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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">This editorial refers to &#8220;Characterization of acute heart failure hospitalizations in a Portuguese cardiology department&#8221; by A&#46;C&#46; Pinho-Gomes et al&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Acute heart failure &#40;AHF&#41; is a highly prevalent condition&#44; a common cause of hospitalization associated with significant in-hospital mortality and poor short- and longer-term outcomes&#44; and represents a significant burden on overall healthcare costs&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The condition is difficult to define and classify&#46; The latest ESC guidelines on acute and chronic heart failure &#40;HF&#41; refer to AHF as &#8220;the term used to describe the rapid onset of&#44; or change in&#44; symptoms and signs of heart failure&#46; It is a life-threatening condition that requires immediate medical attention and usually leads to urgent admission to hospital&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The assumptions included in this apparently undefined &#8220;definition&#8221; of AHF in fact apply to all forms of acute heart failure&#44; a complex clinical syndrome that varies widely in terms of underlying pathophysiologic mechanisms&#44; clinical presentations and targeted therapies&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Most AHF patients presenting to an emergency department are admitted to hospital<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a> and it is the most common diagnosis at discharge in patients aged &#62;65 years&#46; The syndrome&#39;s high in-hospital mortality of 3-12&#37; and short-term readmission rate of 25-30&#37;&#44; with the associated costs&#44; are critical issues worldwide&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;6&#44;13&#44;14</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The heterogeneity of AHF syndrome&#40;s&#41; hinders any attempt at classification or application of a single-algorithm approach&#46; AHF may present either as new-onset HF or worsening of pre-existing HF&#44; and these two forms may differ in causes&#44; precipitating factors&#44; associated comorbidities&#44; therapeutic options&#44; in-hospital mortality and post-discharge prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4&#44;13&#44;15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Regarding clinical presentations&#44; data from the EuroHeart Failure Survey &#40;EHFS&#41; II &#40;3580 patients with AHF enrolled&#41; showed that 65&#46;4&#37; of patients presented with decompensated HF&#44; 11&#46;4&#37; with hypertensive HF&#44; 16&#46;2&#37; with pulmonary edema&#44; 3&#46;9&#37; with cardiogenic shock&#44; and 3&#46;2&#37; with isolated right HF&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Cardiac dysfunction may be due to different causes&#44; including acute coronary syndromes&#44; valve dysfunction&#44; arrhythmias&#44; pericardial disease&#44; and increased left ventricular afterload&#46; These different causes &#40;which can also act as precipitating factors for the syndrome&#41; may coexist and interact in the same patient&#44; modulating clinical presentation and influencing management options and outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Data on AHF studies and registries provide valuable information regarding the pathophysiologic&#44; therapeutic&#44; and prognostic issues related to different clinical scenarios&#59; they are useful for assessing the extent of compliance with heart failure management guidelines and can help improve clinical assessment and both short- and long-term outcome&#46; Also&#44; analysis of similarities and differences in patient characteristics and management in different centers and countries&#44; in various settings&#44; may help to determine the most useful independent predictors of a worse prognosis and to define better strategies to obtain more favorable outcomes&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The paper by Pinho-Gomes et al&#46; in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> presents the results of a hospital-based&#44; observational&#44; retrospective cohort study conducted in a single large Portuguese center &#40;a teaching hospital&#41;&#44; focusing on acute heart failure admissions to the cardiology department during 2010&#46; Patients enrolled met the ESC criteria for HF<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and were selected by review of the medical records of patients discharged with a diagnosis of AHF &#40;either primary or secondary to another acute cardiac event&#41;&#46; Acute coronary syndromes &#40;ACS&#41; patients were included&#46; All patients were followed for at least 12 months after discharge&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The study aimed to clarify the overall clinical characteristics of patients with AHF and their hospital management and outcomes&#44; and also to identify predictors of rehospitalization or death at six and 12 months after discharge&#46; Importantly&#44; patients admitted in two different AHF clinical contexts &#8722; ACS vs&#46; non-ACS &#8722; were compared&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">AHF accounted for 21&#37; of all admissions &#40;201&#47;924&#41; over