BACKGROUND:Administrative data show that acute heart failure (HF) patients are older than those enrolled in clinical registries and frequently admitted to non-cardiological settings of care. The purpose of this study was to describe clinical characteristics of old patients hospitalised for acute HF in Cardiology, Internal Medicine or Geriatrics wards.METHODS:Data came from ATHENA (AcuTe Heart failurE in advaNced Age) registry which included elderly patients (≥ 65 years) admitted to the above mentioned settings of care from December 1, 2014 to December 1, 2015.RESULTS:We enrolled 396 patients, 15.4% assigned to Cardiology, 69.7% to Internal Medicine, and 14.9% to a Geriatrics ward. Mean age was 83.5 ± 7.6 years (51.8% of patients ≥ 85 years) and was higher in patients admitted to Geriatrics (P < 0.001); more than half were females. Medical treatments did not differ significantly among settings of care (in a context of a low prescription rate of renin-angiotensin-aldosterone system inhibitors) whereas significant differences were observed in comorbidity patterns and management guidelines recommendation adherence for decongestion evaluation with comparison of weight and N-terminal pro-B-type natriuretic peptide levels on admission and at discharge (both P = 0.035 and P < 0.001), echocardiographic evaluation ( P < 0.001) and follow-up visits planning ( P < 0.001), all higher in Cardiology. Mean in-hospital length of stay was 9 ± 5.9 days, significantly higher in Geriatrics (13.7 ± 6.5 days) and Cardiology (9.9 ± 6.7 days) compared to Internal Medicine (8 ± 5.2 days), P < 0.001. In-hospital mortality was 9.3%, resulting higher in Geriatrics (18.6%) and Cardiology (16.4%) than Internal Medicine (5.8%), P = 0.001.CONCLUSIONS:In elderly patients hospitalised for acute HF, clinical characteristics and management differ significantly according to the setting of admission.

Atrial fibrillation (AF) is a frequent pathology in Internal Medicine departments. The aim of our study was to identify the risk factors associated with the development of new-onset AF during hospitalization and to evaluate its outcome as in-hospital mortality. We conducted a retrospective case–control study on a cohort of 14,179 patients admitted to an internal medicine department. We included in the study the patients who did not have an anamnestic history of AF, who presented a sinus rhythm at the time of admission and who developed a new-onset AF during hospitalization. For each of these cases, two controls were enrolled who were not affected by AF. The patients included in the study were 588, including 196 cases and 392 controls. Patients who developed AF during hospitalization had significantly more comorbidity than controls. The most frequent causes for hospitalization were sepsis, significantly higher in the case group. From the results of the multivariate analysis, the factors related independently to the development of AF were the presence of a number of comorbidities ≥ 3 (OR = 1.52; p = 0.017), sepsis as a reason of hospitalization (OR = 2, 16; p = 0.001) and glycemic value at the admission ≥ 130 mg/dL (OR = 1.44; p = 0.047). Both the length of hospital stay and in-hospital mortality were higher in the group of patients who developed AF, with a statistically significant difference compared to controls (p < 0.001).

To evaluate the role of performance status evaluated by the Eastern Cooperative Oncology Group (ECOG) score in predicting 30-day mortality in subjects hospitalized for community acquired pneumonia (CAP), this was a prospective study of patients consecutively hospitalized for CAP at a large University Hospital in Italy. Performance status was evaluated using the ECOG score that in a 0–5 point scale indicates progressive functional deterioration. The end-point of the study is the 30-day mortality. Two-hundred-sixteen patients were enrolled, 75.9% were aged > 70 years, 31.5% had severe pneumonia at CURB-65 score (3–4), and 27.5% of patients had severe disability (ECOG 3–4). Thirty-day mortality is 15.3%. Progression in ECOG score independently increases the probability of 30-day mortality at multivariable logistic regression analysis (HR 2.19, 95% CI 1.60–3.01, p < 0.0001). ECOG 3 or 4 determines a four-fold increase in 30-day mortality (HR 4.07, 95% CI 1.84–9.02, p < 0.001). ECOG score 3 or 4 is highly predictive of death in patients classified at low risk of mortality by CURB-65 (0–2 points) score. Functional status is directly related to outcome in elderly patients hospitalized for CAP. The use of a very simple and fast tool, such as the ECOG score, might help to better stratify the risk of short-term mortality, especially in patients otherwise classified at low risk of death by CURB-65 score.

BACKGROUND:Guidelines recommend triple therapy (TT) with ACE inhibitors or ARBs, beta-blockers and mineralcorticoid receptor antagonists in symptomatic heart failure patients with ejection fraction <35 % (HFrEF). Nevertheless, many patients remain untreated. This study was aimed to evaluate the use of TT in HFrEF patients discharged from internal medicine wards of Tuscany, Italy.METHODS AND RESULTS:We analyzed the database of a multicenter observational study which included 770 patients consecutively hospitalized for HF in 32out of 36 Internal Medicine Units of Tuscany, Italy. The value of ejection fraction was available in 490 of the 725 patients discharged alive. Of the 117 patients with HFrEF, only 46 (39.3%) were on TT at discharge while 71 (60.7%) were not. In the latter group we observed a significantly greater percentage of patients with cognitive deficit (25.3% vs 10.8%, p=0.05). In the same group there was a slightly greater percentage of patients with hypertension (61.9% vs 58.6%), diabetes (43.6% vs 36.9%), GFR<60 ml/min (74.6% vs 67.3%), anemia (52.1% vs 45.6%) and atrial fibrillation (40.8% vs 34.7%), but the differences were not statistically significant.CONSLUSIONS:These results indicate that TT is underutilized in internal medicine wards of Tuscany. Untreated patients had a greater rate of cognitive deficit and were probably sicker, more complex and fragile.

