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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction&#58; the problem of heart failure</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure &#40;HF&#41; is a syndrome with high prevalence&#44; morbidity and mortality that represents a considerable economic and social burden&#46; However&#44; in Portugal awareness of the disease is poor among the general public and policy makers&#46; In addition&#44; there has been a lack of concerted efforts in the medical profession to organize the health care process more efficiently&#44; which is essential to improve management of the syndrome and thus to have a positive effect on health indicators&#46; In view of the current and future importance of HF &#8211; which is expected to increase in prevalence and incidence &#8211; it must be seen as a priority in health care in Portugal&#44; and the National Health Service &#40;NHS&#41; should be given the necessary means to improve its performance in clinical terms as well as in its organizational and funding framework&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The present document aims to raise awareness of the urgent need to prioritize HF in the health agenda given its current prevalence and the increase expected in the near future&#44; the associated high mortality and morbidity and the socioeconomic burden for patients&#44; their families&#44; and society&#46; It also aims to help identify the main shortcomings in the management of HF and to propose solutions at different levels of care that will lead to improved integration between the different specialists involved in the diagnosis&#44; treatment and monitoring of HF patients at the national level&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">This analysis is intended for physicians&#44; particularly those involved in the management of HF patients &#40;cardiologists&#44; internists&#44; intensivists and general practitioners &#91;GPs&#93;&#41;&#44; nurses&#44; and health decision-makers&#44; whose determinations may influence attitudes to HF&#46; It is also intended to act as a guide for future initiatives aimed at raising awareness among the general public&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The authors of the present document&#44; who are cardiologists&#44; internists and GPs&#44; work within the NHS&#44; in hospitals &#40;including emergency departments&#41; and in primary health care&#46; The opinions expressed here are based on their personal experience&#44; both clinical and organizational&#44; and are supported by the guidelines published by the European Society of Cardiology &#40;ESC&#41; and the American College of Cardiology&#47;American Heart Association &#40;ACA&#47;AHA&#41;&#46; This consensus statement is endorsed by the main medical societies and associations involved in the treatment of HF &#40;<a class="elsevierStyleCrossRef" href="#sec0130">Appendix 1</a>&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Heart failure in the world and in Portugal&#58; the burden of the syndrome</span><p id="par0025" class="elsevierStylePara elsevierViewall">HF is defined as a syndrome caused by a structural and&#47;or functional cardiac abnormality&#44; resulting in inadequate cardiac output for the metabolic needs of the organism at rest or during exercise&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> In most cases it is the final stage of a continuum initiated by cardiovascular risk factors&#44; which begin earlier in life than previously thought and progress to cardiac dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> It may be asymptomatic at first&#44; with symptoms only appearing later&#46; Typically&#44; the syndrome develops in episodes of decompensation that weaken the patient&#39;s clinical condition&#44; contribute to worsening HF and require urgent medical care&#46; This continuum can be interrupted without warning&#44; at any time&#44; by sudden death or culminate in death due to pump failure&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Heart failure in the world</span><p id="par0030" class="elsevierStylePara elsevierViewall">HF prevalence increases with age&#44; particularly after the age of 65&#44; mainly due to the greater incidence of hypertension and myocardial infarction &#40;MI&#41; after this age and to increased survival of patients after MI&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> HF affects 1-2&#37; of the world&#39;s population and 6-10&#37; of those aged over 65&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;4</span></a> Worldwide&#44; around 26 million adults suffer from HF&#44; on a par with the 32 million with cancer and the 34 million with HIV&#47;AIDS&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> The most recent projections indicate that its prevalence will rise by 25&#37; by 2030&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Episodes of decompensation frequently require visits to the emergency department and hospitalization or rehospitalization&#46; In developed countries&#44; HF accounts for 1-4&#37; of all hospitalizations&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> and is the leading cause of admission in individuals aged over 65 in Europe and the USA&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> Around a quarter of these patients are rehospitalized within a month of discharge&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Each hospitalization represents a further worsening of HF&#44; contributing to the decline in the patient&#39;s clinical condition&#44; until death results&#46; In Europe&#44; in-hospital mortality from HF is 7-9&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> a higher figure than for MI&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> Mortality can reach 27&#37; at six months after hospitalization for HF<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> and 50&#37; at 12 months in those admitted with cardiogenic shock&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> Over 50&#37; of HF patients die within five years of diagnosis&#44; which represents a lower survival rate than some types of cancer&#44; including breast&#44; prostate and colon cancer and leukemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The economic burden of HF is considerable worldwide&#44; accounting for 1-3&#37; of health budgets in the USA and Europe&#44; where it has the greatest economic impact of all diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> In the USA&#44; spending on HF is more than double that of spending on all cancers combined&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> Furthermore&#44; the costs of hospitalizations are considerable&#44; direct medical costs accounting for 68&#37; of the total costs of HF in the USA and Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Heart failure in Portugal&#58; from cardiovascular risk factors to socioeconomic impact</span><p id="par0050" class="elsevierStylePara elsevierViewall">There is a high prevalence of cardiovascular risk factors in Portugal&#58; 24&#37; of the population are smokers<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> and 27&#46;5&#37; have metabolic syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> The country has one of the highest rates of increase in prevalence of overweight and obesity in Europe &#40;53&#37; in those aged between 18 and 64&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> In addition&#44; three million Portuguese have diabetes or impaired glucose metabolism&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> Hypertension affects 42&#37; of adult Portuguese<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> and there are around 12<span class="elsevierStyleHsp" style=""></span>000 cases of MI every year&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The overall prevalence of chronic HF in Portugal was estimated at 4&#46;36&#37; in the EPICA study &#40;1998&#8211;2000&#41;&#44; ranging from 1&#46;36&#37; in those aged 25-49 to 16&#46;14&#37; in those aged over 80&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> Bearing in mind the aging of the population over the last 20 years&#44; these figures are now undoubtedly higher&#59; on the basis of the prevalence in each age-group in the EPICA study and data from the 2011 census&#44; there may now be as many as 380<span class="elsevierStyleHsp" style=""></span>000 cases of HF in Portugal&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">A report by the Portuguese Directorate-General for Health &#40;DGS&#41;&#44; &#8220;Cerebral and Cardiovascular Disease in Numbers 2015&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> cites a principal diagnosis of HF as the second leading source of hospital production&#44; accounting in 2014 for 182<span class="elsevierStyleHsp" style=""></span>512 days of hospitalization &#40;1&#46;9 times more than MI&#41; and 18<span class="elsevierStyleHsp" style=""></span>588 patients discharged after admission for decompensated HF&#46; Mean hospital stay for HF was 9&#46;8 days in 2014&#46; HF is responsible for the highest in-hospital mortality of all cerebral and cardiovascular disease in the country&#44; reaching 12&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In addition&#44; HF is often presented as a secondary diagnosis in medical records&#44; so the actual number of patients hospitalized for HF is higher than reported&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> According to a report from medical consultants IASIST Portugal&#44; &#8220;Impact of hospitalization of chronic patients on the NHS&#8221;&#44; the number of HF admissions rose by 33&#37; between 2004 and 2012&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> but this number is probably an underestimate&#44; in view of shortcomings in the coding of a diagnosis of HF&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> The rate of hospitalization for HF in 2009 was 27&#46;9&#47;100<span class="elsevierStyleHsp" style=""></span>000 population&#44; similar to that for diabetes &#40;30&#46;0&#47;100<span class="elsevierStyleHsp" style=""></span>000&#41;&#44; asthma &#40;29&#46;5&#47;100<span class="elsevierStyleHsp" style=""></span>000&#41; and chronic obstructive pulmonary disease &#40;COPD&#41; &#40;29&#46;4&#47;100<span class="elsevierStyleHsp" style=""></span>000&#41;&#44; some of the major epidemics of the 21st century&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">22&#44;23</span></a> However&#44; in 2012 the mortality rate