Heart failure (HF) is a highly prevalent disease with significant morbidity and mortality worldwide. Portugal is no exception.1,2 According to data from the Portuguese Health Directorate, HF was the second major source of hospital activity, accounting for 19000 admissions, lasting on average 10 days, and with high in-hospital mortality.2 Hospital admissions due to HF consume a high level of resources and readmissions at 30 days are also particularly significant.3–5 HF is a major economic and social burden in Portugal and also a serious public health problem.6 Since HF results from a chain of events that begins with cardiovascular risk factors, which have been on the rise, the burden of the disease is expected to increase progressively, exacerbated by the aging population, in whom the disease is more prevalent. In developed countries estimated prevalence of HF is around 2% of the general adult population.1 The Prevalence of Chronic Heart Failure in Southwestern Europe: the EPICA study, conducted in Portugal in 2002, estimated prevalence of HF in the adult population at 4.36%, rising to over 10% in the more advanced age ranges. More recent data are, however, not available.7 Recent estimates based on expected demographic change in Portugal predict an increase of around 30% in 2035 and 33% in 2060, compared to 2011. This corresponds to more than 450000 individuals with HF.8 The same estimates for hospital admissions suggest figures that will exceed 20000.8 Economic studies conducted in Portugal also point to an increase of 28% in the burden of HF between 2014 and 2036, representing 27059 Disability Adjusted Life Years and 8112 deaths, thus reinforcing the need to make HF a health priority in Portugal.9 Patients admitted for HF are at significant risk of readmission and mortality.3,4 Hospital admission is associated with a worse prognosis and accounts for approximately 70% of all the disease-associated costs.10

The development and setting up of clinics and units specializing in the assessment and treatment of HF are advocated in international recommendations on HF.11 They comprise acute HF in-patient units, which should include streamlined and systematic transition care leading up to patient discharge, agreements with primary health care providers, outpatient HF appointments, HF day hospitals and telemonitoring, including remote monitoring of outpatients. These professionals all require specific training. Studies have revealed the proven benefit of this multidisciplinary approach, such as good cost-effectiveness, and, in particular, improvements in patient quality of life, reductions in hospital admissions and readmissions, use of emergency departments, and mortality.12 Educating patients and caregivers is an essential part of this integrated process.

In contrast, easy access to several complementary diagnostic modalities, including advanced echocardiogram and cardiopulmonary stress testing, is essential in HF follow-up, as is access to cardiac rehabilitation, which according to national data is currently particularly weak.13 Wide-ranging access to more advanced therapies, including support from arrhythmology (cardioverter-defibrillators and cardiac resynchronization), coronary and structural interventional cardiology, coronary or valve heart surgery and heart transplantation or long-term ventricular assist devices is also important for these patients. The treatment of acute HF requires teams of experienced professionals to perform advanced and complex therapies. The main targets of these programs should be symptomatic and high risk patients. The programs should offer an optimized approach (both pharmacologically and the type of devices used); the patient and caregiver should be involved in the individual care and monitoring, and there should be regular follow-up (face-to-face appointments, telephone contact or telemonitoring), with easy access in the event of episodes of decompensated HF, and access to advanced treatment. The need for good support and access to palliative and end-of-life care is discussed much less.

The purpose of this review is two-fold. On the one hand, we aim to describe the current diagnosis and treatment of HF, particularly for those less familiar with this topic, and on the other, to raise awareness of and discuss the importance of a care referral network and proper liaison between stakeholders, the extension of the existing network and the need for an integrated approach, in line with international quality standards. Our intention is not to perform a systematic review of the literature or metanalysis, but to analyze the internationally recommended approach, based on consensus documents that were produced following an extensive review of references.

Easy access to imaging techniques is essential to the diagnosis, etiological study, prognosis, choice of treatment and follow-up of patients with HF. Of the available methods, echocardiography is the preferred diagnostic tool, due to its low cost, wide availability, portability, and also due to the extensive information that can be obtained. Echocardiograms are therefore essential to the diagnosis of systolic or diastolic dysfunction, major valve disease, myocardial disease and right ventricular involvement.11,14 In addition to the traditional transthoracic echocardiography, new technology improves diagnostic capacity. For example, myocardial strain imaging using speckle tracking technology facilitates early detection of ventricular dysfunction in a subclinical phase; and three-dimensional echocardiography enables a more reliable assessment of left and right ventricular function with results that are very similar to those achieved through CMR imaging (Figure 1). The use of stress echocardiography allows the detection of myocardial ischemia, viability, contractile reserve and, in some cases, a more detailed assessment of valve disease. Although clinical trials have not shown any benefit to dyssynchrony evaluation in decisions on the use of cardiac resynchronization therapy (CRT), comprehensive echocardiography prior to the use of this therapy still plays an important role in this decision and also in the optimization of resynchronizer parameters. Recent studies have validated the role of stress echocardiography in assessing potential response to CRT. Parameters such as chronotropic response to stress with dobutamine, the presence of contractile reserve and the association between viability and contractile reserve appear to be promising parameters linked to a favorable response to resynchronization treatment.15–17

Figure 1.