the one-year inclusion period&#46; Most were men &#40;61&#37;&#41; and the mean age was 69 years&#46; AHF was new-onset in 53&#37; and most admissions &#40;63&#37;&#41; were in the context of ACS&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The prevalence of new-onset AHF as well as of ACS as the precipitating factor were both higher than in the EHFSII<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and ALARM-HF<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> studies that included patients of a mixed provenance &#40;internal medicine and cardiology wards&#41;&#46; However&#44; new-onset AHF was lower than in ATTEND&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> an epidemiological study of AHF in the Asia Pacific region that excluded patients with ACS&#46; Acute decompensated chronic heart failure &#40;DCHF&#41; was the clinical presentation in 46&#46;8&#37; of patients and pulmonary edema in 21&#46;4&#37;&#44; similar to other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;14</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Comparison of AHF patients presenting with or without ACS showed significant differences&#44; on the basis of which two different clinical profiles can be defined&#46; Patients presenting with ACS as the precipitating event were younger&#44; less often men&#44; and more commonly had a history of chronic hypertension &#40;72&#46;4&#37; vs&#46; 55&#46;4&#37;&#41; and coronary artery disease &#40;45&#37; vs&#46; 27&#37;&#41;&#46; New-onset HF was the rule &#40;74&#37; vs&#46; 17&#46;6&#37;&#41; and pulmonary edema was a common clinical presentation &#40;26&#37; vs&#46; 13&#46;5&#37;&#41;&#46; In contrast&#44; patients with non-ACS AHF were older and more often men&#44; the cause of cardiac dysfunction was more frequently valve disease &#40;31&#37; vs&#46; 5&#46;5&#37;&#41; or dilated cardiomyopathy &#40;17&#46;6 vs&#46; 1&#46;6&#37;&#41;&#44; and a history of previous HF hospitalizations was more common &#40;25&#46;7&#37; vs&#46; 8&#46;7&#37;&#41;&#44; as was atrial fibrillation &#40;46&#37; vs&#46; 22&#37;&#41;&#46; The factor triggering AHF in this population was frequently arrhythmia &#40;39&#46;2&#37;&#41; and DCHF was the dominant acute clinical presentation &#40;82&#46;4&#37;&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The prevalence of cardiovascular diseases &#8722; hypertension and coronary artery disease being the most common &#8722; and of non-cardiovascular morbidities was comparable to those in previous larger surveys&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;13&#44;14</span></a> Echocardiographic examination and plasma brain natriuretic peptide &#40;BNP&#41; measurement were performed on admission &#40;or within a few days&#41; in 96&#46;5&#37; and 90&#37; of patients&#44; respectively&#44; showing good adherence to the ESC guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Most patients &#40;73&#46;2&#37;&#41; had reduced ejection fraction &#40;77&#46;6&#37; of ACS patients and 65&#37; of non-ACS patients&#41;&#46; However&#44; in proportion&#44; more non-ACS patients showed either more severe systolic dysfunction than ACS patients &#40;42&#37; vs&#46; 32&#46;8&#37;&#44; p&#61;0&#46;01&#41; or preserved systolic function &#40;34&#46;8&#37; vs&#46; 22&#46;4&#37;&#44; p&#61;0&#46;01&#41;&#44; these dissimilar functional phenotypes being in line with the heterogeneity of AHF syndromes&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">On admission&#44; blood pressure&#44; heart rate&#44; oxygen levels&#44; serum hemoglobin&#44; sodium and potassium&#44; and creatinine clearance were similar in patients presenting with ACS to those with non-ACS presentation&#46; Acute coronary syndrome patients&#44; as expected&#44; were admitted more often to the intensive cardiac care unit &#40;ICCU&#41;&#44; more frequently underwent coronary angiography and percutaneous interventions&#44; and were more often treated with intravenous vasodilators&#44; non-invasive ventilation and intra-aortic balloon pump&#46; However&#44; invasive ventilation was needed to a similar degree in both populations&#44; as were therapy with intravenous diuretics and inotropes&#44; renal filtration&#44; and ICD implantation&#46; Overall&#44; acute care management was similar to previous studies&#44; although intravenous inotropes were used less often<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;14</span></a> and percutaneous coronary interventions were performed more frequently<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> due to the high proportion of ST-segment elevation ACS patients in this study&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Rates of prescription of major oral HF medications increased from admission to discharge&#44; a common observation in several previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;13</span></a> One possible reason in the study by Pinho-Gomes et al&#46; may be the low &#40;15&#37;&#41; rate of previous HF-related admissions&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The mean total hospital stay was 11 days and in-hospital mortality was 5&#46;5&#37;&#44; similar in patients with or without ACS presentation&#46; A shorter in-hospital stay &#40;4&#46;3&#8211;9 days&#41; was reported in ADHERE&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> EHFS