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Epidemiology of valvular heart disease in Portugal: The time has come for the heart valve unit
Epidemiologia da doença valvular em Portugal: chegou o tempo da Valvular Heart Unit
Cristina Gavina
Serviço de Cardiologia, Hospital Pedro Hispano - Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal
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IE: infectious endocarditis; MR: mitral regurgitation; MVP: mitral valve prolapse; TR: tricuspid regurgitation; VHD: valvular heart disease.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Fátima Esteves, Dulce Brito, Joana Rigueira, Inês Ricardo, Raquel Pires, Mónica Mendes Pedro, Fátima Veiga, Fausto Pinto" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Ana Fátima" "apellidos" => "Esteves" ] 1 => array:2 [ "nombre" => "Dulce" "apellidos" => "Brito" ] 2 => array:2 [ "nombre" => "Joana" "apellidos" => "Rigueira" ] 3 => array:2 [ "nombre" => "Inês" "apellidos" => "Ricardo" ] 4 => array:2 [ "nombre" => "Raquel" "apellidos" => "Pires" ] 5 => array:2 [ "nombre" => "Mónica Mendes" "apellidos" => "Pedro" ] 6 => array:2 [ "nombre" => "Fátima" "apellidos" => "Veiga" ] 7 => array:2 [ "nombre" => "Fausto" "apellidos" => "Pinto" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918304240?idApp=UINPBA00004E" "url" => "/21742049/0000003700000012/v1_201812280741/S2174204918304240/v1_201812280741/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Epidemiology of valvular heart disease in Portugal: The time has come for the heart valve unit" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "999" "paginaFinal" => "1000" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Cristina Gavina" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Cristina" "apellidos" => "Gavina" "email" => array:1 [ 0 => "cristina.gavina@gmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Serviço de Cardiologia, Hospital Pedro Hispano - Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Epidemiologia da doença valvular em Portugal: chegou o tempo da <span class="elsevierStyleItalic">Valvular Heart Unit</span>" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Significant valvular heart disease (VHD) is a growing public health problem, due to increasing life expectancy and the lack of effective prevention strategies for valve disease of degenerative etiology.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> The characteristics of patients with severe VHD have changed considerably in the last 15 years: they are now older, with more comorbidities, and are more likely to have multivalvular disease.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2,3</span></a> This rapid change means that cardiology departments must make adjustments in order to respond to the rising numbers of these particularly challenging patients.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>, Esteves et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> present a snapshot of patients admitted with a primary or secondary diagnosis of VHD to the cardiology department of Hospital Santa Maria in Lisbon over a period of nearly two years in 2014 and 2015.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The study population consisted of 287 patients with significant VHD or prior heart valve intervention, most (67.9%) with calcified aortic and/or mitral valve disease, 66.9% of whom were admitted as acute cases. Etiology was rheumatic in only 8% of cases, far fewer than the 22% reported by the Euro Heart Survey on Valvular Heart Disease.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> Approximately 14% had been hospitalized in the previous year for VHD.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The mean age of the study population was around 75 years, which is older than in the 2001 Euro Heart Survey on Valvular Heart Disease<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> but similar to the more recent (2017) Valvular Heart Disease II (VHDII) Survey of the European Society of Cardiology's EURObservational Research Programme.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> Multiple comorbidities were found in 53% of patients, the most common of which were coronary artery disease (28.2%), chronic kidney disease (20.9%) and chronic anemia (26.5%). This combination of older patients and multiple comorbidities greatly increases the risks associated with intervention, and raises the question of how to select patients for treatment in such situations.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5,6</span></a> The expectations of patients and their caregivers frequently conflict with those of their physicians, further complicating the calculation of risks versus potential benefits, especially the degree of dependence, worsening of cognitive deficits, and relief of symptoms.