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An approach to improving heart failure management – A local contribution
Perspetiva para a melhoria do tratamento da insuficiência cardíaca – um contributo local
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The data refer to admissions to the internal medicine department in the study period. HF: heart failure; ICD-9: International Classification of Diseases, 9th Revision.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Irene Marques, Sara Abreu, Manuela V. Bertão, Betânia Ferreira, Raquel Lopes Ramos, Juliana Lopes, Sandra Nunes, Denisa Mendonça, Laetitia Teixeira" "autores" => array:9 [ 0 => array:2 [ "nombre" => "Irene" "apellidos" => "Marques" ] 1 => array:2 [ "nombre" => "Sara" "apellidos" => "Abreu" ] 2 => array:2 [ "nombre" => "Manuela V." "apellidos" => "Bertão" ] 3 => array:2 [ "nombre" => "Betânia" "apellidos" => "Ferreira" ] 4 => array:2 [ "nombre" => "Raquel Lopes" "apellidos" => "Ramos" ] 5 => array:2 [ "nombre" => "Juliana" "apellidos" => "Lopes" ] 6 => array:2 [ "nombre" => "Sandra" "apellidos" => "Nunes" ] 7 => array:2 [ "nombre" => "Denisa" "apellidos" => "Mendonça" ] 8 => array:2 [ "nombre" => "Laetitia" "apellidos" => "Teixeira" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255117303372" "doi" => "10.1016/j.repc.2016.10.011" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117303372?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917301721?idApp=UINPBA00004E" "url" => "/21742049/0000003600000006/v1_201707020042/S2174204917301721/v1_201707020042/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "An approach to improving heart failure management – A local contribution" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "439" "paginaFinal" => "441" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Cândida Fonseca" "autores" => array:1 [ 0 => array:4 [ "nombre" => "Cândida" "apellidos" => "Fonseca" "email" => array:1 [ 0 => "mcandidafonseca@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidade de Insuficiência Cardíaca, Serviço de Medicina III, Hospital de S. Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Perspetiva para a melhoria do tratamento da insuficiência cardíaca – um contributo local" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure (HF) is a growing public health problem. Around 26 million individuals worldwide now suffer from HF, a similar figure to the 32 million who are living with cancer and the 34 million around with HIV/AIDS.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> The estimated prevalence of HF in Europe is 2%, and rises sharply after the age of 60; over 80% of HF patients are aged ≥65 years, and it is the leading cause of hospitalization in this age-group, in both Europe and the US.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The number of HF patients is expected to double by 2030 due to aging populations and to more effective treatment of HF and of the heart diseases that lead to it, which will inevitably increase demands on medical services and health institutions.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">At the same time, the epidemiology of HF appears to be changing. A recent systematic review reported that its prevalence among individuals aged ≥60 years is 11.8%, which has remained fairly stable in the last decade, and that HF with preserved ejection fraction (HFpEF) is more common than HF with reduced ejection fraction (HFrEF) (4.9% and 3.3%, respectively), the prevalence of the former increasing and that of the latter apparently decreasing in the 21st century.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite advances in the last 30 years in new pharmacological and non-pharmacological therapies that can effectively treat HFrEF, HF patients are at high risk of early rehospitalization and death after a first admission, especially in the first 30-60 days after discharge. Around a quarter of HF patients aged >65 will be readmitted within 30 days and a half within six months of discharge.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5–7</span></a> HF has a drastic effect on survival and the quality of life of patients and caregivers and on the health budgets of developed countries. It is estimated that costs will rise two and a half times by 2030,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> and hospitalizations account for 60-80% of expenditure on HF.</p><p id="par0025" class="elsevierStylePara elsevierViewall">However, it is acknowledged that most readmissions could be avoided through improvements in hospital care, particularly pre-discharge, and transitional care.