for HF &#40;12&#46;9&#37;&#41; was higher than for diabetes &#40;5&#46;1&#37;&#41;&#44; asthma &#40;0&#46;8&#37;&#41; and COPD &#40;7&#46;5&#37;&#41;&#44; and the same trend was seen for rehospitalizations &#40;14&#46;6&#37; for HF&#44; 8&#46;2&#37; for diabetes&#44; 5&#46;1&#37; for asthma and 14&#46;0&#37; for COPD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The readmission rate&#44; particularly at 30 and 60 days&#44; is increasing&#44; which has serious economic and health care implications&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Official data show that the cost of HF hospitalizations in Portugal in 1998 was approximately 24 million euros&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> similar to that of hospitalizations for COPD in the same year &#40;23 million euros&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Almost 20 years later&#44; the growing prevalence of HF and the increasing sophistication of medical care mean that this figure is likely to be much higher&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Patients hospitalized for HF consume large quantities of resources&#44; due to the high cost of the complex diagnostic exams&#44; drugs&#44; medical devices and surgical procedures that are often required&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> The cost of health care for HF patients is estimated to be well above what is allocated to them by the NHS&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The physical and psychological effects of HF also have important psychosocial implications&#44; such as social isolation&#44; anxiety&#44; frustration and depression&#44; with negative effects on the quality of life of both patients and their caregivers&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> There are no data available for the effects of HF on absenteeism and loss of productivity in Portugal&#44; but this is another important aspect of the burden of HF with repercussions not only for the health system but also for society and the economy&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">The problems with heart failure treatment in Portugal</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Lack of awareness of the importance of heart failure and of an integrated approach</span><p id="par0085" class="elsevierStylePara elsevierViewall">The basic problem with HF in Portugal is that there is no integrated approach on the part of those responsible for its management &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; The result is a lack of awareness of its importance and of its impact on the general population&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Official data on HF in Portugal are also limited and do not fully characterize the real course and management of the syndrome&#46; The only study to date on the prevalence of heart failure in Portugal was published nearly 15 years ago&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> and there are no current data on changes in its prevalence and&#44; more importantly&#44; in its diagnosis and treatment&#46; There are also gaps in the information on HF in the National Program for Cerebral and Cardiovascular Disease of the DGS&#44; which does not provide numbers of rehospitalizations or of emergency department admissions for HF&#46; In addition&#44; the hospital production described in the DGS report is based on the coding of diagnosis-related groups &#40;DRGs&#41;&#44; which&#44; as stated above&#44; does not always reflect the real number of patients hospitalized for HF&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Lack of a structural debate on heart failure within and between specialties</span><p id="par0095" class="elsevierStylePara elsevierViewall">Understanding of the actual importance of heart failure in the medical profession is patchy and there is little or no discussion of the role of the different specialties that deal with the condition&#46; There is thus a need to organize the health care flows and to clearly define responsibilities&#44; in order to ensure that optimal support is provided from the beginning to the end of the patient&#39;s journey through the health system&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The main players in the management of HF are GPs&#44; cardiologists&#44; internists&#44; intensivists and nurses&#44; but HF patients frequently present multiple comorbidities and therefore other specialists also have an important role in clinical management of the syndrome&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Since different specialists will be involved in the management of an individual patient&#44; effective communication and collaboration between them and between the various levels of health care are essential&#46; It has been shown that HF patients are better treated in integrated management programs and by specialized multidisciplinary teams &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;27</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">However&#44; despite the existence of the online Health Data Platform &#40;PDS&#41;&#44; there are weaknesses in the flow of information between the different levels of health care&#46; Communication between primary care centers and hospitals&#44; particularly the cardiology and internal medicine departments&#44; as well as between hospital departments&#44; is clearly in need of improvement&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Lack of an integrated health care process for the management of heart failure and deficiencies throughout the patient&#39;s journey through the health system</span><p id="par0115" class="elsevierStylePara elsevierViewall">The lack of a properly organized integrated health care process for the management of heart failure is reflected in a wide range of deficiencies throughout the patient&#39;s journey through the health system &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Diagnosis</span><p id="par0120" class="elsevierStylePara elsevierViewall">In Portugal&#44; HF is often diagnosed late&#44; frequently at the time of the first hospitalization&#44; instead of being suspected and diagnosed early by the patient&#39;s GP&#46; This is largely due to a lack of awareness of the disease and failure to recognize the characteristic symptoms and signs&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">A suspected diagnosis of HF on the basis of symptoms and signs&#44; and an electrocardiogram and&#47;or chest X-ray&#44; should be confirmed by objective evidence of cardiac dysfunction&#44; and so other diagnostic exams are needed&#44; such as B-type natriuretic peptide &#40;BNP&#41; or N-terminal BNP &#40;NT-proBNP&#41; measurement and&#47;or imaging studies&#44; of which echocardiography is the most accessible&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;27</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">GPs do not have easy access to BNP or NT-proBNP measurements&#44; which are not reimbursed by the NHS for outpatients&#46; Due to their high negative predictive value&#44; low BNP&#47;NT-proBNP levels can avoid false-positive diagnoses of HF and unnecessary use of echocardiography&#44; which is considerably more costly&#46; Making tests of natriuretic peptide levels available to GPs would improve health care by enabling earlier diagnosis and would reduce costs by avoiding repeat exams&#44; incorrect diagnoses and inappropriate referral for hospital services&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">An additional problem is that while echocardiography is now more widely available&#44; the lack of standardization of echocardiographic reports means they are frequently incomplete or inconclusive for confirming or excluding a diagnosis of HF&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Outpatient treatment and referral</span><p id="par0140" class="elsevierStylePara elsevierViewall">There is still uncertainty among GPs as to when to prescribe disease-modifying drugs to treat HF and at what doses&#46; Hospital referral is also subject to certain constraints&#44; and&#44; conversely&#44; communication between hospitals and GPs is limited when patients are returned to primary care after an acute event&#46; There are relatively few HF specialists in Portugal or specialized structures that can provide local health care for HF patients and ensure early treatment of episodes of decompensation&#46; Cardiac rehabilitation programs for HF patients are equally scarce&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Acute phase and hospitalization</span><p id="par0145" class="elsevierStylePara elsevierViewall">As with MI&#44; it is essential that acute HF should be treated as rapidly as possible&#46; However&#44; the guidelines are unclear as to the approach to adopt given the lack of solid evidence in this area&#44; relying mostly on the experience of the individual physician&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> There is no standard and systematically applied treatment protocol in Portugal&#44; nor are there adequately trained multidisciplinary teams to implement such a protocol in most emergency&#44; internal medicine or even cardiology departments&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pre-discharge and vulnerable phases</span><p id="par0150" class="elsevierStylePara elsevierViewall">There is no organized transition care for HF patients in Portugal&#46; Planning for discharge should include guidance for patients and caregivers&#44; prescription and appropriate titration of all drugs that can modify the course of the disease&#44; sharing of information and scheduling of reassessment consultations within two weeks of discharge&#44; in order to reduce the risk of rehospitalization or death during this vulnerable phase&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> It is also recommended that high-risk patients should be referred for integrated multidisciplinary management programs and cardiac rehabilitation programs&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Referral for integrated multidisciplinary management programs</span><p id="par0155" class="elsevierStylePara elsevierViewall">HF clinics are increasingly important in the care of these patients&#46; Such clinics have multidisciplinary teams made up of specialists in HF &#40;cardiologists&#44; internists&#44; GPs and nurses&#41; and other health professionals&#44; pharmacists&#44; dieticians&#44; physiotherapists&#44; psychologists and social workers&#44; who together provide a systematic approach to