Heart failure (HF) is a major public health problem worldwide and is associated with high mortality, morbidity, and healthcare costs. The overall prevalence of HF in the US is 2.4% of the adult population, while the corresponding rates in Europe range between 2% and 4.3%, rising to 10–16.1% among individuals aged ≥70 years.1–3 Acute heart failure (AHF) is a complex pathological entity, defined by the European Society of Cardiology (ESC) guidelines as the rapid onset of, or change in, symptoms and signs of HF.4 In most cases, AHF arises as a result of deterioration in patients with a previous diagnosis of HF (HF with either reduced ejection fraction [HFrEF] or preserved ejection fraction [HFpEF]).4 The prognosis of patients with AHF is poor, with high rates of rehospitalization and mortality. In the US nearly 25% of patients with AHF are rehospitalized within 30 days of the index presentation.5,6 In Europe, approximately 44–50% are rehospitalized within one year of an acute episode,3,7 with significant rates of in-hospital and one-year mortality (6.7%8 and 17.4–21%,7,9 respectively). Long-term all-cause mortality is also very high: nearly 50% of patients with a diagnosis of HF will die within five years.10 A prospective analysis also shows that the rate of HF deaths can rise to 23% at 30 days.11 This has prompted medical societies, researchers, policy makers and the pharmaceutical industry to focus their efforts on consolidating and analyzing evidence and developing innovative solutions for the treatment of patients with AHF.

Despite the advances seen in the treatment of chronic heart failure (CHF) over the past few years, the management of patients with AHF, including classification, diagnosis and treatment, has not changed significantly.3 This can be attributed, at least in part, to the wide heterogeneity in clinical presentation and underlying pathophysiological mechanisms of AHF, which poses challenges for the timely diagnosis and individualized management of these patients. The classification of AHF in the ESC heart failure guidelines has undergone a change. The 2008 classification was based on clinical presentation, including a spectrum of conditions such as worsening or decompensated CHF, pulmonary edema, hypertensive HF, cardiogenic shock, isolated right HF, and acute coronary syndrome (ACS).3 In the latest guidelines (2012), classification is limited to the time of presentation of the acute heart failure episode, i.e., de novo (first presentation) or decompensated (deterioration of previously stable CHF).4

In the 2008 ESC guidelines, the approach to assessment of patients with AHF includes hemodynamic profiles, i.e. the presence or absence of congestion (“wet or dry”) and adequacy of perfusion (“warm or cold”).3 This approach is based on the determination of HF hemodynamics is adopted by the authors of the recently implemented Advanced Heart Failure Support Program (SAVIC), a partnership between the Portuguese and Brazilian Societies of Cardiology.12 According to the 2012 ESC guidelines, the diagnosis of AHF is mainly based on signs and symptoms at the time of presentation and various diagnostic modalities such as electrocardiogram (ECG), chest X-ray, echocardiogram, and biomarkers such as natriuretic peptides and other laboratory tests.4 Furthermore, the 2012 ESC guidelines5 recommend that diagnosis and treatment tasks be performed concomitantly.

Regarding AHF treatment, there have been few advances that have dramatically changed its management. The current treatment of AHF includes loop diuretics, vasodilators, and inotropic agents, and is largely opinion-based with very limited evidence from randomized clinical trials.4 This reflects the lower levels of recommendation for AHF therapies, ranging between IB for intravenous (IV) loop diuretics, and IIaC for inotropes.4 Also, most of these therapies focus on short-term symptomatic relief, and the evidence of their effect on long-term outcomes such as mortality is neutral or negative.

There have been numerous registries and studies on heart failure in several European countries including Portugal, but data on the prevalence and drug management of AHF continues to be scarce. In an attempt to gain a comprehensive understanding of AHF and to identify gaps in its characterization and management in Portugal, this review was performed to review the existing data on the epidemiology, clinical presentation, and therapeutic management of AHF in Portugal and to compare it with data from other European countries.

A literature search was conducted using BIOSIS Previews (1995–2014), EMBASE (1996–2014), Ovid MEDLINE® (without Revisions 1996–October 2014), and Ovid MEDLINE® In-Process & Other Non-Indexed Citations (2014). To ensure that all relevant papers were captured, data from the last 14 years were retrieved. The following text search terms were used: (Incidence OR Prevalence OR Mortality OR Length of stay OR Hospital* OR Cost OR Quality of life OR Outcomes AND Heart failure AND Portugal), (Incidence OR Prevalence OR Mortality OR Length of stay OR Hospital* OR Cost OR Quality of life OR Outcomes AND Heart failure AND Europe). The search terms were free text words rather than MeSH terms, in order to retrieve all relevant articles. The limits applied were: 2000 to October 2014; publication type: articles; humans.