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3,6,8–11</span></a> Against this background, under the scope of a program to reduce readmissions in American hospitals, excessive readmission rates have been subject to financial penalties since 2010. Other countries have opted to reward institutions with better indicators.</p><p id="par0030" class="elsevierStylePara elsevierViewall">HF treatment should also be a priority of the Portuguese national health system, at all levels of care.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> Everyone – patients, health professionals and decision-makers – should be made more aware of the syndrome and take measures to deal with the epidemic in all its aspects.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Rather than punitive measures, the strategy should be based on ongoing clinical research, multicenter national registries and real-life data, which are essential to establishing evidence-based quality indicators and standards that can measure improvements in morbidity and mortality among HF patients.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study by Marques et al. in this issue of the <span class="elsevierStyleItalic">Journal</span> is part of this effort.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> The authors analyze a population of consecutive patients hospitalized in the internal medicine department of a tertiary teaching hospital that is planning to implement an HF clinic based on a multidisciplinary approach to improving the care provided to HF patients.</p><p id="par0045" class="elsevierStylePara elsevierViewall">HF clinics based on integrated management of the syndrome by multidisciplinary teams have been shown to reduce morbidity and mortality and are a class IA recommendation in the European Society of Cardiology guidelines on the treatment of acute and chronic HF (ESC).<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Aware that there is no single one-size-fits-all model, since local needs differ, the authors seek to assess deficiencies and identify areas for improvement.</p><p id="par0055" class="elsevierStylePara elsevierViewall">We highlight certain results of the study that are of particular interest. The patients admitted to the internal medicine department were elderly (mean age 79 years), and the majority were women (62.5%), with multiple comorbidities (not all of which were assessed in the study), and mainly had HFpEF (70.5%). The subjects were thus different from those included in clinical trials and registries from cardiology departments and HF units in Portugal and other European countries, who are generally younger, mainly male and with HFrEF.<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">15,16</span></a> The characteristics of the study population were thus more in line with those reported by many other studies, in which older HF patients with multiple comorbidities and preserved ejection fraction, are more often admitted to internal medicine departments.</p><p id="par0060" class="elsevierStylePara elsevierViewall">A third of the patients died or were rehospitalized within a year, evidence that the long-term prognosis of HFpEF is as poor as that of HFrEF, and belying the myth that the former has a better prognosis.<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">17,18</span></a> In-hospital mortality (7.9%) was as high for HFpEF as for HFrEF, as was the one-year readmission rate (34.3%), which is also higher than that reported in the ESC Heart Failure Long-term Registry, suggesting there is room for improvement.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Reassessment following discharge in specialist consultations (only available for 62% of patients over a period of one year) was late, well after the two weeks recommended in international guidelines. There is no mention of assessment in primary care, which is also recommended within a week of discharge in the ESC guidelines.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Even though hospitalization is an undesirable event and represents a worsening of the clinical course of HF, it does offer a unique opportunity to reassess the patient and optimize therapy, but this is only the first step. The guidelines recommend referral of these high-risk patients to an integrated management program, but only 26 countries in Europe have such programs in more than 30% of their hospitals, and even when they do exist, they are not always properly used.<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">14,20</span></a> Various levels of care, especially primary care, need to be included in the multidisciplinary management of these patients, a measure that has yet to be fully implemented in Europe, including Portugal.