HF&#46; These teams have been shown to be cost-effective and to improve patients&#8217; quality of life and reduce hospitalizations and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Patients and caregivers need to be educated about the importance of adherence to drug and non-drug therapy and early recognition of decompensation in this phase&#46; This is usually done by nurses&#44; who should also be specialized in HF&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Another essential factor is accessibility to these programs&#44; to enable early treatment of decompensation in day care centers&#44; which will avoid rehospitalization and&#47;or visits to the emergency department and thus reduce costs&#46; Telemedicine for management of outpatients is another promising possibility&#44; although further research is needed&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">However&#44; the fact is that these facilities are in short supply in Portugal&#44; as is specialized HF training for nurses&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Cardiac rehabilitation</span><p id="par0175" class="elsevierStylePara elsevierViewall">Also limited&#44; in fact virtually nonexistent&#44; are cardiac rehabilitation programs for HF patients in Portugal&#44; despite their proven benefits&#44; unequivocal recommendations for referral&#44; and the appeal by the Portuguese Society of Cardiology for more action in this area in a document published on the Society&#39;s website&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Palliative and end-of-life care</span><p id="par0180" class="elsevierStylePara elsevierViewall">There is also a need to develop strategies for provision of palliative and end-of-life care for HF patients&#44; which is rarely included in health care planning&#46;</p></span></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Strategies to improve medical care for heart failure patients in Portugal</span><p id="par0185" class="elsevierStylePara elsevierViewall">Below are suggestions for short&#44; medium and long-term measures required to improve medical care for HF patients&#46;</p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Short-term measures</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0195" class="elsevierStylePara elsevierViewall">The most urgent measure to improve the current situation would be to bring the different players together to form an alliance dedicated to making HF a health priority and improving its management&#46; This alliance should include&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">regulatory and political bodies&#44; especially the Health Commission of the Portuguese Parliament and the Ministry of Health&#44; particularly the DGS and the Program for Cerebral and Cardiovascular Disease&#59;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">scientific societies&#44; particularly the Portuguese Societies of Cardiology&#44; Internal Medicine&#44; and Intensive Care&#59;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">the Portuguese Medical Council and the Colleges of the various specialties involved in HF treatment&#59;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">the Portuguese Nursing Council&#59;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">HF patient groups&#59;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">the media&#44; as a means of informing and educating the population&#59;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">the pharmaceutical and medical device industries&#44; as partners in improving health care&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2&#46;</span><p id="par0235" class="elsevierStylePara elsevierViewall">A national plan is needed for training health professionals in HF&#44; particularly physicians and nurses&#44; to encourage specialization in this area&#46; HF should be included in the National Health Plan and clinical guidelines should be drawn up based on the ESC guidelines&#46; The guidelines should be appropriate to the Portuguese context and should take into account the expected increase in HF prevalence in the coming years&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">3&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall">HF should be a priority in the next edition of the National Program for Cerebral and Cardiovascular Disease and in local health programs&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">4&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Diagnosis of HF should be improved by implementing digital diagnostics&#44; and measurement of NT-proBNP should be made available in primary care and be reimbursed by the NHS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">5&#46;</span><p id="par0250" class="elsevierStylePara elsevierViewall">A &#8216;Heart Failure Record&#8217; should be introduced through which clinical information on each HF patient is recorded and can be accessed by all those involved in the care of HF patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">6&#46;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Sharing of best practices should be encouraged between the facilities treating HF patients &#40;cardiology and internal medicine departments and GPs&#41;&#46;</p></li></ul></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Medium-term measures</span><p id="par0260" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">1&#46;</span><p id="par0265" class="elsevierStylePara elsevierViewall">An information and awareness campaign should be launched directed at the general population&#44; patients&#44; nurses and physicians&#46; This could be linked to initiatives of the ESC and the Heart Failure Association&#44; and of the Portuguese Society of Cardiology via its Working Group on Heart Failure&#46; The campaign should include information on the European Heart Health Charter and the HeartFailureMatters website&#44; aimed at patients and caregivers&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">2&#46;</span><p id="par0270" class="elsevierStylePara elsevierViewall">An integrated health care process for the management of HF should be established that is codified and applicable throughout the country&#44; beginning with the creation of protocols designed to promote better integration between primary care and hospitals&#46; This will require the setting up of a national network of multidisciplinary teams for the integrated treatment of HF patients&#46; We also suggest the establishment of HF day hospitals and increasing the availability of cardiac rehabilitation programs for HF patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">3&#46;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Performance indicators should be introduced for the medical care of HF patients&#44; for both outpatient and inpatient care&#44; and applicable to hospital departments and GPs&#46; The performance measures recommended by the ESC and the ACC&#47;AHA could be used for this purpose&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">29&#44;30</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">4&#46;</span><p id="par0280" class="elsevierStylePara elsevierViewall">The definition of HF and its associated costs in the relevant DRG tables&#44; as well as those of HF day hospital sessions&#44; should be revised&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">5&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Echocardiographic reports need to be standardized at national level in order to improve the quality of information available to physicians&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">6&#46;</span><p id="par0290" class="elsevierStylePara elsevierViewall">An effective palliative care network that includes HF patients should be implemented&#46;</p></li></ul></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Long-term measures</span><p id="par0295" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">1&#46;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Electronic systems for sharing clinical information need to be improved&#44; particularly the Health Data Platform &#40;PDS&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2&#46;</span><p id="par0305" class="elsevierStylePara elsevierViewall">Data collection should be systematized in order to update epidemiological data on HF&#44; which will enable the progress of the disease to be monitored&#46; Such data should include information on quality of life&#44; using standardized questionnaires&#44; and on the impact of the syndrome in terms of absenteeism of patients and caregivers&#46;</p></li></ul></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusions</span><p id="par0310" class="elsevierStylePara elsevierViewall">HF is a major public health problem in Portugal due to its high prevalence&#44; morbidity and mortality and its considerable economic impact&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Given the wide variations in the country in health care provision for HF patients&#44; at both primary care and hospital level&#44; this document does not suggest a single model for improvement&#46; On the contrary&#44; it is necessary to define and implement strategies that take account of regional differences&#44; in order to optimize existing resources and the links between them&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">There is a strong desire for change among Portuguese health professionals who deal with HF&#46; This document&#44; prepared by a group of experts&#44; sets out to analyze the problem&#44; identify deficiencies and propose solutions in order to increase awareness of the need to prioritize the management of HF in the interests of public health care in Portugal&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Ethical disclosures</span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Protection of human and animal subjects</span><p id="par0325" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Confidentiality of data</span><p id="par0330" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Right to privacy and informed consent</span><p id="par0335" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0340" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">The present work was supported by an unconditional grant from Novartis&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Heart failure is a syndrome with high prevalence&#44; morbidity and mortality&#44; but awareness of the disease is poor among the general public and policy makers&#46; This document&#44; which was prepared by a group of experts