II<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and ALARM-HF&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> while in ATTEND a surprising long in-hospital stay &#40;21 days&#41; was observed&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In-hospital mortality also varied significantly between different studies&#44; being 3&#46;8&#37; in ADHERE<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and OPTIMIZE-HF&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> 6&#46;7&#37; in EHFS II&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> 7&#46;7&#37; in ATTEND&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and 12&#37; in ALARM-HF&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Lower in-hospital mortality may be related to shorter in-hospital stay&#44; although this may not necessarily translate into better short- or long-term prognosis in HF patients&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Several factors may be expected to be associated with longer in-hospital stay in AHF patients&#44; particularly high BNP on admission and need for ICCU admission&#44; both signs of worse clinical status&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The HF rehospitalization rate and all-cause mortality in this study were respectively 20&#46;9&#37; and 10&#46;9&#37; at six months and 23&#46;9&#37; and 15&#46;9&#37; at 12 months&#44; and did not differ in patients with or without ACS at index presentation&#46; However&#44; HF mortality at six months was significantly higher in patients outside the setting of ACS presentation at index admission &#40;12&#46;2&#37; vs&#46; 4&#46;7&#37;&#44; p&#61;0&#46;053&#41;&#44; a population that presented mostly with DCHF&#46; In fact&#44; post-discharge prognosis appears in general to be better in patients with new-onset AHF&#46; Data from the Italian registries showed that post-discharge mortality at both six months and one year was lower in new-onset AHF patients than in those with pre-existing chronic HF&#44; and the rehospitalization rate was also lower in the former group&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8</span></a> In other studies<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#44;15</span></a> the results were also consistent with a better clinical course in patients with new-onset HF&#44; whereas a previous history of worsening HF was shown to be an independent predictor of mortality&#46; There also appears to be a cumulative risk with increasing duration and number of HF hospitalizations&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In the study by Pinho-Gomes et al&#46;&#44; a previous history of HF hospitalization was an important predictor of rehospitalization or death during one-year follow-up after first hospital discharge &#40;threefold increase in risk&#41;&#46; Low sodium on admission and the presence of atrial fibrillation were the other predictors of higher risk&#44; while reduced LVEF on admission conferred a decreased risk of rehospitalization or death&#46; The reason for this latter finding is not clear&#44; as reduced LVEF was similarly present on admission in patients with or without ACS&#44; the former presenting mostly with new-onset AHF and having better associated long-term prognosis than the latter&#46; Reduced LVEF on admission may have been modified after percutaneous coronary revascularization procedures &#40;performed in half of ACS patients&#41;&#44; or left ventricular remodeling may have occurred during follow-up after the ACS and be a confounding factor regarding the effect of initially measured LVEF on long-term prognosis&#46; Also&#44; patients with reduced or preserved ejection fraction on admission were not compared head-to-head&#46; Comparison was mainly between AHF patients with and without ACS on presentation&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">When comparing AHF studies&#44; several issues need to be clarified&#44; particularly the criteria for syndrome definition on admission&#44; the admission setting &#40;emergency department&#44; intensive care unit&#44; cardiology ward or internal medicine ward&#41; and types of patients included &#40;ACS patients often require different and specific management&#41;&#46; Also&#44; HF with reduced and with preserved ejection fraction are to some extent different entities with distinct risk factors&#44; management and prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Each of these variables contributes to different results because the populations are dissimilar&#44; are managed differently&#44; and may have also different prognosis in both the short and long term&#46; Despite the limitations pointed by the authors&#44; the study by Pinho-Gomes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> contributes significantly to our knowledge of the situation in Portugal concerning acute heart failure admissions and helps to identify a subset of high-risk patients most in need of close surveillance&#44; ideally to be included in an HF management program&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Editorial comment
Profile of the acute heart failure patient in Portugal
Perfil do doente com insuficiência cardíaca aguda em Portugal
Dulce Brito