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">14</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">It is tempting to assume that differences in mortality and rehospitalization rates between different European countries, which are lower in Northern Europe and in certain southern European countries like Italy, are related to the level of access to integrated HF management networks and programs that have long been implemented in these countries.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">20–23</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The introduction of such programs should be encouraged, and we therefore eagerly await the results of the HF clinic that Marques et al. are proposing to implement in their hospital.</p><p id="par0085" class="elsevierStylePara elsevierViewall">We agree that there is a need for studies and multicenter national registries that include cardiology departments as well as internal medicine, geriatric and emergency departments, in order to characterize the HF pandemic more thoroughly and to implement national HF treatment networks that meet patients’ needs. Organizational efforts will be required at both local and national level.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> The time has come to share experiences and coordinate initiatives to raise awareness, improve training, and implement an organizational strategy and policies to improve HF treatment in Portugal.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Fonseca C. Perspetiva para a melhoria do tratamento da insuficiência cardíaca – um contributo local. Rev Port Cardiol. 2017;36:439–441.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0120" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The global health and economic burden of heart failure: lessons learned from hospitalized heart failure registries" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.P. Ambrosy" 1 => "G.C. Fonarow" 2 => "J. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 5 | 12 |
| 2024 October | 28 | 31 | 59 |
| 2024 September | 34 | 20 | 54 |
| 2024 August | 26 | 21 | 47 |
| 2024 July | 29 | 30 | 59 |
| 2024 June | 26 | 21 | 47 |
| 2024 May | 29 | 22 | 51 |
| 2024 April | 28 | 23 | 51 |
| 2024 March | 25 | 21 | 46 |
| 2024 February | 19 | 21 | 40 |
| 2024 January | 20 | 19 | 39 |
| 2023 December | 15 | 23 | 38 |
| 2023 November | 30 | 28 | 58 |
| 2023 October | 17 | 11 | 28 |
| 2023 September | 20 | 17 | 37 |
| 2023 August | 12 | 16 | 28 |
| 2023 July | 21 | 15 | 36 |
| 2023 June | 66 | 11 | 77 |
| 2023 May | 32 | 26 | 58 |
| 2023 April | 14 | 7 | 21 |
| 2023 March | 38 | 23 | 61 |
| 2023 February | 23 | 20 | 43 |
| 2023 January | 11 | 23 | 34 |
| 2022 December | 31 | 34 | 65 |
| 2022 November | 30 | 26 | 56 |
| 2022 October | 21 | 20 | 41 |
| 2022 September | 21 | 23 | 44 |
| 2022 August | 16 | 24 | 40 |
| 2022 July | 23 | 33 | 56 |
| 2022 June | 23 | 23 | 46 |
| 2022 May | 20 | 20 | 40 |
| 2022 April | 25 | 34 | 59 |
| 2022 March | 25 | 45 | 70 |
| 2022 February | 23 | 33 | 56 |
| 2022 January | 27 | 21 | 48 |
| 2021 December | 14 | 29 | 43 |
| 2021 November | 28 | 29 | 57 |
| 2021 October | 39 | 34 | 73 |
| 2021 September | 19 | 27 | 46 |
| 2021 August | 31 | 26 | 57 |
| 2021 July | 21 | 24 | 45 |
| 2021 June | 21 | 17 | 38 |
| 2021 May | 34 | 46 | 80 |
| 2021 April | 63 | 49 | 112 |
| 2021 March | 50 | 18 | 68 |
| 2021 February | 76 | 14 | 90 |
| 2021 January | 22 | 10 | 32 |
| 2020 December | 46 | 6 | 52 |
| 2020 November | 29 | 14 | 43 |
| 2020 October | 15 | 17 | 32 |
| 2020 September | 53 | 8 | 61 |
| 2020 August | 22 | 12 | 34 |
| 2020 July | 48 | 17 | 65 |
| 2020 June | 37 | 13 | 50 |
| 2020 May | 45 | 17 | 62 |
| 2020 April | 42 | 11 | 53 |
| 2020 March | 50 | 25 | 75 |
| 2020 February | 52 | 24 | 76 |
| 2020 January | 48 | 21 | 69 |
| 2019 December | 39 | 14 | 53 |
| 2019 November | 35 | 13 | 48 |
| 2019 October | 33 | 6 | 39 |
| 2019 September | 22 | 8 | 30 |
| 2019 August | 22 | 6 | 28 |
| 2019 July | 40 | 8 | 48 |
| 2019 June | 24 | 14 | 38 |
| 2019 May | 35 | 8 | 43 |
| 2019 April | 21 | 16 | 37 |
| 2019 March | 41 | 13 | 54 |
| 2019 February | 26 | 8 | 34 |
| 2019 January | 51 | 10 | 61 |
| 2018 December | 61 | 8 | 69 |
| 2018 November | 78 | 16 | 94 |
| 2018 October | 205 | 11 | 216 |
| 2018 September | 73 | 12 | 85 |
| 2018 August | 32 | 8 | 40 |
| 2018 July | 18 | 6 | 24 |
| 2018 June | 41 | 7 | 48 |
| 2018 May | 65 | 10 | 75 |
| 2018 April | 57 | 11 | 68 |
| 2018 March | 95 | 18 | 113 |
| 2018 February | 52 | 9 | 61 |
| 2018 January | 62 | 14 | 76 |
| 2017 December | 106 | 17 | 123 |
| 2017 November | 66 | 13 | 79 |
| 2017 October | 32 | 13 | 45 |
| 2017 September | 39 | 13 | 52 |
| 2017 August | 62 | 28 | 90 |
| 2017 July | 92 | 32 | 124 |
| 2017 June | 22 | 5 | 27 |
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