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Some aspects of this study merit particular attention due to the impact they may have on the organization of hospital care.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The large number of admissions for elective valve procedures (33.1%) is a measure of increases not only in percutaneous interventions but also, more generally, in referrals for treatment of VHD, in line with the international guidelines.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">7,8</span></a> Treating these old and frequently frail patients with multiple comorbidities requires specialist support in intensive care units and prolonged hospital stay, and this in turn complicates the management of beds in cardiology wards, which are usually reserved for urgent cases. There is a pressing need for reorganization of the supporting structures for these interventions, and for redefinition of outcomes using patient-reported outcome measures.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The high all-cause (9.8%) and cardiovascular (8.7%) in-hospital mortality in Esteves et al. illustrates the challenges of managing VHD in these patients and the need for the involvement of multidisciplinary teams that include not only clinical cardiologists, interventional cardiologists and thoracic surgeons but also anesthetists, geriatricians, physiatrists and nutritionists, among others. The work of such a heart valve unit will be crucial not only in selecting patients for intervention but also for monitoring them after the procedure in order to ensure an optimal result and rapid functional recovery, in accordance with the patient's expectations.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The picture of the VHD patient hospitalized in the cardiology department is changing rapidly, but hospital structures are not keeping up with these changes. What are we waiting for?</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" 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: Gavina C. Epidemiologia da doença valvular em Portugal: chegou o tempo da <span class="elsevierStyleItalic">Valvular Heart Unit</span>. Rev Port Cardiol. 2018;37:999–1000.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Valvular heart disease: the next cardiac epidemic" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.L. D’Arcy" 1 => "B.D. Prendergast" 2 => "J.B. Chambers" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/hrt.2010.205096" "Revista" => array:6 [ "tituloSerie" => "Heart" "fecha" => "2011" "volumen" => "97" "paginaInicial" => "91" "paginaFinal" => "93" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21149862" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0055" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on Valvular Heart Disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "B. Iung" 1 => "G. Baron" 2 => "E.G. Butchart" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2003" "volumen" => "24" "paginaInicial" => "1231" "paginaFinal" => "1243" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12831818" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0060" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available at: <a class="elsevierStyleInterRef" target="_blank" id="intr0010" href="https://www.escardio.org/Research/Registries-%26-surveys/Observational-research-programme/valvular-heart-disease-ii-vhdii-registry">https://www.escardio.org/Research/Registries-&-surveys/Observational-research-programme/valvular-heart-disease-ii-vhdii-registry</a> [accessed 13.10.18]" "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Valvular Heart Disease II (VHDII) Survey (European Society of Cardiology website)" ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2018" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0065" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Profiles of hospitalized patients with valvular heart disease: experience of a tertiary center" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.F. Esteves" 1 => "D. Brito" 2 => "J. Rigueira" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2018.02.012" "Revista" => array:7 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2018" "volumen" => "37" "paginaInicial" => "991" "paginaFinal" => "998" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30554887" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S014067360761602X" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0070" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac valve surgery in the