RESUMEN
Some patients with COVID-19 have complex hypercoagulable abnormalities that are related to mortality. The optimal dosage of low molecular weight heparin in hospitalized patients with SARS-CoV-2 pneumonia is still not clear. Our objective is to evaluate the effects of adapting the dosage of low molecular weight heparin to thrombotic and bleeding risk scales in this setting. We performed a cohort, retrospective, observational, and analytical study at the Hospital Universitario of Jerez de la Frontera, with patients admitted with SARS-CoV-2 pneumonia from 1 October 2020 to 31 January 2021. They were classified according to whether they received prophylactic, intermediate, or therapeutic doses of enoxaparin. The primary endpoint was intrahospital mortality. Secondary endpoints were the need for invasive ventilation, thromboembolic events, bleeding, and the usefulness of thrombotic and bleeding scales. After binary logistic regression analysis, considering confounding variables, it was found that the use of enoxaparin at therapeutic doses was associated with lower mortality during admission compared to prophylactic and intermediate doses (RR 0.173; 95% CI, 0.038-0.8; p = 0.025). IMPROVE bleeding risk score correlated with a higher risk of minor bleeding (RR 1.263; 95% CI, 1.105-1.573; p = 0.037). In adult hospitalized patients with SARS-CoV-2 pneumonia presenting elevated D-dimer and severe proinflammatory state, therapeutic doses of enoxaparin can be considered, especially if bleeding risk is low according to the IMPROVE bleeding risk score.
RESUMEN
Introduction: There are studies that evaluate the association between chronic obstructive pulmonary disease (COPD) and heart failure (HF) but there is little evidence regarding the prognosis of this comorbidity in older patients admitted for acute HF. In addition, little attention has been given to the extracardiac and extrapulmonary symptoms presented by patients with HF and COPD in more advanced stages. The aim of this study was to evaluate the prognostic impact of COPD on mortality in elderly patients with acute and advanced HF and the clinical manifestations and management from a palliative point of view. Methods: The EPICTER study ("Epidemiological survey of advanced heart failure") is a cross-sectional, multicenter project that consecutively collected patients admitted for HF in 74 Spanish hospitals. Demographic, clinical, treatment, organ-dependent terminal criteria (NYHA III-IV, LVEF <20%, intractable angina, HF despite optimal treatment), and general terminal criteria (estimated survival <6 months, patient/family acceptance of palliative approach, and one of the following: evidence of HF progression, multiple Emergency Room visits or admissions in the last six months, 10% weight loss in the last six months, and functional impairment) were collected. Terminal HF was considered if the patient met at least one organ-dependent criterion and all the general criteria. Both groups (HF with COPD and without COPD) were compared. A Kaplan−Meier survival analysis was performed to evaluate the presence of COPD on the vital prognosis of patients with HF. Results: A total of 3100 patients were included of which 812 had COPD. In the COPD group, dyspnea and anxiety were more frequently observed (86.2% vs. 75.3%, p = 0.001 and 35.4% vs. 31.2%, p = 0.043, respectively). In patients with a history of COPD, presentation of HF was in the form of acute pulmonary edema (21% vs. 14.4% in patients without COPD, p = 0.0001). Patients with COPD more frequently suffered from advanced HF (28.9% vs. 19.4%; p < 0.001). Consultation with the hospital palliative care service during admission was more frequent when patients with HF presented with associated COPD (94% vs. 6.8%; p = 0.036). In-hospital and six-month follow-up mortality was 36.5% in patients with COPD vs. 30.7% in patients without COPD, p = 0.005. The mean number of hospital admissions during follow-up was higher in patients with HF and COPD than in those with isolated HF (0.63 ± 0.98 vs. 0.51 ± 0.84; p < 0.002). Survival analysis showed that patients with a history of COPD had fewer survival days during follow-up than those without COPD (log Rank chi-squared 4.895 and p = 0.027). Conclusions: patients with HF and COPD had more severe symptoms (dyspnea and anxiety) and also a worse prognosis than patients without COPD. However, the prognosis of patients admitted to our setting is poor and many patients with HF and COPD may not receive the assessment and palliative care support they need. Palliative care is necessary in chronic non-oncologic diseases, especially in multipathologic and symptom-intensive patients. This is a clinical care aspect to be improved and evaluated in future research studies.