Inês Araújo

A closer look at acute heart failure: Putting Portuguese and European data into perspective.

INTRODUCTION AND OBJECTIVES Acute heart failure (AHF) is a heterogeneous clinical syndrome requiring urgent therapy. The prognosis is poor after the index hospitalization, with a high risk for rehospitalization and early death. The costs of managing AHF are thus increasing rapidly. A literature review was performed to gather and compare data on prevalence and treatment and to identify gaps in AHF management, based on European and Portuguese studies. METHODS A literature search from 1995 to 2014 was conducted in selected databases (BIOSIS Previews, EMBASE and Ovid MEDLINE). RESULTS AND DISCUSSION Seven Portuguese and nine European studies were analyzed. The mean age of AHF patients was ≥65 years and 30-50% were women. Coronary artery disease (42.3% vs. 61.9%) and hypertension (53.3% vs. 76.7%) were identified as primary etiologies in Europe and in Portugal. Similar proportions of heart failure with preserved ejection fraction were found in the Portuguese (19.9-44.7%) and European (32.8-39.1%) studies. Overall, all-cause mortality rates were comparable (six months: 9.3-25.5% vs. 13.5-27.4%; one year: 15.9-31% vs. 17.4-46.5%), as was in-hospital mortality (5.5-14% vs. 3.8-12%) in Portuguese and European studies, respectively. Length of stay was comparable. The studies were performed in very different hospital settings and data on treatment were scarce. CONCLUSIONS Gaps were identified in treatment and clinical pathways of patients with AHF. Based on the results of this review, collection and investigation of data on the disease and treatment solutions, training in disease management, and improved organization of healthcare should be the subject of further investment.

A systematic review of in-hospital worsening heart failure as an endpoint in clinical investigations of therapy for acute heart failure

BACKGROUND In-hospital worsening heart failure (WHF) occurs frequently in patients hospitalized for acute heart failure (AHF) and has strongly negative prognostic associations. It may be a useful endpoint in studies of AHF management but important questions remain regarding optimization of its definition and variability in its incidence. METHODS Our objective was to survey the full extent of clinical interest in WHF and assess the impact of baseline variables and trial design on outcomes. PubMed, Embase, and BIOSIS were searched systematically for clinical studies that had in-hospital WHF as an endpoint. Differences in definitions of in-hospital WHF were reviewed for their potential impact on observed incidence of WHF and its associations with post-discharge outcomes. RESULTS The search identified 35 publications representing 13 interventional trials, 3 observational studies, several different classes of therapeutic agent, and 78,752 patients overall. Incidence of in-hospital WHF varied greatly-from 4.2% to 37%. Concerning the impact of differences in the way in which WHF was defined, two important factors were physician determination of worsening and whether intensification of diuretic therapy alone was defined as a WHF event. Patients having in-hospital WHF were at substantially greater risk for death and longer length of stay during index hospitalizations, all-cause and heart-failure rehospitalization, cardiovascular complications, renal failure, all-cause death, cardiovascular death, and higher healthcare costs post-discharge. CONCLUSIONS There is diverse interest in selecting in-hospital WHF as an endpoint in clinical trials. Differences in reported incidence are complexly related to differences in the way in which WHF is defined.

Prevalence and pROgnostic impact of anemia and IRON deficiency in patients hospitalized in an internal medicine ward: the PRO-IRON Study

To assess prevalence, predictive factors, and prognostic impact on in‐hospital mortality of anemia, iron deficiency anemia (IDA), iron deficiency with or without anemia (ID), and iron deficiency without anemia (IDWA) in patients admitted to an internal medicine ward.

The Implication of Socioeconomic Profile on Prognosis and Management Programs in Heart Failure Patients~!2009-05-26~!2009-11-02~!2010-02-24~!