Cardiology Department, Santa Maria University Hospital, Lisbon; CCUL (Cardiology Centre, Lisbon University, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">This editorial refers to &#8220;Characterization of acute heart failure hospitalizations in a Portuguese cardiology department&#8221; by A&#46;C&#46; Pinho-Gomes et al&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Acute heart failure &#40;AHF&#41; is a highly prevalent condition&#44; a common cause of hospitalization associated with significant in-hospital mortality and poor short- and longer-term outcomes&#44; and represents a significant burden on overall healthcare costs&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The condition is difficult to define and classify&#46; The latest ESC guidelines on acute and chronic heart failure &#40;HF&#41; refer to AHF as &#8220;the term used to describe the rapid onset of&#44; or change in&#44; symptoms and signs of heart failure&#46; It is a life-threatening condition that requires immediate medical attention and usually leads to urgent admission to hospital&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The assumptions included in this apparently undefined &#8220;definition&#8221; of AHF in fact apply to all forms of acute heart failure&#44; a complex clinical syndrome that varies widely in terms of underlying pathophysiologic mechanisms&#44; clinical presentations and targeted therapies&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Most AHF patients presenting to an emergency department are admitted to hospital<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a> and it is the most common diagnosis at discharge in patients aged &#62;65 years&#46; The syndrome&#39;s high in-hospital mortality of 3-12&#37; and short-term readmission rate of 25-30&#37;&#44; with the associated costs&#44; are critical issues worldwide&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;6&#44;13&#44;14</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The heterogeneity of AHF syndrome&#40;s&#41; hinders any attempt at classification or application of a single-algorithm approach&#46; AHF may present either as new-onset HF or worsening of pre-existing HF&#44; and these two forms may differ in causes&#44; precipitating factors&#44; associated comorbidities&#44; therapeutic options&#44; in-hospital mortality and post-discharge prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4&#44;13&#44;15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Regarding clinical presentations&#44; data from the EuroHeart Failure Survey &#40;EHFS&#41; II &#40;3580 patients with AHF enrolled&#41; showed that 65&#46;4&#37; of patients presented with decompensated HF&#44; 11&#46;4&#37; with hypertensive HF&#44; 16&#46;2&#37; with pulmonary edema&#44; 3&#46;9&#37; with cardiogenic shock&#44; and 3&#46;2&#37; with isolated right HF&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Cardiac dysfunction may be due to different causes&#44; including acute coronary syndromes&#44; valve dysfunction&#44; arrhythmias&#44; pericardial disease&#44; and increased left ventricular afterload&#46; These different causes &#40;which can also act as precipitating factors for the syndrome&#41; may coexist and interact in the same patient&#44; modulating clinical presentation and influencing management options and outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Data on AHF studies and registries provide valuable information regarding the pathophysiologic&#44; therapeutic&#44; and prognostic issues related to different clinical scenarios&#59; they are useful for assessing the extent of compliance with heart failure management guidelines and can help improve clinical assessment and both short- and long-term outcome&#46; Also&#44; analysis of similarities and differences in patient characteristics and management in different centers and countries&#44; in various settings&#44; may help to determine the most useful independent predictors of a worse prognosis and to define better strategies to obtain more favorable outcomes&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The paper by Pinho-Gomes et al&#46; in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> presents the results of a hospital-based&#44; observational&#44; retrospective cohort study conducted in a single large Portuguese center &#40;a teaching hospital&#41;&#44; focusing on acute heart failure admissions to the cardiology department during 2010&#46; Patients enrolled met the ESC criteria for HF<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and were selected by review of the medical records of patients discharged with a diagnosis of AHF &#40;either primary or secondary to another acute cardiac event&#41;&#46; Acute coronary syndromes &#40;ACS&#41; patients were included&#46; All patients were followed for at least 12 months after discharge&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The study aimed to clarify the overall clinical characteristics of patients with AHF and their hospital management and outcomes&#44; and also to identify predictors of rehospitalization or death at six and 12 months after discharge&#46; Importantly&#44; patients admitted in two different AHF clinical contexts &#8722; ACS vs&#46; non-ACS &#8722; were compared&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">AHF accounted for 21&#37; of all admissions &#40;201&#47;924&#41; over the one-year inclusion