Community-acquired pneumonia (CAP) represents a common cause of hospitalization in Internal Medicine wards and a frequent cause of antibiotic prescription. An approach based on procalcitonin (PCT) algorithm, has shown to reduce the antibiotic exposure without affecting outcome, in patients admitted to hospital for pneumonia We conducted a study to evaluate the role of a PCT algorithm in a real-life perspective, to reduce the length of antibiotic treatment (AT) in patients hospitalized with CAP. We performed a prospective case-control study, enrolling patients with CAP admitted to an Internal Medicine ward of Careggi Hospital, between December 2013 and February 2014. We used a validated algorithm of AT guided by PCT in CAP. Discontinuation of AT was strongly indicated when PCT level was normal or reduced by 80% in patients with PCT values higher than 10 pg/mL on admission. PCT was drawn on admission, 24 h, 4th day and 6th day from admission. The outcomes evaluated were the length of AT, the length of in hospital stay, mortality and serious adverse clinical events. Forty-six patients were consecutively enrolled. On 20 patients, AT was discontinued according to protocol and on 26 patients the AT was continued on clinical judgement. At the baseline, both groups were similar regarding clinical, laboratory, microbiology characteristics, and CURB-65 score. PCT guidance reduced total antibiotic exposure (5.1±1.5 vs 9.1±5.8 days, P=0.005) without any increase of mortality or serious clinical event. In our study, a PCT algorithm was a useful and safe tool to guide the AT in patients with CAP, reducing the antibiotic exposure.

BACKGROUND:Severe sepsis and septic shock are leading causes of morbidity and mortality among critically ill patients, thus the identification of prognostic factors is crucial to determine their outcome. In this study, we explored the value of procalcitonin (PCT) variation in predicting 30-day mortality in patients with sepsis admitted to an intermediate care unit.METHODS:This prospective observational study enrolled 789 consecutive patients with severe sepsis and septic shock admitted to a medical intermediate care unit between November 2012 and February 2014. Kinetics of PCT expressed as percentage were defined by the variation between admission and 72 hours, and 24 and 72 hours; they were defined as Δ-PCT0-72h and Δ-PCT24-72h, respectively.RESULTS:The final study group of 144 patients featured a mean age of 73 ± 14 years, with a high prevalence of comorbidities (Charlson index greater than 6 in 39%). Overall, 30-day mortality was 28.5% (41/144 patients). A receiver-operating-characteristic (ROC) analysis identified a decrease of Δ-PCT0-72h less than 15% (area under the curve: 0.75; 95% confidence interval (CI): 0.67 - 0.82) and a decrease of Δ-PCT24-72h less than 20% (area under the curve: 0.83; 95% CI: 0.74 - 0.92) as the most accurate cut-offs in predicting mortality. Decreases of Δ-PCT0-72h less than 15% (HR: 3.9, 95% CI: 1.6 - 9.5; P < 0.0001) and Δ-PCT24-72h less than 20% (HR: 3.1, 95% CI: 1.2 - 7.9; P < 0.001) were independent predictors of 30-day mortality.CONCLUSIONS:Evaluation of PCT kinetics over the first 72 hours is a useful tool for predicting 30-day mortality in patients with severe sepsis and septic shock admitted to an intermediate care unit.

We prospectively evaluated whether the N-terminal brain natriuretic peptide (NT-ProBNP) reduction percentage, during hospitalization for acutely decompensated heart failure (HF), has a prognostic significance in 6-month follow-up. In 120 patients consecutively admitted for acute HF to an internal medicine unit, plasma NT-ProBNP was measured on admission and at discharge. During a 6-month follow-up 52 (43.3%) patients had events: 9 (7.5%) died from cardiovascular causes, and 43 (35.8%) were readmitted for HF. In patients without events,the mean reduction percentage of NT-ProBNP was greater than in patients with events (39.5 +/- 7.4 versus 26.3 +/- 5.9%; P= 0.04). In receiver operating characteristic curve analysis, the mean area under the curve for NT-ProBNP reduction percentage was 0.63 (95% CI, 0.51-0.75; P = 0.04) for the composite end point (death or readmission), and 0.81 (95% CI, 0.65-0.97, P=0.01) for cardiovascular mortality. NT-ProBNP reduction percentage less than 30% was the best cut-off for the identification of patients at risk of events. We suggest that in clinical practice the evaluation of change of NT-ProBNP levels during admission is probably more helpful than predischarge NT-ProBNP absolute value.