consisting of cardiologists&#44; internists and general practitioners&#44; aims to set out in detail the problem of heart failure in Portugal at several levels&#58; burden of the disease&#44; diagnosis&#44; treatment and monitoring&#46; To this end&#44; different aspects of the management of the various stages of the disease are identified and discussed in detail&#44; covering both outpatients and hospitalized patients&#46; In order to optimize the medical care provided to these patients&#44; various short-&#44; medium- and long-term solutions and strategies are put forward that have the potential to improve the integration and use of available resources&#46; The intention is to highlight strategies that are not based on a single model but can be adapted to different regional circumstances&#44; in order to increase awareness and improve management of heart failure in Portugal&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A insufici&#234;ncia card&#237;aca &#233; uma s&#237;ndrome com elevada preval&#234;ncia&#44; morbilidade e mortalidade&#44; sendo&#44; no entanto&#44; pouco reconhecida junto dos cidad&#227;os e decisores pol&#237;ticos&#46; O presente documento foi elaborado por um conjunto de peritos constitu&#237;do por m&#233;dicos especialistas em cardiologia&#44; medicina interna e medicina geral e familiar&#44; e pretende expor detalhadamente o problema da insufici&#234;ncia card&#237;aca em Portugal a v&#225;rios n&#237;veis&#58; peso da s&#237;ndrome&#44; diagn&#243;stico&#44; tratamento e acompanhamento dos doentes&#46; Para tal&#44; s&#227;o identificados e discutidos em detalhe os diferentes aspetos inerentes ao manejo da s&#237;ndrome durante o processo assistencial&#44; nas v&#225;rias fases da doen&#231;a e que incluem doentes hospitalizados e em ambulat&#243;rio&#46; De modo a otimizar a assist&#234;ncia m&#233;dica prestada a estes doentes&#44; s&#227;o apontadas diversas solu&#231;&#245;es e estrat&#233;gias a curto&#44; m&#233;dio e longo prazo com potencial para melhorarem a articula&#231;&#227;o e utiliza&#231;&#227;o dos recursos dispon&#237;veis&#46; Pretendeu-se desta forma destacar estrat&#233;gias que&#44; n&#227;o se traduzindo num modelo &#250;nico de melhoria&#44; poder&#227;o ser adaptadas &#224;s diferentes especificidades regionais&#44; de modo a aumentar o reconhecimento e a aten&#231;&#227;o prestada &#224; insufici&#234;ncia card&#237;aca em Portugal&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fonseca C&#44; Brito D&#44; Cernadas R&#44; Ferreira J&#44; Franco F&#44; Rodrigues T&#44; et al&#46; Pela melhoria do tratamento da insufici&#234;ncia card&#237;aca em Portugal &#8211; documento de consenso 2017&#59;36&#58;1&#8211;8&#46;</p>"
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            "apendice" => "<p id="par0350" class="elsevierStylePara elsevierViewall">Endorsed by the Working Group on Heart Failure of the Portuguese Society of Cardiology&#44; the Heart Failure Nucleus of the Portuguese Society of Internal Medicine&#44; the College of General Practitioners of the Portuguese Medical Council&#44; the Cardiovascular Disease Nucleus of the Portuguese Association of General Practitioners&#44; and the Nursing Nucleus of the Portuguese Society of Cardiology&#46;<elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p>"
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            "titulo" => "Consensus statement on improvement of heart failure treatment in Portugal"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Health care flows for the treatment of heart failure&#44; showing the need for multidisciplinary teams to ensure the integrated management of the syndrome and provide health care in accordance with the international guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> HF&#58; heart failure&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Working Group on Heart Failure of the Portuguese Society of Cardiology</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C&#226;ndida Fonseca &#40;coordinator&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dulce Brito&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Susana Costa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Heart Failure Nucleus of the Portuguese Society of Internal Medicine</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paulo Bettencourt &#40;coordinator&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C&#233;sar Louren&#231;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">In&#234;s Ara&#250;jo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Irene Marques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Joana Pimenta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jorge Mercier&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pedro Morais Sarmento&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Nursing Nucleus of the Portuguese Society of Cardiology</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Manuel Belo Costa &#40;coordinator&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Madalena Carvalho&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Susana Quint&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Marisa Serrano&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ana Catarina Bastos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">College of General Practitioners of the Portuguese Medical Council</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jos&#233; Maria da Silva Henriques &#40;President&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anabela Pimentel Lopes Cunha Vaz&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#194;ngela Maria de Oliveira Teixeira&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ant&#243;nio Nelson Gomes Rodrigues&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">L&#233;nia Isabel de Gouveia Olim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maria de Lourdes Sousa Tavares Da Silva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maria Luciana Gomes Domingues Couto Carvalho&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maria Pacheu Catanho Patr&#237;cio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No&#233;lia Rubina Correia Sousa Costa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pedro Camilo de Ara&#250;jo Lima de Vasconcelos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Cardiovascular Disease Nucleus of the Portuguese Association of General Practitioners</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maria Helena Febra &#40;coordinator&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maria Teressa Lib&#243;rio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maria Helena Oliveira&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carolina Resende&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paula Oliveira&nbsp;\t\t\t\t\t\t\n
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Perspectives in Cardiology
For the improvement of Heart Failure treatment in Portugal - Consensus statement
Pela melhoria do tratamento da insuficiência cardíaca em Portugal – documento de consenso
Cândida Fonsecaa,
Corresponding author
mcandidafonseca@gmail.com

Corresponding author.
, Dulce Britob, Rui Cernadasc, Jorge Ferreirad, Fátima Francoe, Teresa Rodriguesf, João Moraisg, José Silva Cardosoh
a Unidade de Insuficiência Cardíaca, Serviço de Medicina III e Hospital Dia, Hospital São Francisco Xavier – Centro Hospitalar de Lisboa Ocidental, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
b Serviço de Cardiologia, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
c Administração Regional de Saúde (ARS) Norte, Porto, Portugal
d Hospital de Santa Cruz – Centro Hospitalar de Lisboa Ocidental, Serviço de Cardiologia, Lisboa, Portugal
e Hospital Universidade de Coimbra – Centro Hospitalar e Universitário de Coimbra, Serviço de Cardiologia, Coimbra, Portugal
f Hospital de Santa Maria – Centro Hospitalar de Lisboa Norte, Serviço de Urgência, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
g Centro Hospitalar de Leiria, Serviço de Cardiologia, Leiria, Portugal
h Centro Hospitalar de São João, Serviço de Cardiologia, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction&#58; the problem of heart failure</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure &#40;HF&#41; is a syndrome with high prevalence&#44; morbidity and mortality that represents a considerable economic and social burden&#46; However&#44; in Portugal awareness of the disease is poor among the general public and policy makers&#46; In addition&#44; there has been a lack of concerted efforts in the medical profession to organize the health care process more efficiently&#44; which is essential to improve management of the syndrome and thus to have a positive effect on health indicators&#46; In view of the current and future importance of HF &#8211; which is expected to increase in prevalence and incidence &#8211; it must be seen as a priority in health care in Portugal&#44; and the National Health Service &#40;NHS&#41; should be given the necessary means to improve its performance in clinical terms as well as in its organizational and funding framework&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The present document aims to raise awareness of the urgent need to prioritize HF in the health agenda given its current prevalence and the increase expected in the near future&#44; the associated high mortality and morbidity and the socioeconomic burden for patients&#44; their families&#44; and society&#46; It also aims to help identify the main shortcomings in the management of HF and to propose solutions at different levels of care that will lead to improved integration between the different specialists involved in the diagnosis&#44; treatment and monitoring of HF patients at the national level&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">This analysis is intended for physicians&#44; particularly those involved in the management of HF patients &#40;cardiologists&#44; internists&#44; intensivists and general practitioners &#91;GPs&#93;&#41;&#44; nurses&#44; and health decision-makers&#44; whose determinations may influence attitudes to HF&#46; It is also intended to act as a guide for future initiatives aimed at raising awareness among the general public&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The authors of the present document&#44; who are cardiologists&#44; internists and GPs&#44; work within the NHS&#44; in hospitals &#40;including emergency departments&#41; and in primary health care&#46; The opinions expressed here are