period&#46; Most were men &#40;61&#37;&#41; and the mean age was 69 years&#46; AHF was new-onset in 53&#37; and most admissions &#40;63&#37;&#41; were in the context of ACS&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The prevalence of new-onset AHF as well as of ACS as the precipitating factor were both higher than in the EHFSII<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and ALARM-HF<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> studies that included patients of a mixed provenance &#40;internal medicine and cardiology wards&#41;&#46; However&#44; new-onset AHF was lower than in ATTEND&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> an epidemiological study of AHF in the Asia Pacific region that excluded patients with ACS&#46; Acute decompensated chronic heart failure &#40;DCHF&#41; was the clinical presentation in 46&#46;8&#37; of patients and pulmonary edema in 21&#46;4&#37;&#44; similar to other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;14</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Comparison of AHF patients presenting with or without ACS showed significant differences&#44; on the basis of which two different clinical profiles can be defined&#46; Patients presenting with ACS as the precipitating event were younger&#44; less often men&#44; and more commonly had a history of chronic hypertension &#40;72&#46;4&#37; vs&#46; 55&#46;4&#37;&#41; and coronary artery disease &#40;45&#37; vs&#46; 27&#37;&#41;&#46; New-onset HF was the rule &#40;74&#37; vs&#46; 17&#46;6&#37;&#41; and pulmonary edema was a common clinical presentation &#40;26&#37; vs&#46; 13&#46;5&#37;&#41;&#46; In contrast&#44; patients with non-ACS AHF were older and more often men&#44; the cause of cardiac dysfunction was more frequently valve disease &#40;31&#37; vs&#46; 5&#46;5&#37;&#41; or dilated cardiomyopathy &#40;17&#46;6 vs&#46; 1&#46;6&#37;&#41;&#44; and a history of previous HF hospitalizations was more common &#40;25&#46;7&#37; vs&#46; 8&#46;7&#37;&#41;&#44; as was atrial fibrillation &#40;46&#37; vs&#46; 22&#37;&#41;&#46; The factor triggering AHF in this population was frequently arrhythmia &#40;39&#46;2&#37;&#41; and DCHF was the dominant acute clinical presentation &#40;82&#46;4&#37;&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The prevalence of cardiovascular diseases &#8722; hypertension and coronary artery disease being the most common &#8722; and of non-cardiovascular morbidities was comparable to those in previous larger surveys&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;13&#44;14</span></a> Echocardiographic examination and plasma brain natriuretic peptide &#40;BNP&#41; measurement were performed on admission &#40;or within a few days&#41; in 96&#46;5&#37; and 90&#37; of patients&#44; respectively&#44; showing good adherence to the ESC guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Most patients &#40;73&#46;2&#37;&#41; had reduced ejection fraction &#40;77&#46;6&#37; of ACS patients and 65&#37; of non-ACS patients&#41;&#46; However&#44; in proportion&#44; more non-ACS patients showed either more severe systolic dysfunction than ACS patients &#40;42&#37; vs&#46; 32&#46;8&#37;&#44; p&#61;0&#46;01&#41; or preserved systolic function &#40;34&#46;8&#37; vs&#46; 22&#46;4&#37;&#44; p&#61;0&#46;01&#41;&#44; these dissimilar functional phenotypes being in line with the heterogeneity of AHF syndromes&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">On admission&#44; blood pressure&#44; heart rate&#44; oxygen levels&#44; serum hemoglobin&#44; sodium and potassium&#44; and creatinine clearance were similar in patients presenting with ACS to those with non-ACS presentation&#46; Acute coronary syndrome patients&#44; as expected&#44; were admitted more often to the intensive cardiac care unit &#40;ICCU&#41;&#44; more frequently underwent coronary angiography and percutaneous interventions&#44; and were more often treated with intravenous vasodilators&#44; non-invasive ventilation and intra-aortic balloon pump&#46; However&#44; invasive ventilation was needed to a similar degree in both populations&#44; as were therapy with intravenous diuretics and inotropes&#44; renal filtration&#44; and ICD implantation&#46; Overall&#44; acute care management was similar to previous studies&#44; although intravenous inotropes were used less often<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;14</span></a> and percutaneous coronary interventions were performed more frequently<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a> due to the high proportion of ST-segment elevation ACS patients in this study&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Rates of prescription of major oral HF medications increased from admission to discharge&#44; a common observation in several previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3&#44;13</span></a> One possible reason in the study by Pinho-Gomes et al&#46; may be the low &#40;15&#37;&#41; rate of previous HF-related admissions&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The mean total hospital stay was 11 days and in-hospital mortality was 5&#46;5&#37;&#44; similar in patients with or without ACS presentation&#46; A shorter in-hospital stay &#40;4&#46;3&#8211;9 days&#41; was reported in ADHERE&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> EHFS