Heart failure (HF) is a public health priority. In Portugal, there are about 400 000 people living with HF,1 resulting in an estimated disease burden of 21 162 disability-adjusted life years. In the next 20 years, we can expect a significant increase in the number of patients, leading to a similar rise of 28% in disease burden and of 73% in mortality.2

It is a complex problem where several causes concur for multiple effects. The determinants are well-known. They include an aging population, the decrease in mortality from coronary heart disease and other myocardial diseases, the intensification of medical intervention in diseases such as cancer or connective tissue disorders, with greater iatrogenic potential, and even the socioeconomic factors.3 Generally, HF is the consequence of most heart diseases and the increasingly significant comorbidities in our patients.

Until recently, living with HF represented the inevitability of terminal disease for many patients. Nowadays, however, the recent introduction of new therapeutic options with impact on the prognosis have changed the scenario, creating hope for the future and forcing us to reconsider the position of illness. It is no longer ethical to wait for the classic clinical presentation when we can intervene in disease evolution. More than alleviating symptoms, we currently have robust evidence that we can indeed modify natural history and with it also the symptoms, comfort, and the quality of life of our patients.

Success has brought with it an added responsibility. Now, we must create conditions to treat these patients well, which is far from simply prescribing the best medications. In this issue of the Portuguese Journal of Cardiology, the article from Fonseca et al.4 draws attention to the need to provide instruments capable of ensuring access to diagnosis and better guidance for these patients in health services, particularly in primary health care. This study demonstrates that the introduction of N-terminal pro-B-type natriuretic peptide in the decision flowchart decreases the number of medical appointments, the number of ordered tests, the number of hospitalizations, the mortality, and the costs of HF, in a clearly positive cost-effectiveness analysis compared to the current standard of care.

The diagnosis of HF is based on the clinical presentation, on the findings in the physical examination, and on the presence of an abnormal electrocardiogram. Although appropriate training improves specific acuity,5 the progressive nature of HF makes the diagnosis more difficult and means complementary tests are required where the echocardiogram plays a central role. Unfortunately, access to a high-quality echocardiogram is not warranted for everyone compared to blood tests, which are more easily available nationwide. Natriuretic peptides can play this role when reimbursement in a primary care setting is resolved. They present high negative predictive values, with good performance as screening and diagnostic tests in primary health care,6 in addition to the prognostic value in patients with heart failure.7 The 2021 recommendations of the European Society of Cardiology are definitely set the standard for the initial care of these patients.8

This is a crucial aspect, but we still need to review the whole group of people living with HF. Many other factors are important, such us (1) the implementation of integrated management systems for these patients involving the different levels of care, (2) the promotion of continuity of care, avoiding the need for attendance by the emergency services, (3) the structuring of referral networks oriented more toward the patient and not so much toward the dynamics and interests of services, (4) ensuring timely access to health care services, namely for the first hospital appointment, (5) promoting effective communication systems between services and with patients and (6) ensuring access to therapeutic innovation, among others. They represent a multifactorial view of the problem and address the different dimensions.

Also, we cannot forget that the patients are first and foremost responsible for their own health, and that this responsibility depends on how they are able to make their own decision, whether in the primary prevention of lifestyles and risk factors, in secondary prevention of the already present disease, or in tertiary prevention of the optimization of remaining function. Promoting health literacy is the key to quality of care, demanding and rigorous, aiming at everyone being able to access health information, understand it and transform it into concrete actions in their lives, for their own benefit, realizing their current limitations and respecting their autonomy.9

Nevertheless, this analysis from Fonseca et al. provides the ground for an evidence-based decision on making peptides available for the screening and diagnosis of HF at patients’ first point of contact, primary health care. It is now up to whomever is entitled to take advantage of science as support for the production of technical and administrative guidelines to leverage quality and to improve health care for these patients.