based on their personal experience&#44; both clinical and organizational&#44; and are supported by the guidelines published by the European Society of Cardiology &#40;ESC&#41; and the American College of Cardiology&#47;American Heart Association &#40;ACA&#47;AHA&#41;&#46; This consensus statement is endorsed by the main medical societies and associations involved in the treatment of HF &#40;<a class="elsevierStyleCrossRef" href="#sec0130">Appendix 1</a>&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Heart failure in the world and in Portugal&#58; the burden of the syndrome</span><p id="par0025" class="elsevierStylePara elsevierViewall">HF is defined as a syndrome caused by a structural and&#47;or functional cardiac abnormality&#44; resulting in inadequate cardiac output for the metabolic needs of the organism at rest or during exercise&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> In most cases it is the final stage of a continuum initiated by cardiovascular risk factors&#44; which begin earlier in life than previously thought and progress to cardiac dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> It may be asymptomatic at first&#44; with symptoms only appearing later&#46; Typically&#44; the syndrome develops in episodes of decompensation that weaken the patient&#39;s clinical condition&#44; contribute to worsening HF and require urgent medical care&#46; This continuum can be interrupted without warning&#44; at any time&#44; by sudden death or culminate in death due to pump failure&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Heart failure in the world</span><p id="par0030" class="elsevierStylePara elsevierViewall">HF prevalence increases with age&#44; particularly after the age of 65&#44; mainly due to the greater incidence of hypertension and myocardial infarction &#40;MI&#41; after this age and to increased survival of patients after MI&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> HF affects 1-2&#37; of the world&#39;s population and 6-10&#37; of those aged over 65&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;4</span></a> Worldwide&#44; around 26 million adults suffer from HF&#44; on a par with the 32 million with cancer and the 34 million with HIV&#47;AIDS&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> The most recent projections indicate that its prevalence will rise by 25&#37; by 2030&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Episodes of decompensation frequently require visits to the emergency department and hospitalization or rehospitalization&#46; In developed countries&#44; HF accounts for 1-4&#37; of all hospitalizations&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> and is the leading cause of admission in individuals aged over 65 in Europe and the USA&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> Around a quarter of these patients are rehospitalized within a month of discharge&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#44;6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Each hospitalization represents a further worsening of HF&#44; contributing to the decline in the patient&#39;s clinical condition&#44; until death results&#46; In Europe&#44; in-hospital mortality from HF is 7-9&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">7</span></a> a higher figure than for MI&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> Mortality can reach 27&#37; at six months after hospitalization for HF<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">9</span></a> and 50&#37; at 12 months in those admitted with cardiogenic shock&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> Over 50&#37; of HF patients die within five years of diagnosis&#44; which represents a lower survival rate than some types of cancer&#44; including breast&#44; prostate and colon cancer and leukemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;11</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The economic burden of HF is considerable worldwide&#44; accounting for 1-3&#37; of health budgets in the USA and Europe&#44; where it has the greatest economic impact of all diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> In the USA&#44; spending on HF is more than double that of spending on all cancers combined&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> Furthermore&#44; the costs of hospitalizations are considerable&#44; direct medical costs accounting for 68&#37; of the total costs of HF in the USA and Europe&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Heart failure in Portugal&#58; from cardiovascular risk factors to socioeconomic impact</span><p id="par0050" class="elsevierStylePara elsevierViewall">There is a high prevalence of cardiovascular risk factors in Portugal&#58; 24&#37; of the population are smokers<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> and 27&#46;5&#37; have metabolic syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> The country has one of the highest rates of increase in prevalence of overweight and obesity in Europe &#40;53&#37; in those aged between 18 and 64&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> In addition&#44; three million Portuguese have diabetes or impaired glucose metabolism&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> Hypertension affects 42&#37; of adult Portuguese<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> and there are around 12<span class="elsevierStyleHsp" style=""></span>000 cases of MI every year&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The overall prevalence of chronic HF in Portugal was estimated at 4&#46;36&#37; in the EPICA study &#40;1998&#8211;2000&#41;&#44; ranging from 1&#46;36&#37; in those aged 25-49 to 16&#46;14&#37; in those aged over 80&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> Bearing in mind the aging of the population over the last 20 years&#44; these figures are now undoubtedly higher&#59; on the basis of the prevalence in each age-group in the EPICA study and data from the 2011 census&#44; there may now be as many as 380<span class="elsevierStyleHsp" style=""></span>000 cases of HF in Portugal&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">A report by the Portuguese Directorate-General for Health &#40;DGS&#41;&#44; &#8220;Cerebral and Cardiovascular Disease in Numbers 2015&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a> cites a principal diagnosis of HF as the second leading source of hospital production&#44; accounting in 2014 for 182<span class="elsevierStyleHsp" style=""></span>512 days of hospitalization &#40;1&#46;9 times more than MI&#41; and 18<span class="elsevierStyleHsp" style=""></span>588 patients discharged after admission for decompensated HF&#46; Mean hospital stay for HF was 9&#46;8 days in 2014&#46; HF is responsible for the highest in-hospital mortality of all cerebral and cardiovascular disease in the country&#44; reaching 12&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In addition&#44; HF is often presented as a secondary diagnosis in medical records&#44; so the actual number of patients hospitalized for HF is higher than reported&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> According to a report from medical consultants IASIST Portugal&#44; &#8220;Impact of hospitalization of chronic patients on the NHS&#8221;&#44; the number of HF admissions rose by 33&#37; between 2004 and 2012&#44;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> but this number is probably an underestimate&#44; in view of shortcomings in the coding of a diagnosis of HF&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> The rate of hospitalization for HF in 2009 was 27&#46;9&#47;100<span class="elsevierStyleHsp" style=""></span>000 population&#44; similar to that for diabetes &#40;30&#46;0&#47;100<span class="elsevierStyleHsp" style=""></span>000&#41;&#44; asthma &#40;29&#46;5&#47;100<span class="elsevierStyleHsp" style=""></span>000&#41; and chronic obstructive pulmonary disease &#40;COPD&#41; &#40;29&#46;4&#47;100<span class="elsevierStyleHsp" style=""></span>000&#41;&#44; some of the major epidemics of the 21st century&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">22&#44;23</span></a> However&#44; in 2012 the mortality rate for HF &#40;12&#46;9&#37;&#41; was higher than for diabetes &#40;5&#46;1&#37;&#41;&#44; asthma &#40;0&#46;8&#37;&#41; and COPD &#40;7&#46;5&#37;&#41;&#44; and the same trend was seen for rehospitalizations &#40;14&#46;6&#37; for HF&#44; 8&#46;2&#37; for diabetes&#44; 5&#46;1&#37; for asthma and 14&#46;0&#37; for COPD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The readmission rate&#44; particularly at 30 and 60 days&#44; is increasing&#44; which has serious economic and health care implications&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Official data show that the cost of HF hospitalizations in Portugal in 1998 was approximately 24 million euros&#44;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> similar to that of hospitalizations for COPD in the same year &#40;23 million euros&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Almost 20 years later&#44; the growing prevalence of HF and the increasing sophistication of medical care mean that this figure is likely to be much higher&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Patients hospitalized for HF consume large quantities of resources&#44; due to the high cost of the complex diagnostic exams&#44; drugs&#44; medical devices and surgical procedures that are often required&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> The cost of health care for HF patients is estimated to be well above what is allocated to them by the NHS&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The physical and psychological effects of HF also have important psychosocial implications&#44; such as social isolation&#44; anxiety&#44; frustration and depression&#44; with negative effects on the quality of life of both patients and their caregivers&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> There are no data available for the effects of HF on absenteeism and loss of productivity in Portugal&#44; but this is another important aspect of the burden of HF with repercussions not only for the health system but also for society and the economy&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">The problems with heart failure treatment in Portugal</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Lack of awareness of the importance of heart failure and of an integrated approach</span><p id="par0085" class="elsevierStylePara