Left ventricular strain analysis using speckle tracking technology.

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Cardiac magnetic resonance (CRM) imaging is still the gold standard for assessing left ventricular function, but due to its high cost, low accessibility and availability, it has been used more selectively, especially when echocardiography is inconclusive.11,14 It is particularly useful for assessing viability and identifying more uncommon HF etiologies due to late enhancement imaging.

Nuclear medicine can also be useful in specific situations, such as the diagnosis of ischemia and viability, and for example in the diagnosis of cardiac amyloidosis.11 Cardiac computerized tomography enables the assessment of coronary anatomy in patients with a low to intermediate pre-test probability of coronary artery disease.11,14

The use of more invasive methods, including coronary angiography, may be necessary when the diagnosis of myocardial ischemia is inconclusive using non-invasive testing or when the pre-test probability is high.11 In more advanced stages of the disease, full hemodynamic profiling is equally important to investigate the conditions and possible contraindications for more advanced treatment, such as heart transplantation.11,18

Selecting advanced chronic HF patients who may benefit from advanced therapy, such as heart transplantation and the placement of ventricular assist devices, requires a holistic assessment of patients. Although it is not the sole factor in the decision to refer patients for treatment with these therapies, the cardiopulmonary stress test is crucial and assesses the physiology and function of a series of organ systems. Many scientific associations, including the American Heart Association/American College of Cardiology and International Society for Heart and Lung Transplantation, recommend peak oxygen consumption in cardiopulmonary stress testing below 12 ml/kg/min as one of the main referral criteria for heart transplantation or placement of left ventricular assist devices.11,18 Other parameters, such as the VE/VCO2 slope and percentage of predicted peak oxygen uptake may be important for decisions in patients who cannot achieve maximal effort and in men and women under 50 years of age, respectively.11,18 These parameters may be better when determining risk and possibly more suited to listing patients for transplant than others. Table 1 illustrates the criteria for poor prognosis based on the cardiopulmonary stress test.

As HF is an area that is constantly under clinical investigation, treatment options have evolved exponentially over the past 30 years. The available therapeutic arsenal, the use of which has been proven in clinical trials, includes pharmacological and non-pharmacological treatments. HF clinics should follow this evolution and offer the most up-to-date treatment possible to these patients at high risk of cardiac events.

Specialized teams with specific HF training are essential due to the poor prognosis of HF.19 Setting up these teams means treatment can be optimized and the benefits have been observed in several studies and systematic reviews of literature. These studies have shown an optimization of up to five times compared to treatment at the initial introduction of these units for the recommended therapies and a major reduction in HF admissions, which in some series reached almost 50%, although overall it is closer to 25%.3,20–24 There is very little data on experiences in Portugal.24 Data from neighboring Spain show that in 2011 only 37% of hospitals had HF units. Most of these were in level 3 hospitals (with hemodynamic monitoring, electrophysiology and cardiac surgery).25 The majority were managed by the cardiology department (84%) and 78% were general and non-advanced.25 These units also varied significantly in their programs, organization and activities and also in the tasks assigned to nursing staff.25 In 45% of the units, there were cardiac rehabilitation programs, 20% had a telemedicine program (telephone contact, telemonitoring of implantable devices or monitoring of biometric data with remote devices) and 64% had a day hospital. The setting analyzed in 2011 had changed very little since 2006, indicating that there was room for improvement.25 Based on the evidence and recommended standard of care for these patients, especially those admitted recently for decompensated HF, these specific multidisciplinary care programs should be implemented extensively.

Despite the recent development in ambulatory intravenous (IV) treatments for HF, there was already some evidence of their feasibility, benefit, safety and cost-benefit ratio. In a trial that included more than 100 subjects with decompensated heart failure, IV administration of diuretics in an ambulatory setting was safe, cost-effective and reduced hospital admissions.38 Another trial also demonstrated that ambulatory IV administration of loop diuretics according to standardized protocols relieved congestion effectively in decompensated HF patients across the whole EF spectrum.39

Other IV therapies given on an outpatient basis have been studied for improving HF symptoms and preventing hospital admissions. Pulsed infusions of levosimendan in outpatients with advanced HF were analyzed in two randomized clinical trials. In the LevoRep trial, levosimendan (0.2 μg/kg/min) vs. placebo administered for six hours at two-week intervals over six weeks did not significantly affect functional capacity and disease-related quality of life after 24 weeks.40 However, this study provided some indications on the safety and feasibility of an ambulatory treatment strategy, including the possibility of improved event-free survival with levosimendan. In the LION-Heart trial, a six-hour IV infusion of levosimendan (0.2 g/kg/min) every two weeks for 12 weeks, was associated with improved plasma N-terminal pro-brain natriuretic peptide concentrations, quality of life and HF admissions when compared with placebo.41 The intermittent use of levosimendan led to a reduction in hospital admissions and improved quality of life, howeverm there was no clear benefit on mortality. It is therefore indicated for symptomatic relief or as palliative care, but larger studies are needed to define its role better.

