Heart failure (HF) is a major global burden in terms of patients’ quality and duration of life and of health expenditure.1–4 Approximately 1-2% of the adult population in developed countries has HF, the prevalence rising to ≥10% among those 70 years of age or older.1,5,6 In Portugal, the overall prevalence of chronic HF was 4.36% in a community-based epidemiological survey carried out in 1998, rising sharply with age; this was slightly higher than that of other European countries.7

Across the globe, 17-45% of patients hospitalized with HF die within a year of hospitalization3,4,8 and a quarter are rehospitalized within one month and up to two-thirds within a year.1,8–10 HF is the most common reason for hospitalization in people over 65 years of age in economically developed regions.6,9,11–13

According to national registries of the Portuguese Directorate-General of Health, in 2014 18 588 patients were hospitalized for HF and the in-hospital mortality rate was 12.5%.14

The increasing incidence of acute HF and associated morbidity and mortality mean there is an urgent need to better understand this patient population.15 Despite the high prevalence of acute HF, few studies have been conducted specifically in the hospitalized HF population, and data on clinical characteristics and outcomes for these patients are lacking, especially in Portugal. Observational studies provide useful information about real-world patients and routine clinical practice.2 Interest in this type of research has been growing in recent decades, for various reasons.4

According to the latest guidelines on heart failure, the standard-of-care for HF patients recently hospitalized for acute de novo or chronic decompensated HF should include enrollment in a multidisciplinary care management program,5,16 also known as a heart failure clinic.17

The present study covers the year before the implementation of an HF clinic, using a multidisciplinary approach to HF patients, in a Portuguese tertiary university hospital. The study was designed to improve knowledge of the characteristics of patients hospitalized and treated for HF in an internal medicine department and to present one-year follow-up outcomes, reporting in-hospital and one-year mortality and rehospitalization for HF, which will help to evaluate the impact of our HF clinic on those outcomes.

The main results of this study consist of the clinical findings of a large population hospitalized for HF in the internal medicine department of a tertiary university hospital. In Portuguese hospitals, many HF patients are treated by internists, even in hospitals where there is a cardiology department,18,19 so this is a real-world survey, enrolling all patients discharged following hospitalization due to acute or chronic decompensated HF during a one-year period.

Our patients are older, more frequently female and more often with HFpEF than HF patients in other series, who tend to be mainly hospitalized in cardiology departments.2,4 The mean age is similar to that reported in a recent French single-day survey in 170 hospitals of all patients hospitalized for acute HF,13 but 10 years older than in a recent Portuguese study enrolling patients hospitalized for acute HF only in the cardiology department of the other tertiary university hospital in the city where our study took place. In that study 73.2% of patients had HFrEF, which reflects considerable differences between the two study populations and is evidence of how observational studies provide valuable information about acute HF managed in different clinical scenarios.20,21 Our data on gender are in agreement with other reports showing that elderly patients hospitalized with HF are mainly women22 and that patients with HFpEF are older and more often female than those with HFrEF.1,5,6,8,13 HF patients managed by internists are more likely to have the characteristics of those managed by general practitioners. In the UK, the mean age of HF patients in general practice is 77 years, similar to that of our population. The HF patient seen in general practice is generally 15 years older, more often female, more likely to have a history of hypertension and less likely to have had myocardial infarction than the HF patient seen by a cardiologist.1,6 It has been shown that in Portugal chronic HFpEF mainly affects older women7 and that patients aged over 75 hospitalized for acute HF in an internal medicine department mainly have HFpEF.19

The average of three comorbidities per patient shows the complexity of this population and is in agreement with data on older people with HF in the USA.16 Of note, the prevalences of the two commonest comorbidities, hypertension and diabetes, in our study were similar to that report; this is not the case for AF, which was twice as common in the present study.16 Patients with more than three comorbidities have a higher risk of death and HF hospitalization, as shown by van Deursen et al.,23 although in their study only non-cardiovascular comorbidities were analyzed. Another study, on incident HF, reported that patients with HFpEF were more likely to have both cardiac and non-cardiac comorbidities.24

AF and a history of hypertension were more prevalent in this study population than in others in which HFrEF was more prevalent than HFpEF and patients were enrolled in cardiology wards.2,4 This is consistent with the literature on HFpEF populations and with data on Portuguese HF patients.4,19,25

Hypertension was the main etiology for HF, according to its prevalence in this population, but the retrospective nature of the study and the non-invasive diagnostic methods used for determining HF etiology prevent further analysis.

An ischemic etiology was less prevalent (34.6%) than reported by the above-cited European observational trials, which included mostly HFrEF patients (42%-50.7%), as expected.1,3,4,13 It is known that patients with HFpEF are less likely to have coronary heart disease and more likely to have hypertension and AF than those with HFrEF.5,6 We confirmed that ischemic HF patients more often had HFrEF.