The article selection criteria are illustrated in Figure 1. Out of the total of 1507 articles identified from the literature search, 1411 were rejected based on the title and abstract screening. Of the remaining 96 articles, 87 articles were retrieved for full text review, of which a further 68 were rejected as review articles or irrelevant data or due to duplication or inappropriate disease state. A total of 19 articles were finally included in this review.

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Figure 1.

Selection criteria for literature review. CHF: chronic heart failure.

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Seven Portuguese studies were selected for this review (Table 1).13–19 These studies were published between 2004 and 2013 and all of them were observational, single-center studies with a follow-up duration ranging between two and 18 months. Patients in these studies were recruited over a period of six months and AHF was diagnosed on the basis of the diagnostic criteria of the ESC guidelines or the Framingham criteria for HF. A wide variation in sample sizes was observed across the seven studies (n=163 to 924) (Table 1).

Nine European registries were included (Table 2),7,9,20–28 five of which involved multiple centers across several countries: the Europe Acute Heart Failure Global Registry of Standard Treatment (ALARM), Euro Heart Failure Surveys I and II (EHFS I and II), the European Society of Cardiology - Heart Failure (ESC-HF) LongTerm Registry, and the ESC-HF Pilot Survey. Three of these (EHFS I and II and ESC-HF LongTerm Registry)9,22,23 included patients from Portugal. The remaining registries were conducted in France (EFICA [Etude Française de l’Insuffisance Cardiaque Aigue]21 and OFICA [Observatoire Français de l’Insuffisance Cardiaque Aigue]),27 Italy (Italian Registry on Heart Failure Outcome [IN-HF])26 and one combining data from Zurich and Helsinki (Zurich Helsinki Study).28 These European observational studies were published between 2003 and 2013. The recruitment period ranged between five and 24 months, apart from the OFICA study,27 in which the recruitment period was a single day. The follow-up in these registries ranged from 12 weeks to 12 months. The ESC/European Society of Intensive Care Medicine (ESICM) guidelines and physician-based assessments were used for the diagnosis of AHF and recruitment of patients in these registries. The sample sizes in these studies ranged from 312 to 11327 patients.

Data on the pharmacological management of AHF (from the hemodynamic stabilization phase to discharge) are limited in Portuguese and European studies and are not uniformly captured.

This review aimed to gather and compare data on the prevalence and management of AHF from European and Portuguese studies. Gaps were identified in the data on epidemiology, treatment and clinical outcomes in patients with AHF in both the Portuguese studies and European registries. The key limitation of this review is the existence of studies with a small sample size, short follow-up period, lack of comprehensive assessment of clinical outcomes and treatment patterns. When the available data could be compared, the evidence provided by Portuguese and European studies was similar. High mortality and hospitalization rates were observed for AHF in all the studies analyzed, which will presumably be reflected in a proportionally higher impact on costs in all healthcare systems. Acute heart failure should be the focus of the scientific community and public entities so that policies may be generated to help patients and physicians to manage this disease.

Based on the results of this review, three areas of further investment can be identified: collection of data and investigation of the disease and treatment, training in disease management, and improved organization of healthcare.

Regarding the scarcity of data, there is a clear need to implement well-defined studies incorporating larger samples, longer follow-up periods, and better defined clinical endpoints. From a national perspective, in practice this means the need for a Portuguese registry that captures accurate data on acute and chronic HF. Steps have been taken by the Portuguese Society of Cardiology to adopt the design of the ESC-HF Long-Term Registry aiming to include various types of centers: cardiology, internal medicine, and intensive care departments, so that more patients than those included in the ESC-HF Long-Term Registry can be captured. Furthermore, uniformity in reporting the treatment of patients with AHF is crucial to identify gaps in disease management. In terms of research and development of innovative solutions for the treatment of AHF, there is a need for new trials with appropriate endpoints that can capture robust acute phase data.

Identification of challenges and a focus on both management strategies and research needs are required to significantly decrease the burden of AHF. The Portuguese medical community is aware of the need for training in the management of AHF, and to address this, the Portuguese Society of Cardiology is implementing the Advanced Heart Failure Support program, a Portuguese Society of Cardiology/Brazilian Society of Cardiology partnership.

Finally, there is also an urgent need to improve healthcare organization for patients with AHF. Consensual patient flows based on different healthcare levels and specialties involved in AHF management should be implemented to improve patients’ quality of life and survival, and to reduce the burden on the healthcare system.

Daniel Brás is an employee of Novartis Farma S.A., Porto Salvo, Portugal.