In iron-deficient HF patients, a metanalysis of four randomized clinical trials indicated that compared to placebo, the administration of IV ferric carboxymaltose reduces recurrent cardiovascular hospital admissions and is another possible ambulatory IV treatment.42

As part of outpatient clinic treatment (Figure 2), patient education must be boosted, equipping them with the necessary tools for self-monitoring and emphasizing the importance of adhering to their drug regimen, a healthy diet and raising awareness of the factors that lead to decompensation.

Figure 2.

In-patient clinic at Cardiology Department of Hospital de Santa Marta.

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The theoretical potential benefits of patient monitoring in terms of reducing HF admissions have slowly been translated into a reality in clinical practice, due to the exponential growth in technology transmitting data in real-time. HF units currently have various strategies at their disposal and these together with a timely response may improve outcomes for this population. Even though the results from different clinical trials have been disparate, telemonitoring, in which a team receives information and is able to provide timely responses, may reduce HF admissions and all-cause mortality, as shown in the recent Telemedical Interventional Management in Heart Failure II trial (TIM-HF2).43

Remote monitoring is also possible with implantable devices such as ICDs and CRTs, enabling faster recognition of arrhythmias, device-related issues and worsening of HF signs. It is currently recommended when these devices are implanted.44 Although the changes recorded by these devices provide valuable information, direct assessment of filling pressure may provide additional data. The CHAMPION trial demonstrated this using the CardioMEMS™ device, which measures pressure directly in the pulmonary artery and showed that its use led to a reduction in HF hospital admissions.45

As a rule, palliative care has rarely been addressed or discussed. The advent of new forms of treatment has meant there are more treatment options available, resulting in improved patient outcomes and quality of life. However, there are still cases with unfavorable progression, in which easy access to palliative care is vital, thus making cooperation with these units essential. Most patients reject or do not acknowledge the terminal nature of HF, focusing primarily on a day-to-day approach, despite clear clinical worsening. End-of-life approaches should be discussed with a multidisciplinary team, including palliative care specialists and psychologists so that the patient has a well-established and defined end-of-life.62

In view of the different patterns of clinical progression and very variable care needs, these patients will require different levels of care throughout the course of their disease, and their needs will be diverse, both in terms of medical support and nursing, but also the technology used to care for them. These issues have already been debated for other acute or critical diseases, such as trauma, and also for intensive cardiac care. For acute diseases, the classification of the patients according to three levels of severity is recommended; intensive care units are also classified as level I (basic), II (intermediate) and III (advanced), based on the expertise of the staff and techniques available at each unit.63 This approach enables us to obtain more information on how to care for these patients, allocate resources more efficiently and improve outcomes. In an HF treatment setting, profiling the centers based on available human and technical resources, together with the definition of the care required by the patient, may allow them to be included in a referral network for HF treatment in tertiary hospitals and other hospitals, resulting in more efficient use of resources (Figure 3) and a clear definition of when to refer patients to an advanced HF treatment unit.33

Figure 3.

HF guidance algorithm for treating HF patients.

Legend: BB: beta-blockers; CRT: cardiac resynchronization therapy: HF: heart failure; ICD: implantable cardioverter-defibrillator; LVEF: left ventricle ejection fraction; RAAS: renin-angiotensin-aldosterone system; SBP: systolic blood pressure.

Referral for specified treatment to intermediate HF units may also be made from Basic HF Units (via agreements with other hospitals) or by the advanced HF units.

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To achieve greater efficiency when treating HF patients, the existence of guidelines is particularly important (especially “an integrated care process for HF management”) as is the definition of quality indicators for assessing performance relating to the provision of medical care to HF patients and for constructive improvement of care, as has happened in other countries, such as Spain.64 A clearly defined approach in line with internationally recommended standards is essential in order to standardize clinical practice in Portugal. The definition of a national referral network for the treatment of chronic and acute HF might enable the faster provision of appropriate guidance for these patients. Finally, conducting internal and external audits allows us to identify areas that need to be improved locally or nationally, thus permitting a more appropriate use of resources that may be very scarce in some places.

The authors have no conflicts of interest to declare.