octogenarian" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Pretre" 1 => "M. Turina" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Heart" "fecha" => "2000" "volumen" => "83" "paginaInicial" => "116" "paginaFinal" => "121" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10618352" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0075" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Valvular heart disease in patients ≥80 years of age" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S.K. Kodali" 1 => "P. Velagapudi" 2 => "R.T. Hahn" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2018.03.459" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2018" "volumen" => "71" "paginaInicial" => "2058" "paginaFinal" => "2207" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29724358" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0080" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Vahanian" 1 => "O. Alfieri" 2 => "F. Andreotti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ejcts/ezs455" "Revista" => array:6 [ "tituloSerie" => "Eur J Cardiothorac Surg" "fecha" => "2012" "volumen" => "42" "paginaInicial" => "S1" "paginaFinal" => "S44" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22922698" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0085" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R.A. Nishimura" 1 => "C.M. Otto" 2 => "R.O. Bonow" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2017.03.011" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2017" "volumen" => "70" "paginaInicial" => "252" "paginaFinal" => "289" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28315732" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0090" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Wagle N. Implementing patient-reported outcome measures. <a id="intr0015" class="elsevierStyleInterRef" href="https://catalyst.nejm.org/implementing-proms-patient-reported-outcome-measures/">https://catalyst.nejm.org/implementing-proms-patient-reported-outcome-measures/</a>." ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003700000012/v1_201812280741/S2174204918303866/v1_201812280741/en/main.assets" "Apartado" => array:4 [ "identificador" => "9917" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003700000012/v1_201812280741/S2174204918303866/v1_201812280741/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204918303866?idApp=UINPBA00004E" ]
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| 2024 October | 73 | 41 | 114 |
| 2024 September | 67 | 28 | 95 |
| 2024 August | 65 | 27 | 92 |
| 2024 July | 72 | 38 | 110 |
| 2024 June | 41 | 21 | 62 |
| 2024 May | 69 | 28 | 97 |
| 2024 April | 70 | 34 | 104 |
| 2024 March | 83 | 31 | 114 |
| 2024 February | 79 | 22 | 101 |
| 2024 January | 84 | 22 | 106 |
| 2023 December | 66 | 27 | 93 |
| 2023 November | 78 | 31 | 109 |
| 2023 October | 28 | 11 | 39 |
| 2023 September | 19 | 19 | 38 |
| 2023 August | 17 | 19 | 36 |
| 2023 July | 17 | 13 | 30 |
| 2023 June | 29 | 16 | 45 |
| 2023 May | 30 | 32 | 62 |
| 2023 April | 17 | 6 | 23 |
| 2023 March | 29 | 25 | 54 |
| 2023 February | 22 | 30 | 52 |
| 2023 January | 19 | 13 | 32 |
| 2022 December | 32 | 19 | 51 |
| 2022 November | 34 | 20 | 54 |
| 2022 October | 24 | 28 | 52 |
| 2022 September | 31 | 27 | 58 |
| 2022 August | 30 | 30 | 60 |
| 2022 July | 22 | 38 | 60 |
| 2022 June | 28 | 24 | 52 |
| 2022 May | 25 | 32 | 57 |
| 2022 April | 29 | 33 | 62 |
| 2022 March | 27 | 56 | 83 |
| 2022 February | 38 | 34 | 72 |
| 2022 January | 37 | 33 | 70 |
| 2021 December | 25 | 37 | 62 |
| 2021 November | 28 | 28 | 56 |
| 2021 October | 39 | 44 | 83 |
| 2021 September | 16 | 21 | 37 |
| 2021 August | 22 | 27 | 49 |
| 2021 July | 30 | 18 | 48 |
| 2021 June | 11 | 15 | 26 |
| 2021 May | 21 | 40 | 61 |
| 2021 April | 65 | 49 | 114 |
| 2021 March | 25 | 12 | 37 |
| 2021 February | 28 | 19 | 47 |
| 2021 January | 18 | 14 | 32 |
| 2020 December | 18 | 4 | 22 |
| 2020 November | 19 | 18 | 37 |
| 2020 October | 14 | 12 | 26 |
| 2020 September | 27 | 14 | 41 |
| 2020 August | 8 | 8 | 16 |
| 2020 July | 9 | 12 | 21 |
| 2020 June | 17 | 12 | 29 |
| 2020 May | 7 | 4 | 11 |
| 2020 April | 15 | 11 | 26 |
| 2020 March | 12 | 7 | 19 |
| 2020 February | 13 | 30 | 43 |
| 2020 January | 10 | 17 | 27 |
| 2019 December | 24 | 4 | 28 |
| 2019 November | 16 | 6 | 22 |
| 2019 October | 13 | 6 | 19 |
| 2019 September | 19 | 25 | 44 |
| 2019 August | 16 | 7 | 23 |
| 2019 July | 14 | 11 | 25 |
| 2019 June | 18 | 17 | 35 |
| 2019 May | 29 | 13 | 42 |
| 2019 April | 22 | 16 | 38 |
| 2019 March | 17 | 14 | 31 |
| 2019 February | 32 | 17 | 49 |
| 2019 January | 46 | 16 | 62 |
| 2018 December | 12 | 15 | 27 |
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