II<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and ALARM-HF&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> while in ATTEND a surprising long in-hospital stay &#40;21 days&#41; was observed&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In-hospital mortality also varied significantly between different studies&#44; being 3&#46;8&#37; in ADHERE<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and OPTIMIZE-HF&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> 6&#46;7&#37; in EHFS II&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> 7&#46;7&#37; in ATTEND&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and 12&#37; in ALARM-HF&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Lower in-hospital mortality may be related to shorter in-hospital stay&#44; although this may not necessarily translate into better short- or long-term prognosis in HF patients&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Several factors may be expected to be associated with longer in-hospital stay in AHF patients&#44; particularly high BNP on admission and need for ICCU admission&#44; both signs of worse clinical status&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The HF rehospitalization rate and all-cause mortality in this study were respectively 20&#46;9&#37; and 10&#46;9&#37; at six months and 23&#46;9&#37; and 15&#46;9&#37; at 12 months&#44; and did not differ in patients with or without ACS at index presentation&#46; However&#44; HF mortality at six months was significantly higher in patients outside the setting of ACS presentation at index admission &#40;12&#46;2&#37; vs&#46; 4&#46;7&#37;&#44; p&#61;0&#46;053&#41;&#44; a population that presented mostly with DCHF&#46; In fact&#44; post-discharge prognosis appears in general to be better in patients with new-onset AHF&#46; Data from the Italian registries showed that post-discharge mortality at both six months and one year was lower in new-onset AHF patients than in those with pre-existing chronic HF&#44; and the rehospitalization rate was also lower in the former group&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;8</span></a> In other studies<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;7&#44;15</span></a> the results were also consistent with a better clinical course in patients with new-onset HF&#44; whereas a previous history of worsening HF was shown to be an independent predictor of mortality&#46; There also appears to be a cumulative risk with increasing duration and number of HF hospitalizations&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In the study by Pinho-Gomes et al&#46;&#44; a previous history of HF hospitalization was an important predictor of rehospitalization or death during one-year follow-up after first hospital discharge &#40;threefold increase in risk&#41;&#46; Low sodium on admission and the presence of atrial fibrillation were the other predictors of higher risk&#44; while reduced LVEF on admission conferred a decreased risk of rehospitalization or death&#46; The reason for this latter finding is not clear&#44; as reduced LVEF was similarly present on admission in patients with or without ACS&#44; the former presenting mostly with new-onset AHF and having better associated long-term prognosis than the latter&#46; Reduced LVEF on admission may have been modified after percutaneous coronary revascularization procedures &#40;performed in half of ACS patients&#41;&#44; or left ventricular remodeling may have occurred during follow-up after the ACS and be a confounding factor regarding the effect of initially measured LVEF on long-term prognosis&#46; Also&#44; patients with reduced or preserved ejection fraction on admission were not compared head-to-head&#46; Comparison was mainly between AHF patients with and without ACS on presentation&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">When comparing AHF studies&#44; several issues need to be clarified&#44; particularly the criteria for syndrome definition on admission&#44; the admission setting &#40;emergency department&#44; intensive care unit&#44; cardiology ward or internal medicine ward&#41; and types of patients included &#40;ACS patients often require different and specific management&#41;&#46; Also&#44; HF with reduced and with preserved ejection fraction are to some extent different entities with distinct risk factors&#44; management and prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Each of these variables contributes to different results because the populations are dissimilar&#44; are managed differently&#44; and may have also different prognosis in both the short and long term&#46; Despite the limitations pointed by the authors&#44; the study by Pinho-Gomes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> contributes significantly to our knowledge of the situation in Portugal concerning acute heart failure admissions and helps to identify a subset of high-risk patients most in need of close surveillance&#44; ideally to be included in an HF management program&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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ISSN: 21742049
Original language: English
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Revista Portuguesa de Cardiologia (English edition)
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