Introduction: Little is known about the obstacles to patients’ compliance to Heart Failure (HF) treatment. Heart Failure management programs seem to be a strategy to overcome these problems. Aim: To evaluate in HF outpatients the role that socioeconomic characteristics and knowledge about the disease play in their compliance to treatment and long term mortality. Population and methods: We conducted a prospective study of consecutive HF outpatients attending our HF Clinic. Structured questionnaires directed to the patient or care giver were used. Patients ́ socio-economic characteristics and understanding of the disease, as well as, predictors of long term mortality were accessed. Results: We included 59 consecutive NYHA II-III HF patients, age 70.5±11.9 years. Sixty three percent were male and 59.3% had left ventricular systolic dysfunction. Most patients had multiple comorbidities, were polymedicated, lived with their family and belonged to middle-low or low Graffar socioeconomic class. Eighty five percent were retired, median monthly income was 350 , 41.5% had primary education and 22.6% were illiterate. More than half did not know they had HF, what HF was nor its main symptoms/ signs. Four year mortality was 23.6 %. Not knowing “what HF is” was the unique predictor of long-term mortality (p= 0.035; OR 0.097; CI: 0.011-0.846). Conclusions: In our study Heart Failure patients were elderly, retired, and frequently dependent. Literacy was predominantly low. The need of polypharmacy, poor income and poor understanding of the disease were the rule. The later was even a predictor of long term mortality. Heart Failure management programs must be tailored to the needs of their users, taking into account their social environment.

Insuficiência cardíaca em números: estimativas para o século XXI em Portugal

INTRODUCTION AND OBJECTIVE Heart failure is a major public health problem that affects a large number of individuals and is associated with high mortality and morbidity. This study aims to estimate the probable scenario for HF prevalence and its consequences in the short-, medium- and long-term in Portugal. METHODS This assessment is based on the EPICA (Epidemiology of Heart Failure and Learning) project, which was designed to estimate the prevalence of chronic heart failure in mainland Portugal in 1998. Estimates of heart failure prevalence were performed for individuals aged over 25 years, distributed by age group and gender, based on data from the 2011 Census by Statistics Portugal. RESULTS The expected demographic changes, particularly the marked aging of the population, mean that a large number of Portuguese will likely be affected by this syndrome. Assuming that current clinical practices are maintained, the prevalence of heart failure in mainland Portugal will increase by 30% by 2035 and by 33% by 2060, compared to 2011, resulting in 479 921 and 494 191 affected individuals, respectively. CONCLUSIONS In addition to the large number of heart failure patients expected, it is estimated that the hospitalizations and mortality associated with this syndrome will significantly increase its economic impact. Therefore, it is extremely important to raise awareness of this syndrome, as this will favor diagnosis and early referral of patients, facilitating better management of heart failure and helping to decrease the burden it imposes on Portugal.

Distúrbios respiratórios do sono na insuficiência cardíaca: o estado da arte depois do estudo SERVE‐HF

Heart failure (HF) is one of the most prevalent conditions worldwide and despite therapeutic advances, its prognosis remains poor. Among the multiple comorbidities in HF, sleep-disordered breathing (SDB) is frequent and worsens the prognosis. Preliminary observational studies suggested that treatment of SDB could modify the prognosis of HF, and the issue has gained importance in recent years. The diagnosis of SDB is expensive, slow and suboptimal, and there is thus a need for screening devices that are easier to use and validated in this population. The first-line treatment involves optimization of medical therapy for heart failure. Continuous positive airway pressure (CPAP) is used in patients who mainly suffer from obstructive sleep apnea. In patients with predominantly central sleep apnea, CPAP is not sufficient and adaptive servo-ventilation (ASV), despite promising results in observational studies, showed no benefit in patients with symptomatic HF and reduced ejection fraction in the SERVE-HF randomized trial; on the contrary, there was unexpectedly increased mortality in the ASV group compared to controls, and so ASV is contraindicated in these patients, calling into question the definition and pathogenesis of SDB and risk stratification in these patients. There are many gaps in the evidence, and so further research is needed to better understand this issue: definitions, simple screening methods, and whether and how to treat SDB in patients with HF.

ACCURACY OF SEVERITY SCORES IN RISK STRATIFICATION OF INTERNAL MEDICINE WARD PATIENTS

MEDICINE WARD PATIENT’S Ana Abreu, Sara Augusto, Filipa Gandara, Ines Araujo, Rosa Cardiga, Ricardo Ferreira, Marisa Alface, Margarida Proenca, Daniel Romeira, Carolina Carvalho, Henrique Sousa, Bruna Ferreira, Sara Grazina, Elena Ndrio, Filipa Marques, Susana Jesus, Arturo Botella, Ana Leitao, Cândida Fonseca, Fatima Ceia Servico de Medicina III, Hospital Sao Francisco Xavier, Faculdade de Ciencias Medicas da Universidade Nova de Lisboa