elsevierViewall">The basic problem with HF in Portugal is that there is no integrated approach on the part of those responsible for its management &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; The result is a lack of awareness of its importance and of its impact on the general population&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Official data on HF in Portugal are also limited and do not fully characterize the real course and management of the syndrome&#46; The only study to date on the prevalence of heart failure in Portugal was published nearly 15 years ago&#44;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a> and there are no current data on changes in its prevalence and&#44; more importantly&#44; in its diagnosis and treatment&#46; There are also gaps in the information on HF in the National Program for Cerebral and Cardiovascular Disease of the DGS&#44; which does not provide numbers of rehospitalizations or of emergency department admissions for HF&#46; In addition&#44; the hospital production described in the DGS report is based on the coding of diagnosis-related groups &#40;DRGs&#41;&#44; which&#44; as stated above&#44; does not always reflect the real number of patients hospitalized for HF&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Lack of a structural debate on heart failure within and between specialties</span><p id="par0095" class="elsevierStylePara elsevierViewall">Understanding of the actual importance of heart failure in the medical profession is patchy and there is little or no discussion of the role of the different specialties that deal with the condition&#46; There is thus a need to organize the health care flows and to clearly define responsibilities&#44; in order to ensure that optimal support is provided from the beginning to the end of the patient&#39;s journey through the health system&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The main players in the management of HF are GPs&#44; cardiologists&#44; internists&#44; intensivists and nurses&#44; but HF patients frequently present multiple comorbidities and therefore other specialists also have an important role in clinical management of the syndrome&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Since different specialists will be involved in the management of an individual patient&#44; effective communication and collaboration between them and between the various levels of health care are essential&#46; It has been shown that HF patients are better treated in integrated management programs and by specialized multidisciplinary teams &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;27</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">However&#44; despite the existence of the online Health Data Platform &#40;PDS&#41;&#44; there are weaknesses in the flow of information between the different levels of health care&#46; Communication between primary care centers and hospitals&#44; particularly the cardiology and internal medicine departments&#44; as well as between hospital departments&#44; is clearly in need of improvement&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Lack of an integrated health care process for the management of heart failure and deficiencies throughout the patient&#39;s journey through the health system</span><p id="par0115" class="elsevierStylePara elsevierViewall">The lack of a properly organized integrated health care process for the management of heart failure is reflected in a wide range of deficiencies throughout the patient&#39;s journey through the health system &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Diagnosis</span><p id="par0120" class="elsevierStylePara elsevierViewall">In Portugal&#44; HF is often diagnosed late&#44; frequently at the time of the first hospitalization&#44; instead of being suspected and diagnosed early by the patient&#39;s GP&#46; This is largely due to a lack of awareness of the disease and failure to recognize the characteristic symptoms and signs&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">A suspected diagnosis of HF on the basis of symptoms and signs&#44; and an electrocardiogram and&#47;or chest X-ray&#44; should be confirmed by objective evidence of cardiac dysfunction&#44; and so other diagnostic exams are needed&#44; such as B-type natriuretic peptide &#40;BNP&#41; or N-terminal BNP &#40;NT-proBNP&#41; measurement and&#47;or imaging studies&#44; of which echocardiography is the most accessible&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;27</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">GPs do not have easy access to BNP or NT-proBNP measurements&#44; which are not reimbursed by the NHS for outpatients&#46; Due to their high negative predictive value&#44; low BNP&#47;NT-proBNP levels can avoid false-positive diagnoses of HF and unnecessary use of echocardiography&#44; which is considerably more costly&#46; Making tests of natriuretic peptide levels available to GPs would improve health care by enabling earlier diagnosis and would reduce costs by avoiding repeat exams&#44; incorrect diagnoses and inappropriate referral for hospital services&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">An additional problem is that while echocardiography is now more widely available&#44; the lack of standardization of echocardiographic reports means they are frequently incomplete or inconclusive for confirming or excluding a diagnosis of HF&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Outpatient treatment and referral</span><p id="par0140" class="elsevierStylePara elsevierViewall">There is still uncertainty among GPs as to when to prescribe disease-modifying drugs to treat HF and at what doses&#46; Hospital referral is also subject to certain constraints&#44; and&#44; conversely&#44; communication between hospitals and GPs is limited when patients are returned to primary care after an acute event&#46; There are relatively few HF specialists in Portugal or specialized structures that can provide local health care for HF patients and ensure early treatment of episodes of decompensation&#46; Cardiac rehabilitation programs for HF patients are equally scarce&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Acute phase and hospitalization</span><p id="par0145" class="elsevierStylePara elsevierViewall">As with MI&#44; it is essential that acute HF should be treated as rapidly as possible&#46; However&#44; the guidelines are unclear as to the approach to adopt given the lack of solid evidence in this area&#44; relying mostly on the experience of the individual physician&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> There is no standard and systematically applied treatment protocol in Portugal&#44; nor are there adequately trained multidisciplinary teams to implement such a protocol in most emergency&#44; internal medicine or even cardiology departments&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pre-discharge and vulnerable phases</span><p id="par0150" class="elsevierStylePara elsevierViewall">There is no organized transition care for HF patients in Portugal&#46; Planning for discharge should include guidance for patients and caregivers&#44; prescription and appropriate titration of all drugs that can modify the course of the disease&#44; sharing of information and scheduling of reassessment consultations within two weeks of discharge&#44; in order to reduce the risk of rehospitalization or death during this vulnerable phase&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a> It is also recommended that high-risk patients should be referred for integrated multidisciplinary management programs and cardiac rehabilitation programs&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Referral for integrated multidisciplinary management programs</span><p id="par0155" class="elsevierStylePara elsevierViewall">HF clinics are increasingly important in the care of these patients&#46; Such clinics have multidisciplinary teams made up of specialists in HF &#40;cardiologists&#44; internists&#44; GPs and nurses&#41; and other health professionals&#44; pharmacists&#44; dieticians&#44; physiotherapists&#44; psychologists and social workers&#44; who together provide a systematic approach to HF&#46; These teams have been shown to be cost-effective and to improve patients&#8217; quality of life and reduce hospitalizations and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Patients and caregivers need to be educated about the importance of adherence to drug and non-drug therapy and early recognition of decompensation in this phase&#46; This is usually done by nurses&#44; who should also be specialized in HF&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Another essential factor is accessibility to these programs&#44; to enable early treatment of decompensation in day care centers&#44; which will avoid rehospitalization and&#47;or visits to the emergency department and thus reduce costs&#46; Telemedicine for management of outpatients is another promising possibility&#44; although further research is needed&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">However&#44; the fact is that these facilities are in short supply in Portugal&#44; as is specialized HF training for nurses&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Cardiac rehabilitation</span><p id="par0175" class="elsevierStylePara elsevierViewall">Also limited&#44; in fact virtually nonexistent&#44; are cardiac rehabilitation programs for HF patients in Portugal&#44; despite their proven benefits&#44; unequivocal recommendations for referral&#44; and the appeal by the Portuguese Society of Cardiology for more action in this area in a document published on the Society&#39;s website&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Palliative and end-of-life care</span><p id="par0180" class="elsevierStylePara elsevierViewall">There is also a need to develop strategies for provision of palliative and end-of-life care for HF patients&#44; which is rarely included in health care planning&#46;</p></span></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Strategies to improve medical care for heart failure patients in Portugal</span><p id="par0185" class="elsevierStylePara elsevierViewall">Below are suggestions for short&#44; medium and long-term measures required to improve medical care for HF patients&#46;</p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Short-term measures</span><p id="par0190" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0195" class="elsevierStylePara elsevierViewall">The most