The patient characteristics in this study were similar to those reported by a Spanish heart failure unit in a recent paper from the internal medicine department of a tertiary referral hospital, which describes an elderly population with a mean age of 80.3 years, of whom 54.8% were female, 72.2% had HFpEF (≥50% according to the criteria of this study) and the main etiologies were ischemic and hypertensive in the HFpEF group and ischemic in the HFrEF group.26

Infection was the most frequent trigger of HF decompensation in our study, as has been found in other Portuguese and European surveys.7,13,25

In addition to the significant correlation between sleep apnea/hypoventilation syndrome and treatment by NIV during hospitalization, it is noteworthy that the numbers of patients undergoing NIV with and without one of these diagnoses were similar. This probably means that relieving acute pulmonary congestion and improving pulmonary gas exchange were the main treatment goals in a large number of those treated with NIV.

Our in-hospital mortality was double (7.9%) that reported in a large European observational survey (3.8%)2 and in a US registry (4.0%)27 but similar to that reported in other Portuguese studies and in Italian and French surveys (7.7%, 6.9% and 8.2%, respectively).4,13,25

Pharmacological treatment at discharge should be considered in the light of the prevalence of HFpEF in this population. Bearing in mind that no drug therapy has been proved to change prognosis in the HFpEF phenotype,5,16 it is interesting to see that half of the patients were prescribed beta-blockers or ACE inhibitors. This proportion is similar to that reported in the OFICA study in the HFpEF subgroup, in which 44.2% and 47.3% of this group of patients were discharged under ACE inhibitors and beta-blockers, respectively.13 This reflects the use of these drug classes in HFpEF patients with the aim of controlling blood pressure and ventricular rate in AF and decreasing hospitalizations. Ceia et al. found that therapy with ACE inhibitors in Portuguese chronic HF patients was also similar between patients with HFpEF and HFrEF.28

Our finding that beta-blockers and spironolactone were more often prescribed for HFrEF patients shows adherence to current guidelines and their incorporation into clinical practice. The rate of such prescription is similar to that in a European survey for beta-blockers (75.2% vs. 80%) but lower for aldosterone blockers (31.2% vs. 52%).2

The total one-year mortality was higher than that reported from the same European region (34.3% vs. 24.7%) by Maggioni et al. in the ESC-HF Pilot survey for the period 2009-2010 and in an Italian survey (24%).2,4 Cardiovascular causes accounted for half of deaths, a smaller proportion than reported in other observational trials, probably because the type of HF patients hospitalized in cardiology departments are more liable to die of cardiovascular causes, while those hospitalized in internal medicine wards are equally likely to die of other causes. In this respect, it is noteworthy that the patients in our study were 10 years older and had a higher prevalence of comorbidities.3,4 Comorbidity was found to be one of the prime determinants of prognosis in a study of patients hospitalized with HF1 and HFpEF patients have a higher likelihood of non-cardiovascular death,6 supporting our findings.

It should be noted that, although it is commonly accepted that the lower the EF the worse the survival,5 in our predominantly HFpEF population neither mortality nor rehospitalization rates were lower. This is in agreement with other hospital-based studies of patients hospitalized with HF that reported similar one-year mortality rates in patients with HFpEF compared to those with HFrEF,1,6 but not with the OFICA study, which reported higher mortality in the HFrEF population.13

The rehospitalization rate for HF in the first year of follow-up was similar in this study to that found for the same European region in the previously mentioned survey (30.5% vs. 33.9%, respectively). Of note, the highest rates of mortality and rehospitalization for HF were observed in this region, in comparison with three other European regions.3,4 Bearing in mind the differences in prevalence of HFpEF, this is in agreement with studies reporting that HFpEF patients are as likely to be rehospitalized as HFrEF patients.6

The median time between discharge and first follow-up appointment was much longer than the recommended 7-14 days,16 a situation that we expect to change drastically with the implementation of our heart failure clinic.

To our knowledge this is the largest Portuguese observational study of patients hospitalized for HF, and the most recent.

Our findings should be considered in the context of several limitations. This was a retrospective registry and did not include all patients hospitalized for HF, including those admitted to the cardiology department of our hospital. Unmeasured variables may have been present that could have influenced the findings. Chronic renal dysfunction was not included in the comorbidities because of the difficulty of ascertaining the chronicity of renal dysfunction in some patients with cardiorenal syndromes. Rehospitalizations were considered only at the study center, and thus may have been underestimated. We did not examine the use of cardiac devices, although there is unlikely to be a significant number of patients with such devices, given the low prevalence of reduced ejection fraction and the old age of this population.

This is one of the few published observational studies showing the situation in Portugal in terms of HF hospitalization and outcomes. We characterized a large group of patients admitted to an internal medicine department with acute HF: elderly, mostly female, with hypertension and HFpEF. Diabetic patients and those with ischemic heart disease were significantly more likely to have HFrEF. At discharge, more than half of patients were prescribed beta-blockers and ACE inhibitors/ARBs, and those with HFrEF were significantly more often prescribed beta-blockers and spironolactone. Nearly a third of patients died and/or were rehospitalized in the following year.

Multicenter observational studies in the Portuguese HF population are an unmet need. For the time being, the data presented here will be helpful to measure the impact of the heart failure clinic at our institution in important areas, particularly mortality and rehospitalization outcomes.

The authors have no conflicts of interest to declare.