a ified analysis by
depa men s (due o he small numbe o e en s in ce ain ou comes
and/o depa men s). Thi d, in his eal-li e coho wi hou in e en-
ion, a ending physicians ollowed hei usual local p o ocols and did
no ecei e any specific ins uc ions abou he p ecise ime o hospi al
discha ge and pa ien ansi ion. Fou h, he pa ien s we e om a single
coun y wi h a uni e sal public heal h ca e sys em, and since in e na-
ional he e ogenei y in o ganisa ional and ansi ion p ocesses is high
[29], ex e nal alida ion o ou esul s should be ca ied ou in u he
s udies in o he coun ies wi h diffe en heal hca e sys em models. And
fi h, we eco ded he depa men which was esponsible o admission
once eme gency depa men ca e was comple ed, bu we did no ack
u he pa ien ans e s om he ini ial depa men o o he s. The e-
o e, pos -discha ge ou comes canno en i ely be a ibu ed o he
managemen o he depa men o which pa ien s we e ini ially ad-
mi ed. An example o his limi a ion is he sho -s ay uni s whe e,
despi e mos o he pa icipa ing hospi als ha ing a LOH limi ed o 96 h,
some pa ien s ini ially admi ed o hese uni s had a LOH o > 10 (and
e en 15) days, p obably because hey we e mo ed o o he depa men s
o easons we do no know.
Despi e hese limi a ions, we can conclude ha sho hospi alisa-
ions in AHF pa ien s a e no associa ed wi h poo e ou comes, and ha
o he pa icula case o all-cause mo ali y, pa ien s hospi alised
longe han 10 days could be a inc eased isk. No la ge diffe ences in
ou comes we e obse ed among he main depa men s esponsible o
he ini ial hospi alisa ion.
Supplemen a y da a o his a icle can be ound online a h ps://
doi.o g/10.1016/j.ejim.2019.08.007.
Acknowledgemen s
This s udy was pa ially suppo ed by compe i i e g an s om he
Ins i u o de Salud Ca los III suppo ed wi h unds om he Spanish
Minis y o Heal h and FEDER (PI15/01019, PI15/00773, PI18/00393,
PI18/00456), Ca alonia Go e nmen (SGR 2009/1385, 2014/0313,
2017/1424), and Fundació La Ma a ó de TV3 (2015/2510). The ICA-
Resea ch G oup has ecei ed un es ic ed unding om No a is and
O ion Pha ma. The design o he s udy, pa ien inclusion, da a analysis,
discussion and final conclusions we e exclusi ely ca ied ou by he
au ho s wi h no pa icipa ion o he g an e s.
The au ho s ha e no hing o disclose in ela ionship wi h his
manusc ip .
Re e ences
[1] Voig J, Sasha John M, Taylo A, K ucoffM, Reynolds MR, e al. A ee alua ion o
he cos s o hea ailu e and i s implica ions o alloca iono heal h esou ces in he
Uni ed S a es. Clin Ca diol 2014;37:312–21.
[2] Mozaffa ian D, Benjamin EJ, Go AS, A ne DK, Blaha MJ, Cushman M, e al. Hea
disease and s oke s a is ics-2016 upda e: a epo om he Ame ican Hea
Associa ion. Ci cula ion. 2016;133:e38–360.
[3] Shafie AA, Tan YP, Ng CH. Repo demons a ing he majo i y o cos s in HF a e due
o hospi aliza ions. Hea Fail Re 2018;23:131–45.
[4] K umholz HM. Pos -hospi al synd ome: a condi ion o gene alized isk. N Engl J
Med 2013;368:100–2.
[5] Co e G, Da ison BA, Milo O, Bou ge RC, Cleland JG, Jondeau G, e al. P edic o s
and associa ions wi h ou comes o leng h o hospi al s ay in pa ien s wi h acu e
hea ailu e: esul s om VERITAS. J Ca d Fail 2016;22:815–22.
[6] S øm C, S e ansson JS, Fab i ius ML, Rasmussen LS, Schmid TA, Jakobsen JC.
Hospi alisa ion in sho -s ay uni s o adul s wi h in e nal medicine diseases and
condi ions. Coch ane Da abase Sys Re 2018(8):CD012370.
[7] Richa d Espiga F, Mòdol Del ell JM, Ma ín-Sánchez FJ, Fe nández Sie a A,
Fe nández Pé ez C, Juan Pas o A. Impac o an eme gency depa men sho -s ay
uni on clinical managemen and quali y o hospi al ca e indica o s. Eme gencias.
2017;29:147–53.
[8] Jacob Rod íguez J. Sho -s ay uni s: a sa e, winning be o hospi als. Eme gencias.
2017;29:145–6.
[9] Van Spall HGC, Rahman T, My on O, Ramasunda ahe ige C, Ib ahim Q, Kabali C,
e al. Compa a i e effec i eness o ansi ional ca e se ices in pa ien s discha ged
om he hospi al wi h hea ailu e: a sys ema ic e iew and ne wo k me a-analysis.
Eu J Hea Fail 2017;19:1427–43.
[10] Amb osy AP, Fona ow GC, Bu le J, Chioncel O, G eene SJ, Vadugana han M, e al.
The global heal h and economic bu den o hospi aliza ion o hea ailu e. Lessons
lea ned om hospi alized hea ailu e egis ies. JAMA 2014;63:1123–33.