urgent measure to improve the current situation would be to bring the different players together to form an alliance dedicated to making HF a health priority and improving its management&#46; This alliance should include&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">regulatory and political bodies&#44; especially the Health Commission of the Portuguese Parliament and the Ministry of Health&#44; particularly the DGS and the Program for Cerebral and Cardiovascular Disease&#59;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">scientific societies&#44; particularly the Portuguese Societies of Cardiology&#44; Internal Medicine&#44; and Intensive Care&#59;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">the Portuguese Medical Council and the Colleges of the various specialties involved in HF treatment&#59;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">the Portuguese Nursing Council&#59;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">HF patient groups&#59;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">the media&#44; as a means of informing and educating the population&#59;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0230" class="elsevierStylePara elsevierViewall">the pharmaceutical and medical device industries&#44; as partners in improving health care&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2&#46;</span><p id="par0235" class="elsevierStylePara elsevierViewall">A national plan is needed for training health professionals in HF&#44; particularly physicians and nurses&#44; to encourage specialization in this area&#46; HF should be included in the National Health Plan and clinical guidelines should be drawn up based on the ESC guidelines&#46; The guidelines should be appropriate to the Portuguese context and should take into account the expected increase in HF prevalence in the coming years&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">3&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall">HF should be a priority in the next edition of the National Program for Cerebral and Cardiovascular Disease and in local health programs&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">4&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Diagnosis of HF should be improved by implementing digital diagnostics&#44; and measurement of NT-proBNP should be made available in primary care and be reimbursed by the NHS&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">5&#46;</span><p id="par0250" class="elsevierStylePara elsevierViewall">A &#8216;Heart Failure Record&#8217; should be introduced through which clinical information on each HF patient is recorded and can be accessed by all those involved in the care of HF patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">6&#46;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Sharing of best practices should be encouraged between the facilities treating HF patients &#40;cardiology and internal medicine departments and GPs&#41;&#46;</p></li></ul></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Medium-term measures</span><p id="par0260" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">1&#46;</span><p id="par0265" class="elsevierStylePara elsevierViewall">An information and awareness campaign should be launched directed at the general population&#44; patients&#44; nurses and physicians&#46; This could be linked to initiatives of the ESC and the Heart Failure Association&#44; and of the Portuguese Society of Cardiology via its Working Group on Heart Failure&#46; The campaign should include information on the European Heart Health Charter and the HeartFailureMatters website&#44; aimed at patients and caregivers&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">2&#46;</span><p id="par0270" class="elsevierStylePara elsevierViewall">An integrated health care process for the management of HF should be established that is codified and applicable throughout the country&#44; beginning with the creation of protocols designed to promote better integration between primary care and hospitals&#46; This will require the setting up of a national network of multidisciplinary teams for the integrated treatment of HF patients&#46; We also suggest the establishment of HF day hospitals and increasing the availability of cardiac rehabilitation programs for HF patients&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">3&#46;</span><p id="par0275" class="elsevierStylePara elsevierViewall">Performance indicators should be introduced for the medical care of HF patients&#44; for both outpatient and inpatient care&#44; and applicable to hospital departments and GPs&#46; The performance measures recommended by the ESC and the ACC&#47;AHA could be used for this purpose&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">29&#44;30</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">4&#46;</span><p id="par0280" class="elsevierStylePara elsevierViewall">The definition of HF and its associated costs in the relevant DRG tables&#44; as well as those of HF day hospital sessions&#44; should be revised&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">5&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall">Echocardiographic reports need to be standardized at national level in order to improve the quality of information available to physicians&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">6&#46;</span><p id="par0290" class="elsevierStylePara elsevierViewall">An effective palliative care network that includes HF patients should be implemented&#46;</p></li></ul></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Long-term measures</span><p id="par0295" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">1&#46;</span><p id="par0300" class="elsevierStylePara elsevierViewall">Electronic systems for sharing clinical information need to be improved&#44; particularly the Health Data Platform &#40;PDS&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2&#46;</span><p id="par0305" class="elsevierStylePara elsevierViewall">Data collection should be systematized in order to update epidemiological data on HF&#44; which will enable the progress of the disease to be monitored&#46; Such data should include information on quality of life&#44; using standardized questionnaires&#44; and on the impact of the syndrome in terms of absenteeism of patients and caregivers&#46;</p></li></ul></p></span></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusions</span><p id="par0310" class="elsevierStylePara elsevierViewall">HF is a major public health problem in Portugal due to its high prevalence&#44; morbidity and mortality and its considerable economic impact&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Given the wide variations in the country in health care provision for HF patients&#44; at both primary care and hospital level&#44; this document does not suggest a single model for improvement&#46; On the contrary&#44; it is necessary to define and implement strategies that take account of regional differences&#44; in order to optimize existing resources and the links between them&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">There is a strong desire for change among Portuguese health professionals who deal with HF&#46; This document&#44; prepared by a group of experts&#44; sets out to analyze the problem&#44; identify deficiencies and propose solutions in order to increase awareness of the need to prioritize the management of HF in the interests of public health care in Portugal&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Ethical disclosures</span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Protection of human and animal subjects</span><p id="par0325" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Confidentiality of data</span><p id="par0330" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Right to privacy and informed consent</span><p id="par0335" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicts of interest</span><p id="par0340" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">The present work was supported by an unconditional grant from Novartis&#46;</p></span></span>"
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          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0110"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0115"
              "titulo" => "Confidentiality of data"
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            2 => array:2 [
              "identificador" => "sec0120"
              "titulo" => "Right to privacy and informed consent"
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        10 => array:2 [
          "identificador" => "sec0125"
          "titulo" => "Conflicts of interest"
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        11 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2016-10-27"
    "fechaAceptado" => "2016-10-28"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec790444"
          "palabras" => array:5 [
            0 => "Heart failure"
            1 => "Consensus statement"
            2 => "Prevalence"
            3 => "Integrated multidisciplinary treatment"
            4 => "Socioeconomic impact"
          ]
        ]
      ]
      "pt" => array:1 [
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          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec790445"
          "palabras" => array:5 [
            0 => "Insufici&#234;ncia card&#237;aca"
            1 => "Documento de consensos"
            2 => "Preval&#234;ncia"
            3 => "Tratamento multidisciplinar integrado"
