To the Editor,
We read with great interest the article Miró et al1 published in the Revista Española de Cardiología regarding prognostic factors for elderly patients treated for acute heart failure in emergency rooms. The strong point of the study is that it includes all heart failure patients older than 65 years who came to the emergency room during one month and provides an assessment of their functional class according to the Barthel scale, which was one of the prognostic factors for mortality at 30 days. However, we must point out that the left ventricular ejection fraction was not listed among the possible prognostic factors. According to clinical practice guidelines for diagnosing heart failure, heart failure signs and symptoms are required along with objective evidence of a structural or functional change in the heart at rest.2 In daily clinical practice, we often resort to the echocardiogram or the natrurietic peptide results, and one of the limitations in this study, recognised by the authors themselves, is that neither of these tests were used in a large number of patients, despite the fact that as many as 85% were admitted to tertiary hospitals. The Euro Heart Failure Survey II showed that fewer echocardiograms are perfomed elderly patients who are hospitalised due to an episode of acute heart failure than in younger patients3; however, we believe that knowing the left ventricular ejection fraction is a criterion of quality of care for treating patients with heart failure. For this reason, we would like to know how many of the patients in the study conducted by Miró et al. had a known ejection fraction at time of hospitalisation, or at least one from the previous year. We feel that this information is very relevant, since treatments that have been shown to be effective are applied according to this result. Such treatments include inhibition of the renin-angiotensin-aldosterone and sympathetic systems in patients with systolic dysfunction of the left ventricle.2