[11] Mi ó Ò, Rosselló X, Gil V, Ma ín-Sánchez FJ, Llo ens P, He e o-Puen e P, e al.
P edic ing 30-day mo ali y o pa ien s wi h acu e hea ailu e in he eme gency
depa men : a coho s udy. Ann In e n Med 2017;167:698–705.
[12] Mi ó O, Llo ens P, Escalada X, He e o P, Jacob J, Gil V, e al. Analysis o he
diffe en ac o s o p ehospi al ca e o pa ien s wi h acu e hea ailu e in Spain.
Eme gencias 2017;29:223–30.
[13] Ho KKL, Ande son KM, Kannel WB, G osssman W, Le y D. Su i al a e he onse
o conges i e hea ailu e in F amingham hea s udy subjec s. Ci cula ion
1993;88:107–15.
[14] Ponikowski P, Voo s AA, Anke SD, Bueno H, Cleland JG, Coa s AJ, e al. 2016 ESC
guidelines o he diagnosis and ea men o acu e and ch onic hea ailu e: The
Task Fo ce o he diagnosis and ea men o acu e and ch onic hea ailu e o he
Eu opean Socie y o Ca diology (ESC). De eloped wi h he special con ibu ion o
he Hea Failu e Associa ion (HFA) o he ESC. Eu Hea J 2016;37:2129–200.
[15] Lee DS, Aus in PC, Rouleau JL, Liu PP, Naima k D, Tu JV. P edic ing mo ali y
among pa ien s hospi alized o hea ailu e. De i a ion and alida ion o a clinical
model. JAMA 2003;290:2581–7.
[16] G eene SJ, Fona ow GC, Vadugana han M, Khan SS, Bu le J, Gheo ghiade M. The
ulne able phase a e hospi aliza ion o hea ailu e. Na Re Ca diol
2015;12:220–9.
[17] Zap u ko J, Michalak M, Nowicka A, Dankowski R, D ożdżJ, Ponikowski P, e al.
Hospi alisa ion leng h and p ognosis in hea ailu e pa ien s. Ka diol Pol
2017;75:323–31.
[18] Sud M, Yu B, Wijeysunde a HC, Aus in PC, Ko DT, B aga J, e al. Associa ions be-
ween sho o long leng h o s ay and 30-day eadmission and mo ali y in hos-
pi alized pa ien s wi h hea ailu e. JACC Hea Fail 2017;5:578–88.
[19] A o a S, Lahewala S, Hassan Vi k HU, Se a eh-Shenas S, Pa el P, Kuma V, e al.
E iologies, ends, and p edic o s o 30-day eadmissions in pa ien s wi h dias olic
hea ailu e. Am J Ca diol 2017;120:616–24.
[20] Mi kin KA, Enomo o LM, Capu o GM, Hollenbeak CS. Risk ac o s o 30-day
eadmission in pa ien s wi h conges i e hea ailu e. Hea Lung 2017;46:357–62.
[21] Eapen ZJ, Reed SD, Li Y, Kociol RD, A ms ong PW, S a ling RC, e al. Do coun ies
o hospi als wi h longe hospi al s ays o acu e hea ailu e ha e lowe ead-
mission a es?: findings om ASCEND-HF. Ci c Hea Fail 2013;6:727–32.
[22] Jong P, Gong Y, Liu PP, e al. Ca e and ou comes o pa ien s newly hospi alized o
hea ailu e in he communi y ea ed by ca diologis s compa ed wi h o he spe-
cialis s. Ci cula ion 2003;108:184–91.
[23] Boom NK, Lee DS, Tu JV. Compa ison o p ocesses o ca e and clinical ou comes o
pa ien s newly hospi alized o hea ailu e a ended by diffe en physician spe-
cialis s. Am Hea J 2012;163:252–9.
[24] U hamalingam S, Kandala J, Sel a aj V, e al. Ou comes o pa ien s wi h acu e
decompensa ed hea ailu e managed by ca diologis s e susnonca diologis s. Am
J Ca diol 2015;115:466–71.
[25] A igo M, Nijs P, Rudige A. Op imising hea ailu e he apies in he acu e se ing.
Ca d Fail Re 2018;4:38–42.
[26] Vedel I, Khanasso V. T ansi ional ca e o pa ien s wi h conges i e hea ailu e: a
sys ema ic e iew and me a-analysis. Ann Fam Med 2015;13:562–71.
[27] Ma ín-Sánchez FJ, Pe digones J, Fe é Losa C, Llopis F, Na a o Bus os C, Bo az
O das C, e al. 180-day isk o mo ali y in olde pa ien s admi ed o sho -s ay
uni s: he 6-Mon h Sho -S ay Uni (6M UCE) Sco e. Eme gencias 2018;30:315–20.
[28] Mi ó Ò, Ca bajosa V, Peacock WF, Llo ens P, He e o P, Jacob J, e al. The effec o
a sho -s ay uni on hospi al admission and leng h o s ay in acu e hea ailu e:
REDUCE-AHF s udy. Eu J In e n Med 2017;40:30–6.
[29] Bha AB, Chee an DD, Shemisa K, Roy L, Manz BN, Vigen R, e al. Physician-spe-
cific p ac ice pa e ns abou discha ge eadiness and hea ailu e u iliza ion ou -
comes. Ci c Ca dio asc Qual Ou comes 2018;11:e004365.
Ò. Mi ó, e al. Eu opean Jou nal o In e nal Medicine xxx (xxxx) xxx–xxx
9