            4 => "Impacto socioecon&#243;mico"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Heart failure is a syndrome with high prevalence&#44; morbidity and mortality&#44; but awareness of the disease is poor among the general public and policy makers&#46; This document&#44; which was prepared by a group of experts consisting of cardiologists&#44; internists and general practitioners&#44; aims to set out in detail the problem of heart failure in Portugal at several levels&#58; burden of the disease&#44; diagnosis&#44; treatment and monitoring&#46; To this end&#44; different aspects of the management of the various stages of the disease are identified and discussed in detail&#44; covering both outpatients and hospitalized patients&#46; In order to optimize the medical care provided to these patients&#44; various short-&#44; medium- and long-term solutions and strategies are put forward that have the potential to improve the integration and use of available resources&#46; The intention is to highlight strategies that are not based on a single model but can be adapted to different regional circumstances&#44; in order to increase awareness and improve management of heart failure in Portugal&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A insufici&#234;ncia card&#237;aca &#233; uma s&#237;ndrome com elevada preval&#234;ncia&#44; morbilidade e mortalidade&#44; sendo&#44; no entanto&#44; pouco reconhecida junto dos cidad&#227;os e decisores pol&#237;ticos&#46; O presente documento foi elaborado por um conjunto de peritos constitu&#237;do por m&#233;dicos especialistas em cardiologia&#44; medicina interna e medicina geral e familiar&#44; e pretende expor detalhadamente o problema da insufici&#234;ncia card&#237;aca em Portugal a v&#225;rios n&#237;veis&#58; peso da s&#237;ndrome&#44; diagn&#243;stico&#44; tratamento e acompanhamento dos doentes&#46; Para tal&#44; s&#227;o identificados e discutidos em detalhe os diferentes aspetos inerentes ao manejo da s&#237;ndrome durante o processo assistencial&#44; nas v&#225;rias fases da doen&#231;a e que incluem doentes hospitalizados e em ambulat&#243;rio&#46; De modo a otimizar a assist&#234;ncia m&#233;dica prestada a estes doentes&#44; s&#227;o apontadas diversas solu&#231;&#245;es e estrat&#233;gias a curto&#44; m&#233;dio e longo prazo com potencial para melhorarem a articula&#231;&#227;o e utiliza&#231;&#227;o dos recursos dispon&#237;veis&#46; Pretendeu-se desta forma destacar estrat&#233;gias que&#44; n&#227;o se traduzindo num modelo &#250;nico de melhoria&#44; poder&#227;o ser adaptadas &#224;s diferentes especificidades regionais&#44; de modo a aumentar o reconhecimento e a aten&#231;&#227;o prestada &#224; insufici&#234;ncia card&#237;aca em Portugal&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fonseca C&#44; Brito D&#44; Cernadas R&#44; Ferreira J&#44; Franco F&#44; Rodrigues T&#44; et al&#46; Pela melhoria do tratamento da insufici&#234;ncia card&#237;aca em Portugal &#8211; documento de consenso 2017&#59;36&#58;1&#8211;8&#46;</p>"
      ]
    ]
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      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0350" class="elsevierStylePara elsevierViewall">Endorsed by the Working Group on Heart Failure of the Portuguese Society of Cardiology&#44; the Heart Failure Nucleus of the Portuguese Society of Internal Medicine&#44; the College of General Practitioners of the Portuguese Medical Council&#44; the Cardiovascular Disease Nucleus of the Portuguese Association of General Practitioners&#44; and the Nursing Nucleus of the Portuguese Society of Cardiology&#46;<elsevierMultimedia ident="tbl0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix 1"
            "titulo" => "Consensus statement on improvement of heart failure treatment in Portugal"
            "identificador" => "sec0130"
          ]
        ]
      ]
    ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Health care flows for the treatment of heart failure&#44; showing the need for multidisciplinary teams to ensure the integrated management of the syndrome and provide health care in accordance with the international guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> HF&#58; heart failure&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Working Group on Heart Failure of the Portuguese Society of Cardiology</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C&#226;ndida Fonseca &#40;coordinator&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dulce Brito&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Susana Costa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Heart Failure Nucleus of the Portuguese Society of Internal Medicine</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paulo Bettencourt &#40;coordinator&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C&#233;sar Louren&#231;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">In&#234;s Ara&#250;jo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Irene Marques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Joana Pimenta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jorge Mercier&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pedro Morais Sarmento&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Nursing Nucleus of the Portuguese Society of Cardiology</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Manuel Belo Costa &#40;coordinator&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Madalena Carvalho&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Susana Quint&#227;o&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Marisa Serrano&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ana Catarina Bastos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">College of General Practitioners of the Portuguese Medical Council</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jos&#233; Maria da Silva Henriques &#40;President&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anabela Pimentel Lopes Cunha Vaz&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">L&#233;nia Isabel de Gouveia Olim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maria de Lourdes Sousa Tavares Da Silva&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maria Luciana Gomes Domingues Couto Carvalho&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maria Pacheu Catanho Patr&#237;cio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No&#233;lia Rubina Correia Sousa Costa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pedro Camilo de Ara&#250;jo Lima de Vasconcelos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Cardiovascular Disease Nucleus of the Portuguese Association of General Practitioners</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maria Helena Febra &#40;coordinator&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maria Teressa Lib&#243;rio&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maria Helena Oliveira&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carolina Resende&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Paula Oliveira&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:30 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure&#58; the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology &#40;ESC&#41;&#46; Developed with the special contribution of the Heart Failure Association &#40;HFA&#41; of the ESC"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46; Ponikowski"
                            1 => "A&#46;A&#46; Voors"
                            2 => "S&#46;D&#46; Anker"
                          ]
                        ]
                      ]
                    ]
                  ]
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                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2016"
                        "volumen" => "20"
                        "paginaInicial" => "1"
                        "paginaFinal" => "85"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10513291"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "2"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The cardiovascular disease continuum validated&#58; clinical evidence of improved patient outcomes&#58; part I&#58; Pathophysiology and clinical trial evidence &#40;risk factors through stable coronary artery disease&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "V&#46;J&#46; Dzau"
                            1 => "E&#46;M&#46; Antman"
                            2 => "H&#46;R&#46; Black"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIRCULATIONAHA.106.655688"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2006"
                        "volumen" => "114"
                        "paginaInicial" => "2850"
                        "paginaFinal" => "2870"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17179034"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Heart failure - preventing disease and death worldwide"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46; Ponikowski"
                            1 => "S&#46;D&#46; Anker"
                            2 => "K&#46;F&#46; AlHabib"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "ESC Heart Failure"
                        "fecha" => "2014"
                        "volumen" => "1"
                        "paginaInicial" => "4"
                        "paginaFinal" => "25"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Improving care for patients with acute heart failure - before&#44; during and after hospitalization"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "M&#46;R&#46; Cowie"
                            1 => "S&#46;D&#46; Anker"
                            2 => "J&#46;G&#46;F&#46; Cleland"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "ESC Heart Failure"
                        "fecha" => "2014"
                        "volumen" => "1"
                        "paginaInicial" => "110"
                        "paginaFinal" => "145"
                      ]
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                  ]
                ]
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            4 => array:3 [
              "identificador" => "bib0175"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Understanding heart failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46; Mazurek"
                            1 => "M&#46; Jessup"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ccep.2015.08.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Card Electrophysiol Clin"
                        "fecha" => "2015"
                        "volumen" => "7"
                        "paginaInicial" => "557"
                        "paginaFinal" => "575"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26596802"
                            "web" => "Medline"
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                        ]
                      ]
                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0180"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A systematic approach to chronic heart failure care&#58; a consensus statement"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "K&#46; Page"
                            1 => "T&#46;H&#46; Marwick"
                            2 => "R&#46; Lee"
                          ]
                        ]
                      ]
                    ]
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Article information
ISSN: 21742049
Original language: English
DOI:10